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Scope
History Why Perform Antimicrobial Susceptibility Testing? How to Perform an Antimicrobial Susceptibility Test
Isolate Method (phenotypic, special tests, genotypic) Drug Standards (how breakpoints are derived; CLSI, EUCAST, BSAC, CDS)
Summary
History
Source: http://www.s1darvel.com/
Source: http://www.biography.com/
When I woke up just after dawn on September 28, 1928, I certainly didn't plan to revolutionize all medicine by discovering the world's first antibiotic, or bacteria killer. But I suppose that was exactly what I did.
Empiric Therapy
Investigations
Definitive Therapy
Patient LAM
89 year old Chinese female Previously hospitalized 2 months ago for cystitis
Urine culture ESBL positive E. coli Blood cultures negative
Now admitted from the A&E with fever, dysuria and increased urinary frequency for 3 days
Urine microscopy RBC 3, WBC > 2000, EC 0 Urine culture no bacterial growth
Predict treatment outcome Guide selection of most appropriate agent Provide alternatives drug allergy, oral option
Isolate
Method
Drug
Standards
Results
Isolate
Identity of bacterial isolate Normal flora Clinically significant number of colonies Predictable antibiotic susceptibility profile
Method
Phenotypic
Zone diameter Minimum inhibitory concentration (MIC)
Source: http://www.cdc.gov/
Source: http://www.cdc.gov/
Disk Diffusion
Source: http://bacterioweb.univ-fcomte.fr/
Source: http://www.cdc.gov/
Source: http://web.carteret.edu/
Source: http://web.carteret.edu/
Broth Macrodilution
Source: www.biomerieux.com
Source: www.biomerieux.com
Automated (Vitek2)
Source: www.biomerieux.com
Source: http://microblog.me.uk/
Cephalosporin
Clavulanic acid
Cephalosporin
Source: http://www.cepheid.com/
Source: http://www.ahsoman.com/
Source: http://www.pih.org/
Source: http://www.pih.org/
Drug
Species to be tested Institution formulary Commonly used antimicrobials Availability of antimicrobial agent for testing Tailored to specific needs of institution
Infectious disease physicians Clinical microbiologists Pharmacists Committees concerned with institutional formulary
Source: http://www.eucast.org/
Standards
MIC distribution
Wild-type Epidemiological cut-off (ECOFF)
susceptible
80 70 60 50 40 30 20 10 0 0.125 0.25 0.5 1 2 4 8 16
resistant
32
64
128
256
susceptible
80 70 60 50 40 30 20 10 0 0.125 0.25 0.5 1 2 4 8 16
resistant
32
64
128
256
Source: http://mic.eucast.org/
Source: http://mic.eucast.org/
???
Source: http://mic.eucast.org/
Standard CLSI
Media Mueller-Hinton agar Mueller-Hinton agar with 5% sheep blood Mueller-Hinton agar Mueller-Hinton agar with 5% defibrinated horse blood + 20 mg/L -NAD Iso-Sensitest agar Iso-Sensitest agar with 5% defibrinated horse blood + 20 mg/L NAD Sensitest agar Sensitest agar with 5% horse blood
EUCAST
0.5 McFarland
BSAC
United Kingdom
CDS
Australia
CLSI
Source: CLSI M100-S23E Performance Standards for Antimicrobial Susceptibility Testing - 23rd Informational Supplement
Source: CLSI M100-S23E Performance Standards for Antimicrobial Susceptibility Testing - 23rd Informational Supplement
EUCAST
Source: http://www.eucast.org/
Source: http://www.eucast.org/
BSAC
CDS
Categorical Interpretation
Category Susceptible Resistant Intermediate Interpretation High likelihood of therapeutic success High likelihood of therapeutic failure Uncertain therapeutic effect Drug concentration at body sites Buffer zone Antifungal susceptibility testing Susceptibility dependent on achieving maximal possible blood level Often seen with new antimicrobial agents
Nonsusceptible
Source: Rex and Pfaller CID 2002 - Has Antifungal Susceptibility Testing Come of Age?
Summary
Antimicrobial susceptibility tests allows us to
Predict treatment outcome Guide selection of most appropriate agent Provide alternatives
Factors to consider
Isolate Method Drug Standards
Source: http://www.channelnewsasia.com/