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© 2016 Beckman Coulter. All rights reserved. 1
MICROSCAN® SOLUTION &
ANTIBIOTIC RESISTANCES
Mamta Choudhary
Product Manager Microbiology & Urinalysis
© 2016 Beckman Coulter. All rights reserved. 2
MICROSCAN® SOLUTION & ANTIBIOTIC RESISTANCES
› What is the MicroScan Solution for ID/AST testing?
› What antibiotic resistance is clinically important today?
• CDC Antibiotic Resistance Threats
› β-lactamase classes containing carbapenemases and their growing importance in antimicrobial susceptibility testing
• How to detect carbapenemases and accuracy of MicroScan panels
• Recommendations for confirmation
› Methicillin-resistant Staphylococcus aureus (MRSA): Know some facts about MRS and newer mecC-mediated resistance
• Accuracy of MicroScan panels
© 2016 Beckman Coulter. All rights reserved. 3
EMERGING RESISTANCE IS EVERYONE’S PROBLEM
www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf
“Antimicrobial resistance is one of our most serious health threats. Infections from resistant
bacteria are now too common, and some
pathogens have even become resistant to
multiple types or classes of antibiotics…The
loss of effective antibiotics will undermine our
ability to fight infectious diseases and manage the
infectious complications common in vulnerable
patients…”
Dr. Tom Frieden, MD, MPH
Director, U.S. Centers for Disease Control and Prevention
Meeting the Challenges of Drug-Resistant Diseases in Developing
Countries
Committee on Foreign Affairs Subcommittee on Africa, Global Health,
Human Rights, and International Organizations
United States House of Representatives
April 23, 2013
https://www.youtube.com/watch?v=ALryAB_A
YiA&sns=em
© 2016 Beckman Coulter. All rights reserved. 4
MICROSCAN IN THE WORLD
Beckman Coulter is a main Worldwide leader in Microbiology
MicroScan is more than 40%* of Market Share for Automated ID (Identifications) and Automated AST (Antibiotics Susceptibility Testing)
Around 6000 MicroScan instruments* for Automated ID & AST
© 2016 Beckman Coulter. All rights reserved. 5
Instruments & Connectivity ID/AST Panels
Direct MIC testing
Accuracy
Streamlined workflow
Instruments for all volume segments
Reliability
Combining the strength of Maldi ID with
MicroScan AST
Informatics
LabPro - User-
friendly data
management
Easily organize and
manage microbiology
test data
Stay ahead of
emerging resistance
Enhance workflow efficiency,
decrease time to result, and
improve patient care decision making
MICROSCAN SOLUTIONS
© 2016 Beckman Coulter. All rights reserved. 6
MICROSCAN TECHNOLOGY : WHAT MAKES US DIFFERENT?
Technical
Philosophy
Direct read
of growth
Emerging
Resistance
Real MICs
(ISO 20776)
Method &
set-up
choice
AST
Independent
of ID
© 2016 Beckman Coulter. All rights reserved. 7
Combo, MIC- and ID-only Formats
Streamlined Inoculum Prep and Set-up
Fewest Clinically Significant Limitations
Comprehensive Formulary Support
Extensive Organism Database
MICROSCAN PANELS : WHAT MAKES US DIFFERENT?
