Performance Standards for Antimicrobial Susceptibility Testing

26th Edition

M100S Performance Standards for Antimicrobial Susceptibility Testing

This document provides updated tables for the Clinical and Laboratory Standards Institute antimicrobial susceptibility testing standards M02-A12, M07-A10, and M11-A8.

An informational supplement for global application developed through the Clinical and Laboratory Standards Institute consensus process.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. Clinical and Laboratory Standards Institute Setting the standard for quality in medical laboratory testing around the world.

The Clinical and Laboratory Standards Institute (CLSI) is a not-for-profit membership organization that brings together the varied perspectives and expertise of the worldwide laboratory community for the advancement of a common cause: to foster excellence in laboratory medicine by developing and implementing medical laboratory standards and guidelines that help laboratories fulfill their responsibilities with efficiency, effectiveness, and global applicability.

Consensus Process

Consensus—the substantial agreement by materially affected, competent, and interested parties—is core to the development of all CLSI documents. It does not always connote unanimous agreement, but does mean that the participants in the development of a consensus document have considered and resolved all relevant objections and accept the resulting agreement.

Commenting on Documents

CLSI documents undergo periodic evaluation and modification to keep pace with advancements in technologies, procedures, methods, and protocols affecting the laboratory or health care.

CLSI’s consensus process depends on experts who volunteer to serve as contributing authors and/or as participants in the reviewing and commenting process. At the end of each comment period, the committee that developed the document is obligated to review all comments, respond in writing to all substantive comments, and revise the draft document as appropriate.

Comments on published CLSI documents are equally essential, and may be submitted by anyone, at any time, on any document. All comments are managed according to the consensus process by a committee of experts.

Appeals Process

When it is believed that an objection has not been adequately considered and responded to, the process for appeals, documented in the CLSI Standards Development Policies and Processes, is followed.

All comments and responses submitted on draft and published documents are retained on file at CLSI and are available upon request.

Get Involved—Volunteer! Do you use CLSI documents in your workplace? Do you see room for improvement? Would you like to get involved in the revision process? Or maybe you see a need to develop a new document for an emerging technology? CLSI wants to hear from you. We are always looking for volunteers. By donating your time and talents to improve the standards that affect your own work, you will play an active role in improving public health across the globe.

For additional information on committee participation or to submit comments, contact CLSI.

Clinical and Laboratory Standards Institute 950 West Valley Road, Suite 2500 Wayne, PA 19087 USA P: +1.610.688.0100 F: +1.610.688.0700 www.clsi.org [email protected] Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. M100S,M100S, 26th 26th ed. ed.

Performance Standards for Antimicrobial Susceptibility Testing

Abstract

The supplemental information presented in this document is intended for use with the antimicrobial susceptibility testing procedures published in the following Clinical and Laboratory Standards Institute (CLSI)–approved standards: M02-A12—Performance Standards for Antimicrobial Disk Susceptibility Tests; Approved Standard—Twelfth Edition; M07-A10—Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria That Grow Aerobically; Approved Standard—Tenth Edition; and M11-A8—Methods for Antimicrobial Susceptibility Testing of Anaerobic Bacteria; Approved Standard— Eighth Edition. The standards contain information about both disk (M02) and dilution (M07 and M11) test procedures for aerobic and anaerobic bacteria.

Clinicians depend heavily on information from the microbiology laboratory for treatment of their seriously ill patients. The clinical importance of antimicrobial susceptibility test results demands that these tests be performed under optimal conditions and that laboratories have the capability to provide results for the newest antimicrobial agents.

The tabular information presented here represents the most current information for drug selection, interpretation, and QC using the procedures standardized in the most current editions of M02, M07, and M11. Users should replace the tables published earlier with these new tables. (Changes in the tables since the previous edition appear in boldface type.)

Clinical and Laboratory Standards Institute (CLSI). Performance Standards for Antimicrobial Susceptibility Testing. 26th ed. CLSI supplement M100S (ISBN 1-56238-923-8 [Print]; ISBN 1-56238- 924-6 [Electronic]). Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087 USA, 2016.

The data in the interpretive tables in this supplement are valid only if the methodologies in M02-A12—Performance Standards for Antimicrobial Disk Susceptibility Tests; Approved Standard—Twelfth Edition; M07-A10—Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria That Grow Aerobically; Approved Standard—Tenth Edition; and M11-A8—Methods for Antimicrobial Susceptibility Testing of Anaerobic Bacteria; Approved Standard— Eighth Edition are followed.

1 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 1 M100S, 26th ed.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015.2

M100S, 26th ed. January 2016 Replaces M100-S25 Performance Standards for Antimicrobial Susceptibility Testing

Jean B. Patel, PhD, D(ABMM) Franklin R. Cockerill III, MD George M. Eliopoulos, MD

Stephen G. Jenkins, PhD, D(ABMM), F(AAM)

James S. Lewis II, PharmD Brandi Limbago, PhD M100S, 26th ed. David P. Nicolau, PharmD, FCCP, FIDSA January 2016 Robin Patel, MD Replaces M100-S25 PerformanceMair Powell, MD, FRCP,Standards FRCPath for Antimicrobial Susceptibility Testing Sandra S. Richter, MD, D(ABMM) Jana M. Swenson, MMSc JeanMaria B. M. Patel, Traczewski, PhD, D(ABMM) BS, MT(ASCP) FranklinJohn D. Turnidge, R. Cockerill MD III, MD GeorgeMelvin P.M. Weinstein, Eliopoulos, MD MD StephenBarbara L.G. Zimmer,Jenkins, PhD,PhD D(ABMM), F(AAM) James S. Lewis II, PharmD Brandi Limbago, PhD David P. Nicolau, PharmD, FCCP, FIDSA Robin Patel, MD Mair Powell, MD, FRCP, FRCPath Sandra S. Richter, MD, D(ABMM) Jana M. Swenson, MMSc Maria M. Traczewski, BS, MT(ASCP) John D. Turnidge, MD Melvin P. Weinstein, MD Barbara L. Zimmer, PhD

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine

Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015.

M100S, 26th ed. M100S, 26th ed.

Copyright ©2016 Clinical and Laboratory Standards Institute. Except as stated below, any reproduction of content from a CLSI copyrighted standard, guideline, companion product, or other material requires express written consent from CLSI. All rights reserved. Interested parties may send permission requests to [email protected].

CLSI hereby grants permission to each individual member or purchaser to make a single reproduction of this publication for use in its laboratory procedures manual at a single site. To request permission to use this publication in any other manner, e-mail [email protected].

Suggested Citation

CLSI. Performance Standards for Antimicrobial Susceptibility Testing. 26th ed. CLSI supplement M100S. Wayne, PA: Clinical and Laboratory Standards Institute; 2016.

Previous Editions: December 1986, December 1987, December 1991, December 1992, December 1994, December 1995, January 1997, January 1998, January 1999, January 2000, January 2001, January 2002, January 2003, January 2004, January 2005, January 2006, January 2007, January 2008, January 2009, January 2010, June 2010, January 2011, January 2012, January 2013, January 2014, January 2015

ISBN 1-56238-923-8 (Print) ISBN 1-56238-924-6 (Electronic) ISSN 1558-6502 (Print) ISSN 2162-2914 (Electronic) Volume 36, Number 1

4 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015.4 M100S,M100S, 26th 26th ed. ed.

Committee Membership

Consensus Committee on Microbiology

Richard B. Thomson, Jr., PhD, Jean B. Patel, PhD, D(ABMM) Jeffrey L. Watts, PhD, RM(NRCM) D(ABMM), FAAM Centers for Disease Control and Zoetis Chairholder Prevention USA Evanston Hospital, NorthShore USA University HealthSystem Nancy L. Wengenack, PhD, USA Kerry Snow, MS, MT(ASCP) D(ABMM) FDA Center for Drug Evaluation and Mayo Clinic John H. Rex, MD, FACP Research USA Vice-Chairholder USA AstraZeneca Pharmaceuticals Barbara L. Zimmer, PhD USA John D. Turnidge, MD Beckman Coulter, Inc. Australian Commission on Safety and USA Thomas R. Fritsche, MD, PhD Quality in Health Care Marshfield Clinic Australia USA

Subcommittee on Antimicrobial Susceptibility Testing

Jean B. Patel, PhD, D(ABMM) James S. Lewis II, PharmD Mair Powell, MD, FRCP, FRCPath Chairholder Oregon Health and Science University MHRA Centers for Disease Control and USA United Kingdom Prevention USA Brandi Limbago, PhD Sandra S. Richter, MD, D(ABMM) Centers for Disease Control and Cleveland Clinic Franklin R. Cockerill III, MD Prevention USA Vice-Chairholder USA Analyte Health, Inc. John D. Turnidge, MD USA David P. Nicolau, PharmD, FCCP, Australian Commission on Safety and FIDSA Quality in Health Care George M. Eliopoulos, MD Hartford Hospital Australia Beth Israel Deaconess Medical Center USA USA Melvin P. Weinstein, MD Robin Patel, MD Robert Wood Johnson University Stephen G. Jenkins, PhD, D(ABMM), Mayo Clinic Hospital F(AAM) USA USA New York Presbyterian Hospital USA Barbara L. Zimmer, PhD Beckman Coulter, Inc. USA Acknowledgment

CLSI, the Consensus Committee on Microbiology, and the Subcommittee on Antimicrobial Susceptibility Testing gratefully acknowledge the following volunteers for their important contributions to the development of this document:

Jana M. Swenson, MMSc Maria M. Traczewski, BS, USA MT(ASCP) The Clinical Microbiology Institute USA

5

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 5 M100S,M100S, 26th 26th ed. ed.

Working Group on AST Breakpoints

George M. Eliopoulos, MD David P. Nicolau, PharmD, FCCP, Simone Shurland Co-Chairholder FIDSA FDA Center for Devices and Beth Israel Deaconess Medical Hartford Hospital Radiological Health Center USA USA USA Mair Powell, MD, FRCP, Lauri D. Thrupp, MD James S. Lewis II, PharmD FRCPath UCI Medical Center (University Co-Chairholder MHRA of California, Irvine) Oregon Health and Science United Kingdom USA University USA Michael Satlin, MD, MS Hui Wang, PhD Weill Cornell Medical College Peking University People’s Karen Bush, PhD USA Hospital Committee Secretary China Indiana University Paul C. Schreckenberger, PhD, USA D(ABMM), F(AAM) Melvin P. Weinstein, MD Loyola University Medical Center Robert Wood Johnson University Marcelo F. Galas USA Hospital National Institute of Infectious USA Diseases Audrey N. Schuetz, MD, MPH, Argentina D(ABMM) Matthew A. Wikler, MD, MBA, Weill Cornell Medical FIDSA Amy J. Mathers, MD College/NewYork-Presbyterian The Medicines Company University of Virginia Medical Hospital USA Center USA USA Barbara L. Zimmer, PhD Beckman Coulter, Inc. USA

Working Group on Methodology

Stephen G. Jenkins, PhD, Joseph Kuti, PharmD Susan Sharp, PhD, D(ABMM), D(ABMM), F(AAM) Hartford Hospital F(AAM) Co-Chairholder USA American Society for Microbiology New York Presbyterian Hospital USA USA Sandra S. Richter, MD, D(ABMM) Cleveland Clinic Ribhi M. Shawar, PhD, D(ABMM) Brandi Limbago, PhD USA FDA Center for Devices and Co-Chairholder Radiological Health Centers for Disease Control and Darcie E. Roe-Carpenter, PhD, CIC, USA Prevention CEM USA Beckman Coulter, Inc. John D. Turnidge, MD USA Australian Commission on Safety William B. Brasso and Quality in Health Care BD Diagnostic Systems Katherine Sei Australia USA Beckman Coulter, Inc. USA Romney M. Humphries, PhD, D(ABMM) UCLA Medical Center USA

Laura M. Koeth, MT(ASCP) Laboratory Specialists, Inc. USA

6 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015.6 M100S,M100S, 26th 26th ed. ed.

Working Group on Quality Control

Steven D. Brown, PhD, ABMM Stephen Hawser, PhD Ross Mulder, MT(ASCP) Co-Chairholder IHMA Europe Sàrl bioMérieux, Inc. USA Switzerland USA

Sharon K. Cullen, BS, RAC Janet A. Hindler, MCLS, MT(ASCP) Susan D. Munro, MT(ASCP), CLS Co-Chairholder UCLA Medical Center USA Beckman Coulter, Inc. USA USA Robert P. Rennie, PhD Denise Holliday, MT(ASCP) R.P. Rennie Consultations LTD Jim Ross BD Diagnostic Systems Canada Committee Secretary USA JMI Laboratories Frank O. Wegerhoff, PhD, USA Michael D. Huband MSc(Epid), MBA JMI Laboratories USA William B. Brasso USA BD Diagnostic Systems Mary K. York, PhD, ABMM USA Erika Matuschek, PhD MKY Microbiology Consulting ESCMID USA Patricia S. Conville, MS, MT(ASCP) Sweden FDA Center for Devices and Radiological Health USA

Robert K. Flamm, PhD JMI Laboratories USA

Working Group on Text and Tables

Jana M. Swenson, MMSc Dyan Luper, BS, MT(ASCP)SM, MB Dale A. Schwab, PhD, D(ABMM) Co-Chairholder BD Diagnostic Systems Quest Diagnostics Nichols Institute USA USA USA

Maria M. Traczewski, BS, MT(ASCP) Linda M. Mann, PhD, D(ABMM) Richard B. Thomson, Jr., PhD, Co-Chairholder USA D(ABMM), FAAM The Clinical Microbiology Institute Evanston Hospital, NorthShore USA Melissa B. Miller, PhD, D(ABMM) University HealthSystem UNC Hospitals USA Carey-Ann Burnham, PhD, D(ABMM) USA Committee Secretary Nancy E. Watz, MS, MT(ASCP), Washington University School of Susan D. Munro, MT(ASCP), CLS CLS Medicine USA Stanford Hospital and Clinics USA USA

Flavia Rossi, MD Janet A. Hindler, MCLS, MT(ASCP) Mary K. York, PhD, ABMM University of São Paulo UCLA Medical Center MKY Microbiology Consulting Brazil USA USA

Peggy Kohner, BS, MT(ASCP) Mayo Clinic USA

Staff

Clinical and Laboratory Megan L. Tertel, MA, ELS Standards Institute Editorial Manager USA Joanne P. Christopher, MA, ELS Tracy A. Dooley, MLT(ASCP) Editor Project Manager Alexander B. Phucas Editor

7 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 7 M100S, 26th ed.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015.8 M100S,M100S, 26th 26th ed. ed.

Contents

Abstract ...... 1

Committee Membership ...... 5

Summary of Changes ...... 13

of Contents Table Summary of CLSI Processes for Establishing Interpretive Criteria and Quality Control Ranges ...... 22

CLSI Reference Methods vs Commercial Methods and CLSI vs US Food and Drug Administration Interpretive Criteria (Breakpoints) ...... 23

CLSI Breakpoint Additions/Revisions Since 2010 ...... 24

Subcommittee on Antimicrobial Susceptibility Testing Mission Statement ...... 26

Instructions for Use of Tables ...... 27

Table 1A. Suggested Groupings of Antimicrobial Agents With US Food and Drug Administration Clinical Indications That Should Be Considered for Routine Testing and Reporting on Nonfastidious Organisms by Microbiology Laboratories in the United States ...... 40

Table 1B. Suggested Groupings of Antimicrobial Agents With US Food and Drug Administration Clinical Indications That Should Be Considered for Routine Testing and Reporting on Fastidious Organisms by Microbiology Laboratories in the United States ...... 46

Table 1C. Suggested Groupings of Antimicrobial Agents With US Food and Drug Administration Clinical Indications That Should Be Considered by Microbiology Laboratories in the United States if Testing and Reporting on Anaerobic Organisms ...... 50

Tables 2A–2J. Zone Diameter and Minimal Inhibitory Concentration Interpretive Standards for:

2A-1. Enterobacteriaceae ...... 52

2A-2. Epidemiological Cutoff Values for Shigella flexneri and Shigella sonnei ...... 60

2B-1. Pseudomonas aeruginosa ...... 62

2B-2. Acinetobacter spp...... 66

2B-3. Burkholderia cepacia complex ...... 68

2B-4. Stenotrophomonas maltophilia ...... 70

2B-5. Other Non-Enterobacteriaceae ...... 72

2C. Staphylococcus spp...... 74

2D. Enterococcus spp...... 82

9 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 9 M100S, 26th 26th ed. ed.

Contents (Continued)

2E. Haemophilus influenzae and Haemophilus parainfluenzae ...... 86

2F. Neisseria gonorrhoeae ...... 90

2G. Streptococcus pneumoniae ...... 94

2H-1. Streptococcus spp. β-Hemolytic Group ...... 100

Table of Contents Table 2H-2. Streptococcus spp. Viridans Group ...... 104

2I. Neisseria meningitidis ...... 108

2J-1. Anaerobes ...... 112

2J-2. Epidemiological Cutoff Values for Propionibacterium acnes ...... 116

Table 3A. Tests for Extended-Spectrum β-Lactamases in Klebsiella pneumoniae, Klebsiella oxytoca, Escherichia coli, and Proteus mirabilis ...... 118

Introduction to Tables 3B and 3C. Tests for Carbapenemases in Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter spp...... 122

Table 3B. The Modified Hodge Test for Suspected Carbapenemase Production in Enterobacteriaceae ...... 124

Table 3B-1. Modifications of Table 3B When Using Interpretive Criteria for Carbapenems Described in M100-S20 (January 2010) ...... 126

Table 3C. Carba NP Test for Suspected Carbapenemase Production in Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter spp...... 130

Table 3C-1. Modifications of Table 3C When Using Minimal Inhibitory Concentration Interpretive Criteria for Carbapenems Described in M100-S20 (January 2010) ...... 133

Table 3D. Test for Detection of β-Lactamase Production in Staphylococcus species ...... 138

Table 3E. Test for Detection of Methicillin Resistance (Oxacillin Resistance) in Staphylococcus species, Except Staphylococcus pseudintermedius ...... 142

Table 3F. Vancomycin Agar Screen for Staphylococcus aureus and Enterococcus species ...... 146

Table 3G. Test for Detection of Inducible Clindamycin Resistance in Staphylococcus species, Streptococcus pneumoniae, and Streptococcus spp. β-Hemolytic Group ...... 148

Table 3H. Test for Detection of High-Level Mupirocin Resistance in Staphylococcus aureus ...... 152

Table 3I. Test for Detection of High-Level Aminoglycoside Resistance in Enterococcus species (Includes Disk Diffusion) ...... 154

10 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015.10 M100S,M100S, 26th 26th ed. ed.

Contents (Continued)

Table 4A. Disk Diffusion: Quality Control Ranges for Nonfastidious Organisms (Unsupplemented Mueller-Hinton Medium) ...... 156

Table 4B. Disk Diffusion: Quality Control Ranges for Fastidious Organisms ...... 160

Table 4C. Disk Diffusion: Reference Guide to Quality Control Frequency ...... 162

Table 4D. Disk Diffusion: Troubleshooting Guide...... 166 of Contents Table

Table 5A. MIC: Quality Control Ranges for Nonfastidious Organisms (Unsupplemented Mueller- Hinton Medium [Cation-Adjusted if Broth]) ...... 170

Table 5B. MIC: Quality Control Ranges for Fastidious Organisms (Broth Dilution Methods) ...... 174

Table 5C. MIC: Quality Control Ranges for Neisseria gonorrhoeae (Agar Dilution Method) ...... 178

Table 5D. MIC: Quality Control Ranges for Anaerobes (Agar Dilution Method) ...... 180

Table 5E. MIC: Quality Control Ranges for Anaerobes (Broth Microdilution Method)...... 182

Table 5F. MIC: Reference Guide to Quality Control Frequency ...... 184

Table 5G. MIC: Troubleshooting Guide ...... 188

Table 6A. Solvents and Diluents for Preparation of Stock Solutions of Antimicrobial Agents ...... 192

Table 6B. Preparation of Stock Solutions for Antimicrobial Agents Provided With Activity Expressed as Units...... 196

Table 6C. Preparation of Solutions and Media Containing Combinations of Antimicrobial Agents ...... 198

Table 7A. Scheme for Preparing Dilutions of Antimicrobial Agents to Be Used in Agar Dilution Susceptibility Tests ...... 202

Table 8A. Scheme for Preparing Dilutions of Antimicrobial Agents to Be Used in Broth Dilution Susceptibility Tests ...... 204

Table 8B. Scheme for Preparing Dilutions of Water-Insoluble Antimicrobial Agents to Be Used in Broth Dilution Susceptibility Tests ...... 206

Appendix A. Suggestions for Confirmation of Resistant (R), Intermediate (I), or Nonsusceptible (NS) Antimicrobial Susceptibility Test Results and Organism Identification ...... 208

Appendix B. Intrinsic Resistance ...... 214

Appendix C. Quality Control Strains for Antimicrobial Susceptibility Tests ...... 220

Appendix D. Cumulative Antimicrobial Susceptibility Report for Anaerobic Organisms ...... 226

Appendix E. Dosing Regimens Used to Establish Susceptible or Susceptible-Dose Dependent Interpretive Criteria…………………………………………...... 232

11 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 11 M100S, 26th 26th ed. ed.

Contents (Continued)

Appendix F. Cefepime Breakpoint Change for Enterobacteriaceae and Introduction of the Susceptible-Dose Dependent Interpretive Category ...... 234

Appendix G. Epidemiological Cutoff Values ...... 238

Glossary I (Part 1). β-Lactams: Class and Subclass Designation and Generic Name ...... 240

Glossary I (Part 2). Non–β-Lactams: Class and Subclass Designation and Generic Name ...... 242 Table of Contents Table

Glossary II. Abbreviations/Routes of Administration/Drug Class for Antimicrobial Agents Listed in M100S, 26th ed...... 244

Glossary III. List of Identical Abbreviations Used for More Than One Antimicrobial Agent in US Diagnostic Products ...... 248

The Quality Management System Approach ...... 250

Related CLSI Reference Materials ...... 251

The Clinical and Laboratory Standards Institute consensus process, which is the mechanism for moving a document through two or more levels of review by the health care community, is an ongoing process. Users should expect revised editions of any given document. Because rapid changes in technology may affect the procedures, methods, and protocols in a standard or guideline, users should replace outdated editions with the current editions of CLSI documents. Current editions are listed in the CLSI catalog and posted on our website at www.clsi.org. If you or your organization is not a member and would like to become one, and to request a copy of the catalog, contact us at: Telephone: +1.610.688.0100; Fax: +1.610.688.0700; E-mail: [email protected]; Website: www.clsi.org.

12 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015.12 M100S,M100S, 26th 26th ed. ed.

Summary of Changes

This list includes the “major” changes in this document. Other minor or editorial changes were made to the general formatting and to some of the table footnotes and comments. Changes to the tables since the previous edition appear in boldface type.

Additions, Changes, and Deletions The following are additions or changes unless otherwise noted as a “deletion.”

Instructions for Use of Tables

Summary of Changes Listed additional organisms included in the new edition of CLSI document M45 (p. 31).

Clarified recommendations for performance of susceptibility tests on subsequent isolates and expanded text to include information about methicillin-resistant Staphylococcus aureus (MRSA) from patients with prolonged bacteremia (p. 33).

Added new section defining routine, supplemental, screening, surrogate agent, and equivalent agent tests, which replaced the original “Screening Tests” section (p. 33).

Tables 1A, 1B, 1C – Drugs Recommended for Testing and Reporting

Clarified Group B Test/Report Group for Tables 1A and 1B (pp. 40, 42, and 46).

Deleted from Tables 1A, 1B, and/or 1C – dirithromycin, loracarbef, ofloxacin, piperacillin, quinupristin- dalfopristin, spectinomycin, telithromycin, and ticarcillin-clavulanate.

Enterobacteriaceae: Added ceftolozane-tazobactam to Test/Report Group B (p. 40).

Clarified information for use of cefazolin as a surrogate test for uncomplicated urinary tract infections (UTIs) in Group U (p. 41).

Pseudomonas aeruginosa: Moved piperacillin-tazobactam to Test/Report Group A (p. 40).

Added ceftolozane-tazobactam to Test/Report Group B (p. 40).

Staphylococcus spp.: Added oritavancin, tedizolid, and telavancin to Test/Report Group B (p. 40).

Enterococcus spp.: Added oritavancin, tedizolid, and telavancin to Test/Report Group B (p. 40).

Acinetobacter spp.: Moved tetracycline to Test/Report Group U (p. 42).

Burkholderia cepacia complex: Moved levofloxacin and meropenem to Test/Report Group A (p. 42).

Moved chloramphenicol to Test/Report Group C (p. 42).

13 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 13 M100S, 26th 26th ed. ed.

Summary of Changes (Continued)

Stenotrophomonas maltophilia: Moved chloramphenicol to Test/Report Group C (p. 42).

Haemophilus influenzae and Haemophilus parainfluenzae: Moved chloramphenicol to Test/Report Group C (p. 46).

Streptococcus spp. β-Hemolytic Group: Added oritavancin, tedizolid, and telavancin to Test/Report Group C (p. 46).

Summary of Changes Streptococcus spp. Viridans Group: Added ceftolozane-tazobactam, oritavancin, tedizolid, and telavancin to Test/Report Group C (p. 46).

Tables 2A Through 2J-2 – Interpretive Criteria (Breakpoints)

Enterobacteriaceae (Table 2A-1): Added new ceftolozane-tazobactam MIC interpretive criteria (p. 53).

Clarified the interpretive criteria used for cefazolin when it is used for therapy of infections other than uncomplicated UTIs (p. 53).

Clarified the interpretive criteria used for cefazolin when it is used for therapy of uncomplicated UTIs (p. 54).

Clarified the interpretive criteria used for cefazolin results to predict results of oral agents (p. 55).

Separated listing of fluoroquinolones to be tested and reported on Salmonella spp. isolates and those fluoroquinolones to be tested and reported on Enterobacteriaceae isolates (pp. 57 to 58).

Moved piperacillin and ticarcillin-clavulanate to Test/Report Group O (p. 53).

Moved lomefloxacin and ofloxacin to Test/Report Group O (p. 57).

Deleted cephalothin and ticarcillin.

Epidemiological Cutoff Values for Shigella flexneri and Shigella sonnei (Table 2A-2): Added new table with epidemiological cutoff values for azithromycin related to therapy of S. flexneri and S. sonnei infections (p. 60).

Pseudomonas aeruginosa (Table 2B-1): Added new ceftolozane-tazobactam disk diffusion and MIC interpretive criteria (p. 63).

Moved piperacillin to Test/Report Group O (p. 63).

Moved piperacillin-tazobactam to Test/Report Group A (p. 63).

Moved lomefloxacin and ofloxacin to Test/Report Group O (p. 64).

14 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015.14 M100S,M100S, 26th 26th ed. ed.

Summary of Changes (Continued)

Deleted ticarcillin.

Acinetobacter spp. (Table 2B-2): Moved piperacillin and ticarcillin-clavulanate to Test/Report Group O (p. 66).

Moved tetracycline to Test/Report Group U (p. 67).

Deleted mezlocillin and ticarcillin.

Summary of Changes Burkholderia cepacia complex (Table 2B-3): Moved ticarcillin-clavulanate to Test/Report Group O (p. 68).

Moved levofloxacin and meropenem to Test/Report Group A (p. 68).

Moved chloramphenicol to Test/Report Group C (p. 69).

Stenotrophomonas maltophilia (Table 2B-4): Moved ticarcillin-clavulanate to Test/Report Group O (p. 70).

Moved chloramphenicol to Test/Report Group C (p. 71).

Other Non-Enterobacteriaceae (Table 2B-5): Moved piperacillin and ticarcillin-clavulanate to Test/Report Group O (p. 72).

Moved lomefloxacin and ofloxacin to Test/Report Group O (p. 73).

Deleted carbenicillin, mezlocillin, and ticarcillin.

Staphylococcus spp. (Table 2C): Provided recommendations for end-point determination when trailing growth is seen (p. 74).

Clarified testing of penicillin to test susceptibility of staphylococci to all penicillins (p. 76).

Added new oxacillin disk diffusion and MIC interpretive criteria for detecting mecA-mediated resistance in S. pseudintermedius isolates (p. 77).

Added new oritavancin MIC interpretive criteria with note indicating for reporting against S. aureus only, including MRSA (p. 78).

Added new telavancin disk diffusion and MIC interpretive criteria with note indicating for reporting against S. aureus only, including MRSA (p. 78).

Added new tedizolid MIC interpretive criteria with note indicating for reporting against S. aureus only, including MRSA (p. 80).

Moved lomefloxacin and ofloxacin to Test/Report Group O (p. 79).

15 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 15 M100S, 26th 26th ed. ed.

Summary of Changes (Continued)

Enterococcus spp. (Table 2D): Provided recommendations for end-point determination when trailing growth is seen (p. 82).

Added new oritavancin MIC interpretive criteria with note indicating for reporting against vancomycin- susceptible E. faecalis only (p. 84).

Added new telavancin disk diffusion and MIC interpretive criteria with note indicating for reporting against vancomycin-susceptible E. faecalis only (p. 84).

Summary of Changes Added new tedizolid MIC interpretive criteria with note indicating for reporting against E. faecalis only (p. 85).

Haemophilus influenzae and Haemophilus parainfluenzae (Table 2E): Moved lomefloxacin, ofloxacin, and telithromycin to Test/Report Group O (p. 88).

Moved chloramphenicol to Test/Report Group C (p. 89).

Neisseria gonorrhoeae (Table 2F): Moved spectinomycin to Test/Report Group O (p. 92).

Streptococcus pneumoniae (Table 2G): Provided recommendations for end-point determination when trailing growth is seen (p. 94).

Moved ofloxacin and telithromycin to Test/Report Group O (p. 97).

Streptococcus spp. β-Hemolytic Group (Table 2H-1): Provided recommendations for end-point determination when trailing growth is seen (p. 100).

Clarified the use of penicillin as a surrogate for other antimicrobial agents (p. 101).

Added new oritavancin MIC interpretive criteria (p. 101).

Added new telavancin disk diffusion and MIC interpretive criteria (p. 101).

Added new tedizolid MIC interpretive criteria with note indicating for reporting against S. pyogenes and S. agalactiae only (p. 103).

Moved ofloxacin and quinupristin-dalfopristin to Test/Report Group O (pp. 102 to 103).

Streptococcus spp. Viridans Group (Table 2H-2): Provided recommendations for end-point determination when trailing growth is seen (p. 104).

Added new ceftolozane-tazobactam MIC interpretive criteria (p. 105).

Added new oritavancin MIC interpretive criteria (p. 105).

16 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015.16 M100S,M100S, 26th 26th ed. ed.

Summary of Changes (Continued)

Added new telavancin disk diffusion and MIC interpretive criteria (p. 105).

Added new tedizolid MIC interpretive criteria with note indicating for reporting against S. anginosus Group only (p. 106).

Anaerobes (Table 2J-1): Moved piperacillin and ticarcillin-clavulanate to Test/Report Group O (p. 113).

Deleted mezlocillin and ticarcillin. Summary of Changes

Tables 3A Through 3I – Tests for Determining Susceptibility and Resistance to Antimicrobial Agents

Revised titles for Tables 3A through 3I to clarify testing is to determine susceptibility and resistance (pp. 118 to 154).

Carba NP Confirmatory Test for Suspected Carbapenemase Production in Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter spp. (Table 3C) and Modifications of Table 3C When Using Minimal Inhibitory Concentration Interpretive Criteria for Carbapenems Described in M100-S20 (January 2010) (Table 3C-1): Provided new figure showing interpretation of color reactions for the Carba NP test (p. 135).

Tables 4 and 5 – Quality Control

Table 4A (p. 156): Added QC ranges for:

Escherichia coli ATCC® 25922 Aztreonam-avibactam Delafloxacin Gepotidacin Levonadifloxacin

Staphylococcus aureus ATCC® 25923 Delafloxacin Gepotidacin Lefamulin Levonadifloxacin

Pseudomonas aeruginosa ATCC® 27853 Aztreonam-avibactam Delafloxacin Levonadifloxacin

Escherichia coli ATCC® 35218 Aztreonam Aztreonam-avibactam

17 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 17 M100S, 26th 26th ed. ed.

Summary of Changes (Continued)

Klebsiella pneumoniae ATCC® 700603 Aztreonam Aztreonam-avibactam Cefotaxime Cefpodoxime Ceftazidime Ceftriaxone

Summary of Changes Table 4B (p. 160): Added QC ranges for:

Haemophilus influenzae ATCC® 49247 Delafloxacin Lefamulin Levonadifloxacin

Neisseria gonnorrhoeae ATCC® 49226 Solithromycin

Streptococcus pneumoniae ATCC® 49619 Delafloxacin Gepotidacin Lefamulin Levonadifloxacin

Table 4D (p. 166): Added information to troubleshoot reading zone edges when there is possible contamination or lighter growth in zone measure (eg, fuzzy zone edge).

Table 5A (p. 170): Added QC ranges for:

Staphylococcus aureus ATCC® 29213 Amikacin-fosfomycin Cadazolid Cefepime-tazobactam Delafloxacin Gepotidacin Imipenem-relebactam Lefamulin Levonadifloxacin

Enterococcus faecalis ATCC® 29212 Amikacin-fosfomycin Cadazolid Delafloxacin Imipenem-relebactam

18 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015.18 M100S,M100S, 26th 26th ed. ed.

