Traditional and innovative diagnostic tools: when and why they should be applied

The development of new technological methods surely improves the quality of the Diagnostic Services in Parasitology offered to the National Sanitary Service, however, cost and simplicity have not to be neglected, even when the prime consideration is efficiency. Moreover, the mere fact that something can be done by one of these new approaches does not mean that it should be done that way or that it is most cost-effective to do it that way. A review of diagnostic tools in Parasitology is proposed, to evaluate when and why each of them should be applied. Traditional procedures for the diagnosis of parasitosis are only based on the "direct" recovery and recognition of the parasite, with the microscope as main tool and few other instruments as co-operator. The innovative procedures, recently adjusted on the basis of new scientific knowledge and made possible by the development of the laboratory instrument weapons, can evidence the parasites both directly and indirectly. If it is obvious that the direct identification of a pathogen is more reliable than that indirect, is not so evident what is the most useful direct method, and when it would be better to use indirect diagnostic tools. Advantages and disadvantages of each procedure, cost as well as the purpose of the test (diagnosis, post-treatment, research), and the general condition in which the test have to been applied must be taken into account when we are choosing. In general, we can say that the rationale for their use can be summarised as follows: 1) The macroscopic/microscopic analysis of samples is always recommended (with the exception of samples coming from tissues that need surgery). This "old" procedure allows the identification in 20 minutes of all the parasites present in mixed infections, and the evaluation of the parasite load. It is a cost-effective method which relies ultimately on the skill of the observer to detect and identify parasite stages; 2) Parasite antigen detection is an innovative and expensive immunological diagnostic, which can suffer of sensitivity and specificity. It could be useful to directly diagnose "occult" infections; 3) Parasite DNA/RNA direct detection is an innovative, sensitive and specific procedure, which can also identify sibling species. It is expensive, therefore its use is restricted to reference laboratories; 4) Host antibody detection is an innovative indirect tool to evaluate the presence of a parasite by means the evaluation of the host response to infection. It can suffer of sensitivity and specificity, and the interpretation of the test results may be difficult. It could be applied as first step to evaluate the presence of tissue parasites, whose direct diagnosis would require surgery. Some tests can be performed in well-equipped laboratories; other tests are available through research laboratories. The specimens, appropriately collected and preserved, have always to be processed in security for potential risk of infection hazard, and submitted to tests appropriate to the laboratory's goals, where, therefore, field and research diagnostic tools shouldn't be applied. The test selected for routine use has to be chosen taking into account value and limitations of each method. Reduction in excessive and often unnecessary testing is mandatory, and therefore it is critical for the clinical Parasitology to perform relevant testing while maintaining appropriate quality. To date, the microscopic analysis of samples is the only direct method that allows all identifications in short times, at a reduced cost, independently from geographical origin and peculiar status of the patient. It has to be regarded as the first step in diagnostic procedures for all laboratories. Some molecular techniques have greater sensitivity than traditional methods, but at least at the present time, their costs may well preclude their routine use. It is difficult to know, exactly, where diagnostic Parasitology will be moving in the next few years, although many soothsayers feel very strongly that the area of molecular diagnostics will replace more traditional means. It is also possible that immunological or perhaps cytometric procedures will replace our more standard diagnostic approach; nevertheless they will continue to remain oddities on the outside of the general practice and be confined to a few reference laboratories. As far as semi-automated or automated instruments and robotics-based techniques, they are useful when large numbers of the same test are performed. Supposing that they will enter in our laboratory, that will happen in central facility rather than in each local facility. So, the great interest in using new technological methods to solve old problems probably will have to be seen in the right perspective.