OUR EXPERIENCES WITH THE PHOENIX

1. OUR EXPERIENCES WITH THE PHOENIX BSAC 13TH May 2010 J. Hancock CwmTaf Microbiology and Infectious Diseases ( MID ) Service Lead

2. Experiences with the PHOENIX • Why we have the Phoenix • Implementation • Processing • Issues --- ID ---AST ---Practical experiences ---Company support

3. The Royal Glamorgan Hospital

4. 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

5. 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

6. 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

7. 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

8. Automated system for the identification and susceptibility testing of clinically relevant bacteria State-of-the-art instrumentation Direct LIS Connection Optional EpiCenter data management Instrument Overview

9. 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

10. 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

11. 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

12. Phoenix Instrument • 100(99) panel capacity (200 tests) • Incubates panels and reads every 20 minutes • Identification database • BDXpert system

13. Use of up to date Standards EUCAST CLSI SFM Customized adjustment possible Software

14. 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 Panels

15. 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 )

16. Gram negative panel Enterobacteriacae Burkholderia cepacia Pseudomonas spp Problems with :- Mucoid organisms Gram positive panel Staphylococci Enterococci Listeria Corynebacteria Not suitable for fastidious organisms ORGANISM SELECTION

17. Validated Media • Cannot use media containing esculin • Chromagar Orientation may cause false susceptibility results when testing erythromicin with Gram+

18. RGH Organism selection Organisms picked from - - non antibiotic containing medium HBA /heated HBA ( CHOC ) • CLED • MacConkey • Urine Chrom agar ( not the MRSA chrom)

19. Workflow Safety with a closed panel design

20. Phoenix Issues • Sensitivity – 2005 • EQA • Sensitivity - Present • Identification • Instrument

21. Sensitivity 2005

22. 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

23. 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 sensitivities 2005-06

24. Summary EQA Antimicrobial sensitivities 2006-07

25. Summary EQA sensitivities 2008-09

26. Summary EQA Antimicrobial sensitivities 2009-10 Two sensitivity failures :- • 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

27. Sensitivity - Present

28. 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 !

29. Identification

30. Summary of General EQA ID 2008-09 – Phx could not correctly identify Aeromonas hydrophilia or Vibrio parahaemoliyticus to species level and points were lost.

31. 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!!!

32. 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

33. 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

34. 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

35. 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

36. Thanks Kelly Ward - Senior BMS @ RGH Robert Powell - Chief BMS @ RGH Alison King - Chief BMS @ PCH Dr Ali Omrani – Consultant Microbiologist Becton Dickenson

37. Any Questions??