HEFT Pathology Guideline Investigation and Referral Pathways for Anaemia in Primary Care

This guidence covers the following areas

1. Anaemia Testing in Adults

2. Iron Deficiency Anaemia Testing in Adults

3. Iron Deficiency Anaemia Treatment and Monitoring Advice

4. Vitamin B12 Deficiency Testing, Treatment and Monitoring

5. Folate Deficiency Testing, Treatment and Monitoring Advice

6. Renal Anaemia Testing in Adults

Phoning limits for biochemistry tests are as follows:

Decision limits for phoning

Immunology results to be telephoned:

• CD4 count <200 cells/cumm or <10% on new patients (paediatric levels are different, but agreed with Paed consultants)
• Lymphocyte subsets in infants <2yo: Any T cell subset below age-related normal range, any other abnormality suggesting SCID (e.g. MHC class II deficiency). (Note this is not exclusive: any abnormality may be discussed with requesting clinician)
• New positive GBM antibodiest
• New positive MPO antibodies
• New positive PR3 antibodies
• New paraprotein IgG , A or M  > 20g/L
  • IgD or IgE (any size)
  • serum monoclonal free light chains (any size, whether or not with intact paraprotein)

Abnormal Laboratory Test Results – Triggers for Telephoning Results Haematology

• All Positive Malaria Screens
• All Anti FXa results >1.20 iu/ml
• If the patient is known to the department and has had a similar result within the previous 7 days then the urgent contact is not necessary.

HPA Microbiology – List of abnormal results telephoned to clinical staff

Bacteriology

• Gram stain results of positive blood culture on Day 1
• Positive CSF results
• Positive sterile site results
• Significant in-patient results from enteric bench
• Multi resistant gram negative and gram positive isolates including mupirocin resistant MRSA
• Group B streptococcal isolates from neonates
• Group A in patient isolates
• Positive Legionella urinary antigen and Pneumococcal urine antigen results
• Smear and culture positive Mycobacteria
• Antibiotic assay results outside normal ranges
• Any other significant results at the discretion of Medical Microbiologists

Virology

• Serological evidence of acute infection with Hep A, Hep B and in pregnant patients CMV, Parvovirus and Rubella
• New diagnoses of HIV
• VZV IgG negative from exposed patients at risk of severe VZV infection
• New diagnosis of Hep B, Hep C and HIV in haemodialysis patients
• Evidence of Hep B/Hep C and HIV in needle stick injury source patients
• Clinically important positive respiratory PCR results i.e.: influenza, RSV in immunocompromised patients
• Positive PCR results in outbreaks
• Positive blood PCR for CMV and Adenovirus
• Negative blood results for CMV PCR
• Significant blood PCR results for EBV and Polyomavirus
• All positive PCR results on CSF specimens
• All positive Chlamydia PCR results on eye swabs
• All positive PCR results from neonatal unit

In the last 5 years requests for tumour marker tests from Primary Care have more than doubled. This high use in Primary Care is worrying because the majority of tumour markers (eg. CEA, CA19-9) are neither specific nor sensitive enough for use in the diagnosis of malignancy. See this link for a summary of the main tumour markers, their uses and limitations.

The main use for tumour markers is in monitoring disease progression, treatment or recurrence of a histologically diagnosed cancer. A recent audit of Primary Care requests for tumour markers found that only 9% of CEA and 4% of CA19-9 were requested for these reasons; the rest being for non-specific symptoms.

In contrast to the above, CA125 and PSA do have use in diagnosis of their related cancers, however it should also be noted that these are still only a diagnostic aid and should be used with caution as both can be raised in a number of other benign conditions (see table). Please click the relevant links below of links to guidelines relating to their use in Primary Care.

CA125 link https://pathways.nice.org.uk/pathways/ovarian-cancer

PSA link https://www.gov.uk/guidance/prostate-cancer-risk-management-programme-overview

For symptoms and referral guidelines of other malignancies see the NICE Suspected Cancer Recognition and Referral guidelines. http://pathways.nice.org.uk/pathways/suspected-cancer-recognition-and-referral

You can also use the search bar or test database on this website to find more specific information on the use of each tumour marker.