Summary of Changes (Continued)

Escherichia coli ATCC® 25922 Amikacin-fosfomycin Cefepime-tazobactam Delafloxacin Gepotidacin Imipenem-relebactam Levonadifloxacin

® Pseudomonas aeruginosa ATCC 27853 Summary of Changes Amikacin-fosfomycin Cefepime-tazobactam Delafloxacin Imipenem-relebactam Levonadifloxacin

Escherichia coli ATCC® 35218 Imipenem-relebactam

Klebsiella pneumoniae ATCC® 700603 Cefepime-tazobactam

Table 5B (p. 174): Added/changed QC ranges for:

Haemophilus influenzae ATCC® 49247 Amikacin-fosfomycin Cefepime-tazobactam Delafloxacin Gepotidacin Lefamulin Levonadifloxacin

Haemophilus influenzae ATCC® 49766 Imipenem-relebactam

Streptococcus pneumoniae ATCC® 49619 Amikacin-fosfomycin Cefepime-tazobactam Delafloxacin Gepotidacin Lefamulin Levonadifloxacin Meropenem

19 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 19 M100S, 26th 26th ed. ed.

Summary of Changes (Continued)

Table 5C (p. 178): Added QC ranges for:

Neisseria gonnorrhoeae ATCC® 49226 Azithromycin Solithromycin

Table 5D (p. 180):

Summary of Changes Added QC ranges for:

Bacteroides fragilis ATCC® 25285 Eravacycline Secnidazole

Bacteroides thetaiotaomicron ATCC® 29741 Eravacycline Secnidazole

Clostridium difficile ATCC® 700057 Cadazolid Eravacycline Secnidazole

Eggerthella lenta (formerly Eubacterium lentum) ATCC® 43055 Secnidazole

Clarified why there are no QC ranges established for some antimicrobial agents with Eggerthella lenta (formerly E. lentum) ATCC® 43055.

Table 5E (p. 182): Added QC ranges for:

Bacteroides fragilis ATCC® 25285 Eravacycline

Bacteroides thetaiotaomicron ATCC® 29741 Eravacycline

Clostridium difficile ATCC® 700057 Cadazolid Eravacycline

Clarified why there are no QC ranges established for some antimicrobial agents with Eggerthella lenta (formerly E. lentum) ATCC® 43055.

Table 6A – Solvents and Diluents (p. 192):

Added antimicrobial agents:

Cadazolid

20 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015.20 M100S,M100S, 26th 26th ed. ed.

Summary of Changes (Continued)

Delafloxacin Gepotidacin Lefamulin Levonadifloxacin Secnidazole

Table 6C – Preparation of Solutions and Media Containing Combinations of Antimicrobial Agents (p. 198):

Summary of Changes Added:

Amikacin-fosfomycin Cefepime-tazobactam Imipenem-relebactam

Appendixes and Glossaries

Appendix A. Suggestions for Confirmation of Resistant (R), Intermediate (I), or Nonsusceptible (NS) Antimicrobial Susceptibility Test Results and Organism Identification: Added oritavancin, tedizolid, and telavancin to Enterococcus spp.; Staphylococcus aureus; Streptococcus, β-hemolytic group; and Streptococcus, viridans group listings (pp. 209 to 211).

Appendix B. Intrinsic Resistance:

Appendix B1. Enterobacteriaceae: Added additional antimicrobial agents that are intrinsically resistant to Enterobacteriaceae (p. 215).

Appendix B2. Non-Enterobacteriaceae: Deleted resistance “R” for Pseudomonas aeruginosa and fosfomycin.

New Appendix B5. Anaerobic Gram-Positive Bacilli (p. 219)

New Appendix B6. Anaerobic Gram-Negative Bacilli (p. 219)

Appendix C. Quality Control Strains for Antimicrobial Susceptibility Tests: Clarified why there are no QC ranges established for some antimicrobial agents with Eggerthella lenta (formerly E. lentum) ATCC® 43055 (p. 224).

Added E. coli NCTC 13353 as a supplemental QC strain (p. 222).

Glossary I – added amikacin-fosfomycin, cadazolid, cefepime-tazobactam, cefpirome, delafloxacin, gepotidacin, imipenem-relebactam, lefamulin, levonadifloxacin, rifaximin, secnidazole, sulfisoxazole, and trospectomycin (pp. 240 to 243).

Glossary II – added amikacin-fosfomycin, cadazolid, cefepime-tazobactam, cefpirome, delafloxacin, gepotidacin, imipenem-relebactam, lefamulin, levonadifloxacin, rifaximin, secnidazole, and trospectomycin (pp. 244 to 247).

21 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 21 M100S, 26th 26th ed. ed.

Summary of CLSI Processes for Establishing Interpretive Criteria and Quality Control Ranges

The Clinical and Laboratory Standards Institute (CLSI) is an international, voluntary, not-for-profit, interdisciplinary, standards-developing, and educational organization accredited by the American National Standards Institute (ANSI) that develops and promotes use of consensus-developed standards and guidelines within the health care community. These consensus standards and guidelines are developed to cover critical areas of diagnostic testing and patient health care, and are developed in an open and consensus-seeking forum. CLSI is open to anyone or any organization that has an interest in diagnostic testing and patient care. Information about CLSI can be found at www.clsi.org.

The CLSI Subcommittee on Antimicrobial Susceptibility Testing reviews data from a variety of sources and studies (eg, in vitro, pharmacokinetics-pharmacodynamics, and clinical studies) to establish antimicrobial susceptibility test methods, interpretive criteria, and QC parameters. The details of the data necessary to establish interpretive criteria, QC parameters, and how the data are presented for evaluation are described in CLSI document M23—Development of In Vitro Susceptibility Testing Criteria and Quality Control Parameters.

Over time, a microorganism’s susceptibility to an antimicrobial agent may decrease, resulting in a lack of clinical efficacy and/or safety. In addition, microbiological methods and QC parameters may be refined to ensure more accurate and better performance of susceptibility test methods. Because of this, CLSI continually monitors and updates information in its documents. Although CLSI standards and guidelines are developed using the most current information and thinking available at the time, the field of science and medicine is ever changing; therefore, standards and guidelines should be used in conjunction with clinical judgment, current knowledge, and clinically relevant laboratory test results to guide patient treatment.

Additional information, updates, and changes in this document are found in the meeting summary minutes of the Subcommittee on Antimicrobial Susceptibility Testing at www.clsi.org.

22 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015.22 M100S,M100S, 26th 26th ed. ed.

CLSI Reference Methods vs Commercial Methods and CLSI vs US Food and Drug Administration Interpretive Criteria (Breakpoints)

It is important for users of M02-A12, M07-A10, and the M100 Informational Supplement to recognize that the standard methods described in CLSI documents are reference methods. These methods may be used for routine antimicrobial susceptibility testing of clinical isolates, for evaluation of commercial devices that will be used in laboratories, or by drug or device manufacturers for testing of new agents or systems. Results generated by reference methods, such as those contained in CLSI documents, may be used by regulatory authorities to evaluate the performance of commercial susceptibility testing devices as part of the approval process. Clearance by a regulatory authority indicates that the commercial susceptibility testing device provides susceptibility results that are substantially equivalent to results generated using reference methods for the organisms and antimicrobial agents described in the device manufacturer’s approved package insert.

CLSI breakpoints may differ from those approved by various regulatory authorities for many reasons, including different databases, differences in interpretation of data, differences in doses used in different parts of the world, and different public health policies. Differences also exist because CLSI proactively evaluates the need for changing breakpoints. The reasons why breakpoints may change and the manner in which CLSI evaluates data and determines breakpoints are outlined in CLSI document M23—Development of In Vitro Susceptibility Testing Criteria and Quality Control Parameters.

Following a decision by CLSI to change an existing breakpoint, regulatory authorities may also review data in order to determine how changing breakpoints may affect the safety and effectiveness of the antimicrobial agent for the approved indications. If the regulatory authority changes breakpoints, commercial device manufacturers may have to conduct a clinical trial, submit the data to the regulatory authority, and await review and approval. For these reasons, a delay of one or more years may be required if an interpretive breakpoint change is to be implemented by a device manufacturer. In the United States, it is acceptable for laboratories that use US Food and Drug Administration (FDA)–cleared susceptibility testing devices to use existing FDA interpretive breakpoints. Either FDA or CLSI susceptibility interpretive breakpoints are acceptable to laboratory accrediting organizations. Policies in other countries may vary. Each laboratory should check with the manufacturer of its antimicrobial susceptibility test system for additional information on the interpretive criteria used in its system’s software.

Following discussions with appropriate stakeholders, such as infectious diseases practitioners and the pharmacy department, as well as the pharmacy and therapeutics and infection control committees of the medical staff, newly approved or revised breakpoints may be implemented by laboratories. Following verification, CLSI disk diffusion test breakpoints may be implemented as soon as they are published in M100. If a device includes antimicrobial test concentrations sufficient to allow interpretation of susceptibility and resistance to an agent using the CLSI breakpoints, a laboratory could choose to, after appropriate verification, interpret and report results using CLSI breakpoints.

23 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 23 M100S, 26th 26th ed. ed.

CLSI Breakpoint Additions/Revisions Since 2010 Date of Revision* Antimicrobial Agent (M100 edition) Comments Enterobacteriaceae Aztreonam January 2010 (M100-S20) Cefazolin January 2010 (M100-S20) Breakpoints were revised twice since 2010. January 2011 (M100-S21) Cefazolin January 2014 (M100-S24) Breakpoints added to predict results for January 2016 (M100S, cefazolin when cefazolin is used for 26th ed.) therapy of uncomplicated UTIs. Cefepime January 2014 (M100-S24) Cefotaxime January 2010 (M100-S20) Ceftazidime January 2010 (M100-S20) Ceftizoxime January 2010 (M100-S20) Ceftriaxone January 2010 (M100-S20) Doripenem June 2010 (M100-S20-U) No previous CLSI breakpoints existed for doripenem. Ertapenem June 2010 (M100-S20-U) Breakpoints were revised twice since 2010. January 2012 (M100-S22) Imipenem June 2010 (M100-S20-U) Meropenem June 2010 (M100-S20-U) Ciprofloxacin – Salmonella spp. January 2012 (M100-S22) Removed body site–specific breakpoint (including S. Typhi) recommendations in 2013. Ceftaroline January 2013 (M100-S23) No previous CLSI breakpoints existed for ceftaroline. Levofloxacin – Salmonella spp. January 2013 (M100-S23) (including S. Typhi) Ofloxacin – Salmonella spp. June 2013 (M100-S23) (including S. Typhi) Pefloxacin – Salmonella spp. January 2015 (M100-S25) Surrogate test for ciprofloxacin. (including S. Typhi) Azithromycin – S. Typhi only January 2015 (M100-S25) Ceftolozane-tazobactam January 2016 (M100S, No previous CLSI breakpoints existed 26th ed.) for ceftolozane-tazobactam. Pseudomonas aeruginosa Piperacillin-tazobactam January 2012 (M100-S22) Ticarcillin-clavulanate January 2012 (M100-S22) Doripenem January 2012 (M100-S22) Imipenem January 2012 (M100-S22) Meropenem January 2012 (M100-S22) Ticarcillin January 2012 (M100-S22) Piperacillin January 2012 (M100-S22) Ceftolozane-tazobactam January 2016 (M100S, No previous CLSI breakpoints existed 26th ed.) for ceftolozane-tazobactam. Acinetobacter spp. Doripenem January 2014 (M100-S24) Imipenem January 2014 (M100-S24) Meropenem January 2014 (M100-S24) Staphylococcus spp. Ceftaroline January 2013 (M100-S23) No previous CLSI breakpoints existed for ceftaroline. Oritavancin January 2016 (M100S, No previous CLSI breakpoints existed 26th ed.) for oritavancin.

24 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015.24 M100S,M100S, 26th 26th ed. ed.

CLSI Breakpoint Additions/Revisions Since 2010 (Continued) Date of Revision* Antimicrobial Agent (M100 edition) Comments Staphylococcus spp. (Continued) Tedizolid January 2016 (M100S, No previous CLSI breakpoints existed 26th ed.) for tedizolid. Telavancin January 2016 (M100S, No previous CLSI breakpoints existed 26th ed.) for telavancin. Enterococcus spp. Oritavancin January 2016 (M100S, No previous CLSI breakpoints existed 26th ed.) for oritavancin. Tedizolid January 2016 (M100S, No previous CLSI breakpoints existed 26th ed.) for tedizolid. Telavancin January 2016 (M100S, No previous CLSI breakpoints existed 26th ed.) for telavancin. Haemophilus influenzae and Haemophilus parainfluenzae Ceftaroline January 2013 (M100-S23) No previous CLSI breakpoints existed for ceftaroline. Streptococcus pneumoniae Ceftaroline January 2013 (M100-S23) No previous CLSI breakpoints existed for ceftaroline. Tetracycline January 2013 (M100-S23) Doxycycline January 2013 (M100-S23) No previous CLSI breakpoints existed for doxycycline. Streptococcus spp. β-Hemolytic Group Ceftaroline January 2013 (M100-S23) No previous CLSI breakpoints existed for ceftaroline. Oritavancin January 2016 (M100S, No previous CLSI breakpoints existed 26th ed.) for oritavancin. Telavancin January 2016 (M100S, No previous CLSI breakpoints existed 26th ed.) for telavancin. Streptococcus spp. Viridans Group Ceftolozane-tazobactam January 2016 (M100S, No previous CLSI breakpoints existed 26th ed.) for ceftolozane-tazobactam. Tedizolid January 2016 (M100S, No previous CLSI breakpoints existed 26th ed.) for tedizolid. Oritavancin January 2016 (M100S, No previous CLSI breakpoints existed 26th ed.) for oritavancin. Tedizolid January 2016 (M100S, No previous CLSI breakpoints existed 26th ed.) for tedizolid. Telavancin January 2016 (M100S, No previous CLSI breakpoints existed 26th ed.) for telavancin. * Previous breakpoints can be found in the edition of M100 that precedes the document listed here, eg, previous breakpoints for aztreonam are listed in M100-S19 (January 2009). Abbreviation: UTI, urinary tract infection.

25 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 25 M100S,M100S, 26th 26th ed. ed.

Subcommittee on Antimicrobial Susceptibility Testing Mission Statement

The Subcommittee on Antimicrobial Susceptibility Testing is composed of representatives from the professions, government, and industry, including microbiology laboratories, government agencies, health care providers and educators, and pharmaceutical and diagnostic microbiology industries. Using the CLSI voluntary consensus process, the subcommittee develops standards that promote accurate antimicrobial susceptibility testing and appropriate reporting.

The mission of the Subcommittee on Antimicrobial Susceptibility Testing is to:

 Develop standard reference methods for antimicrobial susceptibility tests.

 Provide quality control parameters for standard test methods.

 Establish interpretive criteria for the results of standard antimicrobial susceptibility tests.

 Provide suggestions for testing and reporting strategies that are clinically relevant and cost-effective.

 Continually refine standards and optimize detection of emerging resistance mechanisms through development of new or revised methods, interpretive criteria, and quality control parameters.

 Educate users through multimedia communication of standards and guidelines.

 Foster a dialogue with users of these methods and those who apply them.

The ultimate purpose of the subcommittee’s mission is to provide useful information to enable laboratories to assist the clinician in the selection of appropriate antimicrobial therapy for patient care. The standards and guidelines are meant to be comprehensive and to include all antimicrobial agents for which the data meet established CLSI guidelines. The values that guide this mission are quality, accuracy, fairness, timeliness, teamwork, consensus, and trust.

26 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015.26 For Use With M02-A12 and M07-A10 M100S,M100S, 26th 26th ed. ed.

Instructions for Use of Tables

The following pages include:

1. Tables 1A and 1B—Suggested groupings of antimicrobial agents that should be considered for routine testing and reporting by clinical microbiology laboratories. These guidelines are based on drugs with clinical indications approved by the US Food and Drug Administration (FDA) in the United States. In other countries, placement of antimicrobial agents in Tables 1A and 1B should be based on available drugs approved for clinical use by relevant regulatory agencies.

2. For each organism group, an additional table (Tables 2A through 2I) contains:  Recommended testing conditions  Routine QC recommendations (See also Chapter 4 in M02-A12 and M07-A10.)  General comments for testing the organism group and specific comments for testing particular drug/organism combinations  Suggested agents that should be considered for routine testing and reporting by clinical microbiology laboratories, as specified in Tables 1A and 1B (test/report groups A, B, C, U)  Additional drugs that have an approved indication for the respective organism group, but would generally not warrant routine testing by a clinical microbiology laboratory in the United States (test/report group O for “other”; test/report group Inv. for “investigational” [not yet FDA approved])  Zone diameter and minimal inhibitory concentration (MIC) interpretive criteria

3. Tables 1C and 2J-1 address specific recommendations for testing and reporting results on anaerobes and contain some of the information listed in 1 and 2 above.

4. Tables 3A to 3I describe tests to detect particular types of resistance in specific organisms or organism groups.

I. Selecting Antimicrobial Agents for Testing and Reporting

A. Selection of the most appropriate antimicrobial agents to test and to report is a decision best made by each laboratory in consultation with the infectious diseases practitioners and the pharmacy, as well as the pharmacy and therapeutics and infection control committees of the medical staff. The recommendations for each organism group include agents of proven efficacy that show acceptable in vitro test performance. Considerations in the assignment of agents to specific test/report groups include clinical efficacy, prevalence of resistance, minimizing emergence of resistance, cost, FDA clinical indications for use, and current consensus recommendations for first-choice and alternative drugs. Tests of selected agents may be useful for infection control purposes.

B. Drugs listed together in a single box are agents for which interpretive results (susceptible, intermediate, or resistant) and clinical efficacy are similar. Within each box, an “or” between agents indicates those agents for which cross-resistance and cross-susceptibility are nearly complete. Results from one agent connected by an “or” can be used to predict results for the other agent. For example, Enterobacteriaceae susceptible to cefotaxime can be considered susceptible to ceftriaxone. The results obtained from testing cefotaxime could be reported along with a comment that the isolate is also susceptible to ceftriaxone. For drugs connected with an “or,” combined major and very major errors are fewer than 3%, and minor errors are fewer than 10%, based on a large population of bacteria tested (see CLSI document M23 for description of error

Clinical and Laboratory Standards Institute. All rights reserved. 27 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 27 M100S,M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

types). In addition, to qualify for an “or,” at least 100 strains with resistance to the agents in question must be tested, and a result of “resistant” must be obtained with all agents for at least 95% of the strains. “Or” is also used for comparable agents when tested against organisms for which “susceptible-only” interpretive criteria are provided (eg, cefotaxime or ceftriaxone with Haemophilus influenzae). When no “or” connects agents within a box, testing of one agent cannot be used to predict results for another, owing either to discrepancies or insufficient data.

C. Test/Report Groups

1. As listed in Tables 1A, 1B, and 1C, agents in Group A are considered appropriate for inclusion in a routine, primary testing panel, as well as for routine reporting of results for the specific organism groups.

2. Group B includes antimicrobial agents that may warrant primary testing, but they may be reported only selectively, such as when the organism is resistant to agents of the same antimicrobial class, as in Group A. Other indications for reporting the result might include a selected specimen source (eg, a third-generation cephalosporin for enteric bacilli from CSF or trimethoprim-sulfamethoxazole for urinary tract isolates); a polymicrobial infection; infections involving multiple sites; cases of patient allergy, intolerance, or failure to respond to an antimicrobial agent in Group A; or for purposes of infection control.

3. Group C includes alternative or supplemental antimicrobial agents that may necessitate testing in those institutions that harbor endemic or epidemic strains resistant to several of the primary drugs (especially in the same class, eg, -lactams); for treatment of patients allergic to primary drugs; for treatment of unusual organisms (eg, chloramphenicol for extraintestinal isolates of Salmonella spp.); or for reporting to infection control as an epidemiological aid.

4. Group U (“urine”) includes certain antimicrobial agents (eg, nitrofurantoin and certain quinolones) that are used only or primarily for treating urinary tract infections (UTIs). These agents should not be routinely reported against pathogens recovered from other sites of infection. An exception to this rule is for Enterobacteriaceae in Table 1A, where cefazolin is listed as a surrogate agent for oral cephalosporins. Other antimicrobial agents with broader indications may be included in Group U for specific urinary pathogens (eg, Enterococcus and ciprofloxacin).

5. Group O (“other”) includes antimicrobial agents that have a clinical indication for the organism group but are generally not candidates for routine testing and reporting in the United States.

6. Group Inv. (“investigational”) includes antimicrobial agents that are investigational for the organism group and have not yet been approved by the FDA for use in the United States.

D. Selective Reporting

Each laboratory should decide which agents in the tables to report routinely (Group A) and which might be reported only selectively (from Group B), in consultation with the infectious diseases practitioners, the pharmacy, and the pharmacy and therapeutics and infection control committees of the health care institution. Selective reporting should improve the clinical relevance of test reports and help minimize the selection of multiresistant, health care–associated strains by overuse of broad-spectrum agents. Results for Group B antimicrobial agents tested but not reported routinely should be available on request, or they may be reported for selected specimen types. Unexpected resistance, when confirmed, should be reported (eg, resistance to a secondary agent but susceptibility to a primary agent, such as a P. aeruginosa isolate resistant to amikacin but susceptible to tobramycin; as such, both drugs should be reported). In addition, each laboratory should develop a protocol to cover isolates that are confirmed as resistant to all agents

28 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 28 ©Clinical and Laboratory Standards Institute. All rights reserved. M100S, 26th ed. For Use With M02-A12 and M07-A10 M100S,M100S, 26th 26th ed. ed. types). In addition, to qualify for an “or,” at least 100 strains with resistance to the agents in on its routine test panels. This protocol should include options for testing additional agents in- question must be tested, and a result of “resistant” must be obtained with all agents for at least house or sending the isolate to a reference laboratory. 95% of the strains. “Or” is also used for comparable agents when tested against organisms for which “susceptible-only” interpretive criteria are provided (eg, cefotaxime or ceftriaxone with II. Reporting Results Haemophilus influenzae). When no “or” connects agents within a box, testing of one agent cannot be used to predict results for another, owing either to discrepancies or insufficient data. The minimal inhibitory concentration (MIC) values determined as described in M07-A10 may be reported directly to clinicians for patient care purposes. However, it is essential that an C. Test/Report Groups interpretive category result (S, I, or R) also be provided routinely to facilitate understanding of the MIC report by clinicians. Zone diameter measurements without an interpretive category 1. As listed in Tables 1A, 1B, and 1C, agents in Group A are considered appropriate for inclusion should not be reported. Recommended interpretive categories for various MIC and zone diameter in a routine, primary testing panel, as well as for routine reporting of results for the specific values are included in tables for each organism group and are based on evaluation of data as organism groups. described in CLSI document M23.

2. Group B includes antimicrobial agents that may warrant primary testing, but they may be Recommended MIC and disk diffusion interpretive criteria are based on usual dosage regimens reported only selectively, such as when the organism is resistant to agents of the same and routes of administration in the United States. antimicrobial class, as in Group A. Other indications for reporting the result might include a selected specimen source (eg, a third-generation cephalosporin for enteric bacilli from CSF or A. Susceptible, susceptible-dose dependent, intermediate, resistant, or nonsusceptible interpretations trimethoprim-sulfamethoxazole for urinary tract isolates); a polymicrobial infection; infections are reported and defined as follows: involving multiple sites; cases of patient allergy, intolerance, or failure to respond to an antimicrobial agent in Group A; or for purposes of infection control. 1. Susceptible (S)

3. Group C includes alternative or supplemental antimicrobial agents that may necessitate testing in The “susceptible” category implies that isolates are inhibited by the usually achievable those institutions that harbor endemic or epidemic strains resistant to several of the primary drugs concentrations of antimicrobial agent when the dosage recommended to treat the site of infection (especially in the same class, eg, -lactams); for treatment of patients allergic to primary drugs; is used, resulting in likely clinical efficacy. for treatment of unusual organisms (eg, chloramphenicol for extraintestinal isolates of Salmonella spp.); or for reporting to infection control as an epidemiological aid. 2. Susceptible-Dose Dependent (SDD)

4. Group U (“urine”) includes certain antimicrobial agents (eg, nitrofurantoin and certain The “susceptible-dose dependent” category implies that susceptibility of an isolate is dependent quinolones) that are used only or primarily for treating urinary tract infections (UTIs). These on the dosing regimen that is used in the patient. In order to achieve levels that are likely to be agents should not be routinely reported against pathogens recovered from other sites of infection. clinically effective against isolates for which the susceptibility testing results (either MICs or disk An exception to this rule is for Enterobacteriaceae in Table 1A, where cefazolin is listed as a diffusion) are in the SDD category, it is necessary to use a dosing regimen (ie, higher doses, more surrogate agent for oral cephalosporins. Other antimicrobial agents with broader indications may frequent doses, or both) that results in higher drug exposure than the dose that was used to be included in Group U for specific urinary pathogens (eg, Enterococcus and ciprofloxacin). establish the susceptible breakpoint. Consideration should be given to the maximum approved dosage regimen, because higher exposure gives the highest probability of adequate coverage of an 5. Group O (“other”) includes antimicrobial agents that have a clinical indication for the organism SDD isolate. The dosing regimens used to set the SDD interpretive criterion are provided in group but are generally not candidates for routine testing and reporting in the United States. Appendix E. The drug label should be consulted for recommended doses and adjustment for organ function; NOTE: The SDD interpretation is a new category for antibacterial susceptibility 6. Group Inv. (“investigational”) includes antimicrobial agents that are investigational for the testing, although it has been previously applied for interpretation of antifungal susceptibility test organism group and have not yet been approved by the FDA for use in the United States. results (see CLSI document M27-S4, the supplement to CLSI document M27). The concept of SDD has been included within the intermediate category definition for antimicrobial agents. D. Selective Reporting However, this is often overlooked or not understood by clinicians and microbiologists when an intermediate result is reported. The SDD category may be assigned when doses well above those Each laboratory should decide which agents in the tables to report routinely (Group A) and which used to calculate the susceptible breakpoint are approved and used clinically, and where sufficient might be reported only selectively (from Group B), in consultation with the infectious diseases data to justify the designation exist and have been reviewed. When the intermediate category is practitioners, the pharmacy, and the pharmacy and therapeutics and infection control committees used, its definition remains unchanged. See Appendix F for additional information. of the health care institution. Selective reporting should improve the clinical relevance of test reports and help minimize the selection of multiresistant, health care–associated strains by overuse of broad-spectrum agents. Results for Group B antimicrobial agents tested but not reported routinely should be available on request, or they may be reported for selected specimen types. Unexpected resistance, when confirmed, should be reported (eg, resistance to a secondary agent but susceptibility to a primary agent, such as a P. aeruginosa isolate resistant to amikacin but susceptible to tobramycin; as such, both drugs should be reported). In addition, each laboratory should develop a protocol to cover isolates that are confirmed as resistant to all agents

28 Clinical and Laboratory Standards Institute. All rights reserved. Clinical and Laboratory Standards Institute. All rights reserved. 29 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 29 M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

3. Intermediate (I)

The “intermediate” category includes isolates with antimicrobial agent MICs that approach usually attainable blood and tissue levels, and for which response rates may be lower than for susceptible isolates; NOTE: The intermediate category implies clinical efficacy in body sites where the drugs are physiologically concentrated (eg, quinolones and -lactams in urine) or when a higher than normal dosage of a drug can be used (eg, -lactams). This category also includes a buffer zone, which should prevent small, uncontrolled, technical factors from causing major discrepancies in interpretations, especially for drugs with narrow pharmacotoxicity margins.

4. Resistant (R)

The “resistant” category implies that isolates are not inhibited by the usually achievable concentrations of the agent with normal dosage schedules and/or that demonstrate MICs or zone diameters that fall in the range where specific microbial resistance mechanisms (eg, - lactamases) are likely, and clinical efficacy of the agent against the isolate has not been reliably shown in treatment studies.

5. Nonsusceptible (NS)

The “nonsusceptible” category is used for isolates for which only a susceptible interpretive criterion has been designated because of the absence or rare occurrence of resistant strains. Isolates for which the antimicrobial agent MICs are above or zone diameters below the value indicated for the susceptible breakpoint should be reported as nonsusceptible; NOTE 1: An isolate that is interpreted as nonsusceptible does not necessarily mean that the isolate has a resistance mechanism. It is possible that isolates with MICs above the susceptible breakpoint that lack resistance mechanisms may be encountered within the wild-type (WT) distribution subsequent to the time the susceptible-only breakpoint is set; NOTE 2: For strains yielding results in the “nonsusceptible” category, organism identification and antimicrobial susceptibility test results should be confirmed (see Appendix A).

6. Interpretive Criteria

Interpretive criteria are the MIC or zone diameter values used to indicate susceptible, intermediate, and resistant breakpoints.

Zone Diameter Interpretive Criteria MIC Interpretive Criteria Antimicrobial Disk (nearest whole mm) (µg/mL) Agent Content SIRSI R X 30 μg  20 15–19  14  4 8–16  32 Y – –––  1 2  4 Z 10 μg  16 – –  1 – –

For example, for antimicrobial agent X with interpretive criteria in the table above, the susceptible breakpoint is 4 g/mL or 20 mm and the resistant breakpoint is 32 g/mL or 14 mm.

For some antimicrobial agents (eg, antimicrobial agent Y), only MIC interpretive criteria may be available. For these agents, the disk diffusion zone diameters do not correlate with MIC values. Technical issues may also preclude the use of the disk diffusion method for some agents.

30 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 30 ©Clinical and Laboratory Standards Institute. All rights reserved. M100S, 26th ed. For Use With M02-A12 and M07-A10 M100S,M100S, 26th26th ed.

3. Intermediate (I) For some antimicrobial agents (eg, antimicrobial agent Z) only susceptible criteria exist. For these agents, the absence or rare occurrence of resistant strains precludes defining any results categories The “intermediate” category includes isolates with antimicrobial agent MICs that approach other than “susceptible.” For strains yielding results suggestive of a “nonsusceptible” category, usually attainable blood and tissue levels, and for which response rates may be lower than for organism identification and antimicrobial susceptibility test results should be confirmed (see susceptible isolates; NOTE: The intermediate category implies clinical efficacy in body sites Appendix A). where the drugs are physiologically concentrated (eg, quinolones and -lactams in urine) or when a higher than normal dosage of a drug can be used (eg, -lactams). This category also includes a In both cases, a dash mark (–) indicates that interpretive criteria are not applicable. buffer zone, which should prevent small, uncontrolled, technical factors from causing major discrepancies in interpretations, especially for drugs with narrow pharmacotoxicity margins. Laboratories should only report results for agents listed in the Table 2 specific to the organism being tested; it is not appropriate to apply disk diffusion or MIC interpretive criteria taken from 4. Resistant (R) an alternative Table 2. There may be rare cases where an agent may be appropriate for an isolate but for which there are no CLSI interpretive criteria (eg, tigecycline). In these cases, the FDA The “resistant” category implies that isolates are not inhibited by the usually achievable prescribing information document for the agent should be consulted. concentrations of the agent with normal dosage schedules and/or that demonstrate MICs or zone diameters that fall in the range where specific microbial resistance mechanisms (eg, - B. In place of interpretive criteria (“breakpoints” or “clinical breakpoints”) an epidemiological cutoff lactamases) are likely, and clinical efficacy of the agent against the isolate has not been reliably value (ECV) may be listed for specific organism/antimicrobial agent combinations (see Tables 2A- shown in treatment studies. 2 and 2J-2 and Appendix G). ECVs and breakpoints are very different. Breakpoints are established using MIC distributions, pharmacokinetic-pharmacodynamic (PK-PD) data, and 5. Nonsusceptible (NS) clinical outcome data (as described in CLSI document M23). Because breakpoints are based on pharmacologically and clinically rich datasets, they are considered to be robust predictors of likely The “nonsusceptible” category is used for isolates for which only a susceptible interpretive clinical outcome. By contrast, ECVs are MIC values that separate bacterial populations into those criterion has been designated because of the absence or rare occurrence of resistant strains. with (non-wild-type [NWT]) and without (wild-type [WT]) acquired and/or mutational resistance Isolates for which the antimicrobial agent MICs are above or zone diameters below the value mechanisms based on their phenotypes (MICs). They are, therefore, based on in vitro data only. indicated for the susceptible breakpoint should be reported as nonsusceptible; NOTE 1: An isolate that is interpreted as nonsusceptible does not necessarily mean that the isolate has a ECVs are principally used to signal the emergence or evolution of NWT strains. ECVs are not resistance mechanism. It is possible that isolates with MICs above the susceptible breakpoint that clinical breakpoints, and, thus, proven clinical relevance of ECVs has not yet been identified or lack resistance mechanisms may be encountered within the wild-type (WT) distribution approved by CLSI or any regulatory agency. subsequent to the time the susceptible-only breakpoint is set; NOTE 2: For strains yielding results in the “nonsusceptible” category, organism identification and antimicrobial susceptibility C. For some organism groups excluded from Tables 2A through 2J-1, CLSI document M45— test results should be confirmed (see Appendix A). Methods for Antimicrobial Dilution and Disk Susceptibility Testing of Infrequently Isolated or Fastidious Bacteria provides suggestions for standardized methods for susceptibility testing, 6. Interpretive Criteria including information about drug selection, interpretation, and QC. The organism groups covered in that document are Abiotrophia and Granulicatella spp. (formerly known as nutritionally Interpretive criteria are the MIC or zone diameter values used to indicate susceptible, deficient or nutritionally variant streptococci); Aerococcus spp.; Aeromonas spp.; Bacillus spp. intermediate, and resistant breakpoints. (not B. anthracis); Campylobacter jejuni/coli; Corynebacterium spp. (including C. diphtheriae); Erysipelothrix rhusiopathiae; Gemella spp.; the HACEK group: Aggregatibacter spp. (formerly Zone Diameter Haemophilus aphrophilus, H. paraphrophilus, H. segnis, and Actinobacillus Interpretive Criteria MIC Interpretive Criteria actinomycetemcomitans), Cardiobacterium spp., Eikenella corrodens, and Kingella spp.; Antimicrobial Disk (nearest whole mm) (µg/mL) Helicobacter pylori; Lactobacillus spp.; Lactococcus spp.; Leuconostoc spp.; Listeria Agent Content SIRSI R monocytogenes; Micrococcus spp.; Moraxella catarrhalis; Pasteurella spp.; Pediococcus spp.; Rothia mucilaginosa; potential agents of bioterrorism; and Vibrio spp., including V. cholerae. X 30 μg  20 15–19  14  4 8–16  32

Y – –––  1 2  4 For organisms other than those in the groups mentioned above, studies are not yet adequate to   Z 10 μg 16 – – 1 – – develop reproducible, definitive standards to interpret results. These organisms may need different media or different atmospheres of incubation, or they may show marked strain-to-strain For example, for antimicrobial agent X with interpretive criteria in the table above, the variation in growth rate. For these microorganisms, consultation with an infectious diseases susceptible breakpoint is 4 g/mL or 20 mm and the resistant breakpoint is 32 g/mL or 14 mm. specialist is recommended for guidance in determining the need for susceptibility testing and in the interpretation of results. Published reports in the medical literature and current consensus For some antimicrobial agents (eg, antimicrobial agent Y), only MIC interpretive criteria may be recommendations for therapy of uncommon microorganisms may obviate the need for testing. If available. For these agents, the disk diffusion zone diameters do not correlate with MIC values. necessary, a dilution method usually is the most appropriate testing method, and this may Technical issues may also preclude the use of the disk diffusion method for some agents. necessitate submitting the organism to a reference laboratory. Physicians should be informed of the limitations of results and advised to interpret results with caution.