© 2016 Beckman Coulter. All rights reserved. 8
Conventional Overnight (ID & AST)
Traditional biochemical ID
Growth–based broth
microdilution MIC
Exceptional accuracy
Detection of emerging
resistance
Visual Read or Instrument
Processing
Specialty (ID & AST)
Yeast ID, Anaerobe ID,
HNID (4 hour
Chromogenic)
MICroSTREP plus
(Overnight)
ESBL plus - ESBL
Confirmatory Panel
(Overnight)
Visual Read or Instrument
Processing
Rapid Identification
2 - 2.5 hour Fluorogenic ID
for gram-negative or gram-
positive bacteria
Minimal or no reagents,
depending on product
Good option for
biochemically inert species
WalkAway Processing only
FLEXIBILITY IN MENU FOR ID/AST TESTING
© 2016 Beckman Coulter. All rights reserved. 9
(ID) Identification section = Biochemicals
(AST) Susceptibility section = Drugs
Combo Panel
FLEXIBILITY IN MENU
ID PANELS, AST PANELS AND COMBO PANELS
© 2016 Beckman Coulter. All rights reserved. 10
PROMPT INOCULATION PREPARATION
Prompt™: One step to standardize inoculum preparation for ID and AST Tests
Eliminate 0.5 McF preparation with Turbidity
Inoculum stable for 4 hours (compared to 30 min. with other technologies)
Requires fewer number of isolated colonies
Less likely to pick mixed culture
*Prompt™ is a registered product made by 3M, St. Paul, MN USA
Select colonies Prepare inoculum
© 2016 Beckman Coulter. All rights reserved. 11
Use of Prompt for
“Picking “MICROSCAN and MALDI*
Agar with the
colony
Use prompt on MALDI
inoculation
MALDI TARGET
MICROSCAN PANELS
MALDI-TOF (ID)
MICROSCAN WalkAway Automated microbiological diagnosis using the MALDI-TOF and the Microscan WalkAway System.
C. Lensing1, T. Fenner1, E. Stoetter2, C. Ott2, I. Fenner1. Labor Dr. Fenner und Kollegen, Hamburg, DGHM 2009.
PROMPT: PROMPT™: OPTIMIZED AND SECURED
WORKFLOW WITH MASS SPECTRO
© 2016 Beckman Coulter. All rights reserved. 12
autoSCAN-4
WalkAway 40 plus
Medium Volume (15-30 panels/day)
WalkAway 96 plus
Multiple instrument
systems
High Volume (30 or more panels/day)
autoSCAN-4
Low Volume (0-15 panels/day)
FLEXIBILITY IN AUTOMATION FOR ALL ID/AST VOLUMES
© 2016 Beckman Coulter. All rights reserved. 13
ID & AST SCALABLE SOLUTIONS
15 panels/d
Same technology, same platform
+ Same panels
+ Same software
= Same results
30 panels/d
80 panels/d
160 panels/d
240 panels/d
AutoSCAN-4
WalkAway 40
WalkAway 96
© 2016 Beckman Coulter. All rights reserved. 14
Instruments
IT
AlertEX
Connect
Middleware
Workflow
Efficiency
Consolidate
multiple systems
into one
database.
Provide
traceability
/support
Simplify
dataflow
Minimize LIS
connections
DATA MANAGEMENT AND CONNECTIVITY ARE KEY
Simplify
interaction; focus
on the most
important;
scalability
TAT
Customized-
reporting
© 2016 Beckman Coulter. All rights reserved. 15
Designed by Microbiologists
Easy to Use, Understand, and Learn
Completely Customizable
Built-in Epidemiology Management
Integrated Quality Control
LABPRO INFORMATION MANAGEMENT
© 2016 Beckman Coulter. All rights reserved. 16
INTEGRATED LABPRO EPIDEMIOLOGY
Percent Interpretative Report
Include %S, %I &/or %R and trend
patterns over time
Add additional segmentation, if desired
Exclude repeats; align with CLSI M39
recommendations
Include off-line tests and antibiotics
suppressed from normal reporting
Export data to create antibiograms for
clinical use
Bacterial Incidence Report
Segment data to support Infection
Control initiatives and Outreach value-
added services
Pinpoint areas of a facility that may be
having issues
Monitor outbreaks and resulting
treatments
Query Summary Report
Provide data in a log-type format
Print from Epidemiology or Patient tabs
for slightly different view of the data
Specific patient and specimen
information augment other
epidemiology reports used by Infection
Control
Use either a standard or customized
report format
Cumulative % Inhibited by Drug (MIC
90) Report
Pharmacists can track subtle changes
in antimicrobial resistance patterns
As the MIC 90% increases, generally so
does resistance
Generate with customized
segmentation
© 2016 Beckman Coulter. All rights reserved. 17
Combo, MIC- and ID-only Panels
− Choose best fit testing for your needs
Streamlined inoculum preparation and
set-up
− Supports Lean workflow principles
Direct read of growth
− Results based on actual growth
AST results independent of ID
− Critical antibiotic results can be reported even
without a final identification
Accuracy more important than speed
− Better resistance detection
Visual read compatible
− Confidence in unusual results; built-in back-up
Fewest clinically-significant reporting
limitations
− Maximize primary testing
MicroScan Overnight Panels
MICROSCAN PANELS: WHAT MAKES US DIFFERENT?
