MICROSCAN® SOLUTION & ANTIBIOTIC RESISTANCES

© 2016 Beckman Coulter. All rights reserved. 1

MICROSCAN® SOLUTION &

ANTIBIOTIC RESISTANCES

Mamta Choudhary

Product Manager Microbiology & Urinalysis


MICROSCAN® SOLUTION & ANTIBIOTIC RESISTANCES

› What is the MicroScan Solution for ID/AST testing?

› What antibiotic resistance is clinically important today?

• CDC Antibiotic Resistance Threats

› β-lactamase classes containing carbapenemases and their growing importance in antimicrobial susceptibility testing

• How to detect carbapenemases and accuracy of MicroScan panels

• Recommendations for confirmation

› Methicillin-resistant Staphylococcus aureus (MRSA): Know some facts about MRS and newer mecC-mediated resistance

• Accuracy of MicroScan panels


EMERGING RESISTANCE IS EVERYONE’S PROBLEM

www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf

“Antimicrobial resistance is one of our most serious health threats. Infections from resistant

bacteria are now too common, and some

pathogens have even become resistant to

multiple types or classes of antibiotics…The

loss of effective antibiotics will undermine our

ability to fight infectious diseases and manage the

infectious complications common in vulnerable

patients…”

Dr. Tom Frieden, MD, MPH

Director, U.S. Centers for Disease Control and Prevention

Meeting the Challenges of Drug-Resistant Diseases in Developing

Countries

Committee on Foreign Affairs Subcommittee on Africa, Global Health,

Human Rights, and International Organizations

United States House of Representatives

April 23, 2013

https://www.youtube.com/watch?v=ALryAB_A

YiA&sns=em

https://www.youtube.com/watch?v=ALryAB_AYiA&sns=em

https://www.youtube.com/watch?v=ALryAB_AYiA&sns=em


MICROSCAN IN THE WORLD

Beckman Coulter is a main Worldwide leader in Microbiology

MicroScan is more than 40%* of Market Share for Automated ID (Identifications) and Automated AST (Antibiotics Susceptibility Testing)

Around 6000 MicroScan instruments* for Automated ID & AST


Instruments & Connectivity ID/AST Panels

Direct MIC testing

Accuracy

Streamlined workflow

Instruments for all volume segments

Reliability

Combining the strength of Maldi ID with

MicroScan AST

Informatics

LabPro - User-

friendly data

management

Easily organize and

manage microbiology

test data

Stay ahead of

emerging resistance

Enhance workflow efficiency,

decrease time to result, and

improve patient care decision making

MICROSCAN SOLUTIONS


MICROSCAN TECHNOLOGY : WHAT MAKES US DIFFERENT?

Technical

Philosophy

Direct read

of growth

Emerging

Resistance

Real MICs

(ISO 20776)

Method &

set-up

choice

AST

Independent

of ID


Combo, MIC- and ID-only Formats

Streamlined Inoculum Prep and Set-up

Fewest Clinically Significant Limitations

Comprehensive Formulary Support

Extensive Organism Database

MICROSCAN PANELS : WHAT MAKES US DIFFERENT?


Conventional Overnight (ID & AST)

Traditional biochemical ID

Growth–based broth

microdilution MIC

Exceptional accuracy

Detection of emerging

resistance

Visual Read or Instrument

Processing

Specialty (ID & AST)

Yeast ID, Anaerobe ID,

HNID (4 hour

Chromogenic)

MICroSTREP plus

(Overnight)

ESBL plus - ESBL

Confirmatory Panel

(Overnight)

Visual Read or Instrument

Processing

Rapid Identification

2 - 2.5 hour Fluorogenic ID

for gram-negative or gram-

positive bacteria

Minimal or no reagents,

depending on product

Good option for

biochemically inert species

WalkAway Processing only

FLEXIBILITY IN MENU FOR ID/AST TESTING


(ID) Identification section = Biochemicals

(AST) Susceptibility section = Drugs

Combo Panel

FLEXIBILITY IN MENU

ID PANELS, AST PANELS AND COMBO PANELS


PROMPT INOCULATION PREPARATION

Prompt™: One step to standardize inoculum preparation for ID and AST Tests

Eliminate 0.5 McF preparation with Turbidity

Inoculum stable for 4 hours (compared to 30 min. with other technologies)

Requires fewer number of isolated colonies

Less likely to pick mixed culture

*Prompt™ is a registered product made by 3M, St. Paul, MN USA

Select colonies Prepare inoculum


Use of Prompt for

“Picking “MICROSCAN and MALDI*

Agar with the

colony

Use prompt on MALDI

inoculation

MALDI TARGET

MICROSCAN PANELS

MALDI-TOF (ID)

MICROSCAN WalkAway Automated microbiological diagnosis using the MALDI-TOF and the Microscan WalkAway System.

