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Comparison of the automated Phoenix with the Vitek 2 for the identification of Streptococcus pneumoniae1
Scott A. Mittman, Richard C. Huard, Phyllis Della-Latta, and Susan Whittier
Abstract: Rapid and accurate identification of Streptococcus pneumoniae is a critical component in the optimal management of infected patients. The performance of the BD Phoenix Automated Microbiology System (BD Diagnostic Systems, ´ Sparks, Md.) was evaluated for identification of S. pneumoniae (n = 311) and was compared to the Vitek 2 (bioMerieux, ´ Marcy l’Etoile, France). Strains with discordant identification between methods were resolved with 16S rRNA gene sequencing as the gold standard. The Phoenix and the Vitek 2 correctly identified 96.8% (n = 301) and 95.2% (n = 296) of S. pneumoniae strains, respectively. Overall, there was no statistically significant difference in the performance of the 2 automated systems for the identification of S. pneumoniae in this study. The Vitek 2 mean time-to-results for all streptococcal identification was 1.5 h faster than that for the Phoenix. We conclude that the automated Phoenix and the Vitek 2 systems are comparable in their ability to identify S. pneumoniae and are preferable to the use of routine biochemical assays, which have delayed time-to-results and are not dependably accurate. Key words: identification, Streptococcus pneumoniae. ` ´ ´ Resume : L’identification rapide et fiable de Streptococcus pneumoniae est critique a la prise en charge optimale des pa´ ` ´ ´´ ´ ´ tients infectes. La performance du systeme automatise BD Phoenix (BD Diagnostic Systems, Sparks, Md.) a ete evaluee ´´ ´ ` ` ´ dans l’identification de S. pneumoniae (n = 311), et elle a ete comparee a celle du systeme Vitek 2 (bioMerieux, Marcy ´ ´ ´ ´´ ´ ´ l’Etoile, France). Les souches dont les indentifications par les deux methodes etaient discordantes ont ete resolues par se´ ´ ´ quencage de ARNr 16S comme utilise comme etalon-or. Phoenix et Vitek 2 ont correctement identifie 96,8 % (n = 301) et ¸ ´ 95,2 % (n = 296) des souches de S. pneumoniae, respectivement. Globalement, il n’y avait pas de difference significative ` ´ ´ dans la performance des 2 systemes automatises pour identifier S. pneumoniae dans cette etude. Le temps moyen d’ob´ ´ tention des resultats d’identification de tous les streptocoques du Vitek 2 etait 1,5 h plus rapide que celui du Phoenix. ` ´ ´ ` Nous concluons que les systemes automatises Phoenix et Vitek 2 sont comparables dans leur capacite a identifier S. ´ ´ ` ˆ pneumoniae et qu’ils sont preferables a l’utilisation des essais biochimiques de routine, qui sont plus longs sans etre plus fiables pour autant. ´ Mots-cles : identification, Streptococcus pneumoniae. ´ [Traduit par la Redaction]
Streptococcus pneumoniae infections are a significant cause of morbidity and mortality in the United States and include mucosal infections such as otitis media, conjunctivitis, and sinusitis, as well as invasive infections such as meningitis, bacteremia, and pneumonia. In the United States, S. pneumoniae is the leading cause of community-acquired pneumonia and is the sixth most common cause of death due to an infectious disease (File 2004). The Centers for
Disease Control and Prevention (2008) recently reported that 14% of hospitalized adults with invasive S. pneumoniae do not survive their infections. Consequently, the accurate and rapid identification of S. pneumoniae can impact optimal therapy and could improve patient outcomes. Species-level identification of the a-hemolytic streptococci through phenotypic differentiation can be particularly challenging, given both limited differential species-defining biochemical characteristics and intra-species strain-to-strain biodiversity ¨ (Haanpera et al. 2007). In addition, some pneumococci may
Received 28 October 2009. Revision received 9 February 2010. Accepted 23 February 2010. Published on the NRC Research Press Web site at cjm.nrc.ca on 16 April 2010. S.A. Mittman. Clinical Microbiology Service, NewYork-Presbyterian Hospital, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA. R.C. Huard, P. Della-Latta, and S. Whittier.2 Clinical Microbiology Service, NewYork-Presbyterian Hospital, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA; Department of Pathology, NewYork-Presbyterian Hospital, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA.
of this study were presented at the 2007 American Society of Microbiology 107th General Meeting in Toronto, Ontario, Canada. 2Corresponding author (e-mail: email@example.com).