30 Clinical and Laboratory Standards Institute. All rights reserved. Clinical and Laboratory Standards Institute. All rights reserved. 31 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 31 M100S,M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

D. Policies regarding the generation of cumulative antibiograms should be developed in concert with the infectious diseases service, infection control personnel, and the pharmacy and therapeutics committee. In most circumstances, the percentage of susceptible and intermediate results should not be combined into the same statistics. See CLSI document M39—Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data.

III. Therapy-Related Comments

Some of the comments in the tables relate to therapy concerns. These are denoted with an Rx symbol. It may be appropriate to include some of these comments (or modifications thereof) on the patient report. An example would be inclusion of a comment on Enterococcus susceptibility reports from blood cultures that “combination therapy with ampicillin, penicillin, or vancomycin (for susceptible strains) plus an aminoglycoside is usually indicated for serious enterococcal infections, such as endocarditis, unless high-level resistance to both gentamicin and streptomycin is documented; such combinations are predicted to result in synergistic killing of the Enterococcus.”

Antimicrobial dosage regimens often vary widely among practitioners and institutions. In some cases, the MIC interpretive criteria rely on PK-PD data, using specific human dosage regimens. In cases where specific dosage regimens are important for proper application of breakpoints, the dosage regimen is listed. These dosage regimen comments are not generally intended for use on individual patient reports.

IV. Confirmation of Patient Results

Multiple test parameters are monitored by following the QC recommendations described in M100. However, acceptable results derived from testing QC strains do not guarantee accurate results when testing patient isolates. It is important to review all of the results obtained from all drugs tested on a patient’s isolate before reporting the results. This should include, but not be limited to, ensuring that 1) the antimicrobial susceptibility test results are consistent with the identification of the isolate; 2) the results from individual agents within a specific drug class follow the established hierarchy of activity rules (eg, in general, third-generation cephems are more active than first- or second-generation cephems against Enterobacteriaceae); and 3) the isolate is susceptible to those agents for which resistance has not been documented (eg, vancomycin and Streptococcus spp.) and for which only “susceptible” interpretive criteria exist in M100.

Unusual or inconsistent results should be confirmed by rechecking various parameters of testing detailed in Appendix A. Each laboratory must develop its own policies for confirmation of unusual or inconsistent antimicrobial susceptibility test results. The list provided in Appendix A emphasizes those results that are most likely to affect patient care.

V. Development of Resistance and Testing of Repeat Isolates

Isolates that are initially susceptible may become intermediate or resistant after initiation of therapy. Therefore, subsequent isolates of the same species from a similar body site should be tested in order to detect resistance that may have developed. This can occur within as little as three to four days and has been noted most frequently in Enterobacter, Citrobacter, and Serratia spp. with third-generation cephalosporins; in P. aeruginosa with all antimicrobial agents; and in staphylococci with quinolones. For Staphylococcus aureus, vancomycin-susceptible isolates may become vancomycin intermediate during the course of prolonged therapy.

32 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 32 ©Clinical and Laboratory Standards Institute. All rights reserved. M100S, 26th ed. For Use With M02-A12 and M07-A10 M100S,M100S, 26th ed.ed.

D. Policies regarding the generation of cumulative antibiograms should be developed in concert with In certain circumstances, the decision to perform susceptibility tests on subsequent isolates the infectious diseases service, infection control personnel, and the pharmacy and therapeutics necessitates knowledge of the specific situation and the severity of the patient’s condition (eg, an committee. In most circumstances, the percentage of susceptible and intermediate results should isolate of Enterobacter cloacae from a blood culture on a premature infant or methicillin- not be combined into the same statistics. See CLSI document M39—Analysis and Presentation of resistant S. aureus [MRSA] from a patient with prolonged bacteremia). Laboratory Cumulative Antimicrobial Susceptibility Test Data. guidelines on when to perform susceptibility testing on repeat isolates should be determined after consultation with the medical staff. III. Therapy-Related Comments VI. Warning Some of the comments in the tables relate to therapy concerns. These are denoted with an Rx symbol. It may be appropriate to include some of these comments (or modifications thereof) on Some of the comments in the tables relate to dangerously misleading results that can occur when the patient report. An example would be inclusion of a comment on Enterococcus susceptibility certain antimicrobial agents are tested and reported as susceptible against specific organisms. reports from blood cultures that “combination therapy with ampicillin, penicillin, or vancomycin These are denoted with the word “Warning.” (for susceptible strains) plus an aminoglycoside is usually indicated for serious enterococcal infections, such as endocarditis, unless high-level resistance to both gentamicin and streptomycin “Warning”: The following antimicrobial agent/organism combinations may appear active in is documented; such combinations are predicted to result in synergistic killing of the vitro, but are not effective clinically and must not be reported as susceptible. Enterococcus.” Antimicrobial Agents That Must Not Be Location Organism Reported as Susceptible Antimicrobial dosage regimens often vary widely among practitioners and institutions. In some Table 2A-1 Salmonella spp., Shigella spp. 1st- and 2nd-generation cephalosporins, cases, the MIC interpretive criteria rely on PK-PD data, using specific human dosage regimens. cephamycins, and aminoglycosides In cases where specific dosage regimens are important for proper application of breakpoints, the Table 2D Enterococcus spp. Aminoglycosides (except for high-level dosage regimen is listed. These dosage regimen comments are not generally intended for use on resistance testing), cephalosporins, individual patient reports. clindamycin, and trimethoprim- sulfamethoxazole IV. Confirmation of Patient Results Abbreviation: MRSA, methicillin-resistant S. aureus.

Multiple test parameters are monitored by following the QC recommendations described in VII. Routine, Supplemental, Screening, Surrogate Agent, and Equivalent Agent Testing to M100. However, acceptable results derived from testing QC strains do not guarantee accurate Determine Susceptibility and Resistance to Antimicrobial Agents results when testing patient isolates. It is important to review all of the results obtained from all drugs tested on a patient’s isolate before reporting the results. This should include, but not be Routine test = disk diffusion or broth or agar dilution MIC tests for routine clinical testing limited to, ensuring that 1) the antimicrobial susceptibility test results are consistent with the identification of the isolate; 2) the results from individual agents within a specific drug class Supplemental (not routine) test = test that detects susceptibility or resistance to a drug or follow the established hierarchy of activity rules (eg, in general, third-generation cephems are drug class by method other than routine disk diffusion or broth or agar dilution MIC and more active than first- or second-generation cephems against Enterobacteriaceae); and 3) the does not need additional tests to confirm susceptibility or resistance. Some supplemental isolate is susceptible to those agents for which resistance has not been documented (eg, tests identify a specific resistance mechanism. May be required or optional for reporting vancomycin and Streptococcus spp.) and for which only “susceptible” interpretive criteria exist in clinical results. M100. Screening test = test that provides presumptive results and needs additional testing for Unusual or inconsistent results should be confirmed by rechecking various parameters of testing confirmation of susceptibility or resistance. detailed in Appendix A. Each laboratory must develop its own policies for confirmation of unusual or inconsistent antimicrobial susceptibility test results. The list provided in Appendix A Surrogate agent testing = an agent that replaces testing with the antimicrobial agent of emphasizes those results that are most likely to affect patient care. interest and is used when the agent of interest cannot be tested due to performance issues, availability, or if it performs better than the agent of interest. V. Development of Resistance and Testing of Repeat Isolates Equivalent agent testing = an agent that predicts results of closely related agents of the Isolates that are initially susceptible may become intermediate or resistant after initiation of same class and increases efficiency by limiting testing of multiple closely related agents. therapy. Therefore, subsequent isolates of the same species from a similar body site should be Equivalent agents are identified by: tested in order to detect resistance that may have developed. This can occur within as little as three to four days and has been noted most frequently in Enterobacter, Citrobacter, and Serratia • Listing equivalent agents with an “or” in Tables 1 and 2. “Or” indicates cross- spp. with third-generation cephalosporins; in P. aeruginosa with all antimicrobial agents; and in susceptibility and cross-resistance is nearly complete (very major error [VME] + staphylococci with quinolones. For Staphylococcus aureus, vancomycin-susceptible isolates may major error [ME] < 3%; minor error [mE] < 10%) and only one agent needs to be become vancomycin intermediate during the course of prolonged therapy. tested.

32 Clinical and Laboratory Standards Institute. All rights reserved. Clinical and Laboratory Standards Institute. All rights reserved. 33 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 33 M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

• Listing agents that are equivalent and results that can be deduced by testing the equivalent agent (see Tables 1 and 2).

Supplemental Tests – Required Supplemental Table Test Organisms Test Description Required for: Location Inducible  S. aureus Broth Isolates that test 3G clindamycin  CoNS microdilution or erythromycin resistant and resistance  Streptococcus disk diffusion clindamycin susceptible or pneumoniae with clindamycin intermediate before reporting  Streptococcus spp. β- and the isolate as clindamycin hemolytic Group erythromycin susceptible tested together

β-lactamase  CoNS Chromogenic Isolates that test penicillin 3D cephalosporin susceptible

β-lactamase  S. aureus Chromogenic Isolates that test penicillin 3D cephalosporin susceptible penicillin disk diffusion zone- edge test

Supplemental Tests – Optional Supplemental Table Test Organisms Test Description Optional for: Location ESBL  E. coli Broth Isolates that have reduced 3A  Klebsiella microdilution or susceptibility to  Proteus mirabilis disk diffusion cephalosporins clavulanate inhibition test for Results that indicate presence ESBLs or absence of ESBLs MHT  Enterobacteriaceae Growth Isolates that have reduced 3B, 3B-1 augmentation susceptibility to carbapenems assay for detection of Results that indicate presence carbapenem or absence of some hydrolysis carbapenemases Carba NP  Enterobacteriaceae Colorimetric Isolates that have reduced 3C, 3C-1 assay for susceptibility to carbapenems detection of carbapenem Results that indicate presence hydrolysis or absence of some carbapenemases MRSA Agar  S. aureus Agar dilution; Detecting MRSA. See 3E MHA with 4% cefoxitin surrogate agent NaCl and 6 tests, which are preferred. µg/mL oxacillin

34 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 34 ©Clinical and Laboratory Standards Institute. All rights reserved. M100S, 26th ed. For Use With M02-A12 and M07-A10 M100S,M100S, 26th 26th ed. ed.

• Listing agents that are equivalent and results that can be deduced by testing the Screening Tests equivalent agent (see Tables 1 and 2). When to Perform Screening Confirmatory Confirmatory Table Supplemental Tests – Required Test Organisms Test Description Test? Test Location Supplemental Table Vancomycin  S. aureus Agar dilution; BHI If screen positive Vancomycin 3F Test Organisms Test Description Required for: Location agar screen  Enterococcus with 6 µg/mL MIC Inducible  S. aureus Broth Isolates that test 3G vancomycin clindamycin  CoNS microdilution or erythromycin resistant and HLAR by  Enterococci Disk diffusion with If screen Broth 3I resistance  Streptococcus disk diffusion clindamycin susceptible or disk diffusion gentamicin and inconclusive microdilution, pneumoniae with clindamycin intermediate before reporting streptomycin agar dilution  Streptococcus spp. β- and the isolate as clindamycin MIC hemolytic Group erythromycin susceptible tested together Testing With Surrogate Agents Surrogate Agent Organisms Test Description Results β-lactamase  CoNS Chromogenic Isolates that test penicillin 3D Cefoxitin  S. aureus Broth Predicts results for mecA-mediated oxacillin cephalosporin susceptible  microdilution (S. resistance CoNS  Not for S. aureus only) or β-lactamase  Chromogenic Isolates that test penicillin 3D S. aureus pseudintermedius disk diffusion cephalosporin susceptible Cefazolin  E. coli Broth Predicts results for the oral agents cefaclor, penicillin disk  microdilution or cefdinir, cefpodoxime, cefprozil, cefuroxime, diffusion zone- Klebsiella spp. disk diffusion cephalexin, and loracarbef when used for therapy edge test  P. mirabilis of uncomplicated UTIs. Cefpodoxime, cefdinir, and cefuroxime may be tested individually because Supplemental Tests – Optional some isolates may be susceptible to these agents Supplemental Table while testing resistant to cefazolin. Test Organisms Test Description Optional for: Location Pefloxacin  Salmonella spp. Disk diffusion Predicts reduced susceptibility to fluoroquinolones ESBL  E. coli Broth Isolates that have reduced 3A Nalidixic  Salmonella spp. Broth Predicts reduced susceptibility to fluoroquinolones  Klebsiella microdilution or susceptibility to acid microdilution or  Proteus mirabilis disk diffusion cephalosporins disk diffusion clavulanate Oxacillin  S. pneumoniae Disk diffusion If oxacillin zone ≥ 20 mm, predicts penicillin inhibition test for Results that indicate presence susceptibility. If oxacillin zone ≤ 19 mm, penicillin ESBLs or absence of ESBLs MIC must be done. MHT  Enterobacteriaceae Growth Isolates that have reduced 3B, 3B-1 augmentation susceptibility to carbapenems assay for detection of Results that indicate presence carbapenem or absence of some hydrolysis carbapenemases Carba NP  Enterobacteriaceae Colorimetric Isolates that have reduced 3C, 3C-1 assay for susceptibility to carbapenems detection of carbapenem Results that indicate presence hydrolysis or absence of some carbapenemases MRSA Agar  S. aureus Agar dilution; Detecting MRSA. See 3E MHA with 4% cefoxitin surrogate agent NaCl and 6 tests, which are preferred. µg/mL oxacillin

34 Clinical and Laboratory Standards Institute. All rights reserved. Clinical and Laboratory Standards Institute. All rights reserved. 35 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 35 M100S,M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

Testing With Equivalent Agents (Examples) Agents Organism Identified by Table Location Cefotaxime or Enterobacteriaceae “Or” 1A and 2A-1 ceftriaxone Azithromycin or Staphylococcus spp. “Or” 1A and 2C clarithromycin or erythromycin Penicillin-susceptible Staphylococcus spp. Note listed 1A and 2C staphylococci are susceptible to other β-lactam agents with established clinical efficacy for staphylococcal infections (including both penicillinase- labile and penicillinase-stable agents; see Glossary I). Penicillin-resistant staphylococci are resistant to penicillinase- labile penicillins. The results of ampicillin Haemophilus spp. Note listed 1B and 2E susceptibility tests should be used to predict the activity of amoxicillin. Abbreviations: BHI, Brain Heart Infusion; CoNS, coagulase-negative staphylococci; ESBL, extended-spectrum - lactamase; HLAR, high-level aminoglycoside resistance; MHA, Mueller-Hinton agar; MHT, modified Hodge test; MIC, minimal inhibitory concentration; MRSA, methicillin-resistant S. aureus; UTI, urinary tract infections.

VIII. Quality Control and Verification

Recommendations for QC are included in various tables and appendixes. Acceptable ranges for QC strains are provided in Tables 4A and 4B for disk diffusion and Tables 5A through 5E for MIC testing. Guidance for frequency of QC and modifications of antimicrobial susceptibility testing (AST) systems is found in Table 4C for disk diffusion and Table 5F for MIC testing. Guidance for troubleshooting out-of-range results is included in Table 4D for disks and Table 5G for MIC testing. Additional information is available in Appendix C, Quality Control Strains for Antimicrobial Susceptibility Tests (eg, QC organism characteristics, QC testing recommendations).

Implementation of any new diagnostic test requires verification.1 Each laboratory that introduces a new AST system or adds a new antimicrobial agent to an existing AST system must verify or establish that, before reporting patient test results, the system meets performance specifications for that system. Verification generally involves testing clinical isolates with the new AST system and comparing results to those obtained with an established reference method or a system that has been previously verified. Testing clinical isolates may be done concurrently with the two systems. Alternatively, organisms with known MICs or zone sizes may be used for the verification. Guidance on verification studies is not included in this document. Other publications describe verification of AST systems (eg, CLSI document M52,2 ASM Cumitech 31A3 and Patel J, et al.4).

References

1 Centers for Medicare & Medicaid Services, US Department of Health and Human Services. Part 493—Laboratory Requirements; Standard: Establishment and verification of performance specifications (Codified at 42 CFR §493.1253). US Government Publishing Office; published annually.

36 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 36 ©Clinical and Laboratory Standards Institute. All rights reserved. M100S, 26th ed. For Use With M02-A12 and M07-A10 M100S,M100S, 26th 26th ed. ed.

Testing With Equivalent Agents (Examples) 2 CLSI. Verification of Commercial Microbial Identification and Antimicrobial Agents Organism Identified by Table Location Susceptibility Testing Systems. 1st ed. CLSI guideline M52. Wayne, PA: Clinical and Cefotaxime or Enterobacteriaceae “Or” 1A and 2A-1 Laboratory Standards Institute; 2015. ceftriaxone Azithromycin or Staphylococcus spp. “Or” 1A and 2C 3 Clark RB, Lewinski MA, Loeffelholz MJ, Tibbetts RJ. Cumitech 31A: verification and clarithromycin or validation of procedures in the clinical microbiology laboratory. Washington, DC: ASM erythromycin Press; 2009. Penicillin-susceptible Staphylococcus spp. Note listed 1A and 2C staphylococci are susceptible to 4 Patel J, Sharp S, Novak-Weekley S. Verification of antimicrobial susceptibility testing other β-lactam agents with established clinical efficacy for methods: a practical approach. Clin Microbiol Newslett. 2013;35(13):103-109. staphylococcal infections (including both penicillinase- IX. Abbreviations and Acronyms labile and penicillinase-stable agents; see Glossary I). AST antimicrobial susceptibility testing Penicillin-resistant staphylococci ATCC®a American Type Culture Collection are resistant to penicillinase- BHI Brain Heart Infusion labile penicillins. BLNAR -lactamase negative, ampicillin-resistant The results of ampicillin Haemophilus spp. Note listed 1B and 2E BSC biological safety cabinet susceptibility tests should be BSL-2 biosafety level 2 used to predict the activity of amoxicillin. BSL-3 biosafety level 3 Abbreviations: BHI, Brain Heart Infusion; CoNS, coagulase-negative staphylococci; ESBL, extended-spectrum - CAMHB cation-adjusted Mueller-Hinton broth lactamase; HLAR, high-level aminoglycoside resistance; MHA, Mueller-Hinton agar; MHT, modified Hodge test; MIC, CFU colony-forming unit(s) minimal inhibitory concentration; MRSA, methicillin-resistant S. aureus; UTI, urinary tract infections. CMRNG chromosomally mediated penicillin-resistant Neisseria gonorrhoeae CoNS coagulase-negative staphylococci VIII. Quality Control and Verification CSF cerebrospinal fluid DMF dimethylformamide Recommendations for QC are included in various tables and appendixes. Acceptable ranges for DMSO dimethyl sulfoxide QC strains are provided in Tables 4A and 4B for disk diffusion and Tables 5A through 5E for ECV epidemiological cutoff value MIC testing. Guidance for frequency of QC and modifications of antimicrobial susceptibility ESBL extended-spectrum -lactamase testing (AST) systems is found in Table 4C for disk diffusion and Table 5F for MIC testing. FDA US Food and Drug Administration Guidance for troubleshooting out-of-range results is included in Table 4D for disks and Table HLAR high-level aminoglycoside resistance 5G for MIC testing. Additional information is available in Appendix C, Quality Control Strains HTM Haemophilus Test Medium for Antimicrobial Susceptibility Tests (eg, QC organism characteristics, QC testing I intermediate recommendations). ID identification KPC Klebsiella pneumoniae carbapenemase 1 Implementation of any new diagnostic test requires verification. Each laboratory that LHB lysed horse blood introduces a new AST system or adds a new antimicrobial agent to an existing AST system MHA Mueller-Hinton agar must verify or establish that, before reporting patient test results, the system meets performance MHB Mueller-Hinton broth specifications for that system. Verification generally involves testing clinical isolates with the MHT modified Hodge test new AST system and comparing results to those obtained with an established reference method MIC minimal inhibitory concentration or a system that has been previously verified. Testing clinical isolates may be done MRS methicillin-resistant staphylococci concurrently with the two systems. Alternatively, organisms with known MICs or zone sizes MRSA methicillin-resistant Staphylococcus aureus may be used for the verification. Guidance on verification studies is not included in this NAD nicotinamide adenine dinucleotide document. Other publications describe verification of AST systems (eg, CLSI document NCTC National Collection of Type Cultures 2 3 4 M52, ASM Cumitech 31A and Patel J, et al. ). NDM New Delhi metallo--lactamase NWT non-wild-type References PBP 2a penicillin-binding protein 2a

1 PCR polymerase chain reaction Centers for Medicare & Medicaid Services, US Department of Health and Human Services. PK-PD pharmacokinetic-pharmacodynamic Part 493—Laboratory Requirements; Standard: Establishment and verification of QC quality control performance specifications (Codified at 42 CFR §493.1253). US Government Publishing Office; published annually. a ATCC® is a registered trademark of the American Type Culture Collection.

36 Clinical and Laboratory Standards Institute. All rights reserved. Clinical and Laboratory Standards Institute. All rights reserved. 37 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 37 M100S,M100S, 26th 26thed. ed. For Use With M02-A12 and M07-A10

R resistant S susceptible SDD susceptible-dose dependent TSA tryptic soy agar UTI urinary tract infection WT wild-type

38 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 38 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12 and M07-A10 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 39 M100S, 26th ed. For Use With M02-A12M100S, and 26th M07-A10 ed.

Table 1A. Suggested Groupings of Antimicrobial Agents With US Food and Drug Administration Clinical Indications That Should Be Considered for Routine Testing and Reporting on Nonfastidious Organisms by Microbiology Laboratories in the United States Staphylococcus Enterobacteriaceae Pseudomonas aeruginosa spp. Enterococcus spp.n c Ampicillin Ceftazidime Azithromycinb or Ampicillino clarithromycinb or

p erythromycinb Penicillin

Clindamycinb *,† i,k Table 1A Table Oxacillin

M02 and M07 †Cefoxitini,k

GROUP A (surrogate test for

AND REPORT oxacillin) PRIMARY TEST d Cefazolin Gentamicin Penicillini Tobramycin Suggested Nonfastidious Groupings Nonfastidious Suggested Gentamicinc Piperacillin-tazobactam Trimethoprim- Tobramycinc sulfamethoxazole

Amikacinc Amikacin Ceftarolineh *Daptomycinj *Daptomycinj Aztreonam Linezolid Linezolid Tedizolidm Tedizolidq Amoxicillin-clavulanate Cefepime Doxycycline Ampicillin-sulbactam Minocyclineb Ceftolozane-tazobactam Tetracyclinea Piperacillin-tazobactam Ceftolozane-tazobactam

Cefuroxime Vancomycin *Oritavancin Ciprofloxacin *Vancomycin Telavancin

Levofloxacin *Oritavancinh Telavancinh Cefepime Doripenem Rifamping Cefotetan Imipenem GROUP B Cefoxitin Meropenem

Cefotaximec,d or REPORT SELECTIVELY c,d

OPTIONAL PRIMARY TEST OPTIONAL PRIMARY ceftriaxone Ciprofloxacinc Levofloxacinc Doripenem Ertapenem Imipenem Meropenem Trimethoprim-sulfamethoxazolec

Aztreonam Gentamicin Chloramphenicolb Ceftazidime (high-level resistance testing only) Ceftaroline Ciprofloxacin or Streptomycin levofloxacin (high-level resistance

REPORT Moxifloxacin testing only) GROUP C b,c Gentamicinl SELECTIVELY Chloramphenicol SUPPLEMENTAL Tetracyclinea

Clinical and Laboratory Standards Institute. All rights reserved. 39 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 40 ©Clinical and Laboratory Standards Institute. All rights reserved. M100S,For Use With 26th M02-A12 ed. and M07-A10 M100S, 26th ed.

Table 1A. (Continued) Enterobacteriaceae Pseudomonas aeruginosa Staphylococcus spp. Enterococcus spp.n ‡Cefazolin Norfloxacin Norfloxacin Ciprofloxacin (surrogate test for uncomplicated Levofloxacin UTI) Norfloxacin Fosfomycine Norfloxacin

GROUP U Nitrofurantoin Fosfomycinr SUPPLEMENTAL Table 1A Table FOR URINE ONLY ONLY URINE FOR Sulfisoxazole Nitrofurantoin Nitrofurantoin

Trimethoprim Sulfisoxazole M02 and M07 Trimethoprim Tetracyclinea * Minimal inhibitory concentration (MIC) testing only; disk diffusion test unreliable. † See oxacillin and cefoxitin comments in Table 2C for using cefoxitin as a surrogate for oxacillin.

‡ See cefazolin comments in Table 2A for using cefazolin as a surrogate for oral cephalosporins and for Groupings Nonfastidious Suggested reporting cefazolin when used for therapy in uncomplicated UTIs.

40 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 41 M100S, 26th ed. For Use With M02-A12M100S, and 26th M07-A10 ed.

Table 1A. (Continued) Burkholderia cepacia Stenotrophomonas *Other Non- Acinetobacter spp. complex maltophilia Enterobacteriaceaef Ampicillin-sulbactam *Levofloxacin Trimethoprim- Ceftazidime

sulfamethoxazole Meropenem Ceftazidime Trimethoprim- Ciprofloxacin sulfamethoxazole

GROUP A Levofloxacin Doripenem Gentamicin AND REPORT PRIMARY TEST Table 1A Table Imipenem Tobramycin

M02 and M07 Meropenem Gentamicin Tobramycin

Amikacin Ceftazidime *Ceftazidime Amikacin

Suggested Nonfastidious Groupings Nonfastidious Suggested Aztreonam Levofloxacin Cefepime Piperacillin-tazobactam Minocycline Minocycline Ciprofloxacin Levofloxacin Cefepime Imipenem Cefotaxime Meropenem Ceftriaxone

GROUP B Doxycycline Piperacillin-tazobactam

Minocycline Trimethoprim- sulfamethoxazole REPORT SELECTIVELY

OPTIONAL PRIMARY TEST Trimethoprim-sulfamethoxazole

b b *Chloramphenicol *Chloramphenicol Cefotaxime Ceftriaxone

Chloramphenicolb

GROUP C SUPPLEMENTAL REPORT SELECTIVELY

Tetracyclinea Norfloxacin

Sulfisoxazole GROUP U

a SUPPLEMENTAL

FOR URINE ONLY Tetracycline

Abbreviations: MIC, minimal inhibitory concentration; UTI, urinary tract infection. * MIC testing only; disk diffusion test unreliable.

Clinical and Laboratory Standards Institute. All rights reserved. 41 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 42 ©Clinical and Laboratory Standards Institute. All rights reserved. ForM100S, Use With 26th M02-A12 ed. and M07-A10 M100S, 26th ed.

Table 1A. (Continued)

“Warning”: The following antimicrobial agents should not be routinely reported for bacteria isolated from CSF that are included in this document. These antimicrobial agents are not the drugs of choice and may not be effective for treating CSF infections caused by these organisms (ie, the bacteria included in Tables 2A through 2J):

agents administered by oral route only 1st- and 2nd-generation cephalosporins (except cefuroxime parenteral)

and cephamycins 1A Table

clindamycin M02 and M07 macrolides tetracyclines fluoroquinolones Groupings Nonfastidious Suggested NOTE 1: For information about the selection of appropriate antimicrobial agents; explanation of Test and Report Groups A, B, C, and U; and explanation of the listing of agents within boxes, including the meaning of “or” between agents, refer to the Instructions for Use of Tables that precede Table 1A.

NOTE 2: Information in boldface type is new or modified since the previous edition.

Footnotes

General Comments

a. Organisms that are susceptible to tetracycline are also considered susceptible to doxycycline and minocycline. However, some organisms that are intermediate or resistant to tetracycline may be susceptible to doxycycline, minocycline, or both.

b. Not routinely reported on organisms isolated from the urinary tract.

Enterobacteriaceae

c. WARNING: For Salmonella spp. and Shigella spp., aminoglycosides, first- and second-generation cephalosporins and cephamycins may appear active in vitro, but are not effective clinically and should not be reported as susceptible.

When fecal isolates of Salmonella and Shigella spp. are tested, only ampicillin, a fluoroquinolone, and trimethoprim-sulfamethoxazole should be reported routinely. In addition, for extraintestinal isolates of Salmonella spp., a third-generation cephalosporin should be tested and reported, and chloramphenicol may be tested and reported, if requested. Susceptibility testing is indicated for typhoidal Salmonella (S. Typhi and Salmonella Paratyphi A–C) isolated from extraintestinal and intestinal sources. Routine susceptibility testing is not indicated for nontyphoidal Salmonella spp. isolated from intestinal sources. In contrast, susceptibility testing is indicated for all Shigella isolates.

d. Cefotaxime or ceftriaxone should be tested and reported on isolates from CSF in place of cefazolin.

e. For testing and reporting of E. coli urinary tract isolates only.

42 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 43 M100S, 26th ed. For Use With M02-A12M100S, and 26th M07-A10 ed.

Table 1A. (Continued)

Other Non-Enterobacteriaceae

f. Other non-Enterobacteriaceae include Pseudomonas spp. and other nonfastidious, glucose- nonfermenting, gram-negative bacilli, but exclude Pseudomonas aeruginosa, Acinetobacter spp., Burkholderia cepacia, and Stenotrophomonas maltophilia, because there are separate lists of suggested drugs to test and report for them.

Table 1A Table Recommendations for testing and reporting of Aeromonas hydrophila complex, B. mallei, B.

M02 and M07 pseudomallei, and Vibrio species (including V. cholerae) are found in CLSI document M45.

Staphylococcus spp.

Suggested Nonfastidious Groupings Nonfastidious Suggested g. Rx: Rifampin should not be used alone for antimicrobial therapy.

h. For S. aureus only including methicillin-resistant Staphylococcus aureus (MRSA).

i. Penicillin-susceptible staphylococci are also susceptible to other -lactam agents with established clinical efficacy for staphylococcal infections. Penicillin-resistant staphylococci are resistant to penicillinase-labile penicillins. Oxacillin-resistant staphylococci are resistant to all currently available -lactam antimicrobial agents, with the exception of the newer cephalosporins with anti-MRSA activity. Thus, susceptibility or resistance to a wide array of -lactam antimicrobial agents may be deduced from testing only penicillin and either cefoxitin or oxacillin. Routine testing of other -lactam agents, except those with anti-MRSA activity, is not advised.

j. Daptomycin should not be reported for isolates from the respiratory tract.

k. The results of either cefoxitin disk diffusion or cefoxitin MIC tests can be used to predict the presence of mecA-mediated oxacillin resistance in S. aureus and S. lugdunensis. For coagulase-negative staphylococci (except S. lugdunensis), the cefoxitin disk diffusion test is the preferred method for detection of mecA-mediated oxacillin resistance. Cefoxitin is used as a surrogate for detection of oxacillin resistance; report oxacillin as susceptible or resistant based on cefoxitin results. If a penicillinase-stable penicillin is tested, oxacillin is the preferred agent, and results can be applied to the other penicillinase-stable penicillins. Please refer to Glossary I.

l. For staphylococci that test susceptible, aminoglycosides are used only in combination with other active agents that test susceptible.

m. For reporting against S. aureus only, including MRSA.

