OUR EXPERIENCES WITH THE PHOENIX BSAC 13 TH

OUR EXPERIENCES WITH THE PHOENIX BSAC 13 TH May 2010 J. Hancock Cwm. Taf Microbiology and Infectious Diseases ( MID ) Service Lead

Experiences with the PHOENIX • Why we have the Phoenix • Implementation • Processing • Issues --- ID ---AST ---Practical experiences ---Company support

The Royal Glamorgan Hospital

WHY did we have Phoenix? ? ? • RGH Changed from Vitek 1 to Phoenix in 2005/2006 ‘Free’ from WAG !!!! Welsh Procurement led by the NPHS( PHW ) end of year capital 2005 Aim • Standardise susceptibility testing across Wales • Comparable data across Wales

HOW? it was achieved across Wales Wide Consultation with clinical and laboratory scientific staff from all laboratories Agreement to : • to use British Society for Antimicrobial Chemotherapy systemic breakpoints • design bespoke Welsh panels • to implement according to a testing algorithm ( except RGH ) • Standardise expert interpretation rules within the system

IMPLEMENTATION at RGH (first lab in Wales) • • • Instrument location/ Bench/BD stand Site survey Well ventilated /air conditioned room Space for Epicentre Power( red socket ) LIS connection • Training -Two fully trained BMS staff Local training --- half day Other staff as required ---BMS, MLA, Medical Staff ---basic training

IMPLEMENTATION cont’d Phoenix Sited in the Main lab Boxes of Panels stored – everywhere !!! 3 work areas : – • CL 3 ( storage of boxes) • Urines/faeces • Main lab

Instrument Overview • Automated system for the identification and susceptibility testing of clinically relevant bacteria • State-of-the-art instrumentation • Direct LIS Connection • Optional Epi. Center data management

Phoenix Instrument • Random Panel Entry • Only 1 moving part : rotor • No pipetting of liquids or transfer of samples • Instrument Self-check • No Calibration Required • Minimal Maintenance

Simple daily and weekly checks • • Daily instrument report Temperature Panel status LED Lights Daily back up CD Calibrate the Nephelometers weekly If any checks fail – phone BD Didn’t stop us having a normaliser failure

Phoenix Instrument • Soft-keys Simple to operate • Barcode-reader Fast and easy scanning of panel number BUT Still type in specimen number - transcription errors • Software Easy adding of information? BUT No training on Epicentre

Phoenix Instrument • 100(99) panel capacity (200 tests) • Incubates panels and reads every 20 minutes • Identification database • BDXpert system

Software • Use of up to date Standards – EUCAST – CLSI – SFM • Customized adjustment possible

Phoenix Panels • • Identification & Susceptibility Leak Resistant 51 ID wells (45 substrates) 85 AST wells (doubling dilutions) Room temp storage– (AST INDICATOR -- 4◦C) One type for: – GN (Enterobacteriaceae/Nonfermenters) – GP(Staphylococci/Enterococci/Streptocci) – Streptocci ID/AST) • ONLY Gram-stain necessary! • Many different AST formats available– agreed Welsh Format

PHOENIX Panel Issues • • • ( Identification only Susceptibility only 10, 000 a year usage year to change panels Agreed Welsh Format Storage -- HUGE BOXES – room temp Ensure the caps are on properly caught in the instrument )

ORGANISM SELECTION Gram negative panel § Enterobacteriacae § Burkholderia cepacia § Pseudomonas spp Problems with : Mucoid organisms Gram positive panel § Staphylococci § Enterococci § Listeria § Corynebacteria Not suitable for fastidious organisms

Validated Media Ø Cannot use media containing esculin ØChromagar Orientation may cause false susceptibility results when testing erythromicin with Gram+

RGH Organism selection Organisms picked from - non antibiotic containing medium HBA /heated HBA ( CHOC ) - CLED - Mac. Conkey - Urine Chrom agar ( not the MRSA chrom)

Workflow Safety with a closed panel design

Phoenix Issues • • • Sensitivity – 2005 EQA Sensitivity - Present Identification Instrument

Sensitivity 2005

Initial testing issues 2005 phoenix v Etest • Trimethoprim - Staphylococci BP was 0. 5 Changed to 2 in 2007 • Choramphenicol - Staphyloccocci BP issue ( 8 -16) Not on panel any more • Meropenem - P. mirabilis all Sensitive • Gentamicin – P mirabilis I e. Test always Sensitive • Ertapenem – lots of I/R ? ? Why ? Inoculum dependent * carbapenem resistance marker • Rifampicin – Phoenix gave - X Change of BP and issue resolved • Mupirocin - Staphylococci flagged as high level resistance with an MIC < 1 • ESBLs (1505) need to check the Cephalosporins and confirm with E test any new isolate

