our experiences with the phoenix

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??