MAUDE Adverse Event Report: BIOMÉRIEUX SA CHROMID CPS ELITE 20 PLT TRANS - 418284

Catalog Number 418284

Device Problem False Negative Result (1225)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Type  malfunction  

Event Description

Intended use: isolation, enumeration, and direct or presumptive identification of urinary tract infection organisms.This medium is an isolation, enumeration, and identification medium for urine specimens.This medium enables: the microbial enumeration of the specimen by means of standardized inoculation methods.The direct identification of escherichia coli.The presumptive identification of the following bacterial species or genera: enterococcus; klebsiella, enterobacter, serratia, citrobacter (kesc); proteus, morganella, providencia (pmp).Issue description: a customer in france notified biomérieux of a misidentification of klebsiella pneumoniae associated with chromid cps elite 20 plt trans- ref.(b)(4), lot 1010059790 which led to a delay in patient treatment.The customer identified pink colonies on the chromid cps 20 plates and performed bruker mass spectrometry to confirm the identification as klebsiella pneumoniae.The customer indicated that the isolate was transplanted and tested multiple times with consistent pink growth on chromid cps 20 plates.The customer indicated that this event led to a delay in patient treatment as the pink result on chromid cps elite 20 plt trans was used to select escherichia coli during susceptibility testing with vitek 2 resulting in inconsistent results.The isolate was then tested using bruker mass spectrometry to confirm the identification of klebsiella pneumoniae and retested using vitek 2 with consistent results.At the time of this assessment there is no indication or report from the customer that this event led to any adverse event related to any patient's state of health.

Manufacturer Narrative

An investigation was initiated in relation to a false identification of klebsiella pneumoniae strain on chromid® cps® elite agar (cpse) reference (b)(4), lot 1010059790 (expiration date 24-september-2023).The colonies were pink on the plate, leading to an identification of escherichia coli, but the identification performed on bruker resulted in an identification of klebsiella pneumoniae.During the troubleshooting, local customer service identified off-label use of the incubation of the plates at 35°c with co2, and use of the agar for urogenital swab.According to the package insert, ¿the medium is inoculated directly with urine¿.Furthermore, the incubation of the strains is in aerobic conditions.Conclusion an off-label use of the product was identified, related to incorrect sample tested and incorrect incubation condition.According to the package insert, chromid® cps® elite agar is a medium for isolation, enumeration, and direct or presumptive identification of urinary tract infection organisms.Thus, the medium is inoculated directly with urine.The incubation of the plates was realized in aerobic condition, at 35°c +/- 2°c, and the plates were examined after 18 to 24 hours of incubation.As the investigation did not identify any product performance issue, neither corrective nor preventive actions will be implemented.

Event Description

Intended use: isolation, enumeration, and direct or presumptive identification of urinary tract infection organisms.This medium is an isolation, enumeration, and identification medium for urine specimens.This medium enables: the microbial enumeration of the specimen by means of standardized inoculation methods.The direct identification of escherichia coli.The presumptive identification of the following bacterial species or genera: enterococcus; klebsiella, enterobacter, serratia, citrobacter (kesc); proteus, morganella, providencia (pmp).Issue description: a customer in france notified biomérieux of a misidentification of klebsiella pneumoniae associated with chromid cps elite 20 plt trans- ref.(b)(4), lot 1010059790 which led to a delay in patient treatment.The customer identified pink colonies on the chromid cps 20 plates and performed bruker mass spectrometry to confirm the identification as klebsiella pneumoniae.The customer indicated that the isolate was transplanted and tested multiple times with consistent pink growth on chromid cps 20 plates.The customer indicated that this event led to a delay in patient treatment as the pink result on chromid cps elite 20 plt trans was used to select escherichia coli during susceptibility testing with vitek 2 resulting in inconsistent results.The isolate was then tested using bruker mass spectrometry to confirm the identification of klebsiella pneumoniae and retested using vitek 2 with consistent results.At the time of this assessment there is no indication or report from the customer that this event led to any adverse event related to any patient's state of health.

Manufacturer Narrative

An investigation was initiated in relation to a false identification of klebsiella pneumoniae strain on chromid® cps® elite agar (cpse) reference (b)(4), lot 1010059790 (expiration date 24-september-2023).The colonies were pink on the plate, leading to an identification of escherichia coli, but the identification performed on bruker resulted in an identification of klebsiella pneumoniae.During the troubleshooting, local customer service identified off label use of the incubation of the plates at 35°c with co2, and use of the agar for urogenital swab.According to the package insert, ¿the medium is inoculated directly with urine¿.Furthermore, the incubation of the strains is in aerobic conditions conclusion an off-label use of the product was identified, related to incorrect sample tested and incorrect incubation condition.According to the package insert, chromid® cps® elite agar is a medium for isolation, enumeration, and direct or presumptive identification of urinary tract infection organisms.Thus, the medium is inoculated directly with urine.The incubation of the plates is realized in aerobic condition, at 35°c +/- 2°c, and the plates are examined after 18 to 24 hours of incubation.As the investigation did not identify any product performance issue, neither corrective nor preventive actions will be implemented.

Event Description

Intended use: isolation, enumeration, and direct or presumptive identification of urinary tract infection organisms.This medium is an isolation, enumeration, and identification medium for urine specimens.This medium enables: ¿ the microbial enumeration of the specimen by means of standardized inoculation methods.¿ the direct identification of escherichia coli.¿ the presumptive identification of the following bacterial species or genera: enterococcus; klebsiella, enterobacter, serratia, citrobacter (kesc); proteus, morganella, providencia (pmp) issue description: a customer in france notified biomérieux of a misidentification of klebsiella pneumoniae associated with chromid cps elite 20 plt trans- ref.(b)(4), lot 1010059790 which led to a delay in patient treatment.The customer identified pink colonies on the chromid cps 20 plates and performed bruker mass spectrometry to confirm the identification as klebsiella pneumoniae.The customer indicated that the isolate was transplanted and tested multiple times with consistent pink growth on chromid cps 20 plates.The customer indicated that this event led to a delay in patient treatment as the pink result on chromid cps elite 20 plt trans was used to select escherichia coli during susceptibility testing with vitek 2 resulting in inconsistent results.The isolate was then tested using bruker mass spectrometry to confirm the identification of klebsiella pneumoniae and retested using vitek 2 with consistent results.At the time of this assessment there is no indication or report from the customer that this event led to any adverse event related to any patient's state of health.

• Brand Name: CHROMID CPS ELITE 20 PLT TRANS - 418284
• Type of Device: CHROMID CPS ELITE 20 PLT TRANS
• Manufacturer (Section D): BIOMÉRIEUX SA; 6, c de isaac newton; tres cantos; madrid 28760 ; SP 28760
• Manufacturer (Section G): BIOMÉRIEUX, SA; 6, c de isaac newton; tres cantos; madrid 28760 ; SP 28760
• Manufacturer Contact: benjamen jost ; 595 anglum road; hazelwood, MO 63042
• MDR Report Key: 17541125
• MDR Text Key: 321724469
• Report Number: 3009307598-2023-00002
• Device Sequence Number: 1
• Product Code: JXA
• UDI-Device Identifier: 03573026468828
• UDI-Public: 03573026468828
• Combination Product (y/n): N
• Reporter Country Code: FR
• PMA/PMN Number: C1 EXEMPT
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Health Professional,User Facility
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup,Followup
• Report Date: 09/18/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 08/14/2023
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Expiration Date: 09/24/2023
• Device Catalogue Number: 418284
• Device Lot Number: 1010059790
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 08/22/2023
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1