Enterococcus spp.

n. Warning: For Enterococcus spp., cephalosporins, aminoglycosides (except for high-level resistance testing), clindamycin, and trimethoprim-sulfamethoxazole may appear active in vitro, but are not effective clinically and should not be reported as susceptible.

o. The results of ampicillin susceptibility tests should be used to predict the activity of amoxicillin. Ampicillin results may be used to predict susceptibility to amoxicillin-clavulanate, ampicillin- sulbactam, piperacillin, and piperacillin-tazobactam among non–-lactamase-producing enterococci. Ampicillin susceptibility can be used to predict imipenem susceptibility, providing the species is confirmed to be E. faecalis.

Clinical and Laboratory Standards Institute. All rights reserved. 43 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 44 ©Clinical and Laboratory Standards Institute. All rights reserved. ForM100S, Use With 26th M02-A12 ed. and M07-A10 M100S, 26th ed.

Table 1A. (Continued)

p. Enterococci susceptible to penicillin are predictably susceptible to ampicillin, amoxicillin, ampicillin- sulbactam, amoxicillin-clavulanate, piperacillin, and piperacillin-tazobactam for non–-lactamase– producing enterococci. However, enterococci susceptible to ampicillin cannot be assumed to be susceptible to penicillin. If penicillin results are needed, testing of penicillin is required. Rx: Combination therapy with ampicillin, penicillin, or vancomycin (for susceptible strains) plus an aminoglycoside is usually indicated for serious enterococcal infections, such as endocarditis, unless high-level resistance to both gentamicin and streptomycin is documented; such combinations are

predicted to result in synergistic killing of the Enterococcus. 1A Table

M02 and M07 q. For reporting against E. faecalis only.

r. For testing and reporting of E. faecalis urinary tract isolates only. Suggested Nonfastidious Groupings Nonfastidious Suggested

44 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 45 M100S, 26th ed. For Use With M02-A12M100S, and 26th M07-A10 ed.

Table 1B. Suggested Groupings of Antimicrobial Agents With US Food and Drug Administration Clinical Indications That Should Be Considered for Routine Testing and Reporting on Fastidious Organisms by Microbiology Laboratories in the United States

Haemophilus influenzae Streptococcus and Haemophilus Neisseria Streptococcus Streptococcus spp. spp. parainfluenzaed gonorrhoeaei pneumoniaej β-Hemolytic Groupp Viridans Groupp † a,c c,o m Ampicillind,f Ceftriaxone Erythromycin Clindamycin *Ampicillin †Cefixime *Penicillinm Erythromycina,c,o Table 1B Table GROUP A † k Ciprofloxacin Penicillin †Penicillinn or REPORT AND M02 and M07 (oxacillin disk) † PRIMARY TEST ampicillinn Trimethoprim- †Tetracyclineb Trimethoprim- sulfamethoxazole sulfamethoxazole

Suggested Fastidious Groupings Fastidious Suggested Ampicillin-sulbactam *Cefepime Cefepime or Cefepime *Cefotaximek cefotaxime or Cefotaxime Cefuroxime (parenteral) k *Ceftriaxone ceftriaxone Ceftriaxone

Clindamycinc

Doxycycline

j Cefotaximed or Gemifloxacin Vancomycin Vancomycin j ceftazidimed or Levofloxacin j ceftriaxoned Moxifloxacin

PRIMARY TEST k Meropenemd *Meropenem OPTIONAL GROUP OPTIONAL GROUP B REPORT SELECTIVELY

Tetracyclineb Vancomycink

Azithromycine *Amoxicillin Ceftaroline Ceftolozane- Clarithromycine *Amoxicillin- tazobactam clavulanate Chloramphenicolc

Aztreonam Chloramphenicolc Clindamycinc

Amoxicillin- *Daptomycinq Erythromycina,c clavulanatee

Cefaclore *Cefuroxime Cefprozile Cefdinire or Ceftaroline Levofloxacin cefiximee or cefpodoximee Ceftarolineg Cefuroxime (oral)e Chloramphenicolc Linezolid Linezolid GROUP C Tedizolidr Tedizolids c,d SUPPLEMENTAL Chloramphenicol *Oritavancin *Oritavancin

REPORT SELECTIVELY Ciprofloxacin or *Ertapenem Telavancin Telavancin levofloxacin or *Imipenem moxifloxacin Linezolid

Gemifloxacin Rifampinl Ertapenem or imipenem Rifampinh Tetracyclineb * Minimal inhibitory concentration (MIC) testing only; disk diffusion test unreliable. † Routine testing is not necessary (see footnotes i and n).

Clinical and Laboratory Standards Institute. All rights reserved. 45 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 46 ©Clinical and Laboratory Standards Institute. All rights reserved. ForM100S, Use With 26th M02-A12 ed. and M07-A10 M100S, 26th ed.

Table 1B. (Continued)

“Warning”: The following antimicrobial agents should not be routinely reported for bacteria isolated from CSF that are included in this document. These antimicrobial agents are not the drugs of choice and may not be effective for treating CSF infections caused by these organisms (ie, the bacteria included in Tables 2A through 2J):

agents administered by oral route only

1st- and 2nd-generation cephalosporins (except cefuroxime parenteral) 1B Table

and cephamycins M02 and M07 clindamycin macrolides

tetracyclines Groupings Fastidious Suggested fluoroquinolones

NOTE 1: For information about the selection of appropriate antimicrobial agents; explanation of Test and Report Groups A, B, C, and U; and explanation of the listing of agents within boxes, including the meaning of “or” between agents, refer to the Instructions for Use of Tables that precede Table 1A.

NOTE 2: Information in boldface type is new or modified since the previous edition.

Footnotes

General Comments

a. Susceptibility and resistance to azithromycin and clarithromycin can be predicted by testing erythromycin.

b. Organisms that are susceptible to tetracycline are also considered susceptible to doxycycline and minocycline.

c. Not routinely reported for organisms isolated from the urinary tract.

Haemophilus spp.

d. For isolates of H. influenzae from CSF, only results of testing with ampicillin, one of the third- generation cephalosporins, chloramphenicol, and meropenem are appropriate to report routinely.

e. Amoxicillin-clavulanate, azithromycin, cefaclor, cefdinir, cefixime, cefpodoxime, cefprozil, cefuroxime, and clarithromycin are oral agents that may be used as empiric therapy for respiratory tract infections due to Haemophilus spp. The results of susceptibility tests with these antimicrobial agents are often not useful for management of individual patients. However, susceptibility testing of Haemophilus spp. with these compounds may be appropriate for surveillance or epidemiological studies.

f. The results of ampicillin susceptibility tests should be used to predict the activity of amoxicillin. The majority of isolates of H. influenzae that are resistant to ampicillin and amoxicillin produce a TEM-type -lactamase. In most cases, a direct -lactamase test can provide a rapid means of detecting ampicillin and amoxicillin resistance.

g. For H. influenzae only.

h. May be appropriate only for prophylaxis of case contacts. Refer to Table 2E.

46 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 47 M100S, 26th ed. For Use With M02-A12M100S, and 26th M07-A10 ed.

Table 1B. (Continued)

Neisseria gonorrhoeae

i. Culture and susceptibility testing of N. gonorrhoeae should be considered in cases of treatment failure. Antimicrobial agents recommended for testing include, at a minimum, those agents listed in Group A. The most recent guidelines from the Centers for Disease Control and Prevention for treatment and testing are available at http://www.cdc.gov/std/Gonorrhea/.

Table 1B Table Streptococcus pneumoniae

M02 and M07 j. S. pneumoniae isolates susceptible to levofloxacin are predictably susceptible to gemifloxacin and moxifloxacin. However, S. pneumoniae susceptible to gemifloxacin or moxifloxacin cannot be

Suggested Fastidious Groupings Fastidious Suggested assumed to be susceptible to levofloxacin.

k. Penicillin and cefotaxime, ceftriaxone, or meropenem should be tested by a reliable MIC method (such as that described in M07-A10), and reported routinely with CSF isolates of S. pneumoniae. Such isolates can also be tested against vancomycin using the MIC or disk method. With isolates from other sites, the oxacillin disk test may be used. If the oxacillin zone size is ≤ 19 mm, penicillin, cefotaxime, ceftriaxone, or meropenem MICs should be determined.

l. Rx: Rifampin should not be used alone for antimicrobial therapy.

Streptococcus spp.

m. Rx: Penicillin- or ampicillin-intermediate isolates may necessitate combined therapy with an aminoglycoside for bactericidal action.

n. Penicillin and ampicillin are drugs of choice for treatment of β-hemolytic streptococcal infections. Susceptibility testing of penicillins and other -lactams approved by the US Food and Drug Administration for treatment of β-hemolytic streptococcal infections need not be performed routinely, because nonsusceptible isolates (ie, penicillin MICs > 0.12 and ampicillin MICs > 0.25 g/mL) are extremely rare in any β-hemolytic streptococcus and have not been reported for Streptococcus pyogenes. If testing is performed, any β-hemolytic streptococcal isolate found to be nonsusceptible should be re-identified, retested, and, if confirmed, submitted to a public health laboratory. (See Appendix A for additional instructions.)

o. Rx: Recommendations for intrapartum prophylaxis for Group B streptococci are penicillin or ampicillin. Although cefazolin is recommended for penicillin-allergic women at low risk for anaphylaxis, those at high risk for anaphylaxis may receive clindamycin. Group B streptococci are susceptible to ampicillin, penicillin, and cefazolin, but may be resistant to erythromycin and clindamycin. When Group B Streptococcus is isolated from a pregnant woman with severe penicillin allergy (high risk for anaphylaxis), erythromycin and clindamycin (including inducible clindamycin resistance) should be tested, and only clindamycin should be reported. See Table 3G.

p. For this table, the β-hemolytic group includes the large colony–forming pyogenic strains of streptococci with Group A (S. pyogenes), C, or G antigens and strains with Group B (S. agalactiae) antigen. Small colony–forming β-hemolytic strains with Group A, C, F, or G antigens (S. anginosus group, previously termed “S. milleri”) are considered part of the viridans group, and interpretive criteria for the viridans group should be used.

q. Daptomycin should not be reported for isolates from the respiratory tract.

r. For reporting against S. pyogenes and S. agalactiae only.

s. For reporting against S. anginosus Group (includes S. anginosus, S. intermedius, and S. constellatus) only.

Clinical and Laboratory Standards Institute. All rights reserved. 47 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 48 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12 and M07-A10 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 49 M100S, 26th 26th ed. ed. For Use With M11-A8

Table 1C. Suggested Groupings of Antimicrobial Agents With US Food and Drug Administration Clinical Indications That Should Be Considered by Microbiology Laboratories in the United States if Testing and Reporting on Anaerobic Organisms Bacteroides fragilis Group and

Other Gram-Negative Anaerobes Gram-Positive Anaerobesb Ampicillina Penicillina Amoxicillin-clavulanate Amoxicillin-clavulanate Ampicillin-sulbactam Ampicillin-sulbactam Piperacillin-tazobactam Piperacillin-tazobactam M11

Table 1C Table

Clindamycin Clindamycin Suggested Anaerobe Groupings Anaerobe Suggested Group A Doripenem Doripenem Ertapenem Ertapenem

Primary TestPrimary and Report Imipenem Imipenem Meropenem Meropenem

Metronidazole Metronidazole

Penicillina Ampicillina Cefotetan Cefotetan Cefoxitin Cefoxitin Ceftizoxime Ceftizoxime Ceftriaxone Ceftriaxone

Group C Chloramphenicol

Supplemental Moxifloxacin Moxifloxacin ReportSelectively

Tetracycline

48 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 50 ©Clinical and Laboratory Standards Institute. All rights reserved. M100S, 26th ed. For Use Use With With M11-A8 M11-A8 M100S,M100S, 26th 26th ed. ed.

Table 1C. Suggested Groupings of Antimicrobial Agents With US Food and Drug Administration Table 1C. (Continued) Clinical Indications That Should Be Considered by Microbiology Laboratories in the United States if Testing and Reporting on Anaerobic Organisms NOTE 1: For information about the selection of appropriate antimicrobial agents; explanation of Test and Bacteroides fragilis Group and Report Groups A and C; and explanation of the listing of agents within boxes, refer to the Other Gram-Negative Anaerobes Gram-Positive Anaerobesb Instructions for Use of Tables that precede Table 1A. a Ampicillin a Penicillin NOTE 2: Most anaerobic infections are polymicrobial, including both β-lactamase-positive and β- Amoxicillin-clavulanate Amoxicillin-clavulanate Ampicillin-sulbactam Ampicillin-sulbactam lactamase-negative strains. Testing may not be necessary for polymicrobial anaerobic Piperacillin-tazobactam Piperacillin-tazobactam infections. However, if requested, only the organism most likely to be resistant (eg, B. fragilis M11 group) should be tested and results reported. 1C Table

Clindamycin Clindamycin NOTE 3: Specific Clostridium species (eg, C. septicum, C. sordellii) may be the singular cause of infection, and are typically susceptible to penicillin and ampicillin. Penicillin and clindamycin

resistance has been reported in C. perfringens. Agents in Group A of Table 1C should be Groupings Anaerobe Suggested Group A tested and reported for Clostridium species. Doripenem Doripenem Ertapenem Ertapenem

Primary TestPrimary and Report Imipenem Imipenem NOTE 4: Information in boldface type is new or modified since the previous edition. Meropenem Meropenem Footnotes Metronidazole Metronidazole

General Comment Penicillina Ampicillina a. If -lactamase positive, report as resistant to penicillin and ampicillin. Be aware that β-lactamase- Cefotetan Cefotetan negative isolates may be resistant to penicillin and ampicillin by other mechanisms. Cefoxitin Cefoxitin Ceftizoxime Ceftizoxime Gram-positive Anaerobes Ceftriaxone Ceftriaxone

Group C Chloramphenicol b. Many non–spore-forming, gram-positive anaerobic rods are resistant to metronidazole. Supplemental Moxifloxacin Moxifloxacin ReportSelectively

Tetracycline

48 Clinical and Laboratory Standards Institute. All rights reserved. Clinical and Laboratory Standards Institute. All rights reserved. 49 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 51 M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10 In in veil of swarming re this information with sible thatgrowth can be laced no less than 24 mm nt accurate measurement. Table 2A-1 Table M02 and M07 e diameter. ld the Petri plate ainches few Enterobacteriaceae

Paratyphi A–C) isolated from -lactamase inhibitor e of the zone of inhibited growth.  spp., ignore the th instructions for QC test -lactam/ used for susceptibility testing, spp. isolated from intestinal sources.  (See Tables (See 4A and 5A for 27853 (for carbapenems) ®

Proteus ATCC Salmonella Enterobacteriaceae * 25922 35218 (for Typhi and Salmonella and Typhi ® ® and trimethoprim-sulfamethoxazole should be reported antagoniststhein may medium allow slightsome growth; ( S. ATCC ATCC plasmadrug exposures(in adults withrenal normaland hepatic

strongly recommended that laboratories sha Salmonella ted only a magnifyingwith lens at the edg ded eye), including the diameter of the disk. Ho Routine QC Recommendations QC Routine acceptable QC ranges.) Escherichia coli Escherichia coli combinations) When a commercial test system is Pseudomonas aeruginosa refer to the manufacturer’s recommendations and QC ranges.

diameter should be clearly measurable; overlapping zones preve one margin shouldmargin one be consideredthe showingarea obvious,no vi th around certain antimicrobial agents. With General Comments Comments General e and no more than 6 disks on a 100-mm plate; disks should be p trimethoprim and the sulfonamides, isolates. spp., third-generationa cephalosporin should testedbe and reported, andchloramphenicol may nd therapeutics committees, and infection control committees. Shigella eptibilitytesting is notindicated for nontyphoidal ry Concentration Interpretive Standards for Standards Concentration Interpretive ry Salmonella spp. are tested, only ampicillin, a fluoroquinolone, When implementing new breakpoints, it is ing recommendations, reporting suggestions, and QC. growth of tiny colonies growth of tiny that can be detec less and of the lawn of growth) measure the more obvious margin to determine the zon erican Type Culture Collection. Susceptibility testing is indicated for typhoidal

of complete inhibition (as judged by the unai and Shigella type is new or modified since the previous edition.

extraintestinalisolates of Salmonella spp. may into swarm areas of inhibited grow 2°C; ambient air



Broth dilution: CAMHB Agar dilution: MHA 0.5 McFarland standard Disk diffusion: MHA Disk diffusion: 16–18 hours Dilution methods: 16–20 hours Proteus 35°C method suspension, or direct colony Growth equivalent to a is a registered trademark of the Am Information in boldface ® infectious diseases practitioners, pharmacists, pharmacy a contrast, susceptibility testingindicated is for all functions) on which breakpoints based. were extraintestinal and intestinalRoutine sources. susc growthin an otherwiseobvious zone of growth inhibition. With therefore, disregard slight (20% growth or apart, center to center (see M02-A12, Subchapter 3.6). Each zone Measure the diameter of the zones above a black background illuminated reflected light. Thewith z detected thewith unaided eye. Ignore faint routinely.addition,In for be tested and reported if requested. Strains of For disk diffusion, test a maximum of 12 disks on a 150-mm plat The dosageregimens shown in the comments column below arethose neededto achieve Whenisolatesfecal of Inoculum: Incubation: Testing Conditions Conditions Testing Medium:

NOTE:

Inhibito Minimal and Diameter Zone 2A-1. Table * ATCC (1) (2) Refer to Tables 3A, 3B, and 3C for additional test

(3)

52 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 52 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M02-A12 M02-A12 and M07-A10 and M07-A10 M100S,M100S, 26th 26th e ed.d.

. E. coli E. coli, E. efamandole, P. mirabilis P. Comments uated. If consideringIf uated. ofuse Table 2A-1 Table M02 and M07 Enterobacteriaceae but are not effective clinically and but are not effective clinically Interpretive criteria when cefazolin

can beResults of ampicillin testing For testing and reporting of K. pneumoniae,K. and are basedInterpretive a on criteria regimen dosage everyg 2 of h. 8 (7). comment See (9) is used for therapy of infections other than uncomplicatedUTIs due to

(4) resultspredict to used amoxicillin. for (2). comment See (5) urinary only. isolates tract

in vitro, 8

eral) was also evaluated; however, no change in eral) was also evaluated; however, no change in 32 32 8/4 128

≥

≥  32/16 32/16 128/4 128/2 ≥

 ≥ ≥ ≥ ≥ alosporins (cefazolin, cefotaxime, ceftazidime, ceftizoxime, cefotaxime,(cefazolin, alosporins ceftazidime, e performede 3A.describedTable as in and cefoperazone)and werenot eval may appear active may of repeat isolates may be may warranted.isolates repeat of

4/4

16/8 (µg/mL) – 16 4 – – – – 32–64 generationcephalosporins derepressionof result a as AmpC  -lactamase. of MIC InterpretiveMIC Criteria 8 – 16 8 2

16 terpretive criteria for cephterpretive – 8/4 16/8 8/4 2/4

 ≤ ≤ 16/4 – 32/4–64/4 16/2 – 32/2–64/2

 ≤ ≤ ≤ ≤ ≤ 13 17 11 13 11 17 14 19 –

≤ ≤ ≤ ≤ ≤ ≤ ≤ ≤ ion cephalosporins and cephamycins – 12–14 100-S20) Cefuroxime (parent in this table. and are listed – – 20–22 ZoneDiameter When using the using When before interpretive current necessary longer no is testing (ie, routineresults criteria, reporting ESBL

and MIC distributions, revised in revised distributions, MIC and InterpretiveCriteria (nearest whole mm) treonam, or penicillins from susceptible to resistant). However, ESBL testing may still be useful for epidemiological or be useful for still ESBL to resistant). However, testing may from susceptible treonam, or penicillins sistant to3days4 within after initiation oftherapy. Testing emented the current interpretivecurrent the emented criteria, b should testing ESBL 17 – 14–16 21 – 18–20 15 – 12–14 18 – 14–17 15 – 21 – 18–20 20 – 15–19 23 S SDD I R S SDD I R

≥ ≥ ≥ ≥  ≥ ≥ ≥

ility in manyin countries (eg, cefamandole, cefonicid, ility moxalactam, g g g   

spp., first- and second-generat – Disk 10 10 30 µg 30 100 Content 10/10 µg10/10 spp., performedbe should testing ESBL 3A). c moxalactam,for results the positive, IfTable (see cefonicid, ESBL test isolates may develop resistance during prolonged therapy third-with Proteus Serratia or spp. and Shigella

and

Agent Agent Antimicrobial Salmonella Ampicillin-sulbactam Ceftolozane- tazobactam E. coli, Klebsiella, E.Klebsiella, coli, For For

-LACTAMASEINHIBITOR COMBINATIONS β Piperacillin Piperacillin Ticarcillin-clavulanate µg 75/10 A Cefazolin A Ampicillin A Ampicillin B B Amoxicillin-clavulanate B µg 20/10 Piperacillin-tazobactam µg 100/10 B O Mecillinam O O Group Group

WARNING: Enterobacter, Citrobacter,

Following evaluation of PK-PD properties, limited clinical data, clinical limited properties, PK-PD of evaluation Following -LACTAM/ Test/Report

PENICILLINS β (PARENTERAL)CEPHEMS (Including cephalosporins I, andIII, II, PleaseIV. refer to GlossaryI.) (6) reportedbe not should susceptible. as (7) and ceftriaxone) 2010 (M and aztreonam were first published in January for necessary dosagethe criteriainterpretive was below. indicated az to edit results for cephalosporins, longer necessary it is no Forpurposes. control infection that laboratories haveimpl not thatNote interpretive for criteria availab limited drugs with fordrugs these cefoperazoneand reportedbe should resistant. as (8) Therefore,isolates that are initially susceptible may become re Table 2A-1. (Continued)

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine©Clinical and Laboratory Standards Institute. All rights reserved. 53 Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 53 M100S,M100S, 26th26th ed. For Use With M02-A12 and M07-A10

and

K. pneumoniae, K. Comments Table 2A-1 Table . Interpretive criteria are E. coli, M02 and M07 Enterobacteriaceae Interpretive criteria are based on a Interpretive criteria are based on a Interpretive criteria are based on a Interpretive criteria are based on a The interpretive criterion for P. mirabilis based on dosagea regimen 1 of g every 12h. See additional information below under (ORAL). CEPHEMS dosage regimen dosage everymg 600 of h. 12 (13) dosage 24 h for every of 1 g regimen 1 g and everyceftriaxone 8 h for cefotaxime. (7). comment See (12) susceptible is based on a dosage regimen of 1 g every 12 h. The interpretive criterion for SDD is based on dosing regimens that result in higher cefepime exposure, either higher doses or more frequent doses or both, up to approved dosingmaximum Seeregimens. Appendix interpretiveabout information more for E see the criteria and dosing regimens. Also SDDof definition thein Instructions for section. Tables of Use (14) dosage regimen of at least 8 g per day everyg 2 6 (eg, h). (15) regimen dosage everyg 1.5 of 8 h. (7). comment See (10) Interpretive(10) whencriteria cefazolin isused for therapyof uncomplicated UTIs dueto (11)2 4 4

32 16 64 32 32

≥ ≥ ≥ ≥  ≥ ≥ ≥ – 2 1

(µg/mL) – – 2 – – MIC InterpretiveMIC Criteria 2 4–8 – 1 1 8 – 16 8 – 16

16 16 – 32

0.5

≤ ≤ ≤ ≤ ≤ ≤  ≤

14 19 18 22 19 12 14 14

    ≤ ≤ ≤ ≤ – 20–22 20–22 – – 23–25 – ZoneDiameter InterpretiveCriteria (nearest whole mm)

15 23 19–2425 – 26 23 16 – 13–15 18 – 15–17 18 – 15–17 S SDD I R S SDD I R

≥  ≥ ≥ ≥ ≥ ≥ ≥ g g g g    

Disk 30 30 µg 30 µg 30 30 µg 30 30 30 30 30 µg 30 Content

Agent Agent Antimicrobial Cefotaxime or ceftriaxone (parenteral) Ceftaroline B Cefepime B B B Cefotetan B Cefoxitin B Cefuroxime U CefazolinU C Group Group Test/Report

CEPHEMS (PARENTERAL)CEPHEMS (Including cephalosporins I, andIII, II, PleaseIV. refer to GlossaryI.) (Continued) Table 2A-1. (Continued)

54 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 54 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use With With M02-A12 M02-A12 and M07-A10and M07-A10 M100S,M100S, 26th 26th ed. ed.

or spp. with cefixime, with spp. spp. with cefprozil with spp. e some isolates may e some isolates may

Comments Table 2A-1 Table Morganella M02 and M07 or by cefetamet diffusion. disk and mirabilis. P. spp. with cefdinir or loracarbef by by loracarbef or cefdinir spp. with Enterobacteriaceae Interpretivecefazolinfor are criteria Do not test Providencia Do not test Insufficient new data new Insufficient exist reevaluateto Interpretive are criteria a on based dosage test not Do Interpretive are criteria a on based dosage Do not test Citrobacter, Providencia, (18) g 1 of regimen everyh.12 (7). comment See (19) comments See and (20). (21) (19) comments See and (21). (16) g 1 of regimen everyh.8 (7). comment See (17) here. listed criteria interpretive (19) (20) (19).comment See (22) by disk diffusion because false-susceptible by reported.been have results (19).comment See cefpodoxime, Enterobacter disk diffusion because false-susceptible results reported.been have (19).comment See when cefazolin results are used to predict results for the oral agents cefaclor, cefdinir, cefpodoxime, cefprozil, cefuroxime, cephalexin, loracarbefand forused when therapy of todue UTIs uncomplicated K. coli, E. pneumoniae, Cefdinir, cefpodoxime, and cefuroximebe may tested individually becaus be susceptible to these agents while testing testing to these agents while be susceptible cefazolin. to resistant 4 4 4 8

16 32 (7).comment See 64 32 (7).comment See 64 (7).comment See 64 (7).comment See 32 (19).comment See 32 32 32 32

≥    ≥ ≥ ≥ ≥ ≥   ≥ ≥ ≥ ≥ 8 2 2 2 4 16 32 16 32 16 16 16–32

(µg/mL) – – – – – MIC InterpretiveMIC Criteria 4 – 4 – 8 – 8 – 1 – 8 4 8–16 – 8 16 8 1 1 2 8

16 – 16 – 16 – 16 –

≤ ≤ ≤ ≤ ≤ ≤ ≤      ≤ ≤ ≤ 17 14 12 14 15 21 14 14 14 14 14 16 15 17 14

              ≤ 18–20 15–17 13–15 15–17 16–20 22–24 15–22 15–22 – 15–17 ––– 15–17 17–19 – 16–18 – 18–20 15–17 ZoneDiameter InterpretiveCriteria (nearest whole mm) 21 – 21 – 18 – 16 – 18 – 21 – 25 – 23 23 – 15 – 18 18 20 19 21 18 S SDD I R S SDD I R

≥ ≥ ≥ ≥ ≥ ≥ ≥  ≥       g g g g g g g g g g g g g g g                5 5 Disk 30 30 30 30 75 30 30 30 30 10 30 30 30 Content oral

Agent Agent Antimicrobial

cephalosporins and UTI)uncomplicated (surrogatefortest B Cefuroxime C Ceftazidime U Cefazolin O Cefamandole O Cefmetazole O Cefonicid O Cefoperazone O Ceftizoxime O Moxalactam O Loracarbef O Cefaclor O Cefdinir O Cefixime O Cefpodoxime O Cefprozil Group Group Test/Report CEPHEMS (PARENTERAL)CEPHEMS (Including cephalosporins I, andIII, II, PleaseIV. refer to GlossaryI.) (Continued) (ORAL) CEPHEMS Table 2A-1. (Continued)

©Clinical and Laboratory Standards Institute. All rights reserved. 55 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 55 M100S,M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10 r a urine isolates

Table 2A-1 Table Comments M02 and M07 Enterobacteriaceae r isolates the carbapenem for which Interpretive are criteria a on based dosage Interpretive are criteria a on based dosage Interpretive are criteria a on based dosage Interpretive are criteria a on based dosage For testing and reporting of Interpretive are criteria a on based dosage (26) 8500 of regimen every h.mg (27) g 1 of regimen everyh.24 (28) 6500 of regimen every or h mg every h. g 8 1 (29) g 1 of regimen everyh.8 See comment (21).comment See (23) (24) g 1 of regimen everyh.8 (7). comment See only.

4 2 4 4

16 32 16

≥ ≥ ≥ ≥   ≥ or meropenem of MICs 2–4 or µg/mL ertapenem MIC of 2 8 2 1 2 2 16

(µg/mL) – – – 8 – – – – (January should 2010) MHT,the perform NPCarba the and/o test, MIC InterpretiveMIC Criteria 4 8 4 1 1 1

0.5

       that are largely responsible for MICs and zone diameters in the intermediate and 14 17 17 19 18 19 19

≤ ≤ ≤ ≤   ≤ tend to be higher (eg, MICs in the intermediate or resistant range) than meropenem or tend to be higher (eg, MICs in the intermediate doripenem 20–22 19–21 20–22 20–22 otherthan productionofcarbapenemases. e listed below. Because ofbelow. e listed organisms limited treatment options for infections carbapenem with by caused –– 15–17 18–20 Consultation with an infectious diseases practitioner is recommended fo is recommended an infectious Consultationdiseases practitioner with ZoneDiameter 1-4 InterpretiveCriteria (nearest whole mm) produced the by for isolates carbapenem which MIC are diffusionresults disk test or intermediatewithinthe range and MICand include that distributions described recently carbapenemase-producing interpretiverevised strains, criteria 18 21 – 21 18–20 – 23 – 22 – 23 – 23 S SDD I R S SDD I R

≥ ≥ ≥ ≥ ≥   Morganella morganii hecurrent interpretive criteria, the MHT does not need to be performed forthan other epidemiologicalcontrol infection or are suspicious for carbapenemase production based on imipenem g g spp., and   stingare in the intermediate or resistant ranges. Disk 10µg 10µg 10µg 10 30 10 µg 10 30 µg 30 Content range, clinicians may to designrange,wish carbapenem dosage prolonged clinicians may regimens that use maximum recommended doses and possibly setting carbapenemrevised breakpoints: ated imipenem MICs by mechanisms by MICs imipenem ated MIC interpretive criteria for carbapenemsfor criteria interpretive MIC M100-S20 indescribed as background on carbapenemases in Enterobacteriaceae has been reported in the literature. Enterobacteriaceae

spp., Providencia

Agent Agent Proteus Antimicrobial Enterobacteriaceae

B B Doripenem B Ertapenem B Imipenem Meropenem C Aztreonam is uncertain due to lack of controlled clinical studies. studies. clinical controlled of lack to due uncertain is elevhave may isolates These MICs. Inv. Cefetamet Inv. Ceftibuten Following evaluationFollowing PK-PDof properties, data, clinical limited

Group Group treatmentcarbapenem of effectiveness clinical The infections of MICs for Imipenem Test/Report CEPHEMS (ORAL) (Continued)(ORAL) CEPHEMS MONOBACTAMS CARBAPENEMS (25) for carbapenems first were published in June 2010 (M100-S20-U) and ar MICs or zone diameters in the intermediate intravenous infusion regimens, as diameterzone or MICs fromresults te diffusion disk Laboratoriesusing molecular assay isolates ofwhen (referµg/mL Tablesto implementationAfter 3C). and 3B t of (referpurposes to 3B).Table The following information is provided ranges, resistant rationalethe thus and for  

Table 2A-1. (Continued)

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine56 ©Clinical and Laboratory Standards Institute. All rights reserved. Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 56 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With M02-A12 M02-A12 and and M07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed. except

Table 2A-1 Table Comments M02 and M07 Typhi only: Typhi Interpretive criteria Enterobacteriaceae

Theseinterpretive urinaryfor are criteria Salmonella There noare interpretiveMIC standards.

(32) arebased on MIC distribution data. (23).comment See commentSee (23). (34) isolates of Enterobacteriaceaetract Salmonella. (31)

 4 8 8 8 1 4 8 8 8

16 16 64 64 32 32 16 16 16 64 32 16

≥ ≥     ≥ ≥             

8 8 – – 8 8 8 2 4 4 4 2 4 4 – 8 4 32 32 16 32 0.5

(µg/mL) – – – – – – – – – – – – – – – – – – – – –  MIC InterpretiveMIC Criteria 4 4 8 4 4 4 1 2 2 2 1 2 2 4 2

16 16 16 16 16

      ≤ ≤   0.25  ≤ ≤ ≤ 

      but are not effective clinically and shouldand reportedbe not not are but susceptible. as clinically effective 12 12 14 13 12 – 11 – 12 11 10 12 15 13 14 14 14 15 14 18 12 13 12 15

in vitro in ≤ ≤ ≤ ≤ ≤ ≤ ≤ ≤ ≤ ≤ ≤ ≤ ≤ ≤ ≤ ≤ ≤ ≤ ≤ ≤ ≤ ≤ spp. (Please refer to GlossaryI.)