C. Lensing1, T. Fenner1, E. Stoetter2, C. Ott2, I. Fenner1. Labor Dr. Fenner und Kollegen, Hamburg, DGHM 2009.

PROMPT: PROMPT™: OPTIMIZED AND SECURED

WORKFLOW WITH MASS SPECTRO


autoSCAN-4

WalkAway 40 plus

Medium Volume (15-30 panels/day)

WalkAway 96 plus

Multiple instrument

systems

High Volume (30 or more panels/day)

autoSCAN-4

Low Volume (0-15 panels/day)

FLEXIBILITY IN AUTOMATION FOR ALL ID/AST VOLUMES


ID & AST SCALABLE SOLUTIONS

15 panels/d

Same technology, same platform

+ Same panels

+ Same software

= Same results

30 panels/d

80 panels/d

160 panels/d

240 panels/d

AutoSCAN-4

WalkAway 40

WalkAway 96


Instruments

IT

AlertEX

Connect

Middleware

Workflow

Efficiency

Consolidate

multiple systems

into one

database.

Provide

traceability

/support

Simplify

dataflow

Minimize LIS

connections

DATA MANAGEMENT AND CONNECTIVITY ARE KEY

Simplify

interaction; focus

on the most

important;

scalability

TAT

Customized-

reporting


Designed by Microbiologists

Easy to Use, Understand, and Learn

Completely Customizable

Built-in Epidemiology Management

Integrated Quality Control

LABPRO INFORMATION MANAGEMENT


INTEGRATED LABPRO EPIDEMIOLOGY

Percent Interpretative Report

Include %S, %I &/or %R and trend

patterns over time

Add additional segmentation, if desired

Exclude repeats; align with CLSI M39

recommendations

Include off-line tests and antibiotics

suppressed from normal reporting

Export data to create antibiograms for

clinical use

Bacterial Incidence Report

Segment data to support Infection

Control initiatives and Outreach value-

added services

Pinpoint areas of a facility that may be

having issues

Monitor outbreaks and resulting

treatments

Query Summary Report

Provide data in a log-type format

Print from Epidemiology or Patient tabs

for slightly different view of the data

Specific patient and specimen

information augment other

epidemiology reports used by Infection

Control

Use either a standard or customized

report format

Cumulative % Inhibited by Drug (MIC

90) Report

Pharmacists can track subtle changes

in antimicrobial resistance patterns

As the MIC 90% increases, generally so

does resistance

Generate with customized

segmentation


Combo, MIC- and ID-only Panels

− Choose best fit testing for your needs

Streamlined inoculum preparation and

set-up

− Supports Lean workflow principles

Direct read of growth

− Results based on actual growth

AST results independent of ID

− Critical antibiotic results can be reported even

without a final identification

Accuracy more important than speed

− Better resistance detection

Visual read compatible

− Confidence in unusual results; built-in back-up

Fewest clinically-significant reporting

limitations

− Maximize primary testing

MicroScan Overnight Panels

MICROSCAN PANELS: WHAT MAKES US DIFFERENT?


ANTIBIOTIC RESISTANCE THREATS ACCORDING CDC*

Serious Threats

› Multidrug-resistant Acinetobacter

› Drug-resistant Campylobacter

› Fluconazole-resistant Candida

› Extended spectrum β-lactamase producing Enterobacteriaceae (ESBLs)

› Vancomycin-resistant Enterococcus (VRE)

› Multidrug-resistant P. aeruginosa

› Drug-resistant Non-typhoidal Salmonella

› Drug-resistant Salmonella Typhi

› Drug-resistant Shigella

› Methicillin-resistant Staphylococcus aureus (MRSA)

› Drug-resistant S. pneumoniae

› Drug-resistant tuberculosis

Concerning Threats

› Vancomycin-resistant Staphylococcus

aureus (VRSA)

› Erythromycin-resistant Group A

Streptococcus

› Clindamycin-resistant Group B

Streptococcus

•

*http://www.cdc.gov/drugresistance/biggest_threats.html

Urgent Threats

› Clostridium difficile Prevalence

› Carbapenem-resistant

Enterobacteriaceae (CRE)

› Drug-resistant Neisseria

gonorrhoeae


COMMONLY-USED β-LACTAM ANTIBIOTICS

› Make up over half the drugs on a typical MicroScan Gram Negative panel

Penicillins

Penicillinase-

stable

Penicillins

β-Lactam/ β-

Lactamase

Inhibitor

Combinations

Cephalosporin Cephamycins Monobactams Penems

Penicillin Methicillin Amoxicillin-

clavulanic acid

Cefaclor,

cephalexin (1) Cefotetan Aztreonam Imipenem

Amoxicillin Nafcillin Ticarcillin-

clavulanic acid

Cephalothin,

cefazolin (1) Cefoxitin Meropenem

Ampicillin Dicloxacillin Piperacillin-

tazobactam Cefuroxime (2) Ertapenem

Mezlocillin Oxacillin Ampicillin-

sulbactam Cefotaxime (3) Doripenem

Piperacillin Ceftazidime (3)

