Our experiences with Phoenix - The British Society for Antimicrobial

Report
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)
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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
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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
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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
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(
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
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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
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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??

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