Scottish Microbiology and
Virology Network (SMVN) /
Area 062 ¦ Gyle Square ¦ 1 South Gyle Crescent ¦ Edinburgh EH12 9EB Telephone 0131 275 6575 ¦
Antimicrobial Susceptibility Testing (AST) Group
MinutesSubject:Scottish Microbiology and Virology Network Antimicrobial Susceptibility Testing (AST) Group
Author:Emily Ross (v0.1)
Dr Fiona MacKenzie (v0.2 and all subsequent versions)
Date:26 October 2017
Location:The Melting Pot, Rose Street, Edinburgh
Present
Dr Mairi MacLeod* (Chair; NHS GG&C)
Zoe Black** (NHS Dumfries & Galloway)
Derek Bryce** (NHS Lothian)
Carolyn Cameron** (NHS Highland)
Marilyn Clark** (NHS Tayside)
Paul Clyde (NHS NSS)
Terry Fairbairn** (NHS Borders)
Billy Hislop (NHS NSS)
Liz Kilgour** (NHS Lanarkshire)
Dr Alistair Leonard* (SG)
Dr Michael Lockhart* (HPS) / Dr Fiona MacKenzie (SMVN Manager)
Julie Mallon** (Golden Jubilee)
Dr Bryan Marshall* (NHS Dumfries & Galloway)
Dr Ewan Olson* (NHS Lothian)
Jenny Smith** (NHS Fife)
Tony Stark** (NHS Lanarkshire)
Nigel Stephenson** (NHS Grampian)
Geoff Toner** (NHS Lothian)
Dr Carlos Varon Lopez* (NHS Lanarkshire)
Dr Robbie Weir* (NHS Forth Valley)
Janet Young** (NHS GG&C)
Apologies
Dr Abhijit Bal* (NHS Ayrshire & Arran)
Dr Adam Brown* (NHS Highland)
Dr Ian Gould / (NHS Grampian)Dr David Griffith* (NHS Fife)
Dr Ed James* (NHS Borders) / Henry Mather (NHS GGC)
Martin McGill** (NHS Ayrshire & Arran)
Dr Will Olver* (NHS Tayside)
Ian Pritchard** (NHS Western Isles)
Carolyn Taylor** (Oban)
* Consultant** Biomedical Scientist
1. Welcome and apologies
M. Macleod welcomed everyone to the meeting and round-table introductions were provided. Apologies were as above.
M. Macleod explained that, since the previous meeting. I. Gould had retired from his ConsultantMicrobiologist post in NHS Grampian and had stepped down as Chair of the SMVNAST Group. She wished to record a vote of thanks to I. Gould for his chairmanship of the group since its inception in 2005.
Earlier in the year, requests were made for volunteers to deputise for I. Gould. As a result of that process, M. Macleod has become the new AST Group Chair and E. Olson has become the Deputy Chair.
2. Minutes of previous meeting
The minutes were accepted as an accurate record of the meeting.
3. Matters arising
There were no matters arising.
4. AST Group Terms of Reference (ToR)
It was highlighted that details of the Chair and Deputy Chair need to be updated. It was also noted that NHS Health Board membership needs to be updated. The ToR will be modified to include the above amendments. /Action F. MacKenzie
5. Carbapenemase Producing Organisms (CPO)
- Reference laboratory referrals – update
A. Leanord provided an update from the Reference Laboratory hosted in NHS Greater Glasgow & Clyde. It is one of five satellite laboratories associated with the PHE Antimicrobial resistance and HealthcareAssociated Infections (AMRHAI) reference unit.
- The Glasgow laboratory had received 141 isolates since it opened in June 2017.
- The ratio of fermenters to non-fermenterswas currently 70:30.
- 82 of the 141 isolates,were PCR negative for the “big 5” carbapenemase genes.
- 30 of the 82 were referred to AMRHAI.
The most common enzymes identified in Scotland are OXA-48, KPS and NDM.
To date, the Scottish Satellite AMR Reference Laboratory is not carrying out MICs, but AMRHA is. A. Leanord noted that this dual-referral system had caused difficulties. There are plans for the Scottish Satellite laboratory to carry out MICs, which will avoid da duplicate referral system. He emphasised that GG&C laboratory received only £11,000 of funding to run the service.
