BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    CHROMID CPS ELITE AGAR

    MDR report key: 10678248 · Received October 14, 2020

    Report

    Report Number
    9615755-2020-00017
    Event Type
    Malfunction
    Date Received
    October 14, 2020
    Report Date
    November 17, 2020
    Manufacturer
    BIOMERIEUX S.A.
    Product Code
    JXA
    UDI-DI
    03573026443900
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    FR
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL

    Narratives

    Additional Manufacturer Narrative · 0

    AN INTERNAL BIOMÉRIEUX INVESTIGATION WAS PERFORMED FOLLOWING CUSTOMER NOTIFICATION FROM TWO FRENCH CUSTOMERS OF CONTAMINATION WITH ACINETOBACTER NOSOCOMIALIS IN ASSOCIATION WITH CHROMID® CPS ELITE 100 PL TRANS (REF. (B)(4), LOT 1008224320). THE INVESTIGATION REVIEWED THE PRODUCTION AND RELEASE RECORDS FOR THE LOT IN QUESTION. NO ANOMALIES WERE NOTED DURING THE MANUFACTURING PROCESS. BEFORE RELEASING THE PLATES, QUALITY CONTROL TESTS WERE PERFORMED USING SAMPLES FROM VARIOUS POINTS WITHIN THE PROCESS. ALL RESULTS MET RELEASE CRITERIA FOR DISTRIBUTION. THE INVESTIGATION OBSERVED RETAINED SAMPLES OF THE IMPACTED LOT FOR EVIDENCE OF CONTAMINATION. UPON OPENING OF THE RETAINED PLATE KITS, NO CONTAMINATION WAS VISIBLE. THE RETAINED SAMPLES WERE THEN INCUBATED FOR FIVE DAYS IN AEROBIC CONDITIONS AT 33-37°C. PLATES WERE EXAMINED EACH DAY TO CHECK FOR ANY GROWTH. AFTER FIVE DAYS OF INCUBATION, CONTAMINATION WAS NOT OBSERVED. THE CONTAMINATION REPORTED BY THE CUSTOMER WAS NOT REPRODUCED ON THE RETAINED SAMPLES. THE CUSTOMERS REPORTING THIS ISSUE RETURNED A TOTAL OF 700 PLATES TO BE USED IN THE INVESTIGATION. THE PLATES ARRIVED IN CLOSED PLASTIC PACKS WITH 10 PLATES EACH. THIRTY-FOUR PLATES WERE DISCARDED DUE TO BREAKAGE THAT OCCURRED DURING TRANSPORT. FROM THE REMAINING PLATES, 666 PLATES, SEVEN WERE FOUND TO BE CONTAMINATED UPON OPENING OF THE PLASTIC PACKAGING. THERE WAS A SINGLE BROWN-ISH COLONY ON EACH. THE COLONIES WERE IDENTIFIED AS ACINETOBACTER BAUMANII COMPLEX BY THE VITEK® 2 SYSTEM. THE MANUFACTURING TIMES FOR THESE SEVEN PLATES WERE BETWEEN 11HOURS 10MINUTES AND 11HOURS 21MINUTES. THIS CONTAMINATION MUST HAVE OCCURRED DURING MANUFACTURING AS THE CONTAMINATED PLATES WERE STILL SEALED WITHIN THEIR PLASTIC PACKAGING. NONE OF THE OTHER PLATES (659) PRESENTED ANY CONTAMINATION BEFORE USE. THEY WERE INCUBATED UNDER AEROBIC CONDITIONS AT 33-37°C FOR FIVE DAYS AND CHECKED EACH DAY. NO OTHER CONTAMINATION WAS OBSERVED ON THE REMAINING PLATES. THE CUSTOMER¿S CONTAMINATION AFTER INCUBATION ISSUE WAS NOT REPRODUCED. TREND ANALYSIS REVEALED ONLY THESE TWO CUSTOMER REPORTS OF CONTAMINATION FOR LOT#1008224320. IN CONCLUSION, THE BACTERIAL CONTAMINATION AFTER USE WAS NOT REPRODUCED ON RETAINED SAMPLE PLATES NOR RETURNED PLATES. CONTAMINATION BEFORE USE WAS CONFIRMED WITH THE SAME TYPE OF BACTERIUM FOUND AT THE CUSTOMER¿S SITE AND DURING INVESTIGATION (ACINETOBACTER BAUMANII COMPLEX/NOSOCOMIALIS). HOWEVER, DATA FROM THE INVESTIGATION INDICATES A LOW LEVEL OF CONTAMINATION DURING MANUFACTURING AS ONLY ONE COLONY WAS OBSERVED ON SEVEN OUT OF 666 PLATES PROVIDED FOR THE INVESTIGATION. THIS CONTAMINATION OCCURRED OVER A SHORT PERIOD OF TIME AS THE IMPACTED MANUFACTURING TIMES WERE BETWEEN 11H06 AND 11H31 (MANUFACTURED 05-AUG-2020). FURTHERMORE, AT THE TIME THAT THIS IMPACTED LOT WAS MANUFACTURED, THE ENVIRONMENTAL CONTROL DATA INDICATED THAT ALL THE CONTROLS WERE WITHIN SPECIFICATIONS. THE LEVELS OF CONTAMINATION BY ACINETOBACTER IN THE PRODUCTION AREAS WILL BE MONITORED. THE PROBABILITY OF HARM WAS ASSESSED BY BIOMERIEUX TO BE IMPROBABLE. THE CUSTOMERS WERE REMINDED TO FOLLOW GUIDANCE IN THE INSTRUCTIONS FOR USE FOR PRODUCT CHROMID® CPS® AGAR (CPSE), REFERENCE (B)(4): ¿DO NOT USE PLATES THAT ARE CONTAMINATED.¿

