FRCPath Microbiology part 2: Essay type questions for practice

1. There is a plan for consolidation of pathology services in your region. Your hospital might lose its laboratory in the consolidation process. Please write a report to the trust board explaining its impact on the service you are providing to your users.

2. Your hospital had a large number of C difficile cases last year. Please write a report on your plan for the next year. How you are planning to reduce the C difficile rate?

3. You have been asked to provide ideas for a cost improvement program for Microbiology-virology. Please write a report to trust board how you are going to provide a lean cost effective service without affecting the patient care.

4. You have been approached to provide a result only service. Please write a report to the users about its merits/demerits.

5. You have been notified of an error in the processing of genitourinary medicine specimen over a week. The internal quality control was not properly monitored and it failed several occasion. A very junior member of staff was involved in monitoring of the process, who failed to recognise and report the problem. How are you going to investigate? Write a report for the board and a report to the users. What steps are you going to take to assure the users?

6. Your surveillance has shown an increase in number of VRE cases in renal unit. Write a letter to the renal consultants about the issue and any action that you might want to take. Explain about VRE and its implication.

7. Your laboratory needs a system of screening for carbapenemase producing organisms. Discuss various options – their advantage and disadvantages.

8. A GP surgery in your area has failed to meet the antibiotic prescribing reduction criteria (QP). They have asked you to deliver a lecture on how they can  in antibiotic prescribing. Describe the points that you are going to discuss.

9. Draft a 3-year antimicrobial stewardship strategy and action plan for your region – aiming towards community practice mainly.

10. You have been asked to consider a proposal for providing more active support to the community/GP practice as a microbiologist. At present you only offer telephone based advice to the GPs and community practitioners (Like multiple sclerosis nurse). Suggest a plan how a community based microbiologist improve the service. Will it be a cost effective model? or discuss the advantages and disadvantages of such a practice model.

11. You have been asked to provide a plan to reduce the hospital acquired gram negative bacteraemia rate by 50% by 2020. Please discuss and draft a plan how are you going to achieve the target.

Resources for FRCPath part 2 by Dr Katherine Watson, StR, Microbiology

Here are some of the resources that I used in preparation for FRCPath part 2, April 2016 Bristol. One of the most useful things to do is speak to anyone you know who has already sat the exam and ask for all their past questions and tips.

Mycology – A Canadian microbiologist’s blog, has some really great photos of fungi, very useful for familiarising yourself with organisms for spotters and the practical. I printed quite a few out and stuck them around the house, after seeing them every day I felt confident at quickly recognising organisms.– Website set up by the University of Adelaide, lots of useful mycology information, the mould virtual assessment section is particularly good for testing yourself.– Suggest read the EORTC/MSG definitions of invasive fungal disease. – Recent review article published in the Lancet, update on topical issues surrounding diagnosis and investigation of invasive fungal infection that can come up in many sections of the exam.$FILE/Etest%20AFST%20Reading%20Chart.pdf  – Useful pictures and guidance on how to interpret etests for fungi, useful to have in the lab folder.

Parasitology – CDC website has 18 years’ worth of monthly case study quizzes and A-Z of parasites, excellent practice for spotters, this is the resource I used for most of my parasitology revision.


The Green Book! 
Suggest reading this a few times, the virology paper is only an hour long, but the questions were all very specific questions that you either knew or you didn’t, for example, we had to give dosing schedules for Hepatitis B and rabies and specific regimen for HIV post-exposure prophylaxis. Thankfully, we didn’t get any questions about the new Hepatitis C drugs.…/hev-flowchart-for-laboratory-final_v11.ppt – Screening for Hepatitis E in blood products is a topical issue that we got asked about in the virology paper. – Make sure to read all the latest guidance on the PHE website about the Zika virus, this is very topical so likely to come up in the next exam. We had to write a short note on the laboratory diagnosis of Zika virus.