– 13–14 13–14 15–16 14–17 13–14 12–14 12–14 11–13 13–15 16–20 14–16 15–18 15–17 15–17 16–19 15–17 19–21 13–15 14–18 13–16 16–18 Salmonella – – – – – – – – – – – – – – – ZoneDiameter InterpretiveCriteria (nearest whole mm)

idered susceptible to doxycycline some and minocycline. However, organisms that are intermediate or resistant to 15 – 15 – 15 – 17 – 18 – 15 – 15 13 15 14 16 21 17 19 18 18 20 18 22 16 19 17 19 S SDD I R S SDD I R

≥ ≥ ≥ ≥ ≥ ≥ ≥ ≥ ≥ ≥ ≥ ≥ ≥ ≥ ≥ ≥ ≥ ≥ ≥ ≥ ≥ ≥ g g g g g g g g g g           Enterobacteriaceaeexcept spp., aminoglycosides may appear may active aminoglycosides spp., 5 µg 5 µg 5 µg 5 µg 5 µg 5 µg 5 µg 5 Disk 30 30 10 15 30 30 30 µg 10 µg 10 µg 30 µg 10 10 10 30 100µg Content doxycycline, minocycline, or both. minocycline, doxycycline, spp. and Shigella

Agent Agent

Antimicrobial Salmonella For For Azithromycin Azithromycin Tetracycline Doxycycline Minocycline Ciprofloxacin Levofloxacin Cinoxacin Enoxacin Gatifloxacin Gemifloxacin Grepafloxacin Lomefloxacin Ofloxacin acid Nalidixic Norfloxacin Fleroxacin

A Gentamicin A Tobramycin B Amikacin B B C U U O Kanamycin O Netilmicin O Streptomycin O O O O O O O O O Inv. Inv. Organisms that are susceptible to tetracycline are also cons WARNING: Group Group

Test/Report AMINOGLYCOSIDES (30) MACROLIDES TETRACYCLINES (33) tetracyclinemay to susceptible be for FLUOROQUINOLONES AND QUINOLONES Table 2A-1. (Continued)

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine©Clinical and Laboratory Standards Institute. All rights reserved. 57 Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 57 M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10 that test resistance s resistance spp.

spp. isolated spp. ic acid disks could ic acid disks could Salmonella Comments

Table 2A-1 Table M02 and M07 Enterobacteriaceae Sulfisoxazole to used be can If a ciprofloxacin, levofloxacin, or No single test detect Strains of (36) nonsusceptible to ciprofloxacin,to nonsusceptible or pefloxacin, ofloxacin, levofloxacin, benalidixic acid may associated with clinical failure or delayed response in fluoroquinolone-treated patients with salmonellosis.

See comment (2). comment See (39) any ofrepresent currently the available preparations.sulfonamide Seecomments (36) and (37). (37) be done, ofloxacin MIC test cannot bepefloxacin disk diffusion may used as a Becausetest. surrogate not is pefloxacin United States, aavailable in the both ciprofloxacin disk alone or ciprofloxacin and nalidix tested. be also (38) resulting from all possible fluoroquinolone havethat mechanisms resistance been spp. in Salmonella identified 1 2 2 

32 16 – 

4/76 512 ≥ ≥ ≥

   

– – 0.25–1 0.25–1 0.12–0.5 (µg/mL)

– – – – – – – – MIC InterpretiveMIC Criteria 8

16 – 

2/38 256  0.06 0.12 0.12 

   ≤ ≤ ≤

Routine susceptibility testing susceptibility Routine nontyphoidalfor indicated not is Salmonella

20 13 23 10 12 10 – –

≤ ≤ ≤ ≤ ≤ ≤

– – – 21–30 14–18 Paratyphi A–C). S.

– – – – – ZoneDiameter InterpretiveCriteria (nearest whole mm) . Typhi. and S

31 19 24 – 16 11–15 – 17 13–16 – 16 11–15 – – S SDD I R S SDD I R

≥ ≥ ≥ ≥ ≥ ≥

Salmonellaspp. refer(Please to Glossary I.) g g g μ

– – 5 µg 5 5 μ 5 μ Disk 1.25/ spp. (includingspp. 30 250 or250 300µg Content 23.75 µg23.75

Salmonella

Agent

Antimicrobial

Nalidixic acid acid Nalidixic Pefloxacin (surrogate test for ciprofloxacin) Ciprofloxacin Levofloxacin Ofloxacin sulfamethoxazole

B B O O B Trimethoprim- U U Sulfonamides Trimethoprim Inv. For testing andtesting For reporting of Group Test/Report QUINOLONES AND FLUOROQUINOLONES for for FLUOROQUINOLONES AND QUINOLONES (35) sources. intestinal from (2). comment See PATHWAY INHIBITORS FOLATE

Table 2A-1. (Continued)

58 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 58 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M02-A12 M02-A12 and M07-A10 and M07-A10 M100S,M100S, 26th 26th ed ed..

E. coli E.

g/mL of glucose-  g disk contains fosfomycin Comments  Table 2A-1 Table M02 and M07 Enterobacteriaceae g ofg glucose-6-phosphate. Not routinely reported on isolates For testing reportingand of The 200- The approved only MIC method for  (40) urinarythe from tract. (41) urinaryonly. isolates tract (42) (43) dilutionagar is testing mediaagar using supplemented with 25 6-phosphate. Broth dilution MIC testing performed.be not should 50 -lactamase; I, intermediate; MHA,intermediate; I, -lactamase; Mueller-Hinton 32 rol; R, S, resistant; susceptible; SDD, susceptible-

 256 128

   (µg/mL) – 16 – 128 – 64 MIC InterpretiveMIC Criteria 8

64 32

   12 12 14

≤ ≤ ≤ usted Mueller-Hinton broth;Mueller-Hinton usted extended-spectrumESBL, ZoneDiameter InterpretiveCriteria (nearest whole mm) 18 – 13–17 16 – 13–15 17 – 15–16 S SDD I R S SDD I R

≥ ≥ ≥

Disk 200 µg 200 µg 300 Content mal inhibitory concentration;mal inhibitory PK-PD, pharmacokinetic-pharmacodynamic; cont QC, quality

Agent , American, Culture Type cation-adj CAMHB, Collection; Antimicrobial ®

C U Chloramphenicol Fosfomycin µg 30 U Nitrofurantoin Group Test/Report PHENICOLS FOSFOMYCINS NITROFURANS Table 2A-1. (Continued) ATCC Abbreviations: agar; MHT, modified Hodge test; MIC, mini dependent;dose urinaryUTI, tractinfection.

©Clinical and Laboratory Standards Institute. All rights reserved. 59 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 59 M100S,M100S, 26th ed. ed. ly available for available ly MIC result should should result MIC ansmission: a cross- 2014;63(6):132-133. Table 2A-2 Table with decreased

. i Comments Epidemiological Cutoff Values for Values Epidemiological Cutoff Shigella Shigella sonnei and Shigella flexneri Shigella infection in men who have sex with sex who have men in infection S. flexneri. S. sonne

sis through sexual tr sis . 2015;13(1):69-80. MMWR Morb Mortal Wkly Rep. MMWR Morb Mortal Shigella flexneri Shigella . 1632 For use with For use with

≥ ≥ NWT NWT infection with infection treatment failure due to azithromycin resistance in an g/mL) S. flexneri (  MIC ECV Shigella sonnei Shigella sonnei 8

Expert Rev Anti Infect Ther 16

≤ WT ≤ and General Comment Comment General Shigella flexneri

15 

sease Control and Prevention (CDC). Notes from the field: seaseand Prevention Control ≤ NWT NWT ve sex with States,ve 2002-2013. United men - Shigella infections. Shigella flexneri flexneri Shigella (mm) tbreak of locally acquired azithromycin-resistant modifiedsince the previous edition.

16 

Intercontinental dissemination of azithromycin-resistant shigello azithromycin-resistant of dissemination Intercontinental WT ≥ Zone Diameter ECV Diameter Zone . 2015;15(8):913-921. 2014;42(4):789-790.

Zone diameter correlates are only available for available only are correlates diameter Zone  1-5 Disk . 15 µg Content Content Infection. Lancet Infect Dis 2015;47(1):87-88. and S. sonnei and

Pathology. Azithromycin Azithromycin

men. sectional study. sectional study. who among men to azithromycin ha susceptibility patient. HIV-positive notwith be reported a susceptible, intermediate, or resistant interpretation. dataAdequate to establish ECVs are currently on S. flexneri

Antimicrobial Agent NOTE: Information in boldface type new is or Abbreviations: ECV, epidemiological cutoff value; MIC, minimal inhibitory concentration; NWT, non-wild-type; WT, wild-type. wild-type. WT, non-wild-type; NWT, concentration; inhibitory minimal MIC, value; cutoff epidemiological ECV, Abbreviations: of drug-resistant Treatment N. Klontz KC, Singh PM, et al. Baker KS, Dallman TJ, Ashton Heiman KE, Karlsson M, Grass J, et al.; Centers for Di Valcanis M, Brown JD, HazeltonOu B, et al. Hassing RJ, Melles DC, Goessens WH, Rijnders BJ. Case of

(1) and diffusion disk The breakpoints. clinical as used be not should ECVs The ECVs. of explanation an for G to Refer Appendix 1 2 3 4 5 Table 2A-2. Epidemiological Cutoff Values for Values Epidemiological Cutoff Table 2A-2. 2A-2 for Table References

60 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 60 ©Clinical and Laboratory Standards Institute. All rights reserved. M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 61 M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10 nt accuratent

the disk. Hold the Petri Table 2B-1 Table hareinformationthis with M02 and M07 ing lens at the edge of the -lactamase inhibitor  Pseudomonas aeruginosa Pseudomonas -lactam/  27853 (See Tables (See 4A and 5A for acceptable ® ATCC 35218 (for Pseudomonas aeruginosa Pseudomonas ® ATCC plasma drug exposures (in adults normal renalwith and hepatic

ly determinedly disk by diffusion or dilution methods, but may need 6 disks on a 100-mm plate; disks should be placed no less than 24 mm

Escherichia coli Routine QC Recommendations QC Routine QC ranges.) Pseudomonas aeruginosa combinations) When a commercialsystemtest is used for susceptibility testing, refer to manufacturer’s testthe instructionsQC for recommendations and QC ranges. robial agents. Therefore, isolates that are initially susceptible may become

w breakpoints, w stronglyis it recommendedthat laboratories s ectedThe light. zone margin should be considered the area showing no obvious, visible General Comments Comments General nd therapeutics committees, and infection control committees. ry Concentration Interpretive Standards for Standards Concentration Interpretive ry hapterzone Each 3.6). diametershould clearlybe measurable;overlapping zones preve therapy. Testingtherapy. of repeat isolates be may warranted. of the zones complete inhibition (as judged by the unaided eye), including the diameter of

isolated from patients cystic fibrosiswith can be reliab P. aeruginosa 2°C; ambient air



may develop resistance during prolonged therapy all with antimic Agar dilution: MHA 0.5 McFarland standard Disk diffusion: 16–18 hours Dilution methods: 16–20 hours 35°C Broth dilution: CAMHB method or direct colony Growth suspension, equivalent to a Information in boldface type is or new modified since the previous edition. extended incubation for up to 24 hours before reporting as susceptible. For disk diffusion, test a maximum of 12 disks on a 150-mm plate and no more than P. aeruginosa resistant 3 to 4 days after initiation of within functions) on which breakpoints derived.implementing were When ne infectious diseases practitioners, pharmacists, pharmacy a apart, center apart, center (seeto M02-A12, Subc measurement. Measure the diameter plate a few inches above a black background illuminated refl with growth that can be detected with the unaided eye. Ignore faint growth of tiny colonies that can be detected only a with magnify zone of inhibited growth. The susceptibility of The dosage regimens shown in the comments column below are those necessary to achieve Inoculum: Incubation: Testing Conditions Conditions Testing Disk diffusion: MHA Medium:

NOTE:

Inhibito Minimal and Diameter Zone 2B-1. Table (1) (2) (3) (4)

62 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 62 ©Clinical and Laboratory Standards Institute. All rights reserved. For UseFor Use With With M02-A12 M02-A12 andand M07-A10 M07-A10 M100S,M100S, 26th e26thd. ed.

Table 2B-1 Table Comments M02 and M07 Pseudomonas aeruginosa Pseudomonas Interpretive criteria for doripenem are Interpretive criteria for imipenem are Interpretive criteria for meropenem are Interpretive criteria are based on a Interpretive criteria are based onadosage Interpretive criteria are based onadosage Interpretive criteria for piperacillin (alone or Interpretive criteria for piperacillin (alone or Interpretive or(alone ticarcillin for criteria

(11) based on a dosage regimen of 500every mg h. 8 (12) 8 h based on a dosage regimen of 1 g every everymg 500 or h. 6 (13) basedon adosage regimen of1 8 gevery h. (8) g 1 of regimen everyorh 6 everyg 2 h.8 (9) g 1 of regimen everyorh 8 everyg 2 h.12 (10) regimendosage g1 of every 6 h 2 or everyg h. 8

(5) tazobactam) are based onwith a piperacillin 6 regimen dosage h.every g 3 least at of (6) tazobactam) are based onwith a piperacillin 6 regimen dosage h. every g 3 least at of (7) clavulanate) arewith based on a ticarcillin 6 regimen dosage h.every g 3 least at of

8 8 8 8 8

32 32 32 16 16 64 32

128      16/4

       128/4 128/2

   

4 4 4 4 4 8 8 32 16 16 16 16 8/4 (µg/mL) 32–64 32/4–64/4 32/2–64/2

MIC InterpretiveMIC Criteria 8 8 8 2 2 2 2 2 4 4 8

16 16 4/4

16/4 16/2           

    

16 14 15 14 14 15 15 15 15 10 11 12 12 14 12 14

               

– – 15–20 15–20 16–23 15–17 15–17 16–21 16–18 16–18 16–18 13–14 13–14 15–16 13–14 17–20 ZoneDiameter

InterpretiveCriteria (nearest whole mm)

21 21 21 24 18 18 22 19 19 19 11 12 15 15 17 15 S I S R I R

               

g

g g  g   g g g g g g g g g g g            

Disk 10 10 30 30 30 30 10 10 10 10 30 100 Content 75/10 30/10 300 units 300 100/10

Agent Agent Antimicrobial

Meropenem

-LACTAMASEINHIBITOR COMBINATIONS  Piperacillin Piperacillin Piperacillin-tazobactam

A Ceftazidime B Cefepime B Aztreonam B Doripenem B Imipenem A Gentamicin A Tobramycin B Amikacin B A Ceftolozane-tazobactamB O O Ticarcillin-clavulanate Colistin O O PolymyxinB ONetilmicin Group Group -LACTAM/ Test/Report PENICILLINS  (PARENTERAL)CEPHEMS (Including cephalosporins I, andIII, II, PleaseIV. refer to GlossaryI.) MONOBACTAMS CARBAPENEMS LIPOPEPTIDES AMINOGLYCOSIDES

Table 2B-1. (Continued) Table 2B-1. (Continued)

©Clinical and Laboratory Standards Institute. All rights reserved. 63 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 63 M100S,M100S, 26th26th ed. ed. For Use With M02-A12 and M07-A10 ,

Table 2B-1 Table Comments M02 and M07 Pseudomonas aeruginosa Pseudomonas For testing and reporting of urinary tract

(14) only. isolates 4 8 8 8 8

16

      4 8 2 4 4 4 (µg/mL) MIC InterpretiveMIC Criteria r-Hinton broth; I, intermediate; MHA, Mueller-Hinton agar; MIC 4

1 2 2     2  2  15 13 12 18 12 14

      16–20 14–16 13–16 19–21 13–15 15–17 ZoneDiameter InterpretiveCriteria (nearest whole mm) 21 17 17 22 16 18 S I R S I R

      g g g g g g     5  5  5 5 Disk 10 10 Content y control; R, resistant; S, susceptible.

Agent Agent

, American Type Culture Collection; CAMHB, cation-adjusted Muelle Antimicrobial ® Ciprofloxacin Levofloxacin Norfloxacin Lomefloxacin Ofloxacin Gatifloxacin

B B U O O O Group Group Test/Report FLUOROQUINOLONES

minimal inhibitory concentration; QC, qualit Table 2B-1. (Continued) Abbreviations: ATCC

64 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 64 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12 and M07-A10 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 65 M100S,M100S, 26th ed.ed. For Use With M02-A12 and M07-A10 sible thatgrowth can be nt accurate measurement. Table 2B-2 Table Comments M02 and M07 wth (20% wth or less of the lawn -lactamase inhibitor ld the Petri plate ainches few Acinetobacter spp. 

e of the zone of inhibited growth. -lactam/  27853 (See Tables (See 4A and 5A for ®

ATCC 25922 (for tetracyclines and trimethoprim- ® 35218 (for ® 128

spp. Acinetobacter 32/16 128/4 128/2

    ATCC ATCC 16/8 32–64 (µg/mL) 32/4–64/4 32/2–64/2 ted only a magnifyingwith lens at the edg Escherichia coli Routine QC Recommendations QC Routine acceptable QC ranges.) Escherichia coli sulfamethoxazole) Pseudomonas aeruginosa combinations) When a commercial for test system is used susceptibility testing, refer to the manufacturer’s instructions for QC test recommendations and QC ranges. MIC InterpretiveMIC Criteria 16 8/4

16/4 16/2 than 6 disks on a 100-mm plate; disks should be placed no less than 24 mm

ded eye), including the diameter of the disk. Ho 

  

17 11 17 14

    diameter should be clearly measurable; overlapping zones preve one margin shouldmargin one be consideredthe showingarea obvious,no vi General Comments Comments General

18–20 12–14 18–20 15–19 ZoneDiameter InterpretiveCriteria (nearest whole mm) ry Concentration Interpretive Standards for Standards Concentration Interpretive ry 21 15 21 20 S I R S I R

sts in the medium may allow some slight therefore,growth; disregard slight gro    

g growth of tiny colonies growth of tiny that can be detec g g  g   margin to determine the zone diameter.  Disk

100 Content 10/10 75/10 100/10 Agent Agent 2°C; ambient air; 20–24 hours, all methods



Antimicrobial Ticarcillin-clavulanate Ticarcillin-clavulanate McFarlandstandard Broth dilution: CAMHB 35°C

Disk diffusion: MHA Disk -LACTAMASEINHIBITOR COMBINATIONS

Growth method or direct colony suspension, equivalent to a 0.5 

Information in boldface type is or new modified since the previous edition. Piperacillin Piperacillin A Ampicillin-sulbactam B Piperacillin-tazobactam O O For disk diffusion, test a maximum of 12 disks on a 150-mm plate and no more apart, center to center (see M02-A12, Subchapter 3.6). Each zone Measure the diameter of the zones of complete inhibition (as judged by the unai above a black background illuminated reflected light. Thewith z detected thewith unaided eye. Ignore faint With trimethoprim and the sulfonamides, antagoni of growth) andof growth) measure the more obvious Group Group -LACTAM/

Testing Conditions Conditions Testing Medium: dilution: MHA Agar Inoculum: Incubation: Test/Report PENICILLINS  Inhibito Minimal and Diameter Zone 2B-2. Table (1)

NOTE: NOTE:

66 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 66 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With M02-A12 M02-A12 and and M07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed. , minimal Table 2B-2 Table Comments M02 and M07 Acinetobacter spp. Interpretive doripenemfor criteria onbased are a Interpretiveimipenem criteria for are based on a Interpretive criteria for meropenem are based on

(2) regimen dosage everymg 500 of h. 8 (3) regimen dosage everymg 500 of h. 6 (4) regimendosage a everyg 1 of 8 mg500 or h every 6 h.

4 4 4 8 8

32 32 64 64 16 16 64 32 16 16 16

     4/76

           8 8 8

   

– 4 4 4 – – 8 8 8 8 8 2 4 4 16 16 16 32 16–32 16–32 (µg/mL)

ller-Hinton broth; I, intermediate; MHA, Mueller-Hinton agar; MIC MIC InterpretiveMIC Criteria 8 8 8 8 2 2 2 2 2 4 4 8 4 4 4 1 2 2

16

                  2/38

  9

14 14 14 13 14 18 14 12 12 14 12 11 15 13 14 10 – –

                ≤

– – 15–17 15–17 15–22 14–20 15–17 19–21 15–17 13–14 13–14 15–16 10–12 13–15 12–14 16–20 14–16 15–17 11–15 dered susceptible to doxycycline and minocycline. dered susceptible to doxycycline However, some organisms that are intermediate or resistant to ZoneDiameter InterpretiveCriteria (nearest whole mm)

18 18 23 21 18 22 18 15 15 17 13 16 15 21 17 18 – S I R S I R

   ≥             16 g g g g g g g g g g g g g g g g             

  – – – – – – – 5 5  5 Disk 30 10 30 30 30 10 10 10 30 30 30 30 10 g Content 1.25/23.75  ontrol; R, resistant; S, susceptible.

doxycycline, minocycline, or both.minocycline, doxycycline,

Agent Agent

, American Type Culture Collection; CAMHB, cation-adjusted Mue ®

Antimicrobial

Polymyxin B Polymyxin Colistin Gatifloxacin Cefotaxime Ceftriaxone Doripenem Imipenem Ciprofloxacin Levofloxacin Trimethoprim- sulfamethoxazole

A Ceftazidime B B B Cefepime A A A Meropenem A Gentamicin A Tobramycin B Amikacin B Doxycycline B Minocycline A A B Tetracycline U Tetracycline O O O Netilmicin O Group Group Organisms that are susceptible to tetracycline are also consi Test/Report CEPHEMS (PARENTERAL)CEPHEMS (Including cephalosporins I, andIII, II, PleaseIV. refer to GlossaryI.) CARBAPENEMS LIPOPEPTIDES AMINOGLYCOSIDES TETRACYCLINES (5) tetracyclinemay to susceptible be FLUOROQUINOLONES PATHWAY INHIBITORS FOLATE Table 2B-2. (Continued) Abbreviations:ATCC inhibitory concentration;quality c QC,

©Clinical and Laboratory Standards Institute. All rights reserved. 67 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 67 M100S,M100S, 26th26th ed. For Use With M02-A12 and M07-A10

zones Table 2B-3 Table Comments M02 and M07 complex d be considered the -lactamase inhibitor Burkholderia cepacia complex Burkholderia cepacia  -lactam/

 27853 (See Tables (See 4A and 5A for acceptable QC ® 8

32 16 16

 128/2   

Burkholderia cepacia Burkholderia ATCC  25922 (for chloramphenicol, minocycline, and ® 35218 (for ® 8 8 4 16 ATCC ATCC (µg/mL) 32/2–64/2

on (as judged by the unaided eye), including the diameter 8 4 4 2 MIC InterpretiveMIC Criteria

    16/2

 Escherichia coli trimethoprim-sulfamethoxazole) Pseudomonas aeruginosa Routine QCRoutine Recommendations ranges.) Escherichia coli combinations) When a commercial test system is used for susceptibility testing, refer to the manufacturer’s instructions for QC test recommendations and QC ranges. 17 15 14

  

e unaided Ignoreeye. faint growth of tiny colonies that caben onlydetected e and no more than 6 disks on a 100-mm plate; disks should be placed no less 18–20 16–19 15–18 General Comment Comment General

owth. With trimethoprimowth. and the sulfonamides, antagonists allow in the medium may ZoneDiameter InterpretiveCriteria (nearest whole mm) 21 20 19 S I R S I R

   ry Concentration Interpretive Standards for Standards Concentration Interpretive ry 2, Subchapter 3.6). Each zone diameter should be clearly measurable; overlapping g g g    ight(20% growth or lawn the of less of growth) measureand obviousmore the determineto the margin – – – Disk 30 30 10 ches above a black background illuminated reflectedwith The light. zone margin shoul Content

Measure the diameter of the zones of complete inhibiti

Agent Agent

2°C; ambient air; 20–24 hours, all methods



Antimicrobial

Meropenem Levofloxacin Broth dilution: CAMHB Agar dilution: MHA a 0.5 McFarland standard 35°C method or direct Growth suspension, colony equivalent to -LACTAMASEINHIBITOR COMBINATIONS  Disk diffusion: MHA Disk Information in boldface type is or new modified since the previous edition. Ticarcillin-clavulanate Ticarcillin-clavulanate – – – – B Ceftazidime B Minocycline A A O with a magnifying lens at the edge of the zone of inhibited gr slightsome therefore, growth; disregardsl zone diameter. For disk diffusion, test a maximum of 12 disks on a 150-mm plat than 24 mm apart, center to (see M02-A1 prevent accurate measurement. of the disk. Hold the Petri plate in a few area showing no obvious, visible growth that can be detected th with Group Group Testing Conditions Conditions Testing Medium: Inoculum: Incubation: -LACTAM/ Test/Report  (PARENTERAL)CEPHEMS (Including cephalosporins I, andIII, II, PleaseIV. refer to GlossaryI.) CARBAPENEMS TETRACYCLINES FLUOROQUINOLONES NOTE: Inhibito Minimal and Diameter Zone 2B-3. Table (1)

68 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 68 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use With With M02-A12 M02-A12 and M07-A10and M07-A10 M100S,M100S, 26th 26th e d.ed. , Table 2B-3 Table Comments M02 and M07 Burkholderia cepacia complex Burkholderia cepacia Not routinely reported from theon isolates (2) urinarytract.

32

4/76

  I, intermediate; MHA, Mueller-Hinton agar; MIC

– 16 (µg/mL) 8

MIC InterpretiveMIC Criteria

 2/38

 10

 11–15 ZoneDiameter InterpretiveCriteria (nearest whole mm) 16 S I R S I R

CAMHB, cation-adjusted Mueller-Hinton broth;  g  – – – Disk y control; R, resistant; S, susceptible. Content 1.25/23.75

Agent Agent , American Type Culture Collection; ® Antimicrobial sulfamethoxazole Chloramphenicol

A Trimethoprim- C Group Group Test/Report FOLATE PATHWAY INHIBITORS FOLATE PHENICOLS minimal inhibitory concentration; QC, qualit Table 2B-3. (Continued) Abbreviations: ATCC

©Clinical and Laboratory Standards Institute. All rights reserved. 69 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 69 M100S,M100S, 26th26th ed. For Use With M02-A12 and M07-A10 ld the Petri Petri the ld nt accuratent Table 2B-4 Table M02 and M07 ing lens at the edge of the -lactamase inhibitor  Comments Stenotrophomonas maltophilia Stenotrophomonas diameter of the disk. Ho -lactam/  27853 (See Tables (See 4A and 5A for ®

ATCC 25922 (for chloramphenicol, minocycline, and 35218 (for ® ® 8

32 16

Stenotrophomonas maltophilia    128/2

 ATCC ATCC aided eye), including the 8 4 16 (µg/mL) 32/2–64/2

8 4 2

MIC InterpretiveMIC Criteria Escherichia coli Routine Recommendations QC acceptable QC ranges.) Escherichia coli trimethoprim-sulfamethoxazole) Pseudomonas aeruginosa combinations) When a commercial for test system is used susceptibility testing, refer to the manufacturer’s instructions for QC test recommendations and QC ranges.    16/2

 14 13

 

ectedThe light. zone margin should be considered the area showing no obvious, visible antagonists in the medium may allow some slight disregard therefore, growth; slight growth ate and no more than 6 disks on a 100-mm plate; disks should be placed no less than 24 mm 15–18 14–16 ZoneDiameter General Comment Comment General InterpretiveCriteria (nearest whole mm) 19 17 S I S R I R

  more obvious margin to determine the zone diameter. ry Concentration Interpretive Standards for Standards Concentration Interpretive ry

hapterzone Each 3.6). diametershould clearlybe measurable;overlapping zones preve g g   – – he zones of complete inhibition (as judged by the un 5 Disk 30 Content

Agent Agent

2°C; ambient air; 20–24 hours, all methods

 Antimicrobial

Measure the diameter of t

Broth dilution: CAMHB Agar dilution: MHA 0.5 McFarland standard Levofloxacin 35°C -LACTAMASEINHIBITOR COMBINATIONS method suspension, or direct colony Growth equivalent to a

 Information in boldface type is new or modified since the previous edition. Ticarcillin-clavulanate Ticarcillin-clavulanate – – B Ceftazidime Ceftazidime B B Minocycline B O For disk diffusion, test a maximum of 12 disks on a 150-mm pl center apart, center (seeto SubcM02-A12, measurement. plate a few plate a few inches above a black background illuminated refl with growth that can be detected with the unaided eye. Ignore faint growth of tiny colonies that can be detected only a with magnify zone of inhibited With growth. trimethoprim and the sulfonamides, of growth)(20% or less of the lawn and measure the Group Group -LACTAM/ Testing Conditions Conditions Testing Disk diffusion: MHA Medium: Inoculum: Incubation:

Test/Report  (PARENTERAL)CEPHEMS (Including cephalosporins I, andIII, II, PleaseIV. refer to GlossaryI.) TETRACYCLINES FLUOROQUINOLONES Inhibito Minimal and Diameter Zone 2B-4. Table (1) NOTE: NOTE:

70 ©Clinical and Laboratory Standards Institute. All rights reserved.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 70 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With M02-A12 M02-A12 and and M07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed. , Table 2B-4 Table M02 and M07 Comments Stenotrophomonas maltophilia Stenotrophomonas Not routinelyreported thefrom isolates on (2) urinarytract.

32

4/76

  – 16 (µg/mL) r-Hinton broth; I, intermediate; MHA, Mueller-Hinton agar; MIC 8

MIC InterpretiveMIC Criteria 2/38 

 10  11–15 ZoneDiameter InterpretiveCriteria (nearest whole mm) S I R S I R 16 – – – – Disk Content g y control; R, resistant; S, susceptible. 1.25/23.75 

Agent Agent , American Type Culture Collection; CAMHB, cation-adjusted Muelle Antimicrobial ® Trimethoprim- sulfamethoxazole Chloramphenicol

A C Group Group Test/Report PATHWAY INHIBITORS FOLATE PHENICOLS minimal inhibitory concentration; QC, qualit Table 2B-4. (Continued) Abbreviations: ATCC

©Clinical and Laboratory Standards Institute. All rights reserved. 71 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 71 M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10

for testing oftesting for

M07 Refer to Tablesto Refer

Table 2B-5 Table Comments -lactamase inhibitor  (Refer to Comment 1) Comment (Refer to Other Non- Enterobacteriaceae -lactam/ ermenting, gram-negative bacilli, for QC test recommendations and  27853 (See Tables (See 4A and 5A for ®

ATCC

25922 (for chloramphenicol, tetracyclines, ® 35218 (for 32 32 64 64

128 ®

   128/4 128/2 

 Stenotrophomonas maltophilia.  

ATCC and ATCC respectively, and CLSIdocument M45 ied by theied by subcommittee nor have clinical data been 16 16 16–32 16–32 32–64 (µg/mL) es. 32/4–64/4 32/2–64/2 g

8 8 8 8 MIC InterpretiveMIC Criteria

16

S. maltophilia, 16/4 16/2    

Escherichia coli sulfonamides, and trimethoprim-sulfamethoxazole) Pseudomonas aeruginosa Routine QC Recommendations QC Routine acceptable QC ranges.) Escherichia coli  combinations) When a commercial for test system is used susceptibility testing, refer to the manufacturer’s instructions QC ran   Enterobacteriaceae Enterobacteriaceae Non- Other for g/mL) and ,  – – – –

. complex spp – – – – Vibrio General Comments Comments General ZoneDiameter B. cepaciaB. and InterpretiveCriteria (nearest whole mm) spp. (not P. aeruginosaother) and nonfastidious, glucose-nonf – – – – up, disk diffusion testing recommended. is not currently S I R S I R spp., Burkholderiacepacia, mallei,B. pseudomallei,B. – – – – – – – – – – – – – – Disk Pseudomonas Content Content Aeromonas spp.,

Acinetobacter

the disk diffusion method has not been systematically stud include Acinetobacterspp.,

B. pseudomallei,

Agent Agent Antimicrobial Antimicrobial 2°C; ambient air; 16–20 hours

Enterobacteriaceae, ±

Enterobacteriaceae Piperacillin-tazobactam Piperacillin-tazobactam Ticarcillin-clavulanate Cefotaxime Ceftriaxone McFarlandstandard 35°C Minimal Inhibitory Concentration Interpretive Standards ( Interpretive Concentration Minimal Inhibitory

-LACTAMASE INHIBITOR COMBINATIONS Growth method or direct colony suspension, equivalent to a 0.5  Broth dilution: CAMHB Broth Information in boldface type is or new modified since the previous edition.

Piperacillin Piperacillin B A Ceftazidime B Cefepime collected for review. Therefore, for this organism gro Burkholderia mallei, but excludebut P. aeruginosa, 2B-2, 2B-3,2B-2, and 2B-4 testingfor of C C O O Group Group For other non- Other non- -LACTAM/ Agar dilution: MHA Agar Testing Conditions Conditions Testing Medium: Inoculum: Incubation: Test/Report PENICILLINS  (PARENTERAL)CEPHEMS (Including cephalosporins I, andIII, II, PleaseIV. refer to GlossaryI.)