© 2016 Beckman Coulter. All rights reserved. 18
ANTIBIOTIC RESISTANCE THREATS ACCORDING CDC*
Serious Threats
› Multidrug-resistant Acinetobacter
› Drug-resistant Campylobacter
› Fluconazole-resistant Candida
› Extended spectrum β-lactamase producing Enterobacteriaceae (ESBLs)
› Vancomycin-resistant Enterococcus (VRE)
› Multidrug-resistant P. aeruginosa
› Drug-resistant Non-typhoidal Salmonella
› Drug-resistant Salmonella Typhi
› Drug-resistant Shigella
› Methicillin-resistant Staphylococcus aureus (MRSA)
› Drug-resistant S. pneumoniae
› Drug-resistant tuberculosis
Concerning Threats
› Vancomycin-resistant Staphylococcus
aureus (VRSA)
› Erythromycin-resistant Group A
Streptococcus
› Clindamycin-resistant Group B
Streptococcus
•
*http://www.cdc.gov/drugresistance/biggest_threats.html
Urgent Threats
› Clostridium difficile Prevalence
› Carbapenem-resistant
Enterobacteriaceae (CRE)
› Drug-resistant Neisseria
gonorrhoeae
© 2016 Beckman Coulter. All rights reserved. 19
COMMONLY-USED β-LACTAM ANTIBIOTICS
› Make up over half the drugs on a typical MicroScan Gram Negative panel
Penicillins
Penicillinase-
stable
Penicillins
β-Lactam/ β-
Lactamase
Inhibitor
Combinations
Cephalosporin Cephamycins Monobactams Penems
Penicillin Methicillin Amoxicillin-
clavulanic acid
Cefaclor,
cephalexin (1) Cefotetan Aztreonam Imipenem
Amoxicillin Nafcillin Ticarcillin-
clavulanic acid
Cephalothin,
cefazolin (1) Cefoxitin Meropenem
Ampicillin Dicloxacillin Piperacillin-
tazobactam Cefuroxime (2) Ertapenem
Mezlocillin Oxacillin Ampicillin-
sulbactam Cefotaxime (3) Doripenem
Piperacillin Ceftazidime (3)
Ticarcillin Ceftriaxone (3)
Cefepime (4)
› CREs may hydrolyze all of these too
© 2016 Beckman Coulter. All rights reserved. 20
CRE: CARBAPENEM-RESISTANT Enterobacteriaceae
› Two mechanisms of resistance:
• Production of carbapenemase enzyme
− Enterobacteriaceae have acquired genes for many diverse enzymes
for carbapenemase resistance. Many are plasmid-mediated, so these
are easily transferable between strains, species, genera, patients
and facilities.
• Cephalosporinase combined with porin loss
− Some cephalosporinases (e.g., ampC β-lactamases or ESBLs) have
low-level carbapenemase activity. Coupled with porin loss, this limits
entry of carbapenem into the cell. These are NOT as easily
transferable between strains.
› The first goal is to detect resistance, and then (as needed) to
distinguish these two mechanisms
© 2016 Beckman Coulter. All rights reserved. 21
ACQUIRED CARBAPENEMASES IN Enterobacteriaceae
Molecular
Class Example Types Activity
A
KPCs
Also others, but not
common
Largest number, usually on plasmid,
most inactivated by clavulanic acid
B
NDM, VIM, IMP
Enterobacteriaceae
P. aeruginosa,
Acinetobacter
Metallo β-lactamases (MBL): Resistant
to many drugs, including carbapenems
› Enzyme does not hydrolyze aztreonam
› May require zinc for expression
C (None here)
D OXA enzymes
K. pneumoniae (OXA-48)
OXA-23, -40, -51, -58 in Acinetobacter
Others in Pseudomonas and other NFB
© 2016 Beckman Coulter. All rights reserved. 25
EMERGENCE OF CLASS B NDM
METALLO β-LACTAMASE IN Enterobacteriaceae
© 2016 Beckman Coulter. All rights reserved. 26
EMERGENCE OF CLASS B NDM
METALLO β-LACTAMASE IN Enterobacteriaceae
Lancet Infect Dis. 2010;10:597-602.