Ticarcillin Ceftriaxone (3)

Cefepime (4)

› CREs may hydrolyze all of these too


CRE: CARBAPENEM-RESISTANT Enterobacteriaceae

› Two mechanisms of resistance:

• Production of carbapenemase enzyme

− Enterobacteriaceae have acquired genes for many diverse enzymes

for carbapenemase resistance. Many are plasmid-mediated, so these

are easily transferable between strains, species, genera, patients

and facilities.

• Cephalosporinase combined with porin loss

− Some cephalosporinases (e.g., ampC β-lactamases or ESBLs) have

low-level carbapenemase activity. Coupled with porin loss, this limits

entry of carbapenem into the cell. These are NOT as easily

transferable between strains.

› The first goal is to detect resistance, and then (as needed) to

distinguish these two mechanisms


ACQUIRED CARBAPENEMASES IN Enterobacteriaceae

Molecular

Class Example Types Activity

A

KPCs

Also others, but not

common

Largest number, usually on plasmid,

most inactivated by clavulanic acid

B

NDM, VIM, IMP

Enterobacteriaceae

P. aeruginosa,

Acinetobacter

Metallo β-lactamases (MBL): Resistant

to many drugs, including carbapenems

› Enzyme does not hydrolyze aztreonam

› May require zinc for expression

C (None here)

D OXA enzymes

K. pneumoniae (OXA-48)

OXA-23, -40, -51, -58 in Acinetobacter

Others in Pseudomonas and other NFB


EMERGENCE OF CLASS B NDM

METALLO β-LACTAMASE IN Enterobacteriaceae


EMERGENCE OF CLASS B NDM

METALLO β-LACTAMASE IN Enterobacteriaceae

Lancet Infect Dis. 2010;10:597-602.


CRE DETECTION GOALS

› Detect all carbapenem-resistant organisms.

› Some automated systems do not do as well as others in detection of carbapenem resistance

› Distinguish them from isolates that are resistant to carbapenems because of other mechanisms

› “In the face of • diversity of enzyme types,

• considerable variation in levels of phenotypic carbapenem resistance (e.g., in MIC evaluations) and

• added complexity of non-carbapenemase-mediated carbapenem resistance

› there is no universally applicable method able to realize these aims”

Health Protection Agency. UK Standards for Microbiology Investigations. Laboratory Detection and Reporting of Bacteria with Carbapenem-Hydrolysing β-lactamases (Carbapenemases) UK Protocols | P 8 | Issue no: 1| Issue date: 26.03.13


CDC “VITAL SIGNS” 2013 HEALTH ADVISORY

Carbapenem-resistant Enterobacteriaceae warrant additional action by healthcare providers

› Carbapenems are considered first line therapy for infection with

multidrug-resistant Enterobacteriaceae • Carbapenem agents: doripenem, ertapenem, imipenem, meropenem

› Carbapenem-resistant Enterobacteriaceae (CRE) are bacteria that have developed high-level resistance to the carbapenem class of antibiotics

› MicroScan panels reliably detect carbapenem MIC results

› AlertEX software flags isolates that may need further scrutiny • Five system-defined Alerts

• Institution-specific Alerts can be customized


MEROPENEM AND DETECTION OF KPC

› Tested 46 confirmed KPC

producers by a variety of

methods including

MicroScan conventional

panels

› Results from MicroScan

most closely matched

those of Broth

Microdilution and

yielded zero very major

and major errors

Comparison of Meropenem MICs and Susceptibility for

Carbapenemase producing Klebsiella pneumoniae by Various Testing

Methods

JCM 2010. Bulik CC, KA Fauntleroy, SG Jenkins, M Abuali, VJ LaBombardi, DP Nicolau, and JL Kuti


KPC ENZYMES: AST SYSTEM PERFORMANCE USING MIC ≥2 AND ALL CARBAPENEMS

Method

% Sensitivity/Specificity using Carbapenem MIC of 2 µg/ml

Meropenem Imipenem Ertapenem

Reference BMD 100/93 100/93 100/89

Etest 84/91 90/89 100/84

Disk diffusion NA NA NA

Vitek Legacy NA NA NA

Vitek 2 71/93 94/89 94/89

MicroScan 100/93 100/93 NA

Phoenix 74/96 87/93 NA

Sensititre 81/96 NA NA

Anderson et al. 2007. J Clin Microbiol. 45:2723 N = 31 KPC producers; 45 non-KPC producers