Summary EQA sensitivities 2005 -06 In this year we recieved Issue • 4 x E. coli • 3 x Ps. aeruginosa For 2 of the S. aureus isolates we scored only 1 as the Phoenix • 2 x E. faecalis reported Erythromycin as I and • 1 x E. faecium it should have been R. • 6 x S. aureus - ISSUE We missed the Clindamycin dissociated resistance

Summary EQA Antimicrobial sensitivities 2006 -07 Organism P. aeruginosa Antibiotic Reported Actual NEQAS Result Not Scored S I Not Scored R S Not Scored Gentamicin I S Not Scored Pip/Tazo R S Not Scored Meropenem R S 0 Cefotaxime R S Not Scored Ceftazidime S. haemolyticus S Ciprofloxacin S. marcesens R Amikacin K. pneumoniae Amikacin R S Not Scored Teicoplanin R I Not Scored Tetracycline S R Not Scored

Summary EQA sensitivities 2008 -09 Organism Antibiotic/ Test Reported Actual NEQAS Result Positive Negative Not Scored Rpt still Positive Etest = R Rpt= Sensitive E. coli ESBL E. faecalis Vancomycin R S Not Scored A. haemolyticus Ceftazidime R I Not Scored Pip/Tazo R S Not Scored Extra Etest on BP

Summary EQA Antimicrobial sensitivities 2009 -10 Two sensitivity failures : - 1. Phx ID = Enterobacter cloacae – Expert rules changed sensitivities Actual ID = Klebsiella oxytoca Confidence limits 93% ( 99%) Human and Phoenix Error!! 2. S. aureus Penicillin R >0. 25 BUT rpt organism was SENS ? ? No idea ? Duff panel !!! Score = 0 Not clinically relevant!! But NEQAS relevant

Sensitivity - Present

Current Sensitivity Issues • Staphylococcus aureus – - Phx result = Mupirocin High level Resistant when Low Level = Sensitive - Phx changes Low level to Resistant - Etest always confirms they are sensitive - COST! - Clinical Relevance – Affects treatment of colonised patients if it is not picked up !! • Psuedomonas aeruginosa – -Phx reports Ciprofloxacin as Resistant -Etest confimation = Sensitive - Clinical Relevance – Reported in some Respiratory Samples and is often the only oral drug available for treatment • Escherichia. coli & Klebsiella spp – -Phx reports Ertapenem as Resistant - All Etest results = Sensitive, ? NO CONFIRMED TRUE CARBAPENAMASE RESISTANCE !

Identification

Summary of General EQA ID Year Mean Points lost for Phx id 2008 -09 1. 95 4 2007 -08 1. 97 0 2006 -07 1. 92 0 2005 -06 1. 75 (ano 2 orgs) 0 2008 -09 – Phx could not correctly identify Aeromonas hydrophilia or Vibrio parahaemoliyticus to species level and points were lost.

General Bacteriology EQA 2009 -10 One failure B/C isolate Phx Id of culture -S. hominis ( confidence limits 99%) Actual (NEQAS) – S. epidermidis and rpt S. epidermidis “Double Whammy” Not noted it was a B/C isolate and Reported as No Significant Growth BUT STILL ID WAS WRONG, WOULD HAVE SCORED ZERO!!!

Current Identification Issues 1) Suspected S. aureus • Phx Id’s them as a variety of Coag Neg Staphylococci • Repeat Phx, Staphaurex and DNAse plate = COST • Repeat always confirms S. aureus • Problem since new EUCAST panels were introduced • Clinical Relevance – Delay in reporting 2) Coag Neg Staphylococcus • Rarely get the same organism to ID the same twice • Variety of confidence limits • Clinical Relevance – ICU patients with ? Line associated Infections 3) E. Coli & Shigella • Phx has difficulty distinguishing between them • Repeat Phx and antiserum – Cost and Time 4) Speciation of rarely isolated organisms e. g. Yersinia, Vibrio etc

Instrument Issues Error Codes 1) E 18 & E 23 – Normaliser Alert - Normaliser panal ‘died’ leading to loss of panels - Some tiers e. g. A & C stopped working overnight - All work in these tiers aborted – LOSS OF 50 PANELS!!! - Manual states – ‘the system will alert before expiration to allow replacement’ - No Instrument warning - Unable to supply engineer ( WEEK END ) - Daily checks report showed all normalisers were working! 2) E 13 – Power Supply Failure Back up box failed and had to be replaced

Instrument issues cont’d • Epicenter front screen too “busy” • Still waiting for epicentre training !! Resulted in – - Collation of information difficult - Difficult to resolve transcription error of specimen number entry

Staff Views • • • Easy to use Fits in to the routine working practises Address staff skill mix Excellent ID to genus level not speciation Excellent AST for routine organisms Early ID of e. g Listeria spp / Salmonella spp • Mechanically robust

Thanks Kelly Ward - Senior BMS @ RGH Robert Powell - Chief BMS @ RGH Alison King - Chief BMS @ PCH Dr Ali Omrani – Consultant Microbiologist Becton Dickenson

Any Questions? ?