© 2016 Beckman Coulter. All rights reserved. 29
CRE DETECTION GOALS
› Detect all carbapenem-resistant organisms.
› Some automated systems do not do as well as others in detection of carbapenem resistance
› Distinguish them from isolates that are resistant to carbapenems because of other mechanisms
› “In the face of • diversity of enzyme types,
• considerable variation in levels of phenotypic carbapenem resistance (e.g., in MIC evaluations) and
• added complexity of non-carbapenemase-mediated carbapenem resistance
› there is no universally applicable method able to realize these aims”
Health Protection Agency. UK Standards for Microbiology Investigations. Laboratory Detection and Reporting of Bacteria with Carbapenem-Hydrolysing β-lactamases (Carbapenemases) UK Protocols | P 8 | Issue no: 1| Issue date: 26.03.13
© 2016 Beckman Coulter. All rights reserved. 30
CDC “VITAL SIGNS” 2013 HEALTH ADVISORY
Carbapenem-resistant Enterobacteriaceae warrant additional action by healthcare providers
› Carbapenems are considered first line therapy for infection with
multidrug-resistant Enterobacteriaceae • Carbapenem agents: doripenem, ertapenem, imipenem, meropenem
› Carbapenem-resistant Enterobacteriaceae (CRE) are bacteria that have developed high-level resistance to the carbapenem class of antibiotics
› MicroScan panels reliably detect carbapenem MIC results
› AlertEX software flags isolates that may need further scrutiny • Five system-defined Alerts
• Institution-specific Alerts can be customized
© 2016 Beckman Coulter. All rights reserved. 31
MEROPENEM AND DETECTION OF KPC
› Tested 46 confirmed KPC
producers by a variety of
methods including
MicroScan conventional
panels
› Results from MicroScan
most closely matched
those of Broth
Microdilution and
yielded zero very major
and major errors
Comparison of Meropenem MICs and Susceptibility for
Carbapenemase producing Klebsiella pneumoniae by Various Testing
Methods
JCM 2010. Bulik CC, KA Fauntleroy, SG Jenkins, M Abuali, VJ LaBombardi, DP Nicolau, and JL Kuti
© 2016 Beckman Coulter. All rights reserved. 32
KPC ENZYMES: AST SYSTEM PERFORMANCE USING MIC ≥2 AND ALL CARBAPENEMS
Method
% Sensitivity/Specificity using Carbapenem MIC of 2 µg/ml
Meropenem Imipenem Ertapenem
Reference BMD 100/93 100/93 100/89
Etest 84/91 90/89 100/84
Disk diffusion NA NA NA
Vitek Legacy NA NA NA
Vitek 2 71/93 94/89 94/89
MicroScan 100/93 100/93 NA
Phoenix 74/96 87/93 NA
Sensititre 81/96 NA NA
Anderson et al. 2007. J Clin Microbiol. 45:2723 N = 31 KPC producers; 45 non-KPC producers
NA = not available on tested panel or dilution range not low enough
© 2016 Beckman Coulter. All rights reserved. 33
NEW MEROPENEM PERFORMANCE STUDY
› “Evaluation of MicroScan Dried Overnight Panels to Accurately
Detect Meropenem Resistance with Challenge Gram-Negative
Isolates”
• 116 challenge Gram negative bacteria; 60 Enterobacteriaceae, 17
Pseudomonas aeruginosa, 37 Acinetobacter spp. and 2 additional
Gram negative non-fermenters
– Included the 31 BIT CDC Challenge Isolates
• Tested on reference frozen MIC panels, Gram Negative MIC 38, ESBL
plus and Kirby Bauer
• Analyzed for essential and categorical agreement using either
EUCAST or CLSI breakpoints
› There were no VME using either EUCAST or CLSI M100-S24+
breakpoints
Chipman AM, et al. 2015. ASM Poster C530.
© 2016 Beckman Coulter. All rights reserved. 34
DETECTION OF ESBL ENZYMES (CTX-M, OTHERS)
› Molecularly-characterized ESBL E. coli, Klebsiella spp. and Proteus
mirabilis isolates recovered from patients in the University Health
System, San Antonio, Texas
Overall detection of ESBL-producing isolates (n=100) by the four test
methods
J.H. Jorgensen et al., J. Clin. Microbiol. 48: 120-123
.