It was noted that NHS Forth Valley had sent a number f isolates to AMRHAI, very few of which were confirmed as positive. A.Leanord noted that the modified Carbapenemase test (mCIM) was better used to test for CPE. M. MacLeod also noted that this could impact the reference laboratory report. A. Leanord agreed to raise this at the monthly AMRHAI meeting. Action A. Leanord
- Reporting: text and codes
At the last meeting, the following reporting text and codes for screening samples were agreed by the group:
Screen result / Reporting text / Reporting codeNegative / Carbapenem-resistant organism not isolated / NCPE
Positive / Carbapenem-resistant organism isolated. It may produce a carbapenemase; further investigations are being undertaken / QCPE
Reference Laboratory confirmed positives / Carbapenem resistant organism isolated. Carbapenemase production confirmed / CCPE
F. MacKenzie had circulated the codes round the SMVN laboratory managers and had verified that they were not already in use for any other tests. They were therefore adopted for use across Scotland.
It was decided that an additional code (and reporting text) should be agreed for carbapenem resistant organisms which are not carbapenemase producers. The following was agreed:
Screen result / Reporting text / Reporting codeLocal screening test positive
Reference Laboratory carbapenemase tests negative / Carbapenem resistant organism isolated.
Not a Carbapenemase producer. / XCPE
F. MacKenzie will liaise with Scottish laboratories to establish if this code is already in use anywhere with a view to recommending its use, as above. Action F. MacKenzie
6. ESBL detection and reporting SLWG
M. Macleod noted that this will be progressed after the meeting.Action M. MacLeod
7. Detection of penicillinase in S. aureus
It was noted that this action was closed and M. Clark had circulated the NHS Tayside methodology.
8. Haemophilus/co-amoxiclav
At the previous meeting, M. Macleod reported that NHS Greater Glasgow & Clyde had seen a 20% increase in co-amoxiclav resistance, noting that this was not the highest resistance level in Scotland. It was advised that if a specimen was resistant to three antibiotics it should be sent to a reference laboratory.
NHS Lothian had offered to undertake comparative testing and had sent results to the SMVN AST Group. This could potentially be used to develop a standard method across Scotland.
It was noted that Health Boards across Scotland were using different methods, with some using E-tests and others having difficulties with E and O plates for analysis.
M. MacLeod suggested that the group could focus on Haemophilus which could tie in with the Scottish Antimicrobial Prescribing Group (SAPG) aims of developing Scotland-wide empirical prescribing guidelines.
It was agreed that a questionnaire would be circulated to the SMVN AST Group to further audit. Action F. MacKenzie
9. Maldi-tof user group (SMUG) update
It was noted that there had not been a great deal of discussion in the virtual group. This would be carried over until the next meeting. Action M.McGill
10. bioMérieux / Vitek 2
- Meeting on 1 June 2017
Minutes of the meeting held on 1 June 2017 were circulated for information.
- Meeting on 30 August 2017
Minutes of the meeting held on 30 August 2017 were circulated for information.
- Matters arising from meetings with bioMérieux
It was noted that the meetings of June and August 2017 were organised as a result of Vitek AST card shortages.
J. Young highlighted that it was not clear how laboratories would be able to claim the £250 worth of online training vouchers offered by bioMérieux as compensation for the card shortages. Nobody had claimed their training vouchers to date.It was hoped that bioMérieux will send laboratories a link to a training module. M. MacLeod highlighted that the online training courses offered by bioMérieux were useful.
No laboratory had calculated the costs of validating replacement Vitek AST cards when bioMérieux could not supply Scottish cards and it was suggested that it may be too late to make a claim from the company. Laboratories should be prepared in the evet of future Vitek card shortages.
B. Hislop noted that Vitek computer replacements had been discussed at length during the meetings with bioMérieux.The situation is not clear, as some computers are included in Managed Service Contracts (MSCs) in which a third party would be responsible for upgrading computers. L. Kilgour noted that NHS Lanarkshire had been left exposed due to the WannaCry virus that had infected systems. She noted that nobody at bioMérieux or NHS Lanarkshire claimed ownership for carrying out security patches. B. Hislop noted that National Procurement viewed this to be bioMerieux’s responsibility. He noted that when the original contract was put in place there was no IT involvement. This would be discussed at the next meeting with bioMérieux in December 2017.