Can. J. Microbiol. 56: 326–332 (2010) doi:10.1139/W10-016 Published by NRC Research Press
Marcy ´ l’Etoile. pneumoniae identification ¨ (Kellogg et al.nlm.63 in a 0. In this study. Sparks. pneumoniae ¨ (Haanpera et al. pneumoniae are needed. Species-level identification was accomplished by both BLASTN analysis of full-length consensus sequences in GenBank (http://www. there is currently no phenotypic ‘‘gold standard’’ for accurate S. Isolates that were not identified as S. the BD Phoenix Automated Microbiology System (BD Diagnostic ´ Systems.4%) from the eye. However.gov/BLAST/) as well as by comparing against 16S rRNA sequences in an in-house database. 2007). 2008). Md. The instrument detects bacterial growth and metabolic reactions in the microwells of plastic test cards based on colorimetric changes. Automated systems are commonly used in clinical microbiology laboratories for routine pathogen identification because they generally offer benefits such as enhanced reproducibility. The Vitek 2 is an automated system for identification and antimicrobial susceptibility testing using sealed disposable cards. wound. Remel.ncbi.5–0. 2001. Richter et al. Phoenix The identification of S.5–0. pneumoniae by one or more methods were subjected to 16S rRNA sequencing for species determination. Following 18–24 h of incubation on BAP. Basel. Published by NRC Research Press Materials and methods Study isolates This comparative evaluation studied 311 unique S. misidentification (incorrect assignment). Data on colorimetric and fluorometric signals were automatically collected by the instrument every 20 min and used to derive the kinetic measurements that provided the ID determination. The Phoenix system ID database includes S. Characterization of the nearly full-length 16S rRNA gene sequence (Petti 2007) by this protocol allows for the differentiation of most streptococcal species. reading.g. 2000. The 16S rRNA database was derived from the sequencing of control and QC streptococcal strains of known identity and downloads from the complete genomic sequence of S. low level of discrimination (inability to differentiate between 2 species). Resolution of ID discrepancies IDs other than S. All isolates used in the study had been previously identified as S. pneumoniae and Streptococcus mitis (our unpublished data). pneumoniae strain TIGR4 (GenBank accession No.6%). sequencing. tissue. accuracy. hemolysis on BBL Columbia Agar with 5% sheep blood agar (BAP) (BD Diagnostic Systems). ear. and genotypic identification methods are not widely utilized in most clinical microbiology laboratories.45% sodium chloride solution. logged. to evaluate their ability to correctly identify S. and in silico analysis of the resultant ~1533 bp streptococcal 16S rRNA PCR fragment were performed as previously described (Schlaberg et al.nih. pneumoniae strains (n = 10) were confirmed by 16S rRNA gene sequencing. 36 isolates were derived from blood (11. pneumoniae clinical isolates. optochin susceptibility (P-disk containing 5 mg of optochin (BD Diagnostic Systems) and (or) bile solubility (BD Diagnostic Systems) testing. The inoculum was prepared by adjusting a bacterial suspension to a McFarland standard of 0. The species identity of a random subset of typical S. The Vitek 2 ID database includes 33 streptococcal species. and incubated at 35 8C. they are not often used for S. Amplification. Kanemitsu et al. 2004. 2002. Amplification and sequencing of the 16S rRNA gene Bacterial DNA was extracted from pure cultures using the BioRobot EZ1 Magtration System 68G (Qiagen. Each single isolate was recovered from individual patient specimens at a major academic medical center in New York City over a 4-year period (2003– 2007). and 43 isolates from other sources (e. pneumoniae. Interpretation of results Isolate ID results were divided into one of 4 categories: correct ID. Unfortunately. 2003. with the ID substrates located on one side and the microwells for AST on the other. including S. 2008). 