Bacteriology – Quite time consuming, but I suggest reading all of the SMIs. I printed the flow charts from the identification section to put in my practical folder. I would suggest learning by heart the 2 SMIs under the protocol section which covers identification of ESBLs and CPEs as there were lots of questions and spotters on these topics.
Also, don’t forget to read the quality-related guidance, you can pick up useful information to include the essay question if it is anything about a laboratory service and also in my exam, one of the groups of 4 short notes were all about laboratory quality assurance.
Look out for new SMIs, for example, in the autumn 2015 exam there were questions relating to the new ectoparasite SMI. – I would suggest printing out the BSAC endocarditis guidelines for the lab folder, so if one of the cases is about endocarditis you will have the guidelines to refer to for treatment advice. – Useful picture guide to interpreting etests for bacteria.

Infection Control and Public Health

PHE website has some really good training slides for healthcare professionals with up-dates on specific vaccines, would definitely recommend reading since the vaccination programme seems to have changed quite a bit in recent years.

Must read documents for infection control of CPE.

If you have time before the exam I would suggest completing Dundee University’s 6 week online course on antimicrobial stewardship, which is such a topical issue that can come up in the exam. You can sign up for free:

General – Federation of Infectious Diseases Societies of Southern Africa website, has a case of the month section where you can guess the diagnosis, quite a lot of rare tropical infections. – Another great website for practicing spotters, clinical cases with high-quality pictures of clinical conditions, radiology, histology and organisms then multiple choice questions on diagnosis. You have to sign up to the website, but it’s free to do so.– American Academy of Dermatology has a number of quizzes including some on infectious causes of rashes.

iTunes U – If you search microbiology or virology you can find some series of lectures from American universities, some good basic parasitology and mycology lecturers that you can listen to when walking or driving to work. -A well written article advising how to write an abstract, which is something that you always have to do for each of the critical appraisals. I suggest reading journal articles with the abstract covered and practice writing abstracts, pay careful attention to word counts, you are normally given a 250-word limit.

The Doctor’s Guide to Critical Appraisal Paperback by N. Gosall, G. Gosall – I am terrible at critical appraisal and read a lot of books to try to improve, this was the one I thought was most useful with straightforward explanations of statistical tests and study designs. Other trainees told me that the written paper is where most people fail the exam, I have to agree and would definitely recommend doing a lot of preparation for critical appraisal. I read this book and also Trisha Greenhalgh’s How to Read a Paper: The Basics of Evidence-Based Medicine several times.

Preparing for FRCPath part 1 (Microbiology) by Dr Joanna Lumb, StR, Microbiology

RCPath Microbiology Part 1: Hints and Tips
(This was written in 2015, but there are some tips which are still very useful)

Preparing for a professional exam is a long-haul process, taking several months.  As such, normal life needs to continue in the meantime – paid employment, on calls, shopping, cooking, exercise, childcare – and you need to figure out how to stay sane whilst trying to accomplish it all without feeling guilty about not spending every minute of the day revising.

Plan your study leave in advance, and take advantage of the days you’re allowed to take.  If your rota organiser is sympathetic, ask them to avoid putting you on call for the few weeks leading up to the exam, especially intensive weekends.  Even if you get compensatory rest after an on call you may find yourself too tired to do effective revision, in which case it may be a better use of your time to do something else instead.

I recommend setting up a working environment that allows you to concentrate with minimal distractions, and be disciplined about your work time.  No TV, no music, no phone.  Plan your study time with one evening off per week.  Two or three hours on a week night and five hours a day at the weekend is a plenty gruelling enough schedule for anyone!

Keep some element of a social life if you would go mad without it – if you know someone preparing for the exam at the same time have a go at seeing if you work well together to cement what you’re learning and help fill in each other’s knowledge gaps.

I find a kitchen timer really useful – I set it for an hour of work, with 15 minute breaks in between where I go to a different room and do a completely different activity (i.e. don’t just stay at your desk and browse the internet).  I often play the piano during my breaks.  When you’re working, WORK – effective, targeted revision according to your learning style.