ESBL
confirmed
Equivocal
results1
ESBL not
detected
ESBL plus 98% 1% 1%
Neg MIC 32 95% 5% 0
© 2016 Beckman Coulter. All rights reserved. 35
Staphylococcus aureus
Image: Zimmer 2011
Moreillan, P. et al. 2005. “Staphylococcus aureus (Including Staphylococcal Toxic Shock
Syndrome)”In Mandell, G.E. et al. (eds). Principles and Practices of Infectious Disease. 6th ed.
Elsevier, Inc. Permission to reproduce requested.
© 2016 Beckman Coulter. All rights reserved. 36
STAPHYLOCOCCI, OXACILLIN AND CEFOXITIN
› Two general and historical types of resistance to β-lactam drugs with
staph:
• β-lactamase: resistance to penicillin and β-lactamase labile penicillins
• Altered cell-wall PBP2a, encoded by mecA gene: confers resistance to ALL β-lactam drugs (penicillins, cephalosporins, carbapenems). This is a MRSA.
› Oxacillin historical usage as a representative antimicrobial agent for
β-lactam resistance for staphylococci, encoded by the mecA gene
› Cefoxitin is better able to detect mecA-mediated resistance in S. aureus
• Detection of MRSA is becoming more variable – some are positive by
molecular methods and negative phenotypically, and the reverse
• S. pseudintermedius is being isolated (Ox R, Cfx S)
• mecC has been described (Ox S, Cfx R)
© 2016 Beckman Coulter. All rights reserved. 37
NOVEL mecC ISOLATE
All information and
slide material courtesy
of Dr. Robert Skov,
Statens Serums
Institut, presented at
CLSI January 2012
No. of new human cases per year
Lancet Infect Dis 2011; 11:595-603
© 2016 Beckman Coulter. All rights reserved. 38
STUDY: DETECTION OF NOVEL mecC ISOLATE
› Isolates: 111 S. aureus with mecC
› Genotypic: commercial methods all negative (GeneOhm™ StaphSR (BD), GeneXpert™ MRSA (Cepheid), NucliSENS EasyQ MRSA
(bioMérieux)
› Phenotypic
• Etest, disk diffusion (oxacillin and cefoxitin): variable
• Chromogenic agars MRSA: variable by manufacturer
• PBP2a agglutination: all negative
• Automated systems (cefoxitin >4 µg/mL):
– MicroScan (Beckman Coulter); 106 of 110
– Vitek (bioMerieux); 108 of 111
– Phoenix (BD); 83 of 111
• Automated systems (oxacillin ≥4 mg/L): variable, 0–21/111
All information and
slide material courtesy
of Dr. Robert Skov,
Statens Serums
Institute, presented at
CLSI January 2012
© 2016 Beckman Coulter. All rights reserved. 39
MRSA DETECTION - MICROSCAN
Performance of a New MicroScan WalkAway PC30 Panel and Disk
Diffusion Method for Detection of Oxacillin Resistance in
Staphylococcus spp.
− 370 Clinical Isolates tested
− Oxacillin-resistance detected by PCR in 22.7% of S. aureus isolates
Gallon, O, P Pina, A Gravet, F Laurent, B Lamy, JM Delarbre, F Doucet-Populaire, and JW Decousser. 2011. Performance of a New MicroScan WalkAway
PC30 Panel and Disk Diffusion Method for Detection of Oxacillin Resistance in Staphylococcus spp. J Clin. Microbiol. Vol.49, No.6: 2269-2271.
Results using Oxacillin MIC + Cefoxitin Screen
Sensitivity Specificity PPV NPV
N=370 98.8% 100% 100% 99.6%
© 2016 Beckman Coulter. All rights reserved. 41
THANK YOU!
› Beckman Coulter, the stylized logo, and the
Beckman Coulter product and service marks
mentioned herein are trademarks or
registered trademarks of Beckman Coulter,
Inc. in the United States and other countries.
› All other trademarks are the property of their
respective owners.
› Not all products available in all countries.