2005). Phoenix uses an identification (ID) and antimicrobial susceptibility testing combination panel (SMIC/ID-100). Panels were sealed. slide co-agglutination (Phaedebact.. including those with infrequent species-specific polymorphisms. pneumoniae using the Phoenix system was performed according to the manufacturer’s protocols (Donay et al. France). 2004. Vitek 2 Inoculation. Verhelst et al. body fluid). and expedited time-to-results (TTR). Switzerland) and the Qiagen EZ1 DNA Blood 350 mL kit. Arbique et al. Identification was repeated in parallel on both automated systems alongside routine biochemical testing to confirm results.Mittman et al. 327 yield misidentifications when single biochemical tests for identification are used (Chandler et al. following the instructions of the manufacturer. For these reasons. pneumoniae and 31 other streptococcal species. Lenexa. Pikis et al. Kans. such as those that occur between S. Wester et al.6 McFarland standard of turbidity with a CrystalSpec Nephelometer (BD Diagnostic Systems). 2001. AE005672). 20 isolates (6. and no ID (no assignment). The test pool of isolates was a combination of prospectively acquired (n = 167) and frozen strains (n = 144). Routine culture and biochemical-based identification Streptococcus pneumoniae isolates were identified initially by colony morphology. Briefly. 2007). Respiratory sources accounted for 68% of the total isolates (212 of 311). improved methods for the identification of S. Kellogg et al.) and the Vitek 2 (bioMerieux.). Isolates were subcultured onto BAP and incubated for 24 h at 37 8C before testing on the Vitek 2 system. loaded into the Phoenix carousel. 2001. a bacterial suspension was made in ID broth and adjusted to . and interpretation of Vitek 2 panels were performed according to the manufacturer’s instructions. pneumoniae identification because of system limitations in the identification of a-hemolytic streptococci and laboratory over-reliance on traditional biochemical tests. 2000. pneumoniae generated by either the Phoenix system or the Vitek 2 resulted in repeat testing. pneumoniae by biochemical tests. Haanpera et al. a 0. Whatmore et al. we performed a side-by-side comparison of 2 automated systems.
Each of these was negative for L-pyrrolidonyl arylamidase. pneumoniae discordants Ten of 13 (77. respectively. pneumoniae strains that were difficult to identify using one or both of the automated systems also showed unexpected variability in biochemical testing (Table 2).3) 6 (1. S. pneumoniae strain that produced a low-level discrimination or discordant ID by the Phoenix and (or) the Vitek 2 as compared to the results of repeat biochemical testing.8) 4 (1. pneumoniae isolates Comparative results obtained for the identification of 311 S. pneumoniae. and 2 strains were optochin resistant. With regard to biochemical testing. the Vitek 2 correctly identified 296 strains (95. Such variability in biochemical testing may be suggestive of broader phenotypic heterogeneity and thereby correlate with the misidentification of these strains by the automated systems. pneumoniae. unexpected Published by NRC Research Press . 2 strains were bile insoluble. pasteurianus strain was additionally negative for b-galactopurinosidase. Fisher’s exact test). Confirmatory testing showed that all atypical biochemical results were the same when repeated.8) Performance and statistical analyses The statistical significance of differences in the ID results between the automated systems was calculated using Fisher’s exact test. Overall. accounting for 78% (18/23) of the 23 isolates described in Table 2. Tracheal aspirates (n = 2).4% (306/311). 98. of strains (%) Phoenix Correct ID Species-level ID Low-level discrimination Total Discordant ID Misidentification No ID Total 293 (94. Although there were fewer misidentifications of pneumococci by the Phoenix than by the Vitek 2. Of the 7 biochemically ‘‘atypical’’ pneumococci. Gardnerella vaginalis.2) Vitek 2 296 (95.415. By comparison. the Phoenix resulted in 4 misidentifications and 6 no IDs (3.028. another strain (resulted as Gardnerella vaginalis) was positive for 2 tests (tyrosine arylamidase and D-maltose) that were not indicative of Gardnerella vaginalis but rather of S. mitis/Streptococcus oralis. In terms of discordant IDs. pneumoniae. Overall. 