Automated systems:

an overview
Robin A Howe
Cardiff
Insert name of presentation on Master
Slide
AST standards

• MIC taken as standard measure of

susceptibility
– Agar dilution
– Broth dilution
– Microbroth dilution
• ISO standard
– Broth microdiluion
– Mueller-Hinton Broth
– Inoculum 5x105
cfu/mL
AST standards
• MIC taken as standard measure of
susceptibility
– Agar dilution
– Broth dilution
– Microbroth dilution
• S/I/R Breakpoints defined by
BSAC/EUCAST/CLSI
AST standards
• MIC taken as standard measure of
susceptibility
– Agar dilution
– Broth dilution
– Microbroth dilution
• S/I/R Breakpoints defined by
BSAC/EUCAST/CLSI
• MIC/BP supplemented by “expert rules”
for clinical use
The rationale for automated
systems
• More reliable AST results
– ?closer to “standard”
– Reduced scope for “user” error
– Reproducible
• Improved ID linked to AST
• Embedded expert rules

Automated systems: an overview

Identification required for
interpretation of BP & expert
rules
Welsh variability in ID of
Enterobacter/Klebsiella/Serratia
Inter-laboratory ID comparisons

100%
90%
80%
70%
% Agreement

60%
50% 93.1 94.4 95.5 ID Disagree
40% 75.0 74.7 ID Agree Genus
66.9
30% ID Agree
20%
10%
0%
Lab 1 Lab 2 Lab 3 Lab 4 Lab 5 Total
Laboratory
The rationale for automated
systems
• More reliable AST results
• Improved ID linked to AST
• Embedded expert rules
• Improved speed of results
• Increased number of agents tested

Automated systems: an overview

 Welsh Gram Welsh Gram
positive
Drug
panel
Range
negative panel
Drug Range
Gentamicin 1-4
Amikacin 4 - 32
Penicillin 0.06 - 0.25
Gentamicin 1-8
Oxacillin 1-4
Tobramycin 2-8
Ampicillin 2 - 16
Amoxicillin/Clav 1/0.5 - 16/8
Ampicillin 4 - 32
Levofloxacin 0.5 - 2 Amoxicillin/Clav 2/1 - 32/16
Ciprofloxacin 0.5 - 2 Cefotaxime 1-4
Cefoxitin 2-8 Cefoxitin 1-4
Linezolid 2-8 Ceftazidime 2 - 16
Erythromycin 0.25 - 1 Cefuroxime 4 - 16
Clindamycin 0.25 - 1 Cephalexin 4 - 16
Daptomycin 1 - 16 Ciprofloxacin 0.25 - 2
Chloramphenicol 1 - 16 Aztreonam 1 - 16
Nitrofurantoin 16 - 64 Imipenem 1-8
Fusidic Acid 1-8 Meropenem 1-8
Rifampin 0.25 - 1 Ertapenem 0.5 - 4
Minocycline 0.5 - 2 Colistin 1-4
Mupirocin 1-4
Piperacillin/Tazo 4/4 - 32/4
Mupirocin - HL 256
Trimethoprim 0.5 - 4
Teicoplanin 1 - 16
Trimethoprim/Sulfa 0.8/15.2 - 3.2/60.8
Tetracycline 0.5 - 2
Nitrofurantoin 16 - 64
Trimethoprim 0.5 - 4
Vancomycin 1 - 16 Levofloxacin 0.5-2
GM-Syn 500
ST-Syn 1000
The rationale for automated
systems
• More reliable AST results
• Improved ID linked to AST
• Embedded expert rules
• Improved speed of results
• Increased number of agents tested
• Laboratory workflow
• Staff skill mix
• Epidemiological software

