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
Set the scene – back in 2005 , the laboratory at RGH ‘s standard susceptibility testing was the VITEK one and E tests for fastidious organisms using as was NCCLS break points .The laboratory was fully funded for the consumable cost for automated sensitivities and had realigned its skill mix to support the cost However
this methodology was out of kilter with most labs across Wales who were using disc testing and BSAC 2004 methodology

4. Welsh Procurement led by the NPHS( PHW ) end of year capital 2005
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
Early in 2005 we were approached by the NPHS to see if we would be prepared to take part in an all Wales tender for a new/er automated instument .
When discussed with staff , everyone agreed that they would rather have an updated version of the VITEK but they were prepared to work with any validated automated system . The outcome of the initial tendering process yielded two companies . Both were invited to present their and the procurement team followed the process and finally the contact was awarded to BD and the phoenix rose from the ashes so to speak !!! .

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
There were a number of meetings where we agreed across Wales ( exception of one lab )

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
We had to do the same as always we decided we would have it sited on a bench . Had to decide if the bench would be stong enough so our substantilaly built estates manager sat on the bench and siad – YES no probs ( he did do it proberly as well later on )

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
We decided NOT to centralise susceptibity testing but we agreed to have three main areas for put up – 3 nephelometers - £900 2 gave us 2 buy 3rd
Storage of boxes was an issue . The CL3 lab was the biggest area for storage but we couln’t put them in there – John Daniels – fumigation
It would be an issue if we ever had to fumigate the lab .

8. 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
A maximum of 100 identification and antimicrobial susceptibility tests can be performed in the Phoenix instrument at a time using Phoenix combination panels the id panels are modifications of the classical methods – fermentation , oxidation , degredatiuon and hydrolysis of various substnces . Also uses chromogenic and fluorogenic substnces .
Both microdilution – exposing the nbacteria to decreasing concentrtimns of antimicrobial agents in liquiid media by 2 fold diltion the lowest conc of the antibiotic that in which no visible growth occurs is the mic – the poenix is a miniaturised version of the micro-broth double diluting technique . – it is the determination of bacterial growth in the presence of various concentrations on the antimicrobial agent tested with the aid of the AST indicator in continuously incubated and read micro-wells in the panels .
LIS and Epi interfaces are bi-directional and unsolicited, if the user configures the interface that way.

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
“Pared down” free standing design for customers who do not want added data management.
Maintenance required:
changed 3 filters approx... 6 months
test LED’s weekly
temp check daily or as required by local regulating agency

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
Simple daily checks – print a sheet off the computer which gives confirmation that the instument is ok – nornlise passed
Daily – record the temp on the main screen and the panel temp printer suppy .
Daily check the LED lights and the alert indicator and the audible alarm

11. Phoenix Instrument 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
PANEL nos – code for the GP pos /neg
Insufficient space on panel design for bar code labels – All Panels need to labelled BEFORE working on them -

12. Phoenix Instrument 100(99) panel capacity (200 tests)
Incubates panels and reads every 20 minutes
Identification database
BDXpert system
4 tiers are stacked vertically. Each tier hold 26 panels. (One panel in each tier is a normalizer panel.) 99 ACTUAL – TEMPERATURE PANEL
Readings are on the hour, 20 minutes after the hour and 40 minutes after the hour.
BDXpert system consists of standards breakpoints (NCCLS, SFM or DIN) AND the expert rules to determine resistance markers, intrinsic resistance, etc.