Before you start, look through the curriculum and identify gaps in your knowledge.  Some things will be very familiar to you because you come across them every day at work – don’t spend too much time on those topics, but concentrate on less familiar subjects.  Keep an updated list as you go along – it’s satisfying to cross things off, and as you do past questions you will identify new areas to study.  This will also help when it comes to deciding what might fit into the last 40 minutes of revision before you call it a day.  Sometimes it’s worth going back to the basics first to make sure that your knowledge is well grounded and you understand all the jargon.

I also kept a list of how much time I spent on revision activities each day, so I could look back with satisfaction and see what I had achieved.

Try and keep your revision activities varied to help the information go in.  Use different resources – textbooks, websites, notes and slides from courses, notes from seniors, past questions, flashcards.

Greenwood’s Medical Microbiology and Kudesia and Wreghitt’s Clinical and Diagnostic Virology are good basic textbooks.  Senanayake’s Clinical Cases in Infectious Diseases helps to put a variety of infections into a relatable clinical and public health context, I suggest one chapter a night as bedtime reading.  I was lent a couple of books of MCQs in Medical Microbiology and Infectious Diseases that were published in the 90s – if you’re using old resources just be aware of how much progress has been made since and that some things may be very out of date!

A few useful websites I used include the Centers for Disease Control and PreventionStandards for Microbiology Investigations, and the Green Book.

As the exam is structured as multiple choice questions, you will be faced with a big list of similar diseases, organisms, tests, etc – and have to choose the one that fits the question stem.  Bear this in mind when revising and keep notes of commonly occurring themes.  Keep some categorised notes (Bacteriology, Virology, Parasitology, Mycology, and Infection Control) of these themes which become useful resources in themselves.  For each item in a list you should include one or several distinguishing features that may appear in a question stem.

For example, distinctive bacterial morphology:

  • Actinomyces israelii – Gram positive branching filaments
  • Pasteurella multocida – small ovoid rod with bipolar staining
  • Corynebacterium – Gram positive rods, in V shapes like Chinese writing
  • Haemophilus ducreyi – oval Gram negative bacilli, like shoals of fish
  • Clostridium tetani – Gram variable bacilli with a rounded end like a drumstick

Other useful themes that emerged for me include clinical features of organisms causing pneumonia, causes and clinical features of rashes, modes of action of antibiotics/antivirals/vaccinations/toxins, side-effects, half-lives, clinical and laboratory features of different Mycobacterial or Clostridium species, ingredients of specialised growth media, and animal vectors.  There’s no use accumulating vast amounts of knowledge about a particular organism or disease if you can’t fit it in a useful box.

There is no shame in relying on your short-term memory for some easy marks – if your brain works like that anyway!  I use flashcards, and write things out to test myself, especially for topics that I am less familiar with as a Microbiologist (e.g. antiretrovirals and their modes of action)

For example, I learned this little schematic for the structures of viruses:

  • ds DNA herpesE, adenoC, papilloma, polyoma, vacciniaL
  • ss RNA
    • – senseE RSV, metapn, influenzaS, parainfluenza, measles, mumps, rabies
    • + sense rhino, rubella, entero, Hep A and C
  • ss DNA parvo
  • ds RNA rotaS
  • Retroviruses HIV, HTLV, Hep B

(E = enveloped, C = circular, L = linear, S = segmented)

Though not comprehensive, it makes questions like this a bit easier:

  • Adenovirus
  • Vaccinia virus
  • Influenza virus
  • Parvovirus
  • Papovavirus
  • Paramyxovirus
  • Reovirus
  1. Negative sense SS RNA virus with 8 segments
  2. Circular double stranded DNA virus
  3. Linear double stranded DNA virus
  4. Double stranded RNA virus

There was nothing in my exam about viral cell cultures, which aren’t really done routinely any more anyway, so don’t spend too much time on that (if any).