Automated systems: an overview

Available systems
• MicroScan WalkAway

• Biomerieux Vitek 2

• BD Phoenix
 MicroScan

• 96 well plates
• AST based on conventional
microbroth dilution MIC
• ID currently biochemical
 Microscan
• Conventional panels
• Enterobacteriaceae, gram-negative non-
fermenters, staphylococci, enterococci
• Combo, MIC-only, ID-only
• Rapid panels
– 2 - 2.5 hour ID (pre-formed enzymes)
– AST for Gram negative organisms (MIC > 4
hrs)
• Synergies plus panels
– 2 - 2.5 hour ID (pre-formed enzymes)
– Broth microdilution “Read-when-ready” MIC
– Resistance detection flagged in as few as
4.5 hours • Panels read by
– WalkAway® systems
– All results finalized in 16/18 hours – autoSCAN-4
• Additional – Manual
– Yeast ID, Anaerobe ID, HNID
– MICroSTREP plus ® - dry format
– ESβL plus ® -ESβL Confirmatory Panel
 Microscan
• Expert rules
within LabPro
Alert system
– Pre-loaded
– customisable
 Microscan
• Expert rules
within LabPro
Alert system
– Pre-loaded
– customisable
 Vitek 2

• AST based on broth

susceptibility with specific
cards
• ID currently biochemical

• Growth/reactions
“continuously” monitored
Vitek 2
• ID Cards available for
– Gram positives
– Enterobacteriaceae
– Non-Enterobacteriaceae
– Neisseria/Haemophilus etc
• Up to 22
– Anaerobes
antibiotics tested
– Yeasts on each card
• AST Cards available for
– Gram positive cocci
– Gram negative bacilli
– Yeasts
 VITEK 2 – MIC Interpretation
Interpretation of Raw Data

Growth Parameters

MIC
Raw Data

% Change

Slope

Area

SLPAR
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
TIME (hours)
 Vitek 2
• Expert rules
within the
Advanced Expert
System (AES)
– Extensive
Knowledge Base
• >20,000 MIC
distributions
• >2,500
Phenotypes
• >200 Resistance
Mechanisms
Vitek 2

CARD Type Time to Result

GN ID 2 to  10 hours
GP ID 2 to  8 hours
NH ID 6 hours
ANC ID 6 hours
YST ID 18 hours
GN AST 2 to 18 Hours
GP AST 2 to 18 Hours
AST-YS01 6 hours
 Phoenix
• AST based on broth
susceptibility with specific
cards
• ID currently biochemical

• Growth/reactions
“continuously” monitored
Phoenix

• AST only or Combo

panels available for
– GN (Enterobacteriaceae/
Nonfermenters)
– GP (Staphylococci/
Enterococci/ Streptococci)
– Streptococci ID/AST
 Phoenix
• Readings for each well taken and calculated
every 20 minutes
– ID uses red, green, blue and UV light sources
– AST measures turbidity and color change
– Each well divided into pixels
– Readings taken for each pixel
– Entire process takes 7 minutes
– Pixel data analyzed for each well
– Readings for each well compared to previous
reading and baseline
• Well is complete when specific amount of
change is not seen
• Substrate/antimicrobic algorithm dependent
– Instrument will post results when enough data
collected
 Phoenix
• Expert rules within BDXpert based
on CLSI/SFM/DIN/EUCAST rules
bases
Comparison of systems
Performance
• ID
– Correct to genus >95%
– Correct to Species>90%
– Difficulties with difficult organisms
• Non-fermenters
• Shigella etc
• AST
– Concordant with other methods >95%
– Specific issues with specific drug-bug combinations
& certain instruments
• VISA/VRSA
• Beta-lactams & Pseudomonas
Performance

• ID/AST performance relies on

correct ID, correct AST plus
appropriate expert interpretation
– Incorrect ID can lead to incorrect AST
• Up to 5% errors mean that results
should be examined critically
Conclusions
• Automated systems can provide
– Reliable AST integrated with ID & expert
rules
– Improved speed of results
• Caution about staff skill mix and
interpretation of results
• Microscan/ Vitek 2 /Phoenix have similar
performance overall
– Results should be examined critically