3 were correctly identified by Phoenix and 2 by Vitek 2. pneumoniae strains (2. pneumoniae and 6 strains that the Phoenix either misidentified as S. Results were deemed significant with a p £ 0. In addition. Both Phoenix and Vitek 2 provided discordant IDs for 4 S.9) 10 (3.2%). as suggested by the Phoenix expert system. pneumoniae strains for which Phoenix either provided a correct species-level ID (n = 5) or reported a low-level discrimination ID (n = 6). pneumoniae misidentifications by the Vitek 2 were designated as non-streptococci. as S. Analysis of S. 296 (95.2%) S. the Phoenix tended to provide no ID (6 of 10 strains) while the Vitek 2 was more likely to report an incorrect ID (13 of 15 strains) (p = 0. 9 strains (reported as Granulicatella adiacens) were positive for the a-glucosidase test.8%) and 296 (95. while the S. pneumoniae isolates by the Phoenix and the Vitek 2 are summarized in Table 1. Vol. and routine biochemical results were confirmed with repeat testing. Results Identification of S.0%) S. 2 strains were bile insoluble and optochin resistant. and slide co-agglutination. and 7 were considered atypical with variable biochemical test results. Fisher’s exact test). for difficult-to-identify S. which was consistent with the subsequent test ID result.2) 2 (0. The Phoenix produced an accurate identification for 293 S. with 13 misidentifications and 2 no IDs (4. One strain was slide co-agglutination negative and optochin resistant. Two ‘‘atypical’’ isolates were incorrectly identified by both systems.2) 13 (4.6) 15 (4. pneumoniae strains in this study (p = 0.05. These strains were variably negative for 9 tests that were expected to be positive for S. oralis (n = 1) or provided no ID (n = 2) that the Vitek 2 correctly identified as S.6) 301 (96. 2010 Table 1.2) 8 (2. No. Analysis of Vitek 2 substrate patterns for S. bile solubility. 7 S.7% (310/311) for optochin. 301 (96. Overall. pneumoniae.328 Can.2% in total) compared to the Vitek 2. throat (n = 2). Comparison of automated systems for the identification (ID) of Streptococcus pneumoniae (n = 311). J.2%).6%) had low-level discrimination IDs (S.8%) were typical pneumococci.2) 0. pneumoniae isolates were correctly identified by the Phoenix and Vitek 2. There were also 3 misidentified strains that were correctly identified to the genus level. mitis/S. pneumoniae ID discrepancies The true IDs for discordant isolates were investigated using 16S rRNA sequencing. but with an incorrect species assignment. mitis/S. the strains with low-level discrimination and discordant results were recovered largely from sputum (n = 9) and eye sources (n = 9). Table 3 lists select individual Vitek 2 biochemical tests and the results that were obtained for the misidentified strains. Therefore. there was no statistically significant difference in the performance of the 2 automated systems for the identification of S. but was an expected result for S. Interestingly. mitis (n = 3) or S. Similarly. pneumoniae strains in common. pneumoniae) that were resolved by supplementary bile solubility testing. Table 2 lists the evaluation results of each 16S rRNA sequence-confirmed S.7% (307/311) and 99. oralis (n = 2) and S. or Streptococcus pasteurianus) or reported no ID (n = 1) for S. 56.8% in total). pneumoniae isolates. a result that was inconsistent with a Granulicatella adiacens ID. Microbiol. pasteurianus (n = 1). The data showed that Vitek 2 either misidentified (n = 10) (as Granulicatella adiacens. The proportion of isolates with biochemical test results consistent with those expected for S. pneumoniae were 98. while another 8 S. respectively. In addition. there were no strains with low-level discrimination IDs. pneumoniae strains (94. there were 2 low-level discrimination IDs by the Phoenix that were correctly identified by Vitek 2 as S. and blood (n = 1) accounted for the remainder. 304 of the 311 isolates (98.