NOTE: NOTE: (2) Table 2B-5. (1)

72 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 72 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use With With M02-A12 M02-A12 and M07-A10and M07-A10 M100S,M100S, 26th 26th ed ed.. , , M07 Table 2B-5 Table Comments Other Non- Enterobacteriaceae Not routinely reported from theon isolates Sulfisoxazole can be used to represent any of For testing and reporting of urinary tract (6) urinarytract. (5) currentlythe preparations.sulfonamide available

(4) only. isolates 8 8 4 8 8 8 8

64 64 64 32 16 16 16 16 64 32 16 16 16 16 32

512 4/76       

                

8 8 4 4 8 8 8 8 8 2 4 8 4 4 4 – – 16 16 16 32 32 16–32 16–32 (µg/mL) r-Hintonbroth; intermediate;I, Mueller-Hinton MHA, agar; MIC 8 8 8 4 4 2 2 4 4 8 4 4 4 1 2 4 2 2 2 8 MIC InterpretiveMIC Criteria

16 16

256                 2/38    

   

– – – – – – – ZoneDiameter InterpretiveCriteria ered susceptible to doxycycline andminocycline. However, some organisms that areintermediate or resistant to (nearest whole mm) – – – – – S I R S I R – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – Disk Content y control; R, resistant; S, susceptible.

doxycycline, minocycline, or both.minocycline, doxycycline,

Agent Agent

Antimicrobial ,American Type CultureCollection; CAMHB, cation-adjusted Muelle ®

Ciprofloxacin Levofloxacin sulfamethoxazole Gatifloxacin Lomefloxacin Ofloxacin

B Aztreonam B Imipenem B Meropenem A Gentamicin A Tobramycin B Amikacin B B B Trimethoprim- U TetracyclineU NorfloxacinU Sulfonamides U Chloramphenicol C – – – – O CefoperazoneO Ceftizoxime O MoxalactamO Colistin O O PolymyxinB Netilmicin O Doxycycline O Minocycline O O O O Group Group Organisms that aretetracyclinesusceptible to are also consid Test/Report CEPHEMS (PARENTERAL)CEPHEMS (Including cephalosporins I, andIII, II, PleaseIV. refer to GlossaryI.) (Continued) MONOBACTAMS CARBAPENEMS LIPOPEPTIDES AMINOGLYCOSIDES TETRACYCLINES (3) tetracyclinemay to susceptible be FLUOROQUINOLONES PATHWAY INHIBITORS FOLATE PHENICOLS Table 2B-5. (Continued) Abbreviations:ATCC minimal inhibitory concentration; QC, qualit

©Clinical and Laboratory Standards Institute. All rights reserved. 73 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 73 M100S,M100S, 26th26th ed. For Use With M02-A12 and M07-A10 medium may microdilution MIC, microdilution railing begins. Tiny Tiny begins. railing laced no less thanless no laced 24 Table 2C Table the disk. Hold Petrithe M02 and M07 e unaided eye. Ignore faint Staphylococcus spp. Staphylococcus indicativeresistanceof theto ransmitted light (plate held up (See Tables(See and4A for 5A 29213 25923 ® ® spp. spp. ATCC ATCC ch as changes in affinity of penicillin-binding 80% reduction80% growth in as compared to the

≥ mm plate;mm disks p be should Staphylococcus C at the lowest concentrationwhere the t Dilution methods: Staphylococcus aureus Routine QC Recommendations QC Routine acceptable QC ranges.) Disk diffusion: Staphylococcus aureus Whena commercial test is system usedsusceptibilityfor the manufacturer’sto refer testing, instructions QC test for recommendations and QC ranges. d byd the unaided eye), including the diameter of more than 6disks on a100-

zonediameter should clearlybe measurable;overlapping zones prevent accurate nd 4). With trimethoprim and the sulfonamides, antagonists in the the in antagonists sulfonamides, the and trimethoprim With 4). nd erythromycin, linezolid, tedizolid, and tetracycline by broth by tetracycline and tedizolid, linezolid, erythromycin, ying lens at the edge of the zone of inhibited With trimgrowth. ethoprim and the (see Glossary(see I) beenhas referred to “methicillinas resista nce”or “oxacillinresistance.” General Comments Comments General or another mechanism of methicillin resistance, su mecA ion read the In such difficult. MI cases, ented to 50 µg/mL calcium for ry Concentration Interpretive Standards for for Standards Interpretive Concentration ry allow some slight growth; therefore, disregard slight growth (20% or less of growth) andof the lawn measure sksa on 150-mmplate no and

+

that express of the zonesthe of completeof inhibition (as judge 2% NaCl for oxacillin. Agar dilution has not

+

above 35°C not detect MRS. may S. aureus strains). S. aureus 2°C; ambient air



Disk diffusion: 16–18 hours; 24 hours (CoNS and cefoxitin) Broth dilution: CAMHB; CAMHB 2% NaCl for oxacillin; CAMHB supplem daptomycin Agar dilution: MHA; MHA

Testing at temperatures 35°C been validated for daptomycin. Direct colony suspension, equivalent to a 0.5 McFarland standard mm apart, centerapart, mm (seecenter to M02-A12, Subchapter 3.6).Each measurement. Measurediameterthe plate a few inches above a black background illuminated reflectedwith light, except for linezolid, which should be read t with to light source).The zone margin should be considered the area showing no obvious, visible growth that can be detected th with growth of tiny colonies that can be detected only with a magnif sulfonamides, antagonists in the medium may morethe obvious margin to determine the zone diameter. For linezolid, anydiscernible growth the within zone inhibitionof is respective agent. trailing growth can make end-point determinat end-point make can growth trailing control (see M07-A10, Figure 2). buttons of growth should be ignored (see M07-A10, Figures 3 a 3 Figures M07-A10, (see ignored be should growth of buttons allowsome slight growth; therefore, read the end point at the concentrationwhich in there is MRSAs are those strains of proteins for oxacillin (modified Historically, resistanceto the penicillinase-stable penicillins disk For of maximum a test diffusion, 12 di

Dilution methods: 16–20 hours; 24 hours for oxacillin and vancomycin; Testing Conditions Conditions Testing Medium: Disk diffusion: MHA Inoculum: Incubation: (3) (2) Forwhen staphylococci testing chloramphenicol, clindamycin,

Inhibito Minimal and Diameter Zone 2C. Table (1)

74 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 74 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With M02-A12 M02-A12 and and M07-A10 M07-A10 M100-S25 M100S,M100S, 26th 26th ed. ed.

-lactamase inhibitor  cases of documented Table 2C Table mecC are typically in the M02 and M07 Staphylococcus spp. Staphylococcus -lactam/

 otein 2a (PBP 2a, also called PBP2'). Isolates MICs for strains with strains MICs for with 1 or PBP 2a. mecC. mecA cillin-binding pr -lactam agents, ie, penicillins,  ty), and carbapenems. This is because most homologue, with a novel mecA homologuenovel a in human andwith bovinepopulations in sulfamethoxazole, or a fluoroquinolone).

±

mecA only), refer to Tables 3D, 3E, 3F, 3G, and 3H, respectively. encoding the peni S. aureus mecA, mecA -mediatedoxacillin resistance using cefoxitin, reduced susceptibility vancomycin, to Staphylococcus aureus Staphylococcus 2011;11(8):595-603. are rare and include a novel is not advised, because infections respond to concentrations achieved in urine of antimicrobial agents resistance cannot be detected tests by directed at mecA of the cephalosporins anti-MRSAwith activi -lactam therapy, or because convincing clinical data document that clinical for those efficacy agents have not mecC  ed UTIs (eg, nitrofurantoin, trimethoprim Lancet Infect Dis. n MIC, cefoxitin MIC, or cefoxitin disk test should be reported as oxacillin resistant. S. saprophyticus acillin resistance is mediated by H, et al. Methicillin-resistant H, et al. and CoNS (MRS), are considered resistant to other or PBP 2a should be reported as oxacillin resistant. mecA S. aureus -lactamaseproduction, oxacillinresistance and β Information in boldface type is or new modified since the previous edition. commonly used to treat acute, uncomplicat Isolates that test resistant by Isolates that testoxacilli resistant by Mechanisms of oxacillin resistance other than combinations, cephems (with the exception MRS infections have responded poorly to been presented. resistant range for cefoxitin and/or oxacillin; that test positive for inducible clindamycin resistance, and high-level mupirocin resistance (

Routine testing of urine isolates of Oxacillin-resistant In most staphylococcal isolates, ox for tests For García-ÁlvarezHoldenL, MT, Lindsay the UK and Denmark: a descriptive study.

(6) (Continued) 2C. Table (4) NOTE: ______1 (7) (5)

©Clinical and Laboratory Standards Institute. All rights reserved. 75 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 75 M100S,M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10 Z  - bla  -lactam

See Tables 3D

Perform test(s) to

0.12 µg/mL or zone

≤

Table 2C Table  -lactamase may production  -lactamase. M02 and M07 -lactamase tests. Consequently, Comments  . Penicillin-resistant strains of of strains . Penicillin-resistant

Staphylococcus spp. Staphylococcus 29 beforemm reporting isolatethe as

≥

perazone, cefotaxime, cefotetan, ceftizoxime,cefotetan, cefotaxime, perazone,  -lactamase production foron staphylococci For report oxacillin-resistant staphylococci Penicillin should be used to test the susceptibility be used to test the susceptibility Penicillin should cillinase-labile penicillins. detect MICs are the penicillin which (9) to all penicillinase-labileof all staphylococci penicillins (see Glossary I) produce staphylococci diameters penicillin susceptible. Rare isolates of staphylococci penicillin susceptible. Rare isolates of staphylococci genescontain that for appear negative by for serious infections requiring penicillin therapy, laboratories should perform MIC tests and the from isolates subsequent all on testing lactamase same patient. PCR testing of the isolate for  -lactamase gene may be considered. and 3E. and (10) do or resistant as penicillin report.not ible to: ter M07-A10of ter 3.13 M02-A12.of 3.9 Subchapter and 0.25

 – (µg/mL) undinSubchap 0.12

MIC InterpretiveMIC Criteria  28

illin-tazobactam) piperac illin-tazobactam) -sulbactam,  -lactamwith agents established clinical efficacy for staphylococcal infections (including both β – -lactam antimicrobial agents, with the exception of the newer cephalosporins with anti-MRSA activity. Thus, anti-MRSA with activity. the exception cephalosporins with of the newer  -lactam antimicrobial agents, ZoneDiameter -mediated oxacillin resistance can be fo -mediatedoxacillin resistance penicillinase-stable penicillins (dicloxacillin, methicillin, and nafcillin). For agentsand methicillin, efficacy with established clinical (dicloxacillin, penicillins penicillinase-stable InterpretiveCriteria (nearest whole mm) 29

S I R S I R  mecA cefpodoxime, cefprozil, loracarbef)cefuroxime, (amoxicillin-clavulanate, ampicillin (amoxicillin-clavulanate, -lactam antimicrobial agents may be deduced from testing only penicillin and either cefoxitin or oxacillin. Testing of other Testing or oxacillin. cefoxitin and either penicillin be deduced from testing only -lactam antimicrobial agents may  is not advised. See comments (4) and(4) comments See advised. not is (5). Disk Content te dosing, oxacillin (cefoxitin)-susceptible staphylococci can be considered be te (cefoxitin)-susceptible suscept can oxacillin dosing, staphylococci 10 units 10 cephalexin,

Agent Agent Antimicrobial -lactamasecombinations inhibitor 

A Penicillin  -lactam/ ceftriaxone, cefuroxime,ceftriaxone, ceftaroline, moxalactam) (or cefoxitin) Oxacillin results can be applied to the other Group Group

(cefaclor,cephems Oral cefdinir, cefo cefonicid, cefmetazole, cephalosporinscefepime, cefazolin, (cefamandole, IV and III, II, I, including cephems Parenteral Carbapenems(doripenem, ertapenem, imipenem, meropenem) Test/Report PENICILLINASE-LABILEPENICILLINS Penicillin-susceptible staphylococci are susceptible to other (8) penicillinase-labileand penicillinase-stable agents; see GlossaryI). Penicillin-resistant staphylococci resistantare to peni PENICILLINASE-STABLEPENICILLINS (11) appropriaand infection of site considering     available currently are resistant to all staphylococci Oxacillin-resistant of array wide or resistance to a susceptibility anti-MRSA thoseexcept agents, with activity, Additional explanation on thecefoxitin use of forprediction of (Continued) 2C. Table

76 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 76 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With M02-A12 M02-A12 and andM07-A10 M07-A10 M100S,M100S, 26th 26thed. ed. -

S. S. For

.

only, and . . mecA S. aureus or for PBP 2a or or for

lugdunensis may be appropriatebe may

pseudintermedius . S. lugdunensis

S. mecA interpretive criteria may criteria interpretive and S. and for

Table 2C Table

. Comments M02 and M07 Staphylococcus spp. Staphylococcus testing For reporting against Oxacillin MIC Oxacillin Interpretive are based criteria a dosage on Oxacillin disk testing is not reliable. See testing is not reliable. disk Oxacillin Cefoxitin is tested as a surrogate for including MRSA. including (17) 12600 of regimen every mg h. for strains for which the oxacillin MICs are 0.5–2 are MICs for oxacillin the which strains for µg/mL. with cefoxitin diffusion disk with (15) Neither cefoxitin MIC nor cefoxitin disk reliableare tests detectingfor mecA For use For aureus S. with (16) For use CoNSwith except pseudintermedius (14) serious infections with CoNS other than epidermidis, See comments (5),comments See (8), (11), and (13). mediatedresistance in (12) and comment (5) for reportingcefoxitin oxacillin cefoxitintesting when surrogatea as agent. (13) or resistant report susceptible oxacillin; oxacillin cefoxitinthe on based result. (5),comments See (8), and (11). overcall resistance for some CoNS, because CoNS, some for resistance overcall the which for some non– S. epidermidis strains oxacillin MICs are 0.5–2 µg/mL lack 4 8 4

– 0.5 0.5

≥ ≥ ≥  ≥ (oxacillin) (oxacillin) (oxacillin) (oxacillin) (cefoxitin)

 – – – (µg/mL) 2 4 2 1

– – – ≤ 0.25 0.25 ≤ ≤ 0.25

MIC InterpretiveMIC Criteria ≤  (oxacillin) (oxacillin) (oxacillin) (oxacillin) (cefoxitin)

21 24 20 –

17   ≤ 

 – – – ZoneDiameter InterpretiveCriteria (nearest whole mm)

18 25 24 21–23 – S I R I S R

  ≥ 22

µg – – – Disk 30 g cefoxitin g g oxacillin g µ Content 1 

30 (surrogatetest oxacillin) for cefoxitin µg 30 (surrogatetest oxacillin) for ) ) S. and S. and ) Agent Agent Antimicrobial S. aureus (For lugdunensis (For exceptCoNS S. lugdunensis pseudintermedius (For S. pseudintermedius

A Oxacillin A Oxacillin A Oxacillin B Ceftaroline A OxacillinA Group Group Test/Report PENICILLINASE-STABLEPENICILLINS (Continued) (PARENTERAL)CEPHEMS (Continued) 2C. Table

©Clinical and Laboratory Standards Institute. All rights reserved. 77 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 77 M100S,M100S, 26th26th ed. For Use With M02-A12 and M07-A10 See

from S. aureus for which the vancomycin zones of inhibition. inhibition. of zones Table 2C Table 3F for3F aureus, S. Subchapter Comments

M02 and M07 Staphylococcus spp. Staphylococcus S. aureus g/mL to a reference laboratory.  S. aureus. S. 32

 g/mL to a reference laboratory. See Appendix MIC tests should beperformed todetermine Send any CoNS for the vancomycin which criteriainterpretive diffusion disk Teicoplanin Send any 8 

 is For use For with (19) to of staphylococci the susceptibility of all isolates differentiate not does test disk The vancomycin. isolates of vancomycin-susceptible vancomycin-intermediate isolates, nor does the test differentiate among vancomycin-susceptible, -intermediate, and -resistant isolates of CoNS, all size similar give of which (20) use For CoNS. with (19).comment See (21) MIC is (22) notwere reevaluated concurrent with the reevaluation of disk diffusion vancomycin theseof ability the Therefore, criteria. interpretive criteria to differentiate teicoplanin interpretive teicoplanin-intermediateand teicoplanin-resistant from strains teicoplanin-susceptible staphylococci known. not is A. Alsoto refer Table M07-A10,in 3.13.1.7 Subchapterand 3.9.1.7 in M02-A12. Appendix A. Appendix See also Subchapter 3.13.1.7 in M07-A10, and 3.9.1.7Subchapter M02-A12.in 16 32 32

   – – – – comment See (16). comment See (16). 16 4–8 8–16 (µg/mL) 2 4 8 MIC InterpretiveMIC Criteria

   0.12 0.12 0.12

  10

 – in intermediatein theduring prolongedof course therapy. 11–13 ZoneDiameter InterpretiveCriteria (nearest whole mm) 15 14 S I S R I R

  g g  

– – – – – – Disk 30 30 Content ) Agent Agent Antimicrobial vancomycin-susceptible isolates may become vancomycbecome may vancomycin-susceptibleisolates Vancomycin Vancomycin aureus(For S. Vancomycin CoNS)(For S. aureus,S.

B B C Oritavancin C C Telavancin Inv. Teicoplanin For For Group Group Test/Report GLYCOPEPTIDES GLYCOPEPTIDES (18) LIPOGLYCOPEPTIDES (Continued) 2C. Table

78 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 78 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With M02-A12 M02-A12 and and M07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed.

and S. ). Table 2C Table S. saprophyticusS. M02 and M07 Comments Staphylococcus spp. Staphylococcus ecome resistant within 3 to 4 days (but aureusfor S. not Daptomycin should not be reported for approvedFDA for

(23) tract. respiratory the from isolates (28) epidermidis (25).comment See ptible. 8 8 8 4 8 4 4 2 8 2 4 8 4

16 64 64 32 16 16 16 16 16

                      – 8 8 2 4 8 8 8 2 2 8 4 2 4 2 4 4 1 1 16 32 32 1–4 (µg/mL) 1 4 8 4 2 2 1 2 4 4 4 1 1 4 2 1 2 1 MIC InterpretiveMIC Criteria

16 16 0.5 0.5 0.5

                       12 14 13 12 12 13 13 13 18 15 14 12 14 15 15 20 12 14 19 14 18 14

                     

13–14 15–16 14–17 13–14 13–14 14–17 14–17 14–22 19–21 16–18 15–18 13–15 15–18 16–20 16–18 21–23 13–16 15–17 20–22 15–17 19–21 15–17

ZoneDiameter

InterpretiveCriteria (nearest whole mm) idered susceptible to doxycycline some and minocycline. However, organisms that are intermediate or resistant to used only in combination with other usedwith susce combination test in that agents active only 15 17 18 15 15 18 18 23 22 19 19 16 19 21 19 24 17 18 23 18 22 18 S I S R I R

                      g g g g g g g g g g g g g g g g g g g g g g                       – – 5 5 5 5 5 5 Disk 15 15 15 10 30 30 30 10 15 15 10 10 10 30 30 30 Content doxycycline, minocycline, or both. minocycline, doxycycline,

Agent Agent Antimicrobial spp. may develop spp. may resistance during prolonged therapy b with quinolones. Therefore, susceptible may isolates that are initially Azithromycin or Azithromycin or clarithromycin erythromycin Lomefloxacin Ofloxacin

B Daptomycin B A A A B Tetracycline B Doxycycline B Minocycline C Gentamicin C C C MoxifloxacinC or Ciprofloxacin NorfloxacinU levofloxacin O Amikacin O Amikacin O Kanamycin O Netilmicin O Tobramycin O Telithromycin O Dirithromycin O Enoxacin O Gatifloxacin O Grepafloxacin O O Staphylococcus For staphylococci that test susceptible, aminoglycosides are staphylococciFor aminoglycosides susceptible, test that Not routinely reported organismson tract. urinary the from isolated Organisms that are susceptible to tetracycline are also cons

Group Group Test/Report LIPOPEPTIDES AMINOGLYCOSIDES (24) MACROLIDES (25) TETRACYCLINES (26) tetracyclinemay to susceptible be FLUOROQUINOLONES (27) therapy.of initiation after Testing be may isolates repeat of warranted. (Continued) 2C. Table

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine©Clinical and Laboratory Standards Institute. All rights reserved. 79 Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 79 M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10 3G, 3G,

S Food urinary urinary ng transmittedng light. Table 2C Table M02 and M07 Comments Staphylococcus spp. Staphylococcus istant staphylococci; MRSA, Rifampin should not be used alone for resistant; S, susceptible; UTI, Rx: Sulfisoxazole can be used to represent any Inducible clindamycin resistance Inducible clindamycin can be reporting For methicillin-susceptible against Whendiffusion zones testing linezolid, disk Subchapter 3.10.1 Subchapter M02-A12, in Subchapter and M07-A10).in 3.14.1 (25).comment See

(30) of the currently available sulfonamide preparations. See commentSee (16). (29) thebyusing detected diffusion disk D-zone test brothor by microdilution (see Table (31) (32) aureus. S. (33) should be examined usi disk diffusion by resistant results with Organisms MICan using confirmed be should method. (25).comment See antimicrobial therapy.antimicrobial 2 2 8 4 4 4 8

16 32

128 512        4/76

    

4 – 2 2 1 – – – 1 16 64 1–2 (µg/mL) tion; QC, quality control; R, r-Hinton broth; CoNS, coagulase-negative staphylococci; FDA, U 2 8 8 1 1 MIC InterpretiveMIC Criteria

4 32 0.5 0.5 0.5 256

     2/38 

      15 15 14 14 10 12 10 12 16 15 20

           – MIC, minimal inhibitoryMIC, concentration; MRS, methicillin-res 16–18 16–18 15–16 15–20 11–15 13–16 11–15 13–17 17–19 16–18 ZoneDiameter InterpretiveCriteria (nearest whole mm) 19 19 17 21 16 17 16 18 20 19 21 S I R S I R

           g g g g g g g g g     g g      – – – –   5 5 5 2 5 Disk 30 30 15 300 Content 1.25/23.75 250or 300

PBP 2a, penicillin-binding protein 2a; PCR, polymerase chain reac

Agent Agent , American Type Culture Collection; CAMHB, cation-adjusted Muelle Antimicrobial ®

S. aureus;

sulfamethoxazole dalfopristin

A Clindamycin Clindamycin A Trimethoprim-A Rifampin B Linezolid B U Nitrofurantoin U U Trimethoprim Sulfonamides C Chloramphenicol B Tedizolid O Sparfloxacin O Quinupristin- Inv. Fleroxacin Group Group Test/Report FLUOROQUINOLONES (Continued) NITROFURANTOINS LINCOSAMIDES PATHWAY INHIBITORS FOLATE PHENICOLS ANSAMYCINS STREPTOGRAMINS OXAZOLIDINONES (Continued) 2C. Table Abbreviations: ATCC and Drug Administration; I, intermediate; MHA, Mueller-Hinton agar; methicillin-resistant tract infection.

80 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 80 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12 and M07-A10 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 81 M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10 For Use With M02-A12 and M07-A10 M100S, 26th ed.  -  -lactamase-

prevent amoxicillin. Ampicillin Ampicillin amoxicillin. ampicillin, penicillin, or IC, trailing IC, trailing

egins. Tiny Tiny egins. illin susceptibility can be susceptibility illin indicated for serious for indicated Table 2D Table owththat can be resistance among enterococci resistance E. faecalis.E. M02 and M07 spp. Enterococcus evel aminoglycosideevel Comments  -lactamase-producing enterococci.

(See Tables 4A and 5A for  -lactamase test. Because of the rarity 25923 ® 29212 ®  -lactamase test predicts to resistance penicillin, Combination therapy with

ATCC ATCC

Rx: The results of ampicillin susceptibility tests should be tests should susceptibility of ampicillin results The tosusceptible Enterococci predictably are penicillin Penicillin or Penicillin or ampicillin  -lactamase-positivebe not need test this enterococci,

(5) of used to predict the activity to susceptibility be used to predict may results piperacillin, ampicillin-sulbactam, amoxicillin-clavulanate, among non– and piperacillin-tazobactam producing enterococci. Ampic providing theused to predict imipenem susceptibility, be to confirmed is species (6) ampicillin-sulbactam, amoxicillin, susceptible to ampicillin, piperacillin, and piperacillin- amoxicillin-clavulanate, tazobactam for non– be cannot ampicillin to susceptible enterococci However, beto assumed to susceptible results penicillin.penicillin If required. needed,are is penicillin of testing (7) due to  -lactamasedue production hasbeen reported very to due resistance ampicillin or Penicillin rarely. detected routine reliably with not is production lactamase detected using a direct, is methods, but disk or dilution nitrocefin-based enterococcal infections, such as endocarditis, unless endocarditis, as such infections, enterococcal streptomycin and gentamicin both to resistance high-level are predicted to result is documented; such combinations the Enterococcus. of killing synergistic in (8) of performed routinely, but can be used in selected cases. A positive I). ureidopenicillinsand Glossary (see amino- as well as vancomycin (for vancomycin an plus strains), susceptible aminoglycoside, is usually Enterococcus spp . Enterococcus 16 16

  100-mm plate; disks should be p laced no less than100-mmdisksbe plate; should ld be clearly measurable; overlapping zones only awith magnifying lens at the edge of the zone of testing), cephalosporins, clindamycin, and trimethoprim- – – acceptable QC ranges.) Disk diffusion: Staphylococcus aureus Routine QCRoutine Recommendations When a commercial test system is used for susceptibility testing, refer to the manufacturer’s instructions for QC test recommendations and QC ranges. Dilution methods: Enterococcus faecalis (µg/mL) judged by the unaided eye), including the diameter of the disk. isolates should not be reported as susceptible. 8 8

MIC InterpretiveMIC Criteria e MIC at the lowest concentration where b trailing the lowest concentration the at MIC e  

14 16

natedreflected light,except with vancomycin,for shoul readbe d which with   e and no more than 6 disks on a rginshould consideredbe areathe showing no obvious, visible gr aminoglycoside can be predicted for enterococci by using a high-l General Comments Comments General – – ZoneDiameter ult. In such cases, read th read such cases, In ult. InterpretiveCriteria (nearest whole mm) th of tiny colonies that can coloniestiny that be detectedth of 15 17 Subchapter 3.6). Each zone diameter shou S I S R I R

  but they are but they not effective clinically, and recommendations, reporting suggestions, and QC.

g  in vitro, Disk 10 10 units 10 Content spp., aminoglycosides (except for high-level resistance ) test (see Table ) test (see 3I). Measure the diameter of the zones of complete inhibition (as

2°C; ambient air

±

Agent Agent Enterococcus Disk diffusion: MHA calcium for daptomycin daptomycin McFarland standard Disk diffusion: 16–18 hours Dilution methods: 16–20 hours All methods: 24 hours for vancomycin Broth dilution: CAMHB; CAMHB supplemented to 50 µg/mL Agar dilution: MHA; agar dilution has not been validated for Antimicrobial For 3F and 3I for additional testing

Penicillin Ampicillin 35°C method suspension, Growth or direct colony equivalent to a 0.5 Zone Diameter and Minimal Inhibitory Concentration Interpretive Standards for Standards Interpretive and Minimal Inhibitory Concentration Diameter Zone

Information in boldface type is or new modified since the previous edition. A A (gentamicin and streptomycin growth can make end-point determination diffic determination end-point make growthcan buttons ofgrowth should ignored be (see M07-A10, Figures 3 and 4). WARNING: 24 mm apart, center to (see M02-A12, accurate measurement. Hold the Petri plate inchesfew a above a black background illumi lighttransmitted (plate held lightto up source). The zone ma detected the unaidedwith eye. Ignore faint grow inhibited discernible growth. Any growth the zone of inhibitionwithin indicates vancomycin resistance. sulfamethoxazole may appear active Group Group Testing Conditions Conditions Testing Medium: Inoculum: Incubation: Synergy between ampicillin, penicillin, or vancomycin and an For disk diffusion, test a maximum of 12 disks on a 150-mm plat Test/Report Refer to Tables PENICILLINS

(4) NOTE:

Table 2D. (1) (3) (2) M broth microdilution by tetracycline and tedizolid, linezolid, erythromycin, when chloramphenicol, testing enterococci For

(Continued) 2D. Table

© 82 ©Clinical and Laboratory Standards Institute. All rights reserved. Clinical and Laboratory Standards Institute. All rights reserved. 83 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 82 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With M02-A12 M02-A12 and andM07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed.  -  -lactamase-

amoxicillin. Ampicillin Ampicillin amoxicillin. ampicillin, penicillin, or

illin susceptibility can be susceptibility illin indicated for serious for indicated Table 2D Table resistance among enterococci resistance E. faecalis.E. M02 and M07 spp. Enterococcus Comments  -lactamase-producing enterococci.  -lactamase test. Because of the rarity  -lactamase test predicts to resistance penicillin, Combination therapy with

Rx: The results of ampicillin susceptibility tests should be tests should susceptibility of ampicillin results The tosusceptible Enterococci predictably are penicillin Penicillin or Penicillin or ampicillin  -lactamase-positivebe not need test this enterococci, (5) of used to predict the activity to susceptibility be used to predict may results piperacillin, ampicillin-sulbactam, amoxicillin-clavulanate, among non– and piperacillin-tazobactam producing enterococci. Ampic providing theused to predict imipenem susceptibility, be to confirmed is species (6) ampicillin-sulbactam, amoxicillin, susceptible to ampicillin, piperacillin, and piperacillin- amoxicillin-clavulanate, tazobactam for non– be cannot ampicillin to susceptible enterococci However, beto assumed to susceptible results penicillin.penicillin If required. needed,are is penicillin of testing (7)

due to  -lactamasedue production hasbeen reported very to due resistance ampicillin or Penicillin rarely. detected routine reliably with not is production lactamase detected using a direct, is methods, but disk or dilution nitrocefin-based enterococcal infections, such as endocarditis, unless endocarditis, as such infections, enterococcal streptomycin and gentamicin both to resistance high-level are predicted to result is documented; such combinations the Enterococcus. of killing synergistic in (8) of performed routinely, but can be used in selected cases. A positive I). ureidopenicillinsand Glossary (see amino- as well as vancomycin (for vancomycin an plus strains), susceptible aminoglycoside, is usually 16 16

  – – (µg/mL) 8 8

MIC InterpretiveMIC Criteria   14 16

  – – ZoneDiameter InterpretiveCriteria (nearest whole mm) 15 17 S I S R I R

 

g  Disk 10 10 units 10 Content Agent Agent Antimicrobial Penicillin Ampicillin

A A Group Group Test/Report PENICILLINS

(Continued) 2D. Table

©Clinical and Laboratory Standards Institute. All rights reserved. 83 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 83 M100S,M100S, 26th26th ed. For Use With M02-A12 and M07-A10 E. g/mL,biochemicalperform Table 2D Table  M02 and M07 spp. Enterococcus Comments

Not routinely reported on isolates from the urinarythe from reportedNot routinely isolates on These interpretive criteria apply to urinary tract Daptomycin should not be reported for isolates from When testingWhen vancomycin plates enterococci, against 11) faecalis. (12) tract. (14) only. isolates (9) should be held a full 24 hours for accurate detection of Zonesresistance. be examinedshould transmitted using light;the presence growth of ahaze orany the zone within Organisms with of inhibition indicates resistance. intermediate zones an should be tested by MIC method as theM07-A10. For which described in isolates for 8–16 are MICs vancomycin tests for identification as listed under the MIC“Vancomycin foundtest µg/mL” 8 ≥ 3F.Table in (4)comments See (7).and ( tract. respiratory the

8 4 8 8

32 32 16 16 16 16 –

128    

       8 8 8 2 4 8 4 – – – (10) reportingFor against vancomycin-susceptible – comment See (10). – 64 16 1–4 8–16 (µg/mL)

4 8 4 4 4 4 1 2 4 2

32 0.5

MIC InterpretiveMIC Criteria 0.12 0.12          

    14 10 13 14 12 14 15 13 12 14 14 –

           – – 15–16 11–13 14–22 15–18 13–15 15–18 16–20 14–16 13–16 15–17 15–16 idered susceptible to doxycycline some and minocycline. However, organisms that are intermediate or resistant to ZoneDiameter

InterpretiveCriteria (nearest whole mm) 15 17 14 23 19 16 19 21 17 17 18 17 – S I S R I R

           

g g g g g g g g g g g g         

– – – – – 5  5  5  Disk 30 10 30 30 15 30 30 30 300 Content doxycycline, minocycline, or both.minocycline, doxycycline,

Agent Agent

Antimicrobial Oritavancin Telavancin Ciprofloxacin Levofloxacin Norfloxacin Vancomycin Vancomycin Teicoplanin Daptomycin

B B C C U Tetracycline U U U U Nitrofurantoin O Erythromycin O Doxycycline O Minocycline O Gatifloxacin Inv. Organisms that are susceptible to tetracycline are also cons Group Group Test/Report GLYCOPEPTIDES GLYCOPEPTIDES LIPOGLYCOPEPTIDES LIPOPEPTIDES MACROLIDES TETRACYCLINES (13) tetracyclinemay to susceptible be FLUOROQUINOLONES NITROFURANTOINS (Continued) 2D. Table

84 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 84 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With With M02-A12M02-A12 and and M07-A10 M07-A10 M100S,M100S, 26th 26thed. ed. E. g of g  g/mL ofg/mL µ

. only

urinary tract E. faecalis urinary Table 2D Table

E. faecalisE. M02 and M07 spp. Enterococcus Comments g fosfomycin diskg fosfomycin contains 50  Rifampin aloneused be not should for Rx: For reporting against vancomycin-resistant vancomycin-resistant against For reporting

For testing and reporting of The approved method MICisagar testing dilution. The 200- faecium. faecium. (15) (19) (16) See comment (12).comment See antimicrobial therapy.antimicrobial isolates only. only. isolates (17) Agarmedia should besupplemented with 25 glucose-6-phosphate. Broth testing should not be dilution performed. (18) glucose-6-phosphate. 4 4 8 32

256   

  2 2 4 – – (20) reportingFor against 16 128 (µg/mL) 1 8 1 2

64 MIC InterpretiveMIC Criteria 0.5

      16 12 12 15 20

     17–19 13–15 13–17 16–18 21–22 ZoneDiameter CAMHB, cation-adjustedMueller-Hinton broth; I, intermediate;Mueller-HintonMHA, agar; MIC, InterpretiveCriteria (nearest whole mm) 20 16 18 19 23 S I R S I R I S R I S

     g g g g g     y control; R, resistant; S, susceptible. 5  Disk 30 30 15 200 Content