There are a few past questions released by RCPath but if you ask your seniors you may be forwarded big vague lists of questions that people have remembered from previous sittings.  Some are more useful than others, and don’t often come with reliable answers.  I suggest working through the questions as a closed book exercise first, before using all your available resources to figure out what you think the answers should be.  Then check with whatever ‘official’ answers you have available – which you may or may not agree with based on your research!

In the exam, take your time.  Work through the questions, reading them carefully, marking the answer sheets with answers that you’re confident about first.  Then go through the remaining questions again, taking a little more time to figure things out.  If you’re not sure, make an intelligent guess – it’s not negatively marked.  Keep an eye on the time.

Good luck!

Jo Lumb (passed first attempt, September 2014 – now trying to figure out what this Part 2 thing is all about!)


This information is for educational purpose only. It is not for clinical use.

Class: Cyclic lipopeptide.
Semisynthetic derivative of daptomycin.
Molecular weight: 1680.7 g/mol.
It is minimally absorbed from the bowel.

Mechanism of action:
Depolarisation of the bacterial cell membrane – bactericidal. It does not form pores in the cell membrane.
Inhibition of macromolecular synthesis (in DNA, RNA, proteins, and cell wall).

Gram-positive organism (similar to daptomycin) including MRSA and VRE. It has shown some activity against daptomycin non-susceptible strains in initial evaluations.
It has activity against both growing and non-growing Clostridium difficile (concentration-dependent killing).

Clinical trial:
A randomized, double-blind, Phase 3 trial by Daley et al found Surotomycin non-inferior to vancomycin for treatment of C difficile associated diarrhoea.
In another randomized, double-blind, active-controlled, multicenter, international trial by Boix et al, surotomycin failed to meet the criteria for noninferiority versus vancomycin for the primary and key secondary endpoints.
Surotomycin demonstrated a statistically non-significant reduction in C difficile associated diarrhoea recurrence rates and improved clinical response in BI/NAP1/027-positive case when compared to vancomycin.

Dose used in clinical trials (Phase II-III) 125mg – 250 mg BD.

Adverse effect:
Study-drug related adverse effects reported in the clinical trials – Headache, abdominal cramp, elevated CK. nausea, vomiting, dizziness, increased ALT etc

Mohammed Zahidul Alam et al, Mode of Action and Bactericidal Properties of Surotomycin against Growing and Nongrowing Clostridium difficile, Aug 2015, 59 (9) 5165-5170

Daley et al, Surotomycin versus vancomycin in adults with Clostridium difficile infection: primary clinical outcomes from the second pivotal, randomized, double-blind, Phase 3 trial, Journal of Antimicrobial Chemotherapy, Volume 72, Issue 12, December 2017, Pages 3462–3470

Boix et al, Primary Outcomes From a Phase 3, Randomized, Double-Blind, Active-Controlled Trial of Surotomycin in Subjects With Clostridium difficile Infection, Open Forum Infectious Diseases, Volume 4, Issue 1, Winter 2017, ofw275

M. Lindsay Grayson. Kucers’ The Use of Antibiotics: A Clinical Review of Antibacterial, Antifungal, Antiparasitic, and Antiviral Drugs. 7th Edition. Boca Raton : CRC Press, 2017

Basic microbiology: gram positive and gram-negative organisms

“The colour, the shape and the configuration”

  1. The colour

Gram staining is one of the basic staining techniques used in microbiology laboratories. It was discovered by Hans Christian Gram in 1884. This technique uses bacterial property of having peptidoglycan in their cell wall.

Hence, bacteria lacking a cell wall cannot be stained using Gram stain and are called gram indeterminate- e.g. Mycoplasma.