pneumoniae isolates that were evaluated herein. a Expected results for Streptococcus pneumoniae were (+) for all biochemicals. –. pneumoniae S. D-trehalose. mitis/S. pneumoniae isolates by the Phoenix that we reported is in general agreement with the reported statistics of 85. the Phoenix system averaged 6. but these differences were not statistically significant. Bile solubility: +. SAC. In this study. 97. (2005). NAG. of strains 5 3 1 1 2 1 Vitek 2 ID Granulicatella adiacens Granulicatella adiacens Granulicatella adiacens Gardnerella vaginalis S.16 to 12.5 h and averaged 4. resistant. these 2 methods were comparable in their ability to correctly identify S. there were 8 S. the Phoenix did report fewer S. 8. negative. LAC. mitis/S.5 h) faster than the mean Phoenix ID time. bile solubility (+). oralis S. pneumoniae Granulicatella adiacens Granulicatella adiacens No ID Co-agglutination – + + + + + + + + + + + + + + Bile solubility + + + + + + – + – + – + + + – Optochin R S R S S S S S S S R S R S R Phoenix S. PyrA. it should be noted that each of these studies examined isolate pools of S. positive. pneumoniae strains that proved difficult for one or both of the automated systems to correctly or definitively identify. mitis/S.46 and 5.94 h for concordant isolates. For instance. Overall. BGAR. pneumoniae of a considerably smaller size (n = 92. respectively). Expected results: slide co-agglutination (+).2%) than that reported by the Vitek 2 (4. oralis S. mitis/S.35 h for low-level discrimination IDs (S. Table 2. pneumoniae (96. (2006). mitis/S. D-galactosidase. pasteurianus S. pneumoniae). Discussion To the best of our knowledge. pneumoniae S. It should be noted that in each of the low-level discrimination IDs we described. pneumoniae. TyrA. D-maltose.3 h for misidentification isolates. a-glucosidase. biopatterns of substrate utilization appeared to be the cause of the incorrect identification by the Vitek 2. The correct identification of 96. the Phoenix suggested supplementary tests that Published by NRC Research Press . pneumoniae The TTR for the Phoenix system ranged from 2. pneumoniae S. Table 3.8% by Hirakata et al. Analysis of low-level discrimination and discordant Streptococcus pneumoniae isolatesa (n = 23). pneumoniae S. pneumoniae S. respectively) than the 311 S. R. pneumoniae S. (2005). lactose. there were several S. N-acetyl D-glucosamine.8% of S. pneumoniae discrepant IDs (3. susceptible.48 h. and 100% by Brigante et al. pasteurianus AGLU + + + + + + TyrA + + + + + + BGAR – – – + + – BGAL – – – + + + dMAL – – + + + + SAC – – + – + + dGAL – – – – + + dTRE – – – – + + LAC – – – – + + NAG – – + – + + PyrA – + + – – – Note: AGLU. pneumoniae S. b-galactopurinosidase. No. Time to results for identification of S. oralis No ID No ID No ID No ID Confirmed by 16S rRNA sequencing. 95.8% vs. pneumoniae Granulicatella adiacens Gardnerella vaginalis No ID S.2%. pneumoniae strains for which Phoenix reported a low-level discrimination ID. Automated systems No. The Vitek 2 mean time for all IDs was therefore 28% (~1. mitis S. BGAL.50 h for all isolates. optochin (S).28 h. there are no reports comparing the test characteristics of the Phoenix system against the Vitek 2 that specifically focus on identification of S. dGAL. tyrosine arylamidase. pneumoniae S. In this study. Vitek 2 TTR ranged from 2.8%). dTRE.25 to 8. saccharose– sucrose. dMAL. L-pyrrolidonyl arylamidase. mitis/S. b-galactosidase. pneumoniae S. pneumoniae S. and 12. and 46. of strains 1 4 1 2 1 1 1 2 1 2 1 2 1 2 1 a b 329 Biochemical testsb Vitek 2 Granulicatella adiacens Granulicatella adiacens S.75 h for misidentifications. Optochin susceptibility: S. pneumoniae S. 93.Mittman et al. The TTR average for a concordant ID was 4.9% by Kanemitsu et al. However. mitis S. mitis/S. Vitek 2 discordant identification biochemical analysisa (n = 13). However. with 5.
