WHY did we have Phoenix??? ‘ Free’ from WAG !!!! Welsh Procurement led by the NPHS( PHW ) end of year capital 2005Aim 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 RGH ( except 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-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 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 )
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
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
Summary EQA sensitivities 2008-09 OrganismAntibiotic/ Test ReportedActualNEQAS Result Extra E.coliESBLPositiveNegativeNot ScoredRpt still Positive E.faecalisVancomycinRSNot ScoredEtest = R Rpt= Sensitive A.haemolyticusCeftazidimeRINot Scored Pip/TazoRSNot ScoredEtest 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 = 0 Not clinically relevant!! But NEQAS relevant
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 !
Summary of General EQA ID YearMeanPoints lost for Phx id 2008-091.954 2007-081.970 2006-071.920 2005-06 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 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
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!!! the system will alert before expiration to allow replacement’ - 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
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