Agent Agent , American Type Culture Collection; Collection; Type Culture , American ®

Antimicrobial dalfopristin

B Linezolid B Linezolid U FosfomycinU TedizolidB – – – – O Rifampin O Chloramphenicol O Quinupristin- O Group Group Test/Report ANSAMYCINS FOSFOYCINS PHENICOLS STREPTOGRAMINS OXAZOLIDINONES minimal inhibitory concentration; QC, qualit (Continued) 2D. Table Abbreviations: ATCC

©Clinical and Laboratory Standards Institute. All rights reserved. 85 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 85

M100S,M100S, 26th26th ed. For Use With M02-A12 and M07-A10

H. influenzae e obvious e to margin Haemophilus Haemophilus Table 2E Table mides, antagonists in the and faint growth of tiny colonies of tiny faint growth Haemophilus influenzae minated with reflected light. Theminated with parainfluenzae M02 and M07 parainfluenzae thesespp. bewith compounds may 49247 or and Haemophilus Haemophilus influenzae . ® -lactamase–producing strains of  ATCC rains, basedrains, the antimicrobialon agents to 49247 49766 Haemophilus ® ® cefpodoxime, cefur oxime, and telithromycin are oral See documentCLSI M45 for testing and reporting Haemophilus influenzae influenzae Haemophilus H. parainfluenzae ATCC ATCC 35218 (when testing amoxicillin-clavulanate) ® spp. Thespp. these testssusceptibility of results antimicrobial with or ATCC e third-generation cephalosporins, chloramphenicol, and meropenem

Haemophilus influenzae f, cefdinir, cefixime, Haemophilus 49766 these st of both or ®

Haemophilus influenzae Use either ATCC RoutineTables (See 4A, 4B, 5A, and 5B for Recommendations QC acceptable QC ranges.) Haemophilus influenzae When a commercial test system is used for susceptibility testing, refer to the manufacturer’s instructions for QC test recommendations and QC ranges. be tested.be Neither strain has rangesQC for all agents that bemight tested against H. influenzae Escherichia coli CFU/mL. Exercisecare in preparing thissuspension, because higherinoculum

8 However, susceptibility testing of 10

sible growth that can be detected with the unaided eye. Ignore ×

-lactam antimicrobial agents,particularly when Hold the Petri plate a few inches above a black background illu  General Comments Comments General H. influenzaeH. and parainfluenzae.H. Concentration Interpretive Standards for for Standards Interpretive Concentration .

e, disregarde, slight growth(20% lessor lawnthe of growth) of andmeasure the mor lens at the edge of the zone of inhibited growth. With trimethoprim and the sulfona for respiratoryfor infections tract to due approximately 14 to ithromycin, cefaclor, cefprozil, loracarbe s skson a150-mm plateand 4disks 100-mma on Measureplate. the diameter ofthe zones inhibitioncomplete of (as Haemophilus ; 16–18 hours anagement of individual patients. 2 e-resistant results with some e-resistant results with from CSF,from only results testingof ampicillin,with one th of 2°C;

±

H. influenzae spp., as usedthisin table, includes only

McFarland standard prepared using colonies from an overnight (preferably 20- to 24-hour) chocolate agar comment[see plate (2)] Broth dilution: HTM broth Disk diffusion: 5% CO Broth dilution: ambient air; 20–24 hours 35°C Direct colony suspension, equivalent to a 0.5 concentrations may lead to fals are tested. recommendations for other species of determine the zone diameter. Haemophilus medium may allow some slight growth; therefor are appropriate to report routinely. agentsusedbe may that empiricas therapy appropriate for surveillance or epidemiological studies. judged by the unaided eye), including the diameter of the disk. zone margin should be considered the area showing no obvious, vi that can be detected only a magnifyingwith agents are often not useful for m TheMcFarland0.5 suspension contain di 9 of maximum a disk diffusion, test For For isolates of Amoxicillin-clavulanate, azithromycin, clar Testing Conditions Conditions Testing Medium: Disk diffusion: HTM Inoculum: Incubation: (2) and Minimal Inhibitory Table 2E. Zone Diameter (1) (3) (4) (5) parainfluenzae

86 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 86 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With M02-A12 M02-A12 and and M07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed. H. should vitro in -lactamase. -lactamase test can can test  -lactamase detecting resistance to to detecting resistance -sulbactam, cefaclor, -sulbactam, only. Table 2E Table Comments that are resistant to ampicillin and that are resistant to ampicillin parainfluenzae M02 and M07 parainfluenzae H. influenzae H. Interpretive criteria are based on a dosage Rare BLNAR strains of H. influenzae The results of ampicillin susceptibility tests of ampicillin susceptibility The results For and Haemophilus Haemophilus influenzae be considered resistant to amoxicillin- to resistant be considered clavulanate, ampicillin cefamandole, cefetamet, cefonicid, cefprozil, and piperacillin- loracarbef, cefuroxime, apparentdespite tazobactam, to these of some BLNAR strains susceptibility agents. See comment (4). comment See (7) of should be used to predict the activity isolates of of majority The amoxicillin. influenzae TEM-typea produce  amoxicillin direct a cases, most In provide a rapid means of amoxicillin. and ampicillin (8) See comments (5)comments See (8).and (8). comment See (8). comment See See comment (4). comment See (9) (10) 12600 of regimen every mg h.

See comment (8). comment See (5)comments See (8).and (8). comment See 4

16 16 16 – – – 4/2 8/4 2/4

       mL of 0.01 mol/L NaOH heatwith and stirring until the 2 – – – 8 8 8 – – – – (µg/mL)

1 2 2 2 4 4 4 MIC InterpretiveMIC Criteria

2/1 4/2 1/4 0.5

           18 19 19 16 16 – – –

     on and 5 g of yeast extract to 1 L of MHA and autoclave. autoclaving After and cooling, 50 mg of hematin powder in 100 – – – – – – – 19–21 17–19 17–19 10 mL of distilled filter sterilized) aseptically.water, ZoneDiameter InterpretiveCriteria (nearest whole mm) 22 20 20 21 26 26 26 20 30 20 S I R S I R

         

g g g    g g g g g g g        – – of the hematin stock soluti Disk 30 30 30 10 30 30 30 Content 20/10 10/10 100/10 Agent Agent Antimicrobial Cefotaxime or or ceftazidime ceftriaxone -LACTAMASEINHIBITOR COMBINATIONS 

A Ampicillin A Ampicillin B Ampicillin-sulbactam B B B B Cefuroxime C Amoxicillin-clavulanate C Amoxicillin-clavulanate C Ceftaroline O Piperacillin-tazobactam O Piperacillin-tazobactam O Cefonicid Cefamandole O Information in boldface type is new or modified since the previous edition. Group Group powder is thoroughly dissolved. Add 30 mL add 3 mL of an NAD stock solution (50 mg of NAD dissolved in To make HTM: Prepare a fresh hematin stock solution by dissolving Test/Report -LACTAM/ PENICILLINS  (PARENTERAL)CEPHEMS (Including cephalosporins I, andIII, II, PleaseIV. refer to GlossaryI.)

Table 2E. (Continued) (6) NOTE:

©Clinical and Laboratory Standards Institute. All rights reserved. 87 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 87

M100S,M100S, 26th 26th ed. For Use With M02-A12 and M07-A10 Table 2E Table Comments parainfluenzae M02 and M07 parainfluenzae and Haemophilus Haemophilus influenzae

See comments (5)comments See (8).and (5)comments See (8).and (5)comments See (8).and (8). comment See (5). comment See (5). comment See See comment (5). comment See (5). comment See 8

32 32 16 32 16 32 16 – – – – – – – – –

        – – (4).comment See – – – – – – – – – – (4).comment See 8 – 8 – – – – – – – – 8 4 – – – – – – – – – – – – 16 16 16 16 (µg/mL)

(Continued) 2 2 8 8 1 1 2 4 8 2 4 2 4 1 4 8 4 2 1 2 1 1 2 2 0.5 0.5 MIC InterpretiveMIC Criteria

0.5

                        0.12 0.25  

  

16 14 16 15 14 10 11 25 – – – – – – – – –

        – – – – – – – – – – – – – – – – – – – – 17–19 15–17 17–19 16–18 15–17 11–12 12–14 26–28 ZoneDiameter InterpretiveCriteria (nearest whole mm) 26 26 20 18 20 21 21 20 19 28 18 26 20 19 16 16 12 13 15 29 21 17 18 18 18 24 16 22 S I R S I R

                           

so considered susceptible tosusceptible considered so and doxycycline minocycline. g g g g g g g g g g g g g g g g g g g g g g g g g g g g                          – – 5 5 5 5  5  5  5 5 5 Disk 30 10 15 15 10 30 10 15 10 10 10 30 30 30 30 10 30 30 30 Content Agent Agent Antimicrobial

Cefaclor Cefprozil or Cefdinir or cefixime cefpodoxime orErtapenem imipenem Azithromycin Clarithromycin or Ciprofloxacin or levofloxacin moxifloxacin Telithromycin Telithromycin Lomefloxacin Ofloxacin

B Meropenem C C C C C C Cefuroxime C Aztreonam C C C C C Tetracycline C C C C Gemifloxacin O Cefepime O Ceftizoxime O Loracarbef O Ceftibuten O Doripenem O O Gatifloxacin O Grepafloxacin O O Sparfloxacin O Inv.Cefetamet Group Group Organismsal tetracyclineare to susceptible are that Test/Report CEPHEMS (PARENTERAL)CEPHEMS (Including cephalosporins I, andIII, II, PleaseIV. refer to GlossaryI.) (ORAL) CEPHEMS MONOBACTAMS CARBAPENEMS MACROLIDES KETOLIDES TETRACYCLINES (11) FLUOROQUINOLONES Table 2E. (Continued)

88 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 88 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use WithWith M02-A12 M02-A12 and and M07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed. H. leotide;QC, Table 2E Table Comments disease. parainfluenzae M02 and M07 parainfluenzae Not routinely reported on isolates from the May be appropriate only for prophylaxis of and Haemophilus Haemophilus influenzae

See comment (4). comment See (12) urinarytract. (13) case contacts. These interpretive criteria do not invasive therapyto apply with patients of influenzae 8 4

  4/76

 – – – – 4 2 2/38 (µg/mL) 1/19–

1 2 2 1 MIC InterpretiveMIC Criteria

     0.5/9.5 nimalinhibitory concentration; nicotinamideNAD, adenine dinuc 10 25 16

   – – 11–15 26–28 17–19 -lactamase negative,ampicillin-resistant; CFU, colony-forming unit(s);CSF, cerebrospinal fluid;  wholemm) ZoneDiameter 22 19 16 29 20 S I R S I R

     InterpretiveCriteria (nearest g g g g   g    5 5 Disk 10 30 Content 1.25/23.75

Agent Agent

Antimicrobial ,American Type CultureCollection; BLNAR, ® Test intermediate;I, Medium; Mueller-HintonMHA, agar; mi MIC, sulfamethoxazole

Chloramphenicol A Trimethoprim- C Rifampin C O TrovafloxacinO Haemophilus Inv. Fleroxacin Inv. Group Group Test/Report FLUOROQUINOLONES (Continued) PATHWAY INHIBITORS FOLATE PHENICOLS ANSAMYCINS HTM, quality control; R, resistant; S, susceptible. Table 2E. (Continued) Abbreviations:ATCC

©Clinical and Laboratory Standards Institute. All rights reserved. 89 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 89

M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10 Table 2F Table e, 100 g glucose, 0.02 g olones or cephalosporins, M02 and M07 (See Tables (See 4B

95% for susceptible strains. only with a magnifying lens at

Neisseria gonorrhoeae 49226 ® ATCC ecommendations R supplement (1.1 g L-cystine, 0.03 g guanine HCl, for acceptable QC ranges.)

s either technicala problem that should resolvedbe by Neisseria gonorrhoeae Neisseria D,adenine,g 1 L-glutaming 10 For some agents, eg, fluoroquin When a commercial test issystem used for susceptibility testing, refer to the manufacturer’s instructions for QC test recommendations and QC ranges. Routine QC and 5C Neisseria gonorrhoeae

organisms zones.these with Strains intermediate with zones to agents other than

0.1 g cocarboxylase, 0.25 g NA e. Ignore faint growth colonies of tiny that can be detected und illuminated reflectedwith light. The zone margin should be considered the area showing General Comments Comments General plate and 4 disks on a 100-mm plate.4 disks on a 100-mm and plate ; all methods, 20–24 hours consists of GC agar to a 1%which defined growth eine-containingdefined growth is not required for disk diffusion 2 oncentration Interpretive Standards for for Standards Interpretive oncentration lution test results with other drugs.) lution test results with required agar for dilution tests with ate-buffered saline, pH 7.0, using

24-hour) chocolate agar plate incubated O]) is added after autoclaving. an intermediatean result anfor antimicrobialagent indicate 2 Measurethe diameter zonesthe of comp leteof inhibition judged(as bythe unaided eye), including the diameter of e, cefotetan, cefoxitin,cefotetan, e, spectinomycinand treatingfor infections produce organismsto due intermediate that results N. gonorrhoeae experiencein treating infections dueto ximum of 9 disks on a 150-mm N.gonorrhoeae,

2 1°C (do not exceed 37°C); 5% CO

±

of a cysteine-free growth supplement cysteine-freea of growth supplement is carbapenemsclavulanate.and Cyst supplement does not significantly alter di testing.) in Mueller-Hinton broth or 0.9% phosph colonies from an overnight (20- to 36°C in 5% CO Disk diffusion:Disk agarGC base and1% defined growth supplement. (The use Agardilution: GC agar base and 1% defined growth supplement. (The use 25.9 g L-cysteine HCl [in 1 L H

Direct colony suspension, equivalent to a 0.5 McFarland standard prepared Zone Diameter and Minimal Inhibitory C and Minimal Inhibitory Diameter Zone

Information in boldface type is new or modified since the previous edition. ferric nitrate, 0.003 g thiamine HCl, 0.013 g para-aminobenzoic acid, 0.01 g B12, only2to 3disks be tested may per plate. the disk. Hold the Petri plate a few inches above a black backgro no obvious, visible growth that can be detected thewith unaided ey the edge of the zone of inhibited growth. with these agentswith is unknown. repeattesting a or lack clinicalof cefmetazole, cefotetan, cefoxitin, and spectinomycin have a documented lower clinical cure rate (85% to 95%) compared > with The recommended medium for testing Theeffectivenessclinical cefmetazol of For disk diffusion, test a ma Fordiffusiondisk testing of Testing Conditions Conditions Testing Medium: Inoculum: Incubation: (4) NOTE: (2) Table 2F. (1) (3)

90 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 90 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use WithWith M02-A12 M02-A12 and andM07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed.  - and usedbe may also Table 2F Table Comments M02 and M07 -lactamase test predicts resistance resistance predicts test  -lactamase Neisseria gonorrhoeae N. gonorrhoeaeN. -lactamase test detects one form of penicillin  -lactamase–producing strains. the However, A positive A  of Gonococci that produce zones of inhibition 19 mm around a 10-unit penicillin disk are likely to 19 mm around disk are likely a 10-unit penicillin

See comment (3). comment See (5) ampicillin,penicillin, to amoxicillin. and (6) in resistance information. Strains with to provide epidemiological chromosomally mediated resistance can be detected only by the disk diffusion method or the MICdilution agar method. (7)  (2). comment See (3). comment See (2). comment See (2). comment See

be remains preferable to other lactamase test formethods accurate rapid, susceptibility recognition of this plasmid-mediated penicillin resistance. 2 8 4 8 8

     – – – – – – – – – – – – – – 4 2 – – 4 4 0.12–1 (µg/mL)

2 1 2 2

MIC InterpretiveMIC Criteria 0.5 0.5 0.5 0.5 0.5 0.5

0.06 0.25    

0.25          26 23 25 27 19 –

     – – – – – – – – – – – – – – – – – 27–46 24–27 26–30 28–32 20–25 ZoneDiameter InterpretiveCriteria (nearest whole mm) 47 35 28 31 31 33 31 26 31 38 S I R S I R

          29 29 31 g g g g g g g g g g g g             5 Disk 30 30 10 30 30 30 30 30 30 30 10 10 units 10 Content

Agent Agent

Antimicrobial

Cefoxitin Cefuroxime

A Ceftriaxone A Cefixime O Penicillin O O O Cefepime O Cefmetazole O O O Ceftazidime Cefotaxime O Ceftizoxime Cefotetan O Cefpodoxime Inv.Cefetamet Group Group Test/Report PENICILLINS (PARENTERAL)CEPHEMS (Including cephalosporins I, andIII, II, PleaseIV. refer to GlossaryI.) (ORAL) CEPHEMS Table 2F. (Continued)

©Clinical and Laboratory Standards Institute. All rights reserved. 91 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 91 M100S,M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

g/mL).  ide ide 16

N. gonorrhoeaeN.  g tetracycline disk zone  Table 2F Table Comments M02 and M07 19 mm usually indicate a plasmid- 19 mm usually

 Neisseria gonorrhoeae Gonococci with 30- quality control; NAD, nicotinam (9)

See comment (2). comment See diameters of mediated tetracycline-resistant tetracycline-resistant mediated isolate. Resistance in these strains should be a (MIC by test confirmed dilution 2 1 2 2 2 1

128      



1 64 0.5 0.5–1 0.5–1 0.25–1 0.12–0.5 (µg/mL)

MIC InterpretiveMIC Criteria 32 0.25 0.5

0.06 0.12 0.25 0.25        l inhibitory concentration; QC, 30 27 31 26 24 28 14

       31–37 28–40 32–35 27–37 25–30 29–34 15–17 ZoneDiameter InterpretiveCriteria (nearest whole mm) 38 41 36 38 31 35 18 S I R S I R

       g g g g g g g        so considered susceptible tosusceptible considered so and doxycycline minocycline. 5 5 5 Disk

10 10 30 . 100 Content Agent Agent Antimicrobial

, American Type Culture Collection; I, intermediate; MIC, minima ® Spectinomycin Spectinomycin A Tetracycline A Tetracycline A Ciprofloxacin O Enoxacin O Lomefloxacin O Ofloxacin O Inv. Fleroxacin Inv. Group Group Organismstetracyclineto susceptible are that al are Test/Report TETRACYCLINES (8) FLUOROQUINOLONES (3). comment See AMINOCYCLITOLS Table 2F. (Continued) Abbreviations:ATCC adenine dinucleotide; R, resistant; S, susceptible

92 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 92 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12 and M07-A10 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 93 M100S,M100S, 26th26th ed. For Use With M02-A12 and M07-A10 t

® nists in ATCC crodilution crodilution the trailing the trailing es of complete

from the upperthe from t pneumococcalt Table 2G Table owing no obvious, obvious, no owing M02 and M07 49619 detectedonly a with ® (See Tables (See 4B may allow some slight allow may Streptococcus pneumoniae Streptococcus r to the manufacturer’s ATCC 80% reduction in growth as in growth as reduction 80%

≥ ameter of the zon Staphylococcusaureus the sulfonamides, antago activity is best determined using an MIC in vitro in Streptococcus pneumoniae Streptococcus diffusion:Disk deteriorationof oxacillin contentdisk is assessedbest with 25923, an acceptablewith range of 18–24 mm on unsupplemented MHA. When a commercial test is system used for susceptibility testing, refe instructions for QC test recommendations and QC ranges. Routine Recommendations QC and 5B for acceptable QC ranges.) Streptococcus pneumoniae With trimethoprim and and trimethoprim With ropenemshould be reliablea by tested methodMIC (such tha as

such cases, read the MIC at the lowest concentrationwhere erythromycin, linezolid, tedizolid, and tetracycline by broth mi broth by tetracycline and tedizolid, linezolid, erythromycin, measure the zone of inhibition hemolysis.of Measure the zones of the of Thedisk. zone margin should consideredbe areathe sh ver removed. Ignore faint colonies of tiny growth that can be if necessary for growth with General Comments Comments General

2 ry Concentration Interpretive Standards for for Standards Interpretive Concentration ry Such isolates can also be tested against vancomycin using the MIC or disk method. . sks on a 150-mm plate and 4 disks on a 100-mm plate. Measure the di inhibited growth. With trimethoprim and the sulfonamides, antagonists in the medium (20% or less of the lawn (20% or less of the lawn of growth) and measure the more obvious margin to the determine zone diameter. for preparation of LHB) LHB (2.5% to 5% v/v) ; 20–24 hours should be ignored (see M07-A10, Figures 3 and 4). ignored (see M07-A10, should be 2

) isolated from penicillinCSF, and cefotaxime, ceftriaxone, me or 2°C

±

ar dilution g Disk diffusion: 5% sheep MHA with blood Broth dilution: CAMHB with (see M07-A10 for instructions Agar dilution: MHA sheep with blood(5% studiesrecent v/v); using the agar dilution method have not been performed and reviewed by the subcommittee. Direct colony suspension, equivalent to a 0.5 McFarland 35°C Dilution methods: ambient air; 20–24 hours (CO Disk diffusion: 5% CO a standard, prepared using colonies from an overnight (18- to 20- hour) sheep blood agar plate

S. pneumoniaeS. Information in boldface type is new or modified since the previous edition. MIC, trailing growth can make end-point determination difficult. In difficult. determination end-point make can growth trailing MIC, growth of buttons Tiny begins. the medium may allow some slight growth; therefore, read the end point at the concentrationwhich in there is visible growth canthat be detected the with unaided eye. Do not surface of the agar illuminated reflected light,with the co with magnifying lens at the edge of the zone of therefore,growth; disregard slight growth compared to the control M07-A10, Figure (see 2). inhibition(as judged bythe unaided eye),including the diameter infections; however, reliable disk diffusion susceptibility tests these with agents do not Theiryet exist. method. described in M07-A10), and reported routinely For disk diffusion, test a maximum of 9 di Amoxicillin,ampicillin, cefepime, cefotaxime, ceftriaxone, cefuroxime, ertapenem,imipenem, and meropenem may usedbe treato For Testing Conditions Conditions Testing Medium: Inoculum: Incubation:

(2) (2) clindamycin, chloramphenicol, when testing pneumococci For Inhibito Minimal and Diameter Zone 2G. Table (1) (3) (4)

NOTE: NOTE:

94 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 94 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use WithWith M02-A12 M02-A12 and and M07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed.

0.06

 19 mm

≤ g/mL may g/mL may µ g/mL. Strains g/mL. µ 2

MICs beshould ≤

ts per day)per beused can ts Table 2G Table M02 and M07 Comments 19 mm, do not report penicillin as

≤ 19 mm, because zones of 19 mm, because

Streptococcus pneumoniae Streptococcus ≤ 20 mm are susceptibleare mm 20 (MIC

 Use ofrequires penicillin in meningitis Doses ofDoses 2penicillinintravenous least at of For CSFFor meningitis only report isolates, Rx: Interpretations for oral penicillin be may Rx:

For other than those from CSF, all isolates Isolates of pneumococci with oxacillin zone zone oxacillin Isolates of pneumococci with

-lactams: ampicillin (oral or parenteral), ampicillin- parenteral), or (oral ampicillin -lactams: g/mL)to cefotaxime,penicillin.and Penicillin β (7) (11) reportedthosethan other isolates for CSF. from occur with penicillin-resistant, -intermediate,occur with or For isolates with certain -susceptible strains. zones oxacillin with an intermediatewith MIC of 4 18–24of doses units million penicillin necessitate day.per (8) report interpretations both meningitis and for nonmeningitis. (6) of sizes resistant without awithout performing resistant penicillin test. MIC (9)  ceftriaxone, or meropenem determined for zone those oxacillin isolates with diameters of million units every 4 hours in adults with normal with adults in hours 4 every units million (12function renal uni million to treat nonmeningeal infections due pneumococcal MICs penicillin with strains to therapy maximum doseswith of intravenous penicillin (eg, at 4 hours least 3 million units every normal function).renal with adults in (10) interpretations. 8 2

 0.12 

 4 – (µg/mL) 0.12–1 2

MIC InterpretiveMIC Criteria  0.06 0.06

  20 mm) can predict susceptibility to the following following the to predictcan mm) 20 susceptibility

≥ – – – – – ZoneDiameter ir, cefditoren, cefepime, cefotaxime,ceftaroline, ceftizoxime, ceftriaxone, cefpodoxime, cefprozil, cefuroxime, InterpretiveCriteria (nearest whole mm) 20 S I R S I R

 g/mL (or g/mL zone oxacillin  – – – – – – – – – – – – 0.06

Disk ≤ g oxacillin oxacillin g Content 1 

es, a penicillin MIC of MIC penicillin a es, Agent Agent Antimicrobial

(nonmeningitis) (meningitis) V) A Penicillin A Penicillin A parenteral Penicillin A parenteral Penicillin A penicillin (oral Penicillin sulbactam, amoxicillin, amoxicillin-clavulanate, cefaclor, cefdin amoxicillin-clavulanate, sulbactam, amoxicillin, ertapenem,doripenem, imipenem, meropenem,loracarbef, penicillinand parenteral).or (oral Group Group For nonmeningitis isolat Test/Report PENICILLINS (5) (4). comment See (Continued) 2G. Table

©Clinical and Laboratory Standards Institute. All rights reserved. 95 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 95 M100S,M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10 Table 2G Table Comments M02 and M07 Streptococcus pneumoniae Streptococcus Use or cefotaxime of ceftriaxone in Rx: In theIn United CSFfor States, reportisolates, report theIn only States, United ForCSF report isolates, meningitis only For all isolates other than those from CSF, Interpretive arecriteria based aon dosage (12) nonmeningitisonly interpretations. There is not an FDA-approved indication for the of cefepime use States.United the in meningitis for (13) interpretations for nonmeningitis and include the report.the on notation nonmeningitis (14) interpretations. (15) (16) interpretationsreport and for both meningitis nonmeningitis.

(17) 12600 of regimen every mg h. meningitis requires therapyrequires meningitis doses.with maximum (4). comment See 8 2 4 2 2 4 4 2 4 4 2 2 8 8

8/4

              

2 2 2 2 2 4 4 4 1 1 1 1 1 1 4/2 (µg/mL)

2 1 1 1 1 1 2 2

MIC InterpretiveMIC Criteria

2/1 0.5 0.5 0.5 – 0.5 – 0.5 0.5 0.5

             ≤   – – – – – – – – ZoneDiameter InterpretiveCriteria (nearest whole mm) 26 – – – – – – S I R S I R

≥ g 

– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – Disk 30 Content Agent Agent Antimicrobial Cefotaxime (meningitis) (meningitis)Ceftriaxone Cefotaxime (nonmeningitis) Ceftriaxone(nonmeningitis) Amoxicillin Amoxicillin (nonmeningitis) Amoxicillin-clavulanate (nonmeningitis)

B B (nonmeningitis) Cefepime B – B – B – – C C C C Ceftaroline(nonmeningitis) Cefuroxime(parenteral) C Cefuroxime(oral) – – – – O (meningitis) Cefepime O Cefaclor O Cefdinir O Cefpodoxime O Cefprozil O Loracarbef Group Group Test/Report PENICILLINS(Continued) (PARENTERAL)CEPHEMS (Including cephalosporins I, andIII, II, PleaseIV. refer to GlossaryI.) (5). comment See (ORAL) CEPHEMS (5). comment See (Continued) 2G. Table

96 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 96 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use WithWith M02-A12 M02-A12 and and M07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed. S. isolates susceptible to to susceptible isolates Table 2G Table M02 and M07 Comments susceptible to gemifloxacin or susceptible to gemifloxacin Streptococcus pneumoniae Streptococcus Rifampin should not be used alone for S. pneumoniaeS. Rx:

See comments (4)comments See (6).and (19).comment See (22)

(21) therapy.antimicrobial levofloxacin are predictably susceptible to susceptible to levofloxacin are predictably moxifloxacin.and gemifloxacin However, pneumoniae moxifloxacin cannot be assumed to be levofloxacin. to susceptible

1 4 1 1 2 1 2 4 1 8 4 8 8 4 4 2

0.5

                4/76 4 

 

erythromycin. erythromycin. 2 4 2 2 – – – – (4).comment See 2 2 4 – 2 1 1 1 0.5 0.5 0.5 0.5 0.25 2/38 1/19– (µg/mL) 0.25–0.5

1 1 1 1 1 2 1 1 2 4 1

MIC InterpretiveMIC Criteria

 0.5 0.5 0.5

           0.25 0.12 0.25 0.25 0.25 0.12

         0.5/9.5

15 13 16 13 15 24 24 19 13 14 17 12 15 15 20 16

               

– – 14–17 17–20 14–17 16–18 25–27 25–27 18–20 13–15 16–18 16–18 17–18 16–20 20–22 14–16 15–17 ZoneDiameter

InterpretiveCriteria (nearest whole mm)

17 21 18 21 18 19 28 28 23 17 18 21 16 19 19 21 19 S I R S I R

                 omycin, and omycin, dirithromycin predicted be testing can by so considered susceptible tosusceptible considered so and doxycycline minocycline. g  g g g g g g g g g g g g g g g g         

     – – – – – – – – – – – – – – – – 5 5 5  5  5 5 5 Disk 1.25/ 30 30 30 15 15 15 15 30 15 Content 23.75

Agent Agent

Antimicrobial

Gemifloxacin Levofloxacin Moxifloxacin sulfamethoxazole Tetracycline Tetracycline Doxycycline Telithromycin Telithromycin Ofloxacin

B MeropenemB Vancomycin B Erythromycin A B B B B B Trimethoprim-A C Ertapenem C Imipenem C Chloramphenicol C Rifampin O Doripenem O Azithromycin O Clarithromycin O Dirithromycin O O Gatifloxacin O O Sparfloxacin Susceptibility and Susceptibility azithromycin, to resistance clarithr Not routinely reported organismsfor urinarythe from isolated tract. Organismsal tetracyclineare to susceptible are that Group Group Test/Report CARBAPENEMS (5). comment See GLYCOPEPTIDES MACROLIDES (18) (19) TETRACYCLINES (20) FLUOROQUINOLONES PATHWAY INHIBITORS FOLATE PHENICOLS ANSAMYCINS (Continued) 2G. Table

©Clinical and Laboratory Standards Institute. All rights reserved. 97 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 97 M100S,M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

Table 2G Table M02 and M07 Comments Streptococcus pneumoniae Streptococcus Inducible clindamycin resistance Inducible clindamycin can be (23) the D-zone test or diffusion using disk detected by test single-well broth microdilution using the by andboth (containing clindamycin) erythromycin (see Table 3G, Subchapter 3.10.1 in M02-A12, Subchapter and M07-A10).in 3.14.1 (19).comment See 1 4

  2 – – 0.5 (µg/mL) r-Hinton broth; CSF, cerebrospinal fluid; FDA, US Food and 1 2

MIC InterpretiveMIC Criteria 0.25  

 15 15

  Mueller-Hinton agar; inhibitoryminimal MIC, concentration; quality control;QC, R, – 16–18 16–18 ZoneDiameter InterpretiveCriteria (nearest whole mm) 19 19 21 S I R S I R

   g g g    2 Disk 30 15 Content

Agent Agent , American Type, American Culture Collection; CAMHB, cation-adjusted Muelle Antimicrobial ®

B Clindamycin B Clindamycin C Linezolid C Linezolid O Quinupristin-dalfopristin Group Group Test/Report LINCOSAMIDES STREPTOGRAMINS OXAZOLIDINONES (Continued) 2G. Table Abbreviations: ATCC Administration;Drug intermediate;I, horse lysed LHB, blood; MHA, resistant; S, susceptible.

98 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 98 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12 and M07-A10 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 99 M100S,M100S, 26th26th ed. For Use With M02-A12 and M07-A10 h h because -lactams

), C, G or  S. anginosusS. trationwhere the 49619 Table 2H-1 Table ly ly collectedclinical data ® vious, visible growth thatvious, visible growth (See Tables (See 4B M02 and M07 -Hemolytic Group Group -Hemolytic β magnifying lens at the edge of ATCC should re-identified,be retested, Streptococcus pyogenes spp. spp. s species, pharmacokinetics of the spp. β -Hemolytic Group spp. Streptococcus -hemolytic streptococcus and have not-hemolytic β need benot performedroutinely, eptibilitytesting penicillinsof and other Streptococcus Streptococcus Measure the zones from the upper surface of the agar criteria for the viridans group should be used (see Table

When a commercial test system is used for susceptibility testing, refer to the manufacturer’s instructions for QC test recommendations and QC ranges. Routine Recommendations QC and 5B for acceptable QC ranges.) Streptococcus pneumoniae isolatefound beto nonsusceptible -hemolyticstrains C,A, Group with F, ( antigens G or β members subcommittee.the of Systematical cin, erythromycin, linezolid, tedizolid, and tetracycline by brot by tetracycline and tedizolid, linezolid, erythromycin, cin, difficult. In such cases, read the MIC at the lowest concen -hemolyticstreptococcal infections 0.25 µg/mL) are extremely rare in any

β pyogenic strains of streptococci Group A with ( >

nd 4 disks on a 100-mm plate. Measure the diameter of the zones of complete inhibition sk. The zone margin should be considered the area showing no ob -hemolyticstreptococcal infections.Susc -hemolytic streptococcal β General Comments Comments General if necessary for growth with agar 2 ignored (see M07-A10, Figures 3 and 4). Figures 3 and 4). ignored (see M07-A10, v); recent studies using the agar dilution )antigen. Small colony–forming ry Concentration Interpretive Standards for Standards Concentration Interpretive ry measure the zone of inhibition of hemolysis. a 0.5 McFarland0.5 a standard, from colonies using 0.12 and ampicillin MICs

-hemolytic group are proposed based on population distributions of variou > literature,and clinicalthe experience of

S.agalactiae ) are considered part of the viridans group, and interpretive growth should be should growth recommendations, reporting suggestions, and QC.