Richter et al. were our differentiation based upon optochin testing alone. Werno and Murdoch 2008). By increasing the inoculum density. Wester et al. pneumoniae and S. but in contrast to the Phoenix. Pikis et al. Balsalobre et al. Verhelst et al. 2005. Vitek 2 was unable to identify a single Granulicatella adiacens isolate (of 7).2% to 96. pneumoniae (Wester et al. 56. 2002. In terms of the Phoenix S. 2003. pneumoniae misidentifications. For example. mitis and 1 strain was S. and serological methods of S. Similar observations have been made by others where the reliance on ‘‘classic criteria’’ for S. cephalosporins. a bacterium belonging to a genus also known as nutritionally deficient streptococci (Robson et al. 1998. Sequencing of 16S rRNA determined that 8 strains were S. the potential exists for biovariable strains that will confound identification. 4 of 6 of which were also problematic with Vitek 2.63). 2000. 2008. for example. 2004). pneumoniae on the basis of biochemical testing alone. 2001. Optochin-sensitive oral nonpneumococcal streptococci are increasingly reported as well (Whatmore et al. Richter et al. Although statistics regarding bile-insoluble S. Abele-Horn et al. mitis group (Facklam 2002. these strains gave mixed patterns of results for slide co-agglutination. Microbiol. Richter et al. pneumoniae antigen detection are widely used assays that are generally reported to have very high sensitivities and high specificities (Kellogg et al. there are increasing reports of atypical S. pneumoniae strains (1. oralis (Facklam 2002). mitis. 2002. resulted by the Vitek 2. there were 4 strains that were reported as S. Arbique et al. 2001. pneumoniae could result (Haanpera et al. Kellogg et al. Ko et al. pneumoniae misidentifications that were observed. have been reported to have very high specificities and sensitivities (Kellogg et al. mitis group. Kaijalainen et al. pneumoniae isolates. pneumoniae are given between 1% (Robson et al. are >99% identical (Spellerberg and Brandt 2007). (2003). (2006) reported similar misidentifications with Vitek 2. However. 4 of the 16S rRNA sequencing-confirmed S. pneumoniae and other a-hemolytic streptococci (Chandler et al. given the high percentage of penicillin resistance with S. This modification in protocol might therefore be helpful in resolving similar unexpected Vitek 2 calls in the future. That is. In fact. estimates of optochin resistance among S. mitis. As the Phoenix and Vitek 2 systems utilize ID paradigms that rely upon expected biopatterns. there were substrate utilization signals that were counterindicative of the Vitek 2 assignment and yet agreed with the S. optochin susceptibility. we encountered 9 streptococcal strains that could not be definitively identified or excluded as S. Vol. With each of the Vitek 2 S. Pikis et al. pneumoniae are lacking. 2000. This has clinical relevance owing to the potential consequence of unnecessary changes in antibiotic prescription practices. Overall. The challenge posed by the aforementioned species to the automated systems might therefore be explained by their close genetic relationship. inferred from the high interspecies 16S rRNA sequence similarity that exists among members of the S. where they found Granulicatella adiacens and Gardnerella vaginalis named 6 times out of 162 pneumococci tested. pneumoniae is a member of the S. 2001) Published by NRC Research Press . and trimethoprim–sulfamethoxazole (Patel et al. pneumoniae strains as Granulicatella adiacens (n = 9).7 McFarland turbidity (from 0. 