dr gillian wood - austin health - microbiology automation
DESCRIPTION
Dr Gillian Wood delivered the presentation at 2014 National Pathology Forum. The National Pathology Forum 2014 featured case studies on innovative testing methods in the fields of genetics, biobanking and PoCT. The highly interactive nature of the National Pathology Forum allowed delegates to network with each other and converse with the speakers asking questions as part of debates, industry roundtables, short workshops and panel discussions. For more information about the event, please visit: http://bit.ly/pathology14TRANSCRIPT
Forward to the Future
Gillian WoodMicrobiologist and Infectious Diseases Physician
Austin Health
Mercy Hospital for Women
Melbourne
Automation in the Microbiology Laboratory
Microbiology Automation
• Component parts to microbiology automation• 3 systems: fundamentally the same
• Kiestra system and what it does
• Reasons for automation
BD Kiestra Work Cell
BD Kiestra Total Laboratory
Automation (TLA)
WASPLab
BioMerieux FMLAFull Microbiology Lab Automation
SpecimenHoly Grail
The Single Colony
ORGANISMIdentification
and Susceptibilities
Report
MICROBIOLOGY (BACTERIOLOGY)
Current Microbiology (Bacteriology)
Specimen: •Registration•Bar code •Setup protocol
Plate:Selection labelling Inoculation streaking
Plate Incubation:Overnight1st plates– 24hLast plates – 10h
Plate Reading+
Colony pick off
Identification:MALDI: Minutes Others: 8-24h
Susceptibility testing:AST: 8-24hDDS/Etest: 18-24h
•1st shift: hours•Plates on bench•Negatives with positives•Colonies of different maturity
Specimens•Registration •Bar coded•Setup protocol
Manual Inoculation
NON-liquids
What is Microbiology Automation?Schematic Diagram
AutomatedSpecimenProcessor
Plate selection, Bar coding
Liquid specimensInoculation + streakingBroths+DDSSlides
Eswabs!
Dacron Gel vs Eswab
READING ROOMReading of Digital ImagesContinuously available!
Standardised incubation timeColonies targeted
Specimens•Registration •Bar coded•Setup protocol
Predetermined Incubation time
RoboticIncubators
CO2, O2
Digital Plate
Imaging
Manual Inoculation
NON-liquids
Work BenchesManualColony Pick Off
Automatedcolony pickerInoculation of
MALDI + broths forAST+ DDS
What is Microbiology Automation?Schematic Diagram
AutomatedSpecimenProcessor
Plate selection, Bar coding
Liquid specimensInoculation + streakingBroths+DDSSlides
MALDI-TOFOther ID systems
Automated
SusceptibilitySystems (AST)
Broth Disc Susceptibility (DDS)
Eswabs!
BD Kiestra Work Cell
This is where went!
MAY TO SEPTEMBER 2014
Inoqula
Reading Room/Training Room
InoculA• Automatic specimen processor• Largest capacity
– Loading: 288 tubes– 400 plates/hour– Plate silos: 720+
• Decapping/capping• Broth + slide inoculation• Manual interactive station
• Non-liquid specimens
• Soon - disc dispenser• DDS
• Pipette inoculation– 10uL +
• Magnetic bead streaking• Reusable
Protocol B: Mixed Cultures Suspension C: 80% E. Coli + 10% E. Faecalis + 10% S. Aureus x5 plates
(single colony count + standardization)
InoqulA: Manual
Single Colonies
1 drop BC into Eswab 10uL urine
Wound Eswab
Lawn Suspension
“SMART” INCUBATORSReadA Compact
• 1152 plate capacity
• Each plate has a uniquelocation
• Random access/rapid retrieval
• Controlled temp + CO2 or O2
• Hepa filtered imaging section
Digital Imaging
Software
Vision Tool Box
High resolution digital enhancements
Sophisticated image acquisition
Differential analysis
• Artefact free, accurate digital representation of the culture plate
• Ability to recall and collate the images as desired
• Permanent record
Imaging track
Output track
Input track
Digital Image Reading
Reading Room Digital colony targeting
Digital Images
• All of the plates on a specimen together
• Same plates over time– All scientists working on a culture
see same culture “history”
• Patient centred images– All plates from all specimens on
same patient over time!
– Stops work up of same colony from different specimens
– Very different work flow/training• Patient centred not specimen
centred.
