OUR EXPERIENCES WITH THE PHOENIX BSAC 13TH May 2010 J. Hancock CwmTaf 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 :– • CL3 ( 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 EpiCenter 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 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 Cannot use media containing esculin Chromagar 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 - MacConkey - 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 eTest 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 K.pneumoniae S.marcesens S.haemolyticus Antibiotic Reported Actual NEQAS Result Amikacin R S Not Scored Amikacin S I Not Scored Ciprofloxacin 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 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 (ano2 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) E18 & E23 – 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) E13 – 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??