our experiences with the phoenix
DESCRIPTION
OUR EXPERIENCES WITH THE PHOENIX. BSAC 13 TH 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 - PowerPoint PPT PresentationTRANSCRIPT
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OUR EXPERIENCES WITH THE PHOENIX
BSAC 13TH May 2010
J. Hancock CwmTaf Microbiology and Infectious Diseases ( MID ) Service
Lead
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Experiences with the PHOENIX
• Why we have the Phoenix • Implementation • Processing • Issues --- ID ---AST ---Practical experiences ---Company support
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The Royal Glamorgan Hospital
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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
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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
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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
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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
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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
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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
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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
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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
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Phoenix Instrument
• 100(99) panel capacity (200 tests)
• Incubates panels and reads every 20 minutes
• Identification database
• BDXpert system
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Software
• Use of up to date Standards– EUCAST– CLSI – SFM
• Customized adjustment possible
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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
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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 )
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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
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Validated Media
Cannot use media containing esculin
Chromagar Orientation may cause false susceptibility results when testing erythromicin with Gram+
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RGH Organism selection
Organisms picked from -
- non antibiotic containing medium HBA /heated HBA ( CHOC )
- CLED - MacConkey - Urine Chrom agar ( not the MRSA
chrom)
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Workflow Safety with a closed panel design
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Phoenix Issues
• Sensitivity – 2005• EQA • Sensitivity - Present • Identification • Instrument
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Sensitivity 2005
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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
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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
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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
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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
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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
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Sensitivity - Present
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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 !
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Identification
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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.
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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!!!
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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
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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
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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
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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
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Thanks
Kelly Ward - Senior BMS @ RGH Robert Powell - Chief BMS @ RGH Alison King - Chief BMS @ PCH Dr Ali Omrani – Consultant Microbiologist Becton Dickenson
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Any Questions??