Scan 1
Scan 2
Digital Images
• Separates negative plates from positive – MRSA screening
– Urines
• 12-20 negative plates per screen
• 15 seconds to read and report 20 samples– Automated soon
Digital Images
Other uses• Remote bacteriology
• Telemedicine
• Assist colleagues
• Second opinions– Less experienced
• eLearning– Hugh database of culture
plates
• Collaboration
House
iPhone/ iPad
After Incubation:
Work Benches → Colony Processing
• Manual retrieval of plates from incubators• Take plates to work benches• Pick off targeted colonies:
• Perform appropriate work for ID and Senses etc?Automated?
The Case for Automation It is fun, interesting and exciting!
It is expensive!
Decreased turnaround time to clinically useful results
– Greatest potential of the systems = Faster Microbiology
– Paradigm shift for microbiology FROM• Single daily plate reading
• Leaving plates on benches pre and post incubation
• De-emphasis of “waiting for bugs to grow”
• As soon as culture is ready the instrument will go bing!
Matthews. Clin Microbiol Infect 2011;17:651-654
The Case for Automation
Results available 10-12 hours earlier– Enhanced treatment effectiveness
– Improved antibiotic stewardship • Fewer DDD of antibiotics
– Infection control (MROs)
– Results available to those working extended hours
– Results available earlier in the morning• Ward rounds = decision-makers (consultants) present
– Earlier hospital discharges
• Assists ED with NEAT targets
• Reduced LOS per DRG
• Research needs to be directed at relating this to:Matthews. Clin Microbiol Infect 2011;17:651-654
The Case for Automation
Increased productivity: 2.5 fold increase
• Staffing issues
– Cope with more specimens!!!
– Possibly fewer and/or lower grades of staff• 25% lab FTE in inoculating plates and broths
– Staff do other things• Freed from repetitive boring work
• Research, development, teaching
Matthews. Clin Microbiol Infect 2011;17:651-654Mischnik. J Clin Micro 2012:50:2732-2736
The Case for Automation
Inoqula– Plating 60 vs 24 samples per hour
• Plates into incubator ASAP
• No tea breaks
• Not affected by hangovers or influenza
– Aim for all samples to be plated within 20 minutes!
– Fewer mistakes and less rework• Mislabelled plates, wrong plates, contamination
– 5-15% more single colonies• Saves replating
• Saves 24 hours on time-to-results
– 3 fold increase in recovery of bacteria (liquid media)
– Shorter time to commence incubation
Matthews. Clin Microbiol Infect 2011;17:651-654Mischnik. J Clin Micro 2012:50:2732-2736
The Case for Automation
Smart Incubators – ReadA Compact
– Controlled internal temperature and atmosphere
– Each plate has a unique location
– Random access/rapid retrieval
– No opening and shutting doors
– No plates sitting on benches for hours!• Out of incubator > 1 minute to be photographed
– Improved plate incubation and reading
• Shorter time to identification and susceptibility results
Matthews. Clin Microbiol Infect 2011;17:651-654Mischnik. J Clin Micro 2012:50:2732-2736
The Case for Automation
Digital images– Produced automatically
• Set times
• Different lighting and exposures
• Images available constantly at shortest possible time
– Effective incubation and plate reading through the day • Aim to have all specimens in incubators
• Better with a 24/7 lab - ESSENTIAL
– Reduced incubation times• Digital image resolution
– Superior and earlier growth detection
– Negative cultures
» Automatic and early reporting
The Case for Automation
Digital image analysis!– Vision Toolbox assisted imaging
– Time course imaging, growth curves and software• Earlier detection and pick off of colonies
• Identification of organisms by growth characteristics and colour
– Earlier reading of the disc zones• Disc susceptibilities go back into incubators
– Optimum incubation
– Image analysis allows detection of result as earliest possible time
– EUCAST DDS: 12 hours incubation
Reduced TAT For preliminary and completed results
The Case for Automation
Increased accuracy and traceability
• Error rate <0.5%
• Fewer mistakes– Labelling plates
– Plate selection
– Specimen mix-ups
– NO lost plates!