Gram staining process
1. Make a smear on a glass slide, heat gently to fix it.
2. Put 0.5% crystal violet (blue/purple dye) – 30 sec.
Tilt the slide to drain, and rinse with water carefully. Get rid of the excess water.
3. Put (1%) Lugol’s iodine (to fix the dye) – 30 sec.
Tilt the slide and wash off the iodine with water
4. Decolourise using 95 – 100% ethanol or acetone until colour ceases to run out of the smear – If the bacteria have a large amount of peptidoglycan in their cell wall, i.e. they have a thick cell wall, they will retain the blue dye, these are gram-positive organisms.
Rinse with water.
5. Put a red/pink stain – 0.1% counterstain safranin for 30s-1min(alternative – neutral red, carbol fuschin ) – bacteria with a thin cell wall with a small amount of peptidoglycan, would have lost the blue stain in the previous stage. These will appear red/pink; these are gram negative.
Wash with water and blot dry.
Use oil immersion objective.

Gram staining video from youtube

So, gram-positive organisms are blue/purple, gram-negatives are red/pink.
However, there are some situations where we may see an inconsistent pattern where the bacteria may show both/either colour. These are called gram variables.
It may happen during the growth phase of bacteria when the peptidoglycan content is changing. Some bacteria, however, are notoriously gram-variable – Actinomyces, Corynebacterium etc.

2. The shape

We classify bacteria based on their shape and
Common shapes are –
round = coccus (pl. cocci)
long rod-like = bacillus (pl. bacilli)
(There is a genus of bacteria called Bacillus – do not confuse these two terms. Genus Bacillus is indeed a bacillus/rod-shaped bacterium but, there are other bacteria with this shape e.g. E coli, Klebsiella, Clostridium etc).
However, some bacteria may appear somewhat in the middle of these two categories – they are called coccobacilli. Some bacilli may show branching e.g Actinomyces.

3. The configuration:

The bacteria cells spatial relation to each other can give us an important clue about the genus of bacteria. However, it is difficult to tell the species of bacteria. The proper identification process must be followed in the laboratory.

Here are some examples

Gram-positive cocci in cluster:

Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus capitis, Staphylococcus lugdunensis, Staphylococcus saprophyticus, Staphylococcus simulans etc.

Gram positive cocci in chains:
Streptococcus pyogenes (Group A Strep), Streptococcus agalactiae (Group B Strep), Streptococcus dysgalactiae (Group C/G Strep), Streptococcus gallolyticus (Group D Strep), Streptococcus anginosus (milleri) group.

Gram positive cocci in pairs:

Pneumococcus (Streptococcus pneumoniae), Streptococcus from mouth flora (These are alpha haemolytic Strep – Strep salivarius, Strep sanguinis, Strep oralis, Strep mitis, Strep mutans etc).

Enterococcus (Enterococcus faecalis, E faecium etc) usually present as short chain or in pairs.

Gram positive rod/bacilli

Bacillus cereus, Bacillus anthracis (causes anthrax), Clostridium difficile, Clostridium tetany (causes tetanus), Clostridium botulinum, Clostridium perfringens, Clostridium novyi (causes gas gangrene), Listeria (meningitis, neonatal infection etc), Corynebacterium sp. (causes diphtheria but also some species live on our skin and normally harmless)

Gram negative cocci:

Coccobacilli: Acinetobacter, Moraxella.
Diplococci: Neisseria meningitidis, Neisseria gonorrhoea.

Gram negative rod/bacilli

Escherichia coli, Klebsiella, Enterobacter, Serratia, Salmonella, Shigella, Yersinia, Proteus, Morganella

Some gram negative bacilli may have typical appearance-

Campylobacter (curved gram negative rod)

Vibrio e.g Vibrio cholerae (comma shaped)

Fusobacterium nucleatum (an anaeorobic bacteria from the mouth) – needle shaped

If you are preparing for FRCPath Microbiology

I get asked frequently what resources do we have to prepare for the examination. Here I have listed some useful information and links that you may want to explore. This list is not a complete list and there are many wonderful resources out there which can help you prepare for the examination. If you find this list useful – please leave a comment. If you know of any other resource that has helped you or you find useful please let me know.

For non-UK trainees/ International graduates (IG), my advise is that please remember this is a UK examination. Hence, you need to know what a UK trainee expected to know and what are the issues we face in the NHS. Your microbiology knowledge is adequate if you have already done post-graduation, but you need to adapt revise those issues more which are common in the UK. For example, you do not need a lot of parasitology, but need to know about infection control.