    Description of Event or Problem · 1

    A CUSTOMER FROM (B)(6) NOTIFIED BIOMÉRIEUX OF CONTAMINATION WITH ACINETOBACTER NOSOCOMIALIS IN ASSOCIATION WITH CHROMID® CPS ELITE 100 PL TRANS (REF. 416172, LOT 1008224320). THE CUSTOMER RECEIVED A TOTAL OF FIFTEEN KITS OF 100 PLATES EACH OF LOT 1008224320; TOTAL OF ONE HUNDRED FIFTY (150) AGAR PLATES WERE IDENTIFIED AS CONTAMINATED. THE CUSTOMER STATED FOUR (4) PATIENT URINE SAMPLES WERE TESTED USING THE CONTAMINATED PLATES. AGAR PLATES FROM TWO PATIENTS OBTAINED A RESULT OF ACINETOBACTER NOSOCOMIALIS ONLY; AGAR PLATES FROM THE OTHER TWO PATIENT SAMPLES OBTAINED RESULTS OF ACINETOBACTER NOSOCOMIALIS AND ESCHERICHIA COLI. STERILITY TESTING WAS PERFORMED USING TEN (10) AGAR PLATES FROM LOT 1008224320, SIX OF THE TEN PLATES FAILED THE STERILITY TEST AND EXHIBITED GROWTH. THE CUSTOMER STATED THE RESULT OF ACINETOBACTER NOSOCOMIALIS WAS REPORTED TO THE TREATING PHYSICIAN; HOWEVER, THERE IS NO INDICATION OR REPORT FROM THE LABORATORY THAT THE DISCREPANT RESULTS LED TO ANY ADVERSE EVENT RELATED TO ANY PATIENT'S STATE OF HEALTH. BIOMÉRIEUX HAS INITIATED AN INTERNAL INVESTIGATION.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1145238 CHROMID CPS ELITE AGAR CHROMID® CPS ELITE AGAR JXA BIOMERIEUX S.A. 1008224320 03573026443900

    Patients

    Seq Age Sex Outcome Treatment
    1