Automated Identification System and Antimicrobial Susceptibility Testing

Silva, Ivan V.
Introduction
Misidentification of pathogens, contamination of samples, and failure to follow complex
laboratory procedures, are just a few of the factors that cause result errors in clinical
microbiology. These factors (Rossi et al., 2023) are brought about by the utilization of
conventional methods in analyzing and preparing samples. In line with this, the use of
this methodology is directly related to being too time consuming, too labor-extensive
and being less precise and inaccurate.

However, in light of the emergence of technology, instrumental analysis in clinical

laboratory analysis paved the way for a much more efficient, highly automated, and
accurate analysis of substances sought to provide physicians with enough data to help
their patients. Various instrumentation techniques are applied to various samples, hence
various basic principles of chemistry should also be understood to better interpret and
analyze data (Rouessac, 2022). Clinical instrumentation ensures that the choice of
instrumentation, processing and treatment of the sample is well established through
standardization of procedures. In line with this, errors are much minimized, producing
quality samples. Thus, Clinical instrumentation plays a significant role in modern
healthcare, particularly in the diagnosis, monitoring, and treatment of patients because
instrumentation offers much accurate sensitivity and specificity (Bakan & Umudum,
2021).

Nevertheless, the fast and precise identification of pathogens, and knowing the
susceptibility and resistance of pathogens, are the two of the most important and two of
the most challenging tasks in clinical microbiology. However, with the abovementioned
significance of clinical instrumentation, and rapid adaptation of clinical laboratories to
technology, identification and classifying the properties of the pathogens have come a
long way. It is now fast, precise, efficient, and automated through the help of VITEK 2
(Decarli et al., 2022).

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Principle of the Technique
When performing microbial identification and antimicrobial susceptibility testing,
specimens such as blood culture, urine culture, and wound culture are utilized. These
specimens carry the substance being sought, or the analyte– being the different
microorganism to be identified and analyzed.

Different microorganisms are said to have different biochemical properties, different

biochemical properties means different microorganisms undergo different biochemical
reactions (El-Masry et al., 2023). The sample that carries the microorganism to be
identified is inoculated in a special test containing biochemical substances specific for
different samples and is then incubated. The microorganism is expected to react with
the biochemical substances. Thus, this provides VITEK 2’s microbial identification
system the data to recognize biochemical behaviors in a substance that provides data in
the identification of microorganisms.

On the other hand, the antimicrobial susceptibility testing in VITEK 2’s system is
measured by how the microorganism present on the specimen grows when inoculated
on a specific test for the substance carrying the specimen incubated with minimal
chemical concentration of antibiotics. The minimal concentration of antibiotics is
recorded as the minimum inhibitory concentration of the reaction (Henderson et al.,
2021). The gathered data on the microorganism’s growth pattern and minimum
inhibitory concentration are then compared to the database of the VITEK 2’s system. As
a result of VITEK 2’s efficient and reliable automation, identification of microorganisms
and their susceptibility to antibiotics are now time-saving, and are cost-effective.

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Operating Procedure/Technique/Process

According to the manufacturing company, Biomerieux, the first process in this

instrumentation technique when utilizing the VITEK 2 is the specimen collection, it is
where a clinical sample, for example blood, is collected from the patient suspected of
having a bacterial infection. The phlebotomist is expected to gather venous blood.
Special culture bottles are utilized to promote bacterial growth within the sample. Also,
the special culture bottles are designed to be integrated into the VITEK 2.

Note: specimen samples for this technique are not limited to blood. Urine, Sputum, and
even wounds are other clinical samples that can be cultured and be tested for
microorganisms along with their antibiotic resistance.

It is immediately followed by specimen processing, where the specimen in the special

culture bottle is observed. When bacterial growth is seen within 18 to 24 hours, it is
cultured and processed to a solid medium, particularly a non-selective agar plate. This
process isolates the microorganism.

After isolation, Inoculation is performed, where a VITEK 2 test card is inoculated with
the isolated bacterial using a sterile inoculating loop. The test card contains different

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growth medium concentrations of antibiotics. A 15-minute interval is observed so that
reaction readings can be read in the optical system.

The growth and resistance of microorganisms to antibiotics can be further observed in

Incubation within the system. It is where the inoculated VITEK 2 test card is placed into
the VITEK 2 instrument, which automatically incubates the card and monitors the
growth of the bacterial strain in each well over a specified period of time.