13. Software Use of up to date Standards Customized adjustment possible
EUCAST
CLSI
SFM
Customized adjustment possible
Upgrades are fairlyt simple and usually by the lab staff via a CD and a verbal talk through

14. 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
A sealed and self-inoculating molded polystyrene tray, with 136 micro-wells containing dried reagents, serves as the Phoenix disposable.
The combination panel includes an ID side with dried substrates for bacterial identification and an AST side with varying concentrations of antimicrobial agents, growth and fluorescent controls at appropriate well locations.
The Phoenix system utilizes an optimized colorimetric redox indicator for AST, and a variety of colorimetric and fluorometric indicators for ID.
The Phoenix Panel is comprised of a 51 well ID side and an 85 well AST side.
The ID side contains 45 wells with dried biochemical substrates and 2 fluorescent control wells.
The AST side potentially contains up to 84 wells with dried antimicrobial agents and 1 growth control well.
Panels are available as ID only, AST only, or ID/AST combination. Unused wells are reserved for future use.
Panel has one format; ID only will have only the ID side filled, AST only will have only AST side filled.
The only refrigerated component is the AST Indicator.

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 )
CAPS HAVE CHANGED – Removel of outer edge which was the bit that got caught
Although they state that they have id and ast panels it has since transpired that if you have bespoke panels , you have to guarentee 10,000 usuage per year and if ypu want to change the format of your panel it can take a year before the new panels are available .
From our lab perspective as we have agreed to use the welsh format it prohibits us using the ast panels that are used by Europe – hopefully this will be adddressd soon .
Storage of the panels is an issue because of the size but it would be even worse if they had to be fridrged .
In the early days , we had some issues with staff not pushing the caps down firmly enough and the edges of the caps caught in the instument .
The company appear to have solved this issue by changing the style of the cops and the edges do not over lap now .

16. Not suitable for fastidious organisms
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
Can have id but no AST

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
The test organism is inoculated in to the broth – 0.5/0.6 McFarland as measured by the nephelometer . Select appropriate panel
Open foil and place in inoculating rack
Place ID and AST broths in rack
Add one drop of indicator to AST broth
Prepare organism suspension in ID broth
Take 25µl of ID broth into AST broth
Pour broths into wells of panel
Fit closures to panel
Transfer to vertical holding racks
Load on PHOENIX

20. Phoenix Issues Sensitivity – 2005 EQA Sensitivity - Present
Identification
Instrument
Initially when we statred using the instrument Dr White had a feeling there were some issues so the lab performed a number of e tests to investigate .

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
Most of the initial work was requested by Dr White as she wished to ensure that the reults that the phx was generated were accurate .
This work resulted in the lab perfoming a lot of E tests to confirm or not as the case might be if the phx resluts were accuratae
THE RESISTANCE TO TRIM ON STAPHS ESPECIALLY MRSA was very high . Due to the inappropriate BP set at 0.5 changed to 1 and then 2 this was reviewed in O7
Prot mirabilis Mero all sensitive even though the organism has low level resistance to IMP .
Often have a flag for
ACINS AND PSEUDO RESISTANT

23. Summary EQA sensitivities 2005-06
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

24. Summary EQA Antimicrobial sensitivities 2006-07
Organism
Antibiotic
Reported
Actual
NEQAS Result
P.aeruginosa
Amikacin R S
Not Scored I
Ciprofloxacin
Gentamicin
K.pneumoniae
Pip/Tazo
Meropenem
S.marcesens
Cefotaxime
Ceftazidime
S.haemolyticus
Teicoplanin
Tetracycline

25. Summary EQA sensitivities 2008-09
Organism
Antibiotic/
Test
Reported
Actual
NEQAS
Result
Extra
E.coli
ESBL
Positive
Negative
Not Scored
Rpt still
E.faecalis
Vancomycin R S
Etest = R
Rpt= Sensitive
A.haemolyticus
Ceftazidime I
Pip/Tazo
Etest on BP

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 !
We still have currrent issues that are the same as the itial issues that we found !!!

29. Identification

30. Summary of General EQA ID
Year
Mean
Points lost for Phx id
1.95 4
1.97
1.92
1.75 (ano2 orgs)
– 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
We had a few months where we had this E18 – normaliser alert

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 PCH
Dr Ali Omrani – Consultant Microbiologist
Becton Dickenson

37. Any Questions??