It was noted that bioMérieux was poorly staffed / represented in Scotland and their personnel cover both Scotland and Ireland.
P. Clyde noted that this was a new area for current National Procurement staff who had inherited the contract from previous National Procurement colleagues. He noted that regular meetings had been set up with bioMérieux since the start of 2017 and highlighted that first meeting was set up to react to major supply issues. Since then engagement and communications had improved, although not all issues had been resolved.
F.MacKenzie noted that, although relationships with bioMérieux had improved at a national level,this may not have been seen at laboratory level. It was highlighted that bioMérieux customer service is still not adequate.
During meetings with bioMérieux, the possibility of initiating a new tender exercise has been discussed. bioMérieux are likely to appreciate that there are alternative suppliers which could submit tenders and therefore,their business in Scotland may be in jeopardy.
- Contacting bioMérieux
F. MacKenzie highlighted that laboratories should be using generic contact details provided by bioMérieux to log complaints and issues. Although there are good relationships with bioMérieux employees on the ground, generic contact details should always be used by individual laboratories to ensure the correct process for logging and /
following up on complaints and issues is taken. F. MacKenzie highlighted that bioMérieux have stated that there is no mechanism whereby the SMVN can officially report issues on behalf of the network. L. Kilgour noted that any issues in NHS Lanarkshire must be logged through their MSC.
J. Young noted that NHS GGC had experienced NEQAS issues regarding Tigecycline fails. bioMérieux said this was due to a predefined rule that had not been enabled but M. MacLeod fedback that rule was not applicable to EUCAST / Scotland. Rachel Mason, bioMérieux, has been asked for a list of all predefined rules. M. MacLeod will forward the list of rules used in NHS GG&C to the AST group. Action M. Macleod
G. Toner highlighted that it has been difficult to contact bioMérieux out-of-hours for some time now and that bioMérieux personnel who man this service are often not knowledgeable about issues raised. It was suggested that appropriate levels of out-of-hours support hold; be included in future contracts. Action P. Clyde, B. Hislop
- bioMérieux remote access to Viteks
F. MacKenzie noted that this had been requested by the SMF / SMVN since the contract’s inception. A bioMérieux “ViLink” brochure had been circulated to the group. It is available at no extra cost but requires an N3 connection. Some Boards were in discussion with their e-Health departments as to whether or not it can be introduced. Health Boards have different systems which may complicate remote access nationally.
- bioMérieux field safety notices/letters
A database of all field safety notices is now available on the SMVN members’ website. The large number of field safety notices issued recently is of concern but that it was encouraging that bioMérieux had been in regular contact. AST Group members noted that there were still people who should be receiving notices that had not done so recently. This will be fed back to bioMérieux. Action F. MacKenzie
- New Scottish Gram negative AST cards
F. MacKenzie reported that the new cards had been signed off after lengthy discussions about discrepant results for co-amoxiclav comparing old and new cards. BioMérieux have reported that the new cards will available in December/January 2018.
- EUCAST BPs / interpretative criteria – rollout
The Scottish update to EUCAST 2017 guidelines has been a significant step forward. M. Macleod noted that the 2018 EUCAST guidelines will be reviewed in December 2017.
M. MacLeod noted that the rollout of the 2017 EUCAST breakpoints across NHS GGC had gone well. Subsequent testing of NEQAS samples did not flag any issues.
M. Macleod noted that there may be issues with Candida breakpoints with the new bioMérieux Candida AST cards. BPs to be an issue. It was reiterated that SMVN laboratories should be using EUCAST breakpoints and, if not available, CLSI values should be used.
- Vitek 2 card product limitations / rules
F. MacKenzie noted that a call would take place the week beginning 13th November with Rachel Mason on this topic.
- Reporting “intermediate” results
E. Olson noted that ECOSS did not always use the minimum inhibitory concentration (MIC) value bur rather, used S/I/R data. He noted that NHS Lothian had changedall “intermediate” to “resistant” on clinical reports. The practice in other Health Boards varied.