Data is then generated. The first data that will be gathered is the identity of the
microorganism. Based on the biochemical reactions of the microorganism, the VITEK 2
will compare the reactions to other reactions in the database. The second data
generated is the antimicrobial susceptibility of the microorganism which is based on
measuring the minimum chemical concentration of antibiotics that the microorganism is
susceptible to.

After data is gathered, it is then analyzed and interpreted. The results of the
identification and susceptibility testing are analyzed and interpreted by trained clinical
laboratory analysts who are knowledgeable about the guidelines, criteria, and principles
of VITEK 2’s system. The analysts determine the clinical significance of the results and
make recommendations for antimicrobial therapy. Results are then reported immediately
to the attending physician of the patient. In line with this, limitations of the test are also
discussed and pointed out.

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Analysis and Interpretation of Data

Identified Confidence Level Certaint

Microorganis of Identification y of Probability of Identification
m presenc
(simulation) e

Klebsiella Excellent 1 96% to 99%

pneumoniae

Pseudomonas Very Good 1 93% to 95%

aeruginosa

Acinetobacter Good 1 89% to 92%

baumannii

Candida Low Discrimination 2 to 3 Probability depends on Clinical analyst’s

Albicans choice

Mycobacterium Unidentified > 3 or 0 N/A

Tuberculosis Organism

Probability of Identification Interpretation from Biomerieux

≥99.9% Highly reliable identification
99.0-99.9% Reliable identification
95.0-98.9% Moderately reliable identification
90.0-94.9% Less reliable identification
<90.0% Identification not reliable

A probability of <90.0% can suggest that the microorganism is not yet defined in
the VITEK 2 system, or there are preparation errors that caused impurities (Pindicus,
2012).

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 Example of this is Minimum Inhibitory Susceptibility
Staphylococcus aureus. Concentration

Amoxicillin ≤2 Susceptible

Ampicillin 4 Intermediate

Ceftriaxone ≤1 Susceptible

Susceptibility in minimum inhibitory concentration shows that in a minimum chemical

concentration of the antibiotics, microorganisms are restrained or inhibited.
Susceptibility is based on Criteria set by Biomerieux.

According to UCD Research (2019), the ideal dosage of antibiotic can be calculated
through pharmacodynamics using this formula:
Dose = Cmax x Vd/F (mg/kg.day)

Applications

The Identification of microorganisms and microbial susceptibility testing can help

diagnose different tract infections that are due to the presence of harmful
microorganisms. (Wrenn, 2021)

Bloodstream infections, such as hospital-acquired bacteremia that are acquired during

hospitalization can cause conditions that can pose threat to one’s life. With the help of
the identification system and antimicrobial susceptibility testing using VITEK 2 (Barman,
2018), we can determine the microorganism, like the Staphylococcus aureus, that
causes the infection just by collecting and culturing blood specimens. With this, we can
have susceptibility testing to identify what antibiotic should be administered to the
infected person.

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Escherichia coli that causes urinary tract infection can also be identified by the VITEK 2
system. Urine samples are collected and cultured. To this, the identification and
susceptibility to antibiotics of the microorganisms collected from the data of the VITEK 2
system can be used to guide physicians, like the urologists, to properly prescribe the
right amount and type of antibiotics for the infection.

Lastly, pneumonia and bronchitis which are caused by viral pathogens can also be
identified by sputum specimens. Just like the previous infections, microorganisms
responsible for respiratory infections are identified to restrain them using the right type
and dosage of antibiotics with the help of gathered data. These data produced by the
VITEK 2 are relevant, not just in the microbiology section, but also to the whole clinical
laboratory setting.

References

Rossi, C.S., Coulon, F., Ma, S., Zhang, Y.S, Yang, Z. 2023. Microfluidics for Rapid
Detection of Live Pathogens. John Wiley & Sons, Ltd.

Rouessac. 2022. Chemical Analysis: Modern Instrumentation Methods and Techniques.

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Bakan E., Umudum, F.Z., 2021. Automation of extra-analytical phase for clinical
laboratory. Turkish Journal of Biochemistry

Decarli, A., Nascimento, L.V., Hiromi, S.E., Arenas, P., Yuki, V.M., 2022. The impact of
VITEK 2 implementation for identification and susceptibility testing of microbial isolates
in a Brazilian public hospital. Journal of Medical Microbiology.

El-Masry, E.A., Alruwaili F.M., Taha., A., Saad., A.E., Taher., I. 2023. Prevalence of
extended-spectrum beta-lactamase-producing Enterobacteriaceae among clinical

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Dublin.

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