• Consistent and standardised incubation, inoculation, streaking» More single colonies
• Permanent record of plate and susceptibility images
• Complete traceability – Media batches, inoculated plates, digital images, results
– Required now for Lab and hospital accreditation
What We Have
BD Kiestra Work Cell
Thank You
Implementation• Head Key User (implementation person)• Key User Group
– 6 staff– 2 and a half days training
• IT Specialists– 3 staff
• 1 IT, 2 lab staff
• Front Line support Staff– 3 staff (good with screw drivers)
• Quality validations– 3 staff
• Staff training– One and a half days training
Automation Evaluation and Changes
Data from Everyone in Micro
Compiled Peter Ward
Eswab Collection and Transport System
Amies Liquid + Nylon Flocked Swab
White Cap
NEW ESWABPathology Department
21st July 2014
Peel apart plastic film layers
Stand tube upright Avoid spills
DO NOT DISCARD LIQUIDRemove swab from package
Collect specimen
Remove lidReturn swab to container
Snap of swab at score line
Replace lidSwab shaft is captured in lid
Complete Patient details
Dacron Gel vs Eswab
Bacterial Survival
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
MRSAGel
swab
MRSAEswab
PsaeGel
swab
PsaeEswab
H.infGel
swab
H.infEswab
N.gonGel
swab
N.gonEswab
P anaGel
swab
P anaEswab
Log10 Survival at 4ºC
4° 0 hrs
4° 4 hrs
4° 24 hrs
4° 48 hrs
at 4ºC after 24 hrs
at RT after 24 hrs
N gonorrhoea SurvivalEswab vs. Gel Swab
Pos BC
Kiestra Manual Manual Kiestra
Aim of Kiestra Users?
Get everything into an Eswab container!
– Either as a Eswab or just using the container!
– Eswabs are better than dacron swabs
– Eswabs can be automatically plated by Kiestra
– Streaking by Kiesta provided more single colonies
Blood Culture Gram Stains
• Compare Manual Gram vs. Kiestra Gram prep
– Similar numbers of organisms (++ vs. ++)
– Often clearer and better quality because of even spread of material
Urines
• >200 urines plated Kiestra vs. manual
– More isolated colonies
– Contamination easier to see
– Very heavy growth isolated colonies on K, confluent on manual
UrinesManual 1uL loopKiestra 10uL spot
UrinesManual 1uL loopKiestra 10uL spot
UrinesKiestra 10uL spot Manual 1uL loop
Urogenital/Wounds Semi-automated Gel vs manual Gel
• 40 samples from wounds & urogenital swabs• Gel swabs run in parallel (manual vs InoqulA).
• NO significant differences
• Recommendation:
• Split HBA/MAC plates are suitable for urogenital & wound swabs instead of full HBA and full MAC
UrogenitalSemi-auto vs manual Gel
UrogenitalSemi-auto vs manual Gel
UrogenitalSemi-auto vs manual Gel
Sputum
• Semi-automated Kiestra vs full manual
– Similar culture results,
– More isolated colonies
– Limited numbers available
– Need to use the SL (sputum lysis) system
Buccal Swabs
• Kiestra/Eswab vs. Gel/Manual systems
• Culture– More isolated colonies
– >>more AnO2 colonies on Kiestra and improved growth
• Gram stains– More even and easier to examine instead of
searching
MRSA
• MRSA Screening • Change to combined swab of 2
sites instead of separate sites as per CDC etc.
• CDC recommend pooling MRSA screening swabs
» http://hicsigwiki.asid.net.au/index.php?title=Screening_and_Clearance_Process-MRSA
• Waiting for swabs
– Survival already validated
– Split chrome to be checked for MSSA/MRSA
Mediastinal Collection Aspiration Gel swab and Eswab saturated with specimen
Gram Stains
Gel Eswab
Mediastinal collection asp @ 24 hrs
Mediastinal collection asp @ 48 hrs
Eswab/Kiestra Eswab/KiestraGel swab/Manual Gel swab/Manual
Mediastinal collection asp Anaerobic @ 48 hrs
Eswab/Kiestra Gel swab/Manual
Future
More and improved automation = Processing• Colony picker
• Biohazard hood
Digital image analysis = Vision Toolbox = Diagnositics!– Reduced incubation times
• Now usually 18-24 hours: < 12 hours
• EUCAST DDS incubation of 12 hours
– Digital image resolution• Negative cultures: Automatic and early reporting
– Time course imaging, growth curves and software• Earlier detection and pick off of colonies
• Identification of organisms by growth characteristics
• Earlier reading of the disc zones
– Reduced TAT For preliminary and completed results
Kiestra Total Laboratory Automation (TLA)