Post on 08-Jan-2016
description
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???
‘Free’ from WAG !!!! Welsh Procurement led by the NPHS( PHW ) end of year capital 2005
Aim Aim • Standardise susceptibility testing
across Wales • Comparable data across Wales
• RGH Changed from Vitek 1 to Phoenix in 2005/2006
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 RGHexcept 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-keysSimple to operate
• Barcode-readerFast and easy scanning of
panel number BUT Still type in specimen
number - transcription errors
• SoftwareEasy 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 0.5Changed 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 - In this year we recieved - • 4 x E.coli• 3 x Ps.aeruginosa• 2 x E.faecalis • 1 x E.faecium • 6 x S.aureus - ISSUE
Issue
For 2 of the S.aureus isolates we scored only 1 as the Phoenix reported Erythromycin as I and it should have been R.
We missed the Clindamycin dissociated resistance
Summary EQA Antimicrobial sensitivities 2006-07
Organism Antibiotic Reported Actual NEQAS Result
P.aeruginosa Amikacin R S Not Scored
Amikacin S I Not Scored
Ciprofloxacin
R S Not Scored
Gentamicin I S Not Scored
K.pneumoniae Pip/Tazo R S Not Scored
Meropenem R S 0
S.marcesens Cefotaxime R S Not Scored
Ceftazidime R S Not Scored
S.haemolyticus Teicoplanin R I Not Scored
Tetracycline S R Not Scored
Summary EQA sensitivities 2008-09
Organism Antibiotic/Test
Reported
Actual NEQAS Result
Extra
E.coli ESBL Positive Negative Not Scored Rpt still Positive
E.faecalis Vancomycin
R S Not Scored Etest = RRpt= Sensitive
A.haemolyticus
Ceftazidime
R I Not Scored
Pip/Tazo R S Not Scored 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 = 0Not 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)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 Issues1) 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 the system will alert before expiration to allow replacement’expiration to allow replacement’- No Instrument warning - 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??