RCPath curriculum – this is a very important resource and should be your starting point. Go through the curriculum and do a gap analysis. Know what you need to revise.
Access it here.

Past papers:
RCPath does not allow storing of past papers. You can get samples papers from here. You should discuss with trainees who have appeared in the examination recently and seek their counsel.

Preparatory course:
I do not know of any course in the UK which can help you to prepare for the examination. Individual deaneries may organise a local course for their trainees. It is difficult to know if you are not in that deanery. If you are an IG search for local courses.

RCPath examination FAQ:
Please go through this page. It will answer a lot of questions that you may have.

This is a list of books I suggest but, if you have a specific book that you find useful, please read that. Part 1 examination looks for a breadth of knowledge more than depth. Part 2 is, on the other hand, expect a much more comprehensive knowledge as you are expected to have knowledge adequate to practice independently and safely in the UK.
1. Oxford Handbook of Infectious Diseases and Microbiology
This is probably the most important book in my opinion.
2. Medical Microbiology: Greenwood
Medical Microbiology: Patrick Murray
I used another textbook with the Oxford handbook when I was preparing for the exam. You can use either Greenwood or Patric Murray or any other book you like.
3. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases
I used it as a reference book.
4. Clinical and Diagnostic Virology – Kudesia
Virology: Principles and Applications – Carter, Saunders
Virology: You will get a lot from Oxford handbook and Murray/Greenwood. I read Kudesia but there has not been a new publication for some time. John Carter’s book looks good to me. You will learn a lot of virology from other resources. Non-UK trainees – assuming you have already done post-grad in Microbiology you are likely to have enough knowledge. However, the Microbiology/virology in the UK is very clinical. Learn about the common virology related clinical scenarios that microbiologists/virology encounter. You may not need basic virology books after all. Read about recent hdevelopments from journals.
5. Atlas of Clinically Important Fungi
Mycology: A costly book, but useful. Maybe the department or library can help.
6. Lange flashcards
It can help you to prepare. Some people found USMLE books useful.
7. How to Read a Paper: The Basics of Evidence-Based Medicine
Practice writing abstract. Make a list of different statistical terms (e.g Sensitivity, specificity, NNT) and learn how to apply them.
8. Manual of Infection Prevention and Control
Communicable Disease Control and Health Protection Handbook
An infection control book is useful.

Infection control:
It is a very important topic to learn. You should google search for NHS trust infection control policy and read them. Supplement with NICE and EPIC guidelines at least.

Vaccine and Immunisation:
Greenbook MCQ

Laboratory investigation:
National SMI

Sensitivity test:
Read relevant topics from the BSAC.

read UK journals and some good EU/US journals. Here is a list, but there are many more. Go back at least 1 year from your exam day. I recently came across an app called researcher, which helps me to keep myself updated.
Journal Antimicrobial Chemotherapy
The Journal of Hospital Infection
Infection Prevention in Practice
Journal of Infection
The Lancet Infectious Diseases

Read antibiotics that are in the BNF and also new antibiotics. However, only reading the BNF is sufficient. You need to learn antibiotics in-depth.

Some useful websites:
These websites will also help you to learn important microbiology/infection related NHS issues and NHS in general. Read only what is relevant.
1. Public Health England
2. PHE A to Z
3. Health Protection Report (Subscribe)
4. Health and Safety Executive (HSE)
5. Health Technical Memoranda (HTM)
(Water, ventilation, decontamination, waste)
National Health Executive
NHS improvement
The Medic Portal
NHS England
Health Education England
The sepsis trust

It is difficult to list all the guidelines – review the various UK, EU and US guidelines.
PHE common infections
IDSA (However, the practice might be different in the UK, e.g. Teicoplanin is not available in the USA)

Also, search for NHS antibiotic guidelines or access via an app e.g Microguide.