- Antifungal BPs / interpretative criteria
There was varied practice across Scotland. M. MacLeod noted that there was an antifungal group within SAPG. It was noted that testing varied across Health Boards.
- General mycology AST
It was noted that Liz Johnson (Bristol) would be presenting at the SMVN educational event in November 2017. It was suggested that an SMVN antifungal subgroup be established and an open invitation be sent out. Action F. MacKenzie
11. Outline business case to retender for standardised AST systems
F. MacKenzie reported that at the last meeting with bioMérieux the fact that many Vitek machines and computers had outlived the recommended seven years life expectancy was raised. F. MacKenzie had highlighted the possibility of securing new financial support to purchase new equipment at the meeting. This would be through the Diagnostic Steering Group (DSG) which has a direct link to Health Board Chief Executives who have the power to sanction a refresh of AST equipment across Scotland. F. MacKenzie had suggested that she / the SMVN write an outline business case with input from National Procurement to be submitted to the DSG in time for the December meeting. It was noted that due to the capital required National Procurement had advised that a new tender be proposed rather than a refresh of the Vitek systems.
It was highlighted that bioMérieux had already replaced some Vitek equipment and computers. NHS Tayside noted that they now had a surplus of Viteks due to a new replacement by bioMérieux.
B. Hislop noted that the Shared Services agenda could affect future National Procurement tenders. He noted that NHS Highland and NHS Grampian were currently entering into MSCs and these could complicate achieving the following Scottish Government aims laid out in the CLO letter: [Ref: CEL 30(2008), CNO letter F3643324]
“Vitek 2 should be the primary method of (antibiotic) sensitivity testing to allow efficiencies of detection and reporting and integration into other electronic reporting systems within NHS Boards and for national surveillance”.
It was advised that the outline business case for a new tender exercise be paused until greater clarity of the Shared Services agenda and regionalisation of Health Boards had taken place.
It was suggested that the AST Group had time to establish if any other companies could compete for the Scottish AST work. E. Olson agreed to send on the report on EUCAST AST device compliance to the rest of the AST Group. Action E. Olson
12. SAPG update
M. MacLeod represents the SMVN AST Group at SAPG and will continue to provide a link between the two groups. She noted that development of empirical guidelines on antibiotic prescription across Scotland is a SAPG priority.
HEALTH PROTECTION SCOTLAND
13. Colistin testing / Scottish AMR Satellite Reference Laboratory
M. Lockhart noted that the remit of the Scottish AMR Satellite Reference Laboratory was limited to CPO detection. He noted that they were trying to avoid duplication of effort. Laboratories will have to continue to send isolates to two different laboratories as AMRHAI is developing Colistin broth AST testing but this will eventually be taken on by the Scottish laboratory and will avoid duplicate isolate being sent.
In general, M. Lockhart noted that any isolates sentto a Public Health England (PHE) laboratorymust be on the list agreed via the Service Agreement (SA) between NHS National Services Scotland and PHE. He will share the SLA / listwith the SMVN. He noted that £150,000 is spent per year on testingin PHE laboratories. AST testing accounts for a large portion of this. Action M. Lockhart
14. Gonorrhoea and emerging resistance
E. Olson noted that NHS Lothian had surveyed current testing methods across Scotland and the report will be shared with the SMVN AST group. It was noted that all specimens should be sent to the reference laboratory in NHS Lothian. Action E. Olson
15. AMR Alert data
M. Lockhart noted that this had been developed almost a decade before the weekly AMR alerts system was introduced. He noted that the AMT Alert list was based on an agreed list of exceptional drug / bug issues and was now included in national Infection Prevention and Control manual. It was agreed that the SMVN AST group was the right one to determine if the list was appropriate.It was suggested that exceptional resistances could be fed back at the next SMVN AST meeting.
M. Lockhart noted that some laboratories were sending incomplete data to ECOSS and it was agreed that all AST members should check how integrated their Health Board LIMS is with ECOSS. A separate report or grouping of each organism was suggested.
It was highlighted that laboratories could see how they were performing against the rest of Scotland if they logged onto the ECOSS website. In order for the data report to be more useful it was suggested that laboratories should not be anonymised.
It was suggested that AMR alerts should be communicated as soon as they are identified rather than on a weekly schedule.