NA = not available on tested panel or dilution range not low enough


NEW MEROPENEM PERFORMANCE STUDY

› “Evaluation of MicroScan Dried Overnight Panels to Accurately

Detect Meropenem Resistance with Challenge Gram-Negative

Isolates”

• 116 challenge Gram negative bacteria; 60 Enterobacteriaceae, 17

Pseudomonas aeruginosa, 37 Acinetobacter spp. and 2 additional

Gram negative non-fermenters

– Included the 31 BIT CDC Challenge Isolates

• Tested on reference frozen MIC panels, Gram Negative MIC 38, ESBL

plus and Kirby Bauer

• Analyzed for essential and categorical agreement using either

EUCAST or CLSI breakpoints

› There were no VME using either EUCAST or CLSI M100-S24+

breakpoints

Chipman AM, et al. 2015. ASM Poster C530.


DETECTION OF ESBL ENZYMES (CTX-M, OTHERS)

› Molecularly-characterized ESBL E. coli, Klebsiella spp. and Proteus

mirabilis isolates recovered from patients in the University Health

System, San Antonio, Texas

Overall detection of ESBL-producing isolates (n=100) by the four test

methods

J.H. Jorgensen et al., J. Clin. Microbiol. 48: 120-123

.

ESBL

confirmed

Equivocal

results1

ESBL not

detected

ESBL plus 98% 1% 1%

Neg MIC 32 95% 5% 0


Staphylococcus aureus

Image: Zimmer 2011

Moreillan, P. et al. 2005. “Staphylococcus aureus (Including Staphylococcal Toxic Shock

Syndrome)”In Mandell, G.E. et al. (eds). Principles and Practices of Infectious Disease. 6th ed.

Elsevier, Inc. Permission to reproduce requested.


STAPHYLOCOCCI, OXACILLIN AND CEFOXITIN

› Two general and historical types of resistance to β-lactam drugs with

staph:

• β-lactamase: resistance to penicillin and β-lactamase labile penicillins

• Altered cell-wall PBP2a, encoded by mecA gene: confers resistance to ALL β-lactam drugs (penicillins, cephalosporins, carbapenems). This is a MRSA.

› Oxacillin historical usage as a representative antimicrobial agent for

β-lactam resistance for staphylococci, encoded by the mecA gene

› Cefoxitin is better able to detect mecA-mediated resistance in S. aureus

• Detection of MRSA is becoming more variable – some are positive by

molecular methods and negative phenotypically, and the reverse

• S. pseudintermedius is being isolated (Ox R, Cfx S)

• mecC has been described (Ox S, Cfx R)


NOVEL mecC ISOLATE

All information and

slide material courtesy

of Dr. Robert Skov,

Statens Serums

Institut, presented at

CLSI January 2012

No. of new human cases per year

Lancet Infect Dis 2011; 11:595-603


STUDY: DETECTION OF NOVEL mecC ISOLATE

› Isolates: 111 S. aureus with mecC

› Genotypic: commercial methods all negative (GeneOhm™ StaphSR (BD), GeneXpert™ MRSA (Cepheid), NucliSENS EasyQ MRSA

(bioMérieux)

› Phenotypic

• Etest, disk diffusion (oxacillin and cefoxitin): variable

• Chromogenic agars MRSA: variable by manufacturer

• PBP2a agglutination: all negative

• Automated systems (cefoxitin >4 µg/mL):

– MicroScan (Beckman Coulter); 106 of 110

– Vitek (bioMerieux); 108 of 111

– Phoenix (BD); 83 of 111

• Automated systems (oxacillin ≥4 mg/L): variable, 0–21/111

All information and

slide material courtesy

of Dr. Robert Skov,

Statens Serums

Institute, presented at

CLSI January 2012


MRSA DETECTION - MICROSCAN

Performance of a New MicroScan WalkAway PC30 Panel and Disk

Diffusion Method for Detection of Oxacillin Resistance in

Staphylococcus spp.

− 370 Clinical Isolates tested

− Oxacillin-resistance detected by PCR in 22.7% of S. aureus isolates

Gallon, O, P Pina, A Gravet, F Laurent, B Lamy, JM Delarbre, F Doucet-Populaire, and JW Decousser. 2011. Performance of a New MicroScan WalkAway

PC30 Panel and Disk Diffusion Method for Detection of Oxacillin Resistance in Staphylococcus spp. J Clin. Microbiol. Vol.49, No.6: 2269-2271.

Results using Oxacillin MIC + Cefoxitin Screen

Sensitivity Specificity PPV NPV

N=370 98.8% 100% 100% 99.6%


THANK YOU!

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MICROSCAN® SOLUTION & ANTIBIOTIC RESISTANCES

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