JOURNAL OF CLINICAL MICROBIOLOGY, Dec. 2007, p. 4088–4089 0095-1137/07/$08.00⫹0 doi:10.1128/JCM.01847-07 Copyright © 2007, American Society for Microbiology. All Rights Reserved.
Vol. 45, No. 12
Letters to the Editor Evaluation of the Inoculation Procedure Using a 0.25 McFarland Standard for the BD Phoenix Automated Microbiology System䌤 Rapid bacterial identification (ID) and antimicrobial susceptibility tests (AST) can have a significant impact on the management of infections, especially those caused by antibiotic-resistant bacteria (1, 2, 5). However, these rapid automated methods do not overcome the need for the preparation of a suspension of the organism at a fixed density (0.5 to 0.6 McFarland standard [MF]; 1.5 ⫻ 108 CFU/ml). Subculturing the isolate to obtain the required number of colonies is the usual solution to insufficient numbers of colonies available on primary isolation agar plates, but this equates to a further 24-h delay in completing the test and, in turn, in providing results to the clinician. In these cases, the rapid automated methods offer no time advantage compared to manual methods. In order to overcome this problem, BD, for its Phoenix automated microbiology system, has recently developed new software and a database for ID using a lower inoculation density, a 0.25 MF (7.5 ⫻ 107 CFU/ml) instead of the previously used 0.5 MF, for the inoculation of panels. The new capability to determine ID involves the use of separate ID substrate databases for substrate reactions for each method. The AST inoculation density, 5 ⫻ 105 CFU/ml, is maintained following the procedure with the 0.25 MF by transfer of twice as much ID suspension (50 l instead of 25 l) to the AST broth. We conducted a prospective study over a 1-month period to evaluate and validate the possibility of using the 0.25 MF in our facility. This study compared inoculation with the currently used 0.5 MF, used for 6 years in our laboratory (3), to inoculation with a 0.25 MF for the exact same isolates (Table 1). Accurate ID at the species level was achieved for 95.5% of the isolates by use of the 0.25 MF and for 95.5% of the isolates by use of the 0.5 MF. Ten of 132 clinical isolates (7.3%) had discordant ID results by the two methods (Table 1). No discordant identification results were observed for Staphylococcus aureus and Pseudomonas aeruginosa isolates. Differences between the two ID approaches were not statistically significant. Errors were less than 1.4% among 2,654 performed AST. No very major errors (the method with the 0.25 MF indicating sensitivity and that with the 0.5 MF indicating resistance) were found. Totals of 32 (1.2%) major errors (ME; the method with the 0.25 MF indicating resistance and that with the 0.5 MF indicating sensitivity) and 37 (1.4%) minor errors (mE; the method with the 0.25 MF indicating an intermediate result and that with the 0.5 MF indicating sensitivity or resistance) were obtained (not shown). There were 7 ME and 7 mE for Enterobacteriaceae, 5 ME and 1 mE for staphylococci, 18 ME and 18 mE for Pseudomonaceae (mainly P. aeruginosa), and 2 ME and 11 mE for enterococci. Although we used the inoculation method with a 0.5 MF as the comparative method (which is not truly a reference method), we have 6 years of experience with this system and have confidence in its accuracy for most organism-antibiotic
TABLE 1. List of discordant results obtained by comparing methods with a 0.25 MF and a 0.5 MFa Organism identified by ID procedure with: Bacteria 0.25 MF
Enterobacteriaceae
Enterobacter cloacae Salmonella enterica subsp. arizonae Pantoea agglomerans Citrobacter freundii No ID No ID
Staphylococci
No ID No ID
Enterococci
Enterococcus durans No ID
0.5 MF
API strips
Klebsiella pneumoniae Escherichia coli
Enterobacter cloacae Escherichia coli
Klebsiella pneumoniae Escherichia coli Serratia marcescens No ID
Pantoea agglomerans Citrobacter freundii Serratia marcescens Escherichia coli
Staphylococcus capitis Staphylococcus warneri
Staphylococcus capitis Staphylococcus epidermidis
Enterococcus faecium Enterococcus faecium
Enterococcus durans Enterococcus faecalis
a The 132 clinical strains were 55 Enterobacteriaceae, 31 Pseudomonaceae, 25 staphylococci, and 21 enterococci. Discordant IDs were tested by API strips (API-20E, 32-STREP, and 32-STAPH; bioMerieux, Marcy l’Etoile, France), and the API result was used to select or adjudicate the correct ID result.
combinations. In addition, we developed several confirmatory tests for some combinations with which the system’s accuracy is weaker (3). The performance of the low-inoculum-density method based on presented results has allowed us to start to use this approach routinely in our laboratory. (Part of this work was presented at the 107th General Meeting of the American Society for Microbiology, Toronto, Ontario, Canada, 21 to 25 May 2007 [4].) We are grateful to Ben Marshall (Southampton University Hospital, Southampton, United Kingdom) for carefully reading the manuscript. REFERENCES 1. Barenfanger, J. C., C. Drake, and G. Kacich. 1999. Clinical and financial benefits of rapid bacterial identification and antimicrobial susceptibility testing. J. Clin. Microbiol. 37:1415–1418. 2. Doern, G., R. Vautour, M. Gaudet, and B. Levy. 1994. Clinical impact of rapid in vitro susceptibility testing and bacterial identification. J. Clin. Microbiol. 32:1757–1762. 3. Donay, J.-L., D. Mathieu, P. Fernandes, C. Pre´germain, P. Bruel, A. Wargnier, I. Casin, F. X. Weill, P. H. Lagrange, and J. L. Herrmann. 2004. Evaluation of the automated Phoenix system for potential routine use in the clinical microbiology laboratory. J. Clin. Microbiol. 42:1542–1546.
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VOL. 45, 2007 4. Donay, J.-L., P. Fernandes, P.-H. Lagrange, and J.-L. Herrmann. 2007. Abstr. 107th Gen. Meet. Am. Soc. Microbiol., abstr. C-145. 5. Sanders, C. C., M. Peyret, E. Smith Moland, S. J. Cavalieri, C. Shubert, K. S.
LETTERS TO THE EDITOR
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Thomson, J. M. Boeufgras, and W. E. Sanders, Jr. 2001. Potential impact of the VITEK 2 system and the Advanced Expert System on the clinical laboratory of a university-based hospital. J. Clin. Microbiol. 39:2379–2385.
J.-L. Donay P. Fernandes P. H. Lagrange J.-L. Herrmann*† Service de Microbiologie Ho ˆpital Saint Louis 1 Avenue Claude Vellefaux Paris, France *Phone: 33 1 47 10 79 50 Fax: 33 1 47 10 79 49 E-mail:
[email protected] † Present address: Service de Microbiologie, Ho ˆpital Raymond Poincare´, 104 Boulevard Raymond Poincare´, 92380 Garches, France. 䌤 Published ahead of print on 3 October 2007.