2003. pneumoniae strains (1. as truly penicillin-resistant S. 12 of the problematic strains were retested at an adjusted bacterial suspension of 0. were not pneumococci. 2001.330 Can. the Vitek 2 produced an incorrect ID (Granulicatella adiacens (n = 5) or S. pasteurianus (n = 1)). pneumoniae and S. 2000.8% (data not shown). these isolates could have been identified by default because of poor growth within the microwells on the Vitek 2 GP card. pneumoniae ID has been suggested to occasionally result in the misidentification of oropharyngeal streptococci as S. resolving 5 of the discrepant Granulicatella adiacens IDs. 2000. oralis. Whatmore et al. such as by slide co-agglutination. oralis (n = 1). 2001. In an attempt to improve identification success with the Vitek 2. (2008) showed that approximately 5% of S. mitis with unusual patterns of bile solubility and (or) optochin susceptibility that might make their identification and differentiation challenging (Phillips et al. 2000). a microorganism that is commonly understood to be resistant. Fenoll et al. with 1 strain not being identified and 3 others assigned to Granulicatella adiacens. pneumoniae ID. S. 2008). (2006) described optochin susceptibility for S. Granulicatella adiacens should be viewed with a high degree of suspicion and be confirmed by supplemental testing. The 16S rRNA of S. 5 of the 16S rRNA sequencing-confirmed S. the ID confidence percentages were high (data not shown). Moreover. Phillips et al. we were able to improve the ID concordance with the Vitek 2 from 95. According to another study from Woo et al. Kearns et al. 2007) and 4% (Spellerberg and Brandt 2007). In the course of routine clinical laboratory testing coincident with this study. 2007).6%) studied here (Table 2) would have been misidentified. 2010 confirmed a S. which includes S. the subsequent overreporting of ¨ penicillin-resistant S. In this study. 1988). pseudopneumoniae. optochin susceptibility appears to be the phenotypic characteristic most frequently used to differentiate between S. In fact. collected from 41 US medical centers for surveillance purposes.5–0. but that were correctly identified by the Vitek 2. Bile solubility. mitis (Spellerberg and Brandt 2007) and S. Looking more closely at these identifications and their respective substrate utilization patterns (Table 3). Therefore. for most of the misidentified strains. 2004) and oftentimes is used singularly for identification. and examples have been noted in reports going back at least 20 years (Kontiainen and Sivonen 1987. 1990. 2002). It is noteworthy that S.3%) we evaluated gave an unexpected bile insolubility test result (Table 2). 2001). rather than generating a definitive incorrect ID. and Streptococcus sanguinis. other biochemical tests used to detect the presence of capsular antigens. Six of the aforementioned Phoenix nondiscriminatory ID isolates were a source of difficulty with the Vitek 2 as well. Mundy et al. Bosshard et al. Streptococcus pseudopneumoniae. mitis. J. mitis (n = 3) and S. there were 6 S. pneumoniae expected biopattern. However. 1988. Woo et al. pneumoniae isolates that were not identified by the Phoenix. bile solubility or insolubility. On the other hand. 2007) and 1 other as Gardnerella vaginalis.65–0. At present. thus giving the false impression of an accurate final result. Indeed. pneumoniae isolates are also recognized to be less susceptible to macrolides. the Vitek 2 incorrectly identified 9 S. Pikis et al. and optochin susceptibility or resistance (data not shown).
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