;20–24 hours . If testing is performed,is testing If . any ugs of choicetreatmentfor of β 2 “S. milleri”“S. MHA with 5% sheep5% blood with MHA Streptococcus spp. β -hemolytic group includes the large colony–forming β S.pyogenes 2°C



LHB) to 50 µg/mL calcium for daptomycin (see M07-A10 for instructions for preparation of methodhave not been performed andreviewed by thesubcommittee. dilution) Disk diffusion: 5% CO 5% diffusion: Disk Dilution methods: ambient air; 20–24 hours (CO Agar dilution: MHA sheepwith blood (5% v/ Disk diffusion: Disk Broth dilution: CAMHB with LHB 5%to (2.5% v/v);with CAMHB supplementeddilution: be Broth should CAMHB the an overnight (18-overnight an 20-hour)to sheep agar blood plate -hemolytic streptococciwhen testing chloramphenicol, clindamy 35°C β to equivalent suspension, colony Direct 2H-2). nonsusceptible isolates (ie, penicillin MICs illuminated reflectedwith light, the coverwith removed. Ignore faint growth of tiny colonies that can be detected only with a (as judged by the unaided eye), including the diameter of the di can be detected the unaidedwith eye. Do not the zone of inhibited growth. buttons of begins. Tiny trailing approvedby the FoodUS andDrug Administration for treatment of beenreported for and, if confirmed, submitted to a public health laboratory. (See Appendix A for additional instructions.) antimicrobialagents, previously published microdilution MIC, trailing growth can make end-point determination determination end-point make can growth trailing MIC, microdilution antigensand strains Group B( with group, previously termed were not were available for review of the many with antimicrobial agents in this table. For this table, the For disk diffusion, of 9 disks on a 150-mm test a maximum plate a Interpretive criteria for Penicillinand ampicillinare dr

Testing Conditions Conditions Testing Medium:

Inoculum: Incubation: (3) (4)

(2) For Inhibito Minimal and Diameter Zone 2H-1. Table Refer to Table 3G for additional testing (1) (5)

100 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 100 ©Clinical and Laboratory Standards Institute. All rights reserved.

ForFor UseUse WithWith M02-A12 M02-A12 and M07-A10and M07-A10 M100S,M100S, 26th26th ed.ed. streptococci, streptococci, does not need to be -hemolytic β Table 2H-1 Table M02 and M07 Comments GroupA . For . spp. β -Hemolytic Group spp. Streptococcus Interpretive criteria are based on a dosage Daptomycin reportedbe not should isolatesfor enem

(7) 12600 of regimen every h.mg See comment (4). comment See

(8) respiratorythe tract.from – – – – – when used for approved indications and when ampicillin, amoxicillin, amoxicillin-clavulanate, ampicillin-sulbactam, ampicillin-sulbactam, amoxicillin-clavulanate, amoxicillin, ampicillin, – – – – – – – – – – – – – – – – – – – (µg/mL) listed here

1 1 1

0.5 0.5 0.5 0.5 0.5

MIC InterpretiveMIC Criteria 0.25 0.25 0.12 0.12 0.25 0.12   

         

– – – – – , penicillin is a surrogate for – – – – – – – ZoneDiameter InterpretiveCriteria (nearest whole mm) 15 24 24 24 24 24 26 – – 17 S I R S I R

taxime,ceftriaxone, ceftizoxime, imipenem, ertapenem, and merop  ≥       -hemolytic streptococci β g g g g g g g       

– – – – – – – – – – – – – – – – – – – – Disk 30 30 30 10 30 30 30 10 units 10 an be considered susceptible to antimicrobial agents antimicrobial agents to an be considered susceptible Content cefaclor, cefdinir, cefprozil, ceftibuten, cefuroxime,ceftibuten, cefprozil, cefdinir, cefaclor, cefpodoxime.and or Groups A, B, C, and G F Agent Agent . Antimicrobial

Penicillin or Penicillin ampicillin Cefepimeor or cefotaxime ceftriaxone

(6). Information in boldface type is new or modified since the previous edition. A A B B B B Vancomycin C CeftarolineC OritavancinC TelavancinC DaptomycinC O DoripenemO ErtapenemO MeropenemO Group Group An organism that is susceptible to penicillin c to penicillin susceptible An organism that is Test/Report PENICILLINS (6) tested against those agents ceftaroline, cefepime, cefazolin, cephalothin,cephradine, cefo penicillinalso surrogateforis a (PARENTERAL)CEPHEMS (Including cephalosporins I, andIII, II, PleaseIV. refer to GlossaryI.) (6). comment See CARBAPENEMS comment See GLYCOPEPTIDES LIPOGLYCOPEPTIDES LIPOPEPTIDES Table 2H-1. (Continued) NOTE:

©Clinical and Laboratory Standards Institute. All rights reserved. 101 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 101 M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10

is isolated from a pregnant is isolated Table 2H-1 Table M02 and M07 Comments Recommendations for intrapartum Streptococcus spp. β -Hemolytic Group spp. Streptococcus Rx: Inducibleresistance clindamycin can be (11) (10) comments See and (11). (13) D-zonebythe detected using diffusion disk andtest See Table 3G, Subchapter microdilution. broth 3.10.1 in M02-A12, and Subchapter 3.14.1 in M07- A10. See comment (10).comment See

prophylaxis for Group B streptococciprophylaxis or are penicillin is recommended for cefazolin ampicillin. Although penicillin-allergic at lowwomen risk for anaphylaxis, at highthose risk for anaphylaxis may receive Groupto susceptible are streptococci clindamycin. B ampicillin, penicillin, and cefazolin, but may be resistant to erythromycin and clindamycin. When a Group B woman with severe penicillin allergy for risk (high allergy penicillin severe woman with clindamycin and erythromycin anaphylaxis), clindamycin inducible (including shouldresistance) should be reported. clindamycin be tested, and only 3G.Table See 1 2 1 2 8 8 4 2 8 4 1

16

            1 1 1 4 4 2 4 2 8 0.5 0.5 0.5 (µg/mL) 2 2 1 2 1 4

0.5 0.5 0.5

0.25 MIC InterpretiveMIC Criteria 0.25 0.25      

      15 13 16 13 18 13 17 15 12 15 17 15

            17–20 14–17 16–20 14–17 19–22 14–16 18–20 16–18 13–15 16–18 18–20 16–18 ZoneDiameter InterpretiveCriteria ndcan dirithromycin by predicted be erythromycin. testing (nearest whole mm) 21 18 23 17 21 19 16 19 21 19 S I R S I R

          21 18

so considered susceptible tosusceptible considered so and doxycycline minocycline. g g g g g g g g g g g g             5 5 2 5 5 Disk 30 15 15 15 15 30 10 Content Agent Agent

Antimicrobial

Ofloxacin

A Erythromycin A Erythromycin A Clindamycin C Levofloxacin C Chloramphenicol O Azithromycin O Azithromycin O Clarithromycin O Dirithromycin O Tetracycline O Gatifloxacin O Grepafloxacin O O Trovafloxacin Not routinely tract. reported urinary the from isolates on Organismsal tetracyclineare to susceptible are that Group Group Susceptibility a clarithromycin, azithromycin, to resistance and Susceptibility Test/Report MACROLIDES MACROLIDES (9) (10) TETRACYCLINES (12) FLUOROQUINOLONES PHENICOLS LINCOSAMIDES Table 2H-1. (Continued)

102 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 102 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use WithWith M02-A12 M02-A12 and and M07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed. and S. Mueller- Table 2H-1 Table M02 and M07 Comments . spp. β -Hemolytic Group spp. Streptococcus Report against pyogenes. S. (14)

agalactiae only 4

 2 – – – – (15) reportingFor against S. pyogenes (µg/mL) r-Hinton broth; I, intermediate; LHB, lysed horse blood; MHA, 1 2

0.5

MIC InterpretiveMIC Criteria    15

 – 16–18 ZoneDiameter InterpretiveCriteria (nearest whole mm) 19 21 S I R S I R

  QC,resistant; S, susceptible. control; quality R, g g   – – – – Disk 15 30 Content

Agent Agent Antimicrobial , American Type Culture Collection; CAMHB, cation-adjusted Muelle ®

Quinupristin-dalfopristin C Linezolid C Linezolid C Tedizolid O Group Group Test/Report STREPTOGRAMINS OXAZOLIDINONES Hinton agar; MIC, minimal inhibitory concentration; Table 2H-1. (Continued) Abbreviations: ATCC

©Clinical and Laboratory Standards Institute. All rights reserved. 103 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 103 M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10 group, wth of tiny tiny of wth bovis group, 49619 ® ly collected clinical data Table 2H-2 Table M02 and M07 meter of the disk. Themeter disk. the of zone ATCC spp. Viridans Group Group Viridans spp. -hemolytic strains Groups A, C, with spp. Viridans Viridans Group spp. Streptococcus group, salivarius β mutans

and 5B for acceptable QC ranges.)

Streptococcus Streptococcus ributions of various species, pharmacokinetics of the the unaided eye. Do not measure the zone of inhibition When commerciala test system usedis for susceptibilityrefertesting, to manufacturer’sthe instructions for QC test recommendations and QC ranges. Routine (See Tables QC Recommendations 4B Streptococcus pneumoniae ead the MIC at the lowest concentration where concentrationead the MIC at lowest trailing the with reflected light,with the cover with removed. Ignore faint gro groupsmallincludes colony–forming

anginosus growthcan be detected that with damycin, erythromycin, linezolid, tedizolid, and tetracycline by broth microdilution microdilution broth by tetracycline and tedizolid, linezolid, erythromycin, damycin, inical experience of members of the subcommittee. Systematical General Comments Comments General within thewithin groups, please refer to recent literature. group. The if necessary for agar dilution) with growth necessary if g fiveg groups, severalwith species each within group: 2 forpreparationfor instructions LHB)of lens at of inhibited the edge of the zone growth. mitis recentdilution agar the using studies method surface of the agar illuminated ry Concentration Interpretive Standards for Standards Concentration Interpretive ry a 0.5 McFarland0.5 a an standard from colonies using the zonesthe inhibitioncomplete of judged(as byunaided the eye),including dia the ” group), and spp. viridans group are proposed based on population dist end-point determination difficult. In such cases, r end-point determination difficult. ;20–24 hours 2 S. milleri Streptococcus MHA with 5% sheep5% blood with MHA 2°C



Measure the zones from the upper

group (previously “ 50 µg/mL calcium for daptomycinfor calcium µg/mL 50 M07-A10 (see Disk diffusion: 5% CO 5% diffusion: Disk Dilutionmethods: ambient air; 20 to24 hours (CO Agar dilution: MHA with sheep MHAdilution: Agar v/v); (5% blood with Disk diffusion: Disk Broth dilution: CAMHB with LHB (2.5% to 5% v/v); the CAMHB should be supplemented to LHB v/v);5% to to with (2.5% supplemented CAMHB be dilution: should Broth CAMHB the havenot been performed and reviewed the by subcommittee. (18-overnight to 20-hour)bloodsheep plateagar 35°C to equivalent suspension, colony Direct Information in boldface type is new or modified since the previous edition. margin should be considered the area showing no obvious, visible colonies that can be detected only a magnifyingwith begins.Tiny buttons of growth should ignored be (see M07-A10, Figures 3 and 4). MIC, trailing growth can make antimicrobial agents, previously published literature, and the cl not were available for review of the many with antimicrobial agents in this table. of hemolysis. F, and G antigens. For detailed information on the species anginosus For disk diffusion, measure the diameter of Theviridans group streptococciof includes the followin Interpretive criteria for

Testing Conditions Conditions Testing Medium:

Inoculum: Incubation:

Inhibito Minimal and Diameter Zone 2H-2. Table (1) (3) (2) (2) clin chloramphenicol, when testing streptococci For viridans NOTE: (4)

104 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 104 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With M02-A12 M02-A12 and and M07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed. cillin-intermediate isolated from normally bactericidal action. bactericidalaction. Comments Table 2H-2 Table M02 and M07 Penicillin- or ampi or Penicillin- spp. Viridans Viridans Group spp. Streptococcus Rx: Daptomycin should not be reported for Viridans streptococci (7) tract. respiratory the from isolates

(5) sites body sterile (eg, CSF, blood,bone) should using an susceptibility penicillin be tested for method.MIC (6) isolates may necessitate combined therapy with aminoglycosidean for 4 8 4 4 4 1 2 1 2 8

  32/4 32/4        



2 2 2 – – – – – – – 4 – – – – – – 1 1 0.5 0.5 16/4 0.5–4 0.25–2 (µg/mL)

1 1 1 1 1 1 1 2

0.5 0.5 0.5 MIC InterpretiveMIC Criteria

0.25 0.25 0.12      0.25 0.25    0.12 0.25

         8/4

 21 25 24 15 13 16 13 18 – – –

        – – – – – – – – – 22–23 26–27 25–26 16–20 14–17 17–20 14–17 19–22 ZoneDiameter InterpretiveCriteria (nearest whole mm) ndcan dirithromycin by predicted be erythromycin. testing 15 24 28 27 17 21 18 21 18 23 S I S R I R

          so considered susceptible tosusceptible considered so and doxycycline minocycline. g g g g g g g g g g          

– – – – – – – – – – – – – – – – – Disk 30 30 30 30 15 15 15 30 15 30 Content es from the urinary tract. urinary the from es Agent Agent Antimicrobial

Penicillin Ampicillin Cefepime Cefotaxime Ceftriaxone

-LACTAMASE INHIBITOR COMBINATIONS  A A B B B Vancomycin B C Ceftolozane-tazobactam – – – – C Oritavancin C Telavancin C Erythromycin O Doripenem O Ertapenem O Meropenem O Daptomycin O Azithromycin O Clarithromycin O Dirithromycin O Tetracycline Organismsal tetracyclineare to susceptible are that Group Group Susceptibility a clarithromycin, azithromycin, to resistance and Susceptibility Not routinely reportedisolat on -LACTAM/ Test/Report PENICILLINS  (PARENTERAL)CEPHEMS (Including cephalosporins I, andIII, II, PleaseIV. refer to GlossaryI.) CARBAPENEMS GLYCOPEPTIDES LIPOGLYCOPEPTIDES LIPOPEPTIDES MACROLIDES (8) (9) TETRACYCLINES (10) Table 2H-2. (Continued)

©Clinical and Laboratory Standards Institute. All rights reserved. 105 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 105 M100S,M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

. , lysed , lysed S. anginosus S. anginosus, S.

S. constellatusS. only) Table 2H-2 Table Comments M02 and M07 and (includes spp. Viridans Viridans Group spp. Streptococcus

. intermedius,

See comment (9). comment See Group See comment (9). comment See 8 8 4 2 4 4

16

      1   4 4 2 1 2 – – (11) For reporting against 8 2 – – 0.5 (µg/mL) l; R, resistant; S, susceptible r-Hinton broth; CSF, cerebrospinal fluid; I, intermediate; LHB 2 2 1 1 4 1 2

MIC InterpretiveMIC Criteria 0.5

       0.25 0.25

   13 12 17 15 15 17 15 15

        – 18–20 16–18 16–18 14–16 13–15 18–20 16–18 16–18 ZoneDiameter concentration; qualityQC, contro InterpretiveCriteria (nearest whole mm) 17 16 21 19 19 21 19 19 21 S I R S I R

         g g g g g g g g g    

     – – – – 5 5 5 5 2 Disk 10 15 30 30 Content

Agent Agent Antimicrobial , American Type Culture, American Collection; CAMHB, cation-adjusted Muelle ®

Levofloxacin Ofloxacin Gatifloxacin Grepafloxacin Trovafloxacin

C Chloramphenicol C Clindamycin C Linezolid C Tedizolid O O O O O O Quinupristin-dalfopristin Group Group Test/Report FLUOROQUINOLONES PHENICOLS LINCOSAMIDES STREPTOGRAMINS OXAZOLIDINONES Table 2H-2. (Continued) Abbreviations: ATCC horse blood; MHA, Mueller-Hinton agar; MIC, minimal inhibitory

106 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 106 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12 and M07-A10 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 107 M100S,M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

(except 2 .html). Vaccination posureto droplets or res, and containment Table 2I Table M02 and M07 tionusing phenolizedsaline ties or high concentrations of

Neisseria meningitidis . instructions for QC test 2 49619: be incubated in ambient air). ® (See Tables (See 4A, 4B, 5A, and . 2 to the current recommendations of the 5th ed. Washington,ed. 5th USDC: Department ATCC outside a BSC is associated increasedwith risk for 25922 ® Neisseria meningitidis Neisseria ATCC in 5% CO Disk diffusion: incubate Broth microdilution: incubate in ambient air or CO must azithromycin that tests QC Disk diffusion, broth microdilution or agar dilution for ciprofloxacin,nalidixic acid, minocycline, sulfisoxazole:and incubate in ambient air or CO

N. meningitidis E. coli Routine QCRoutine Recommendations 5B for acceptable QC ranges.) Streptococcus pneumoniae When a commercial test system is used for susceptibility testing, refer to the manufacturer’s recommendations and QC ranges. tostainingGram serogroupor identifica should consider vaccination according 100% andeffective does notprovide protection against serogroup B,a frequent

olates to a reference or public health laboratory a minimumwith of BSL-2 facilities. acquiredinfection. Rigorous protectionfrom dropletsor aerosols is mandated when in a BSC. Manipulating General Comments Comments General N. meningitidis osol production and for activities involving production quanti N. meningitidis isolates. Biosafetyin Microbiological and Biomedical Laboratories. Concentration Interpretive Standards for Standards Interpretive Concentration AdvisoryImmunizationCommittee on Practi ces (http://www.cdc.gov/vaccines/acip/index ; equivalent; 0.5a to McFarland 2 theseisolates should be minimized, limited www.cdc.gov/biosafety/publications/bmbl5/. inely to potential aerosols of he riskhe infection,of becauselessis it than ; 20–24 hours BSL-3 facilities are not available, is forward 2 Perform all AST of N. meningitidis islikelymost the for risk laboratory- 2°C; 5% CO



N. meningitidisN. Direct colony suspension from 20–24 hours growth from chocolate agar incubated35°C;at 5% CO standard. Colonies grown on sheep blood agar may be used for inoculumpreparation. However, the 0.5 McFarlandsuspension obtained from sheep blood agar containwill approximately 50% CFU/mL.fewer This must be taken into account preparingwhen the final dilution before panel inoculation, as guided colony by counts. 35°C Disk diffusion: 5% sheep MHA with blood Broth microdilution:CAMHB supplemented LHB 5% to (2.5% with v/v) (see M07-A10 for preparation of LHB) Agar dilution: MHA supplemented sheepwith blood (5% v/v) Centers for Disease Control and Prevention eliminatedecreases but does not t Recommended precautions: contractingmeningococcal disease.Laboratory-acquired meningococcal disease is associated acase fatality with rate of 50%. Ex aerosolsof microbiological procedures (including AST) are performed on all solution, while a laboratorywearing coat and gloves and working behind a full face splash shield. Use BSL-3 practices, procedu equipment for activities a high potentialwith for droplet or aer infectious materials. If BSL-2 or Laboratorians arewho exposed rout cause of laboratory-acquired cases.

is BSC a If unavailable,manipulation of Testing Conditions Conditions Testing Medium: Inoculum: Incubation:

(3) Minimal InhibitoryTable 2I. Zone Diameter and ForImportant: complete information safetyon precautions, see of Health and Human Services; 2009. http:// (1) (2)

108 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 108 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With M02-A12 M02-A12 and andM07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed. inhibited growth.With Table 2I Table M02 and M07 Comments d with reflected light, with the d reflected light, with with ly published literature, and the Neisseria meningitidis armacodynamic calculations. calculations. armacodynamic May be appropriate only for prophylaxis of

(7) interpretive meningococcal case contacts. These criteria do not apply to therapy of patients with disease. meningococcal invasive 2

0.5

  e the diameterthe e zonesthe of inhibitioncomplete of (as – – – – – – – – (6).comment See th; therefore, disregard slight growth (20% or less of the lawn of 0.25–1 (µg/mL) 0.12–0.25 2 MIC InterpretiveMIC Criteria

 0.06 0.12 0.12 0.12 0.25

     – – ectedonly a with magnifyinglens theat edge zonethe of of – – – – – – Measure the zones from the uppersurface of the agar illuminate Cs of various agents, pharmacokinetics of the agents, previous lly usinglly MICs determined incubationby in ambient air for the ph ZoneDiameter InterpretiveCriteria (nearest whole mm) 34 34 30 20 – S I R S I R

    in the medium may allow some slight grow g g g g on a 150-mm a on and plate disks2 100-mma on Measurplate.     Disk 30 30 10 15 Content – the subcommittee. Systematically collected clinical not data available of the antimicrobialwere to reviewmany agentswith Agent Agent Antimicrobial

Penicillin Penicillin Ampicillin

Information in boldface type is new or modified since the previous edition.

C C C C Cefotaxime or C Meropenem ceftriaxone C Azithromycin For disk diffusion, test a maximum of 5disks of maximum diffusion,testa disk For judgedthe by unaidedeye), including the diameter theof disk. removed.cover Ignore faint growth tiny of coloniescanthat be det Interpretive criteria are based on population distributions of MI clinical experience of members of in this table. With azithromycin, interpretive criteria developedwere initia trimethoprim and the sulfonamides, antagonists andgrowth) measure the more obvious margin to determine the zone diameter. Group Group Test/Report PENICILLINS CEPHEMS CARBAPENEMS MACROLIDES Table 2I. (Continued) (4) (5) (6)

NOTE: NOTE:

©Clinical and Laboratory Standards Institute. All rights reserved. 109 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 109 M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10 azole and sulfonamides. Table 2I Table M02 and M07 Comments Neisseria meningitidis er-Hinton agar; MIC, minimal Not routinely reported on isolates from the Trimethoprim-sulfamethoxazole is the See comment (7). comment See (10) urinarytract. (7). comment See (9) preferred disk for detection of sulfonamide resistance. Trimethoprim-sulfamethoxazole and resistance to susceptibility testing predicts trimethoprim-sulfamethox beSulfonamides may appropriate only for meningococcalof prophylaxis contacts. case See comment (7). comment See

safety cabinet; BSL-2, biosafety level 2; BSL-3, 8 8 2

   0.12 0.12 9.5

0.5/   1 – – (7).comment See 4 4 0.06 0.06 0.25/4.75 (µg/mL) 2 2 2

0.5

MIC InterpretiveMIC Criteria  0.03 0.03   2.4 0.12/

    32 25 19 19

    – 33–34 26–29 20–25 20–24 25 mm may may mm 25 diminishedcorrelate with susceptibility. fluoroquinolone

≤ , American CultureType Collection; BSC, biological ZoneDiameter ® InterpretiveCriteria (nearest whole mm) 26 35 30 26 25 S I R S I R

     g/mL org/mL zonea g  g g g g   8 

  – – – – – – – –  5 5 Disk 1.25/ 30 30 ueller-Hinton broth; CFU, colony-forming uni t(s); blood; horse lysed Muell LHB, MHA, Content 23.75 ontrol; R, resistant; S, susceptible.

Agent Agent Antimicrobial

sulfamethoxazole

C Minocycline C Minocycline C Ciprofloxacin C Levofloxacin C Sulfisoxazole C Trimethoprim- C Chloramphenicol C Rifampin Group Group For nalidixica purposes, surveillance MIC acid Test/Report TETRACYCLINES FLUOROQUINOLONES (8) PATHWAY INHIBITORS FOLATE PHENICOLS ANSAMYCINS biosafety level 3; CAMHB, cation-adjusted M inhibitory concentration;quality c QC, Table 2I. (Continued) Abbreviations: AST, antimicrobial susceptibility testing; ATCC

110 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 110 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12 and M07-A10 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 111 M100S,M100S, 26th 26th ed. For Use With M11-A8 B. fragilis B. fragilis nt MICs areMICs nt thein M11 43055 ® Table 2J-1 Table Anaerobes ancillary therapy, should be ed. Ancillary therapy, such as sms for the antimicrobial which ) ATCC testing members of the r susceptibility testing, refer to the r the to testing, refer susceptibility 29741 ® ATCC Eubacterium lentum 25285 700057 ® ® ATCC ATCC (formerly (formerly organisms for which the antimicrobialorganismsage for which organisms, it should be used only for When a commercial test system is used fo manufacturer’s instructions for QC test recommendations and QC ranges. Routine QC Recommendations (See Tables 5D and 5E for acceptable QC ranges.) Test one or more of the following organisms. The choice and number of QC shouldtested strains be based obtainingon on-scaleend points the for antimicrobial agent tested. Bacteroides fragilis Bacteroides thetaiotaomicron Clostridium difficile Eggerthella Ienta

d/or poorly perfused tissues. If this approach is taken,d/or poorly organi perfused tissues. group. MIC values for agar or broth microdilution are considered equivalent for that group. measured by patient clinical response should be carefully monitor General Comments Comments General gren agar (former reference medium) are considered equivalent. group only): g/mL), Vitamin tance for proper management of anaerobic infections.  B. fragilis g/mL), and laked sheep  (1 ge are generally amenable to therapy. Those arege generally amenable to therapy. 1 validate broth microdilution for testing other

Bacteroides fragilis

g/mL), Vitamin K  CFU/mL CFU per spot 6 5 1°C, anaerobically g/mL), and LHB (5% v/v) g/mL), and

 ±

(1 1 Growth methodGrowth or direct colony suspension, equivalent to 0.5 McFarland suspension; Agar: 10 blood (5% v/v) Agar dilution (for all anaerobes): Brucella agar supplemented with hemin (5 Broth microdilution (for Brucellabroth supplemented with hemin(5 K Broth microdilution: 46–48 hours Agar dilution: 42–48 hours Broth: 10 Broth: 36°C Information in boldface type is or new modified since the previous edition. used to achieve the best possible levels of drug in abscesses an agentfall MICs susceptible the ran within intermediate range may respond, but in such cases efficacy as drainage procedures and debridement, are of great impor group. For isolates for the antimicrobialwhich agent MICs fall thewithin intermediate category, maximum dosages, along properwith Refer to Figures 2 and 3 in CLSI document M11 for examples of reading end points. MIC values using either Brucella blood agar or Wilkins Chal Broth microdilution recommended is only for testing the Until additional studies are performed to Inoculum: Inoculum: Testing Conditions Conditions Testing Medium:

Incubation: NOTE: Standards for Anaerobes Interpretive Concentration Minimal Inhibitory Table 2J-1. (1) (3)

(4) (2) (5)

112 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 112 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use WithWith M11-A8 M11-A8 M100S,M100S, 26th 26th ed. ed.  - higher

 -lactamase- M11 Table 2J-1 Table Anaerobes mechanisms. Because L) adequatewith dosage regimen might be negative, but not for gram-negative but not for negative, organisms

-lactams by other -lactams by Comments -lactamase activity with a chromogenic cephalosporin; if-lactamase activity positive. positive.  -lactamase β -lactamase β

group are presumedB. fragilis to be resistant. Other gram-negative and gram- positive, report as resistant to penicillin, ampicillin, and amoxicillin. Be aware that aware Be amoxicillin. and ampicillin, positive, report as resistant to penicillin,

anaerobes may be screenedanaerobes may for Results of ampicillin testing can be used to predict results for amoxicillin. amoxicillin. for results predict to used be can ampicillintesting of Results Members of the Ampicillin and penicillin are recommended penicillin testingfor for gram-positive and primary organisms Ampicillin  -lactamase be resistant to lactamase-negative isolates may positive

producing organismsproducing µg/m(2–4 MICs higher with treatable. blood levels are achievable with these antimicrobial agents, non–infection with (GroupC) because are many (Group A) because of them are most (8) (7) (6) 2 2 8 8

64 64 64 64 64 64 16 16 16 16

128 128  16/8   

32/16 128/4 128/2          

     

1 1 4 8 8 8 8 4 64 32 32 64 32 32 32 32 8/4 16/8 64/4 64/2

(µg/mL) 2 4 4 4 4 2

MIC InterpretiveMIC Criteria

32 16 16 32 16 16 16 16 S I S R 0.5 0.5 4/2 8/4

32/4 32/2      

             

Agent Agent

a a Antimicrobial

Piperacillin Piperacillin

Penicillin Ampicillin

-LACTAMASEINHIBITOR COMBINATIONS 

Ticarcillin-clavulanate Ticarcillin-clavulanate A Amoxicillin-clavulanate A Ampicillin-sulbactam A Piperacillin-tazobactam A Doripenem A Ertapenem A Imipenem A Meropenem C Cefotetan C Cefoxitin C Ceftizoxime C Ceftriaxone C Tetracycline C Moxifloxacin O O O Cefmetazole O Cefoperazone O Cefotaxime A/C A/C A/C Group Group -LACTAM/ Test/Report PENICILLINS  (PARENTERAL)CEPHEMS (Including cephalosporins I, andIII, II, PleaseIV. refer to GlossaryI.) CARBAPENEMS TETRACYCLINES FLUOROQUINOLONES (Continued) Table 2J-1.

©Clinical and Laboratory Standards Institute. All rights reserved. 113 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 113 M100S,M100S, 26th26th ed. For Use With M11-A8 ry M11 Table 2J-1 Table Anaerobes c rods are resistantare rods c metronidazole.to Comments B, lysed horse blood; MIC, minimal inhibito 105 105 Many non–spore-forming, gram-positive anaerobi

(9)

colony-forming unit(s); I, intermediate; LH 8

Footnote Footnote 32 32

   B. fragilis and other gram-negative organisms.Table Refer to 1C. 4 16 16 (µg/mL) MIC InterpretiveMIC Criteria 2 8 8

S I R    R, resistant; S, susceptible. Institute. All rights reserved. rights Institute. All reserved. ive organisms and Group C for

Agent Agent , American Type Culture Collection; CFU, Antimicrobial ® A Clindamycin A Clindamycin A Metronidazole C Chloramphenicol C Group Group Test/Report LINCOSAMIDES PHENICOLS NITROIMIDAZOLES Clinical and Laboratory Standards Laboratory Standards and Clinical (Continued) Table 2J-1. Abbreviations: ATCC concentration; QC, quality control; a. A/C: Group A for gram-posit 

114 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 114 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M11-A8 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 115 M100S,M100S, 26th26th ed. 4

≥ Clostridium reported with a reported with AntimicrobAgents

ibioticsusceptibility of Clostridium perfringens, Table 2J-2 Table t nicillinagainst tide telavancin (TD-6424),

Propionibacterium acnes Propionibacterium Epidemiological Cutoff Values for Values Epidemiological Cutoff infection, clinical breakpoints have not

P. acnes isolates acquiredwithout and/or mutational 2006;50(8):2728-2731. Comments WT 1-4 Propionibacteriumacnes tation resulting in reduced susceptibility, vancomycin MIC values

inhibitory concentration; NWT,non-wild-type; WT, wild-type. be used as used be clinicalbreakpoints. The shouldresult MIC be not question #4 for additional information. 2005;11(1-2):93-95. 4

≥ ndez HT. In vitro activities of the new semisynthetic glycopep NWT NWT ancein AnaerobicBacteria. European surveillance antstudy the on General Comment Comment General Anaerobe. ancin(LY333328), vancomycin, clindamycin, metronidazole and agains g/mL) g/mL) (  MIC ECV MIC 2

2 µg/mL. ECVs can be used as a measure of the emergence of strains reducedwith susceptibility to a

≤ WT ≤ C resultC generatedmust discussedbe appropriate with clinical specialists infectious (eg, diseasesand Propionibacterium acnes Propionibacterium on clinical outcomes MIC. Based onby ECVs, Propionibacterium acnes. Antimicrob Agents Chemother. Agents Antimicrob acnes. Propionibacterium 2005;11(3):204-213. comparator agents against anaerobic gram-positivespecies and Corynebacterium spp. and ECVs. WhenECVs. considering vancomycin therapy a for ggests that infections due to NWT P. acnes strains are less likely to respond to vancomycin therapy. The need for a interpretation.Refer Appendixto G,

Clin Microbiol Infect. and anaerobic Gram-positive cocci.

strains to acquirewere a resistance gene or undergo gene mu Vancomycin Antimicrobial Agent P. acnes Abbreviations: ECV, epidemiological cutoff value; MIC, minimal 2004;48(6):2149-2152. Information in boldface type is new or modified since the previous edition.

given agent. If Propionibacterium acnes.

been established due to lack of sufficient data resistance mechanisms have vancomycin MICs of µg/mL be expected.would Experience su vancomycin MICandresult anyvancomycin MI pharmacy) using when ECVs Theinterpretation. for shouldECVs not KwokDM, Citron ApplemanYY, vitroIn MD. activity oritavof Goldstein EJ, Citron DM, Merriam CV, Warren YA, Tyrrell KL, Ferna vancomycin,daptomycin, linezolid, and four Chemother. Group on Antimicrobial Study NordC, Oprica ESCMID CE; Resist KL, CitronTyrrell DM, Warren YA, Fernandez HT , Merriam CV, Goldstein EJ. In vitro activities of daptomycin, vancomycin, and pe difficile, C. perfringens, Finegoldia magna, susceptible, intermediate, or resistant Propionibacteriumacnes,

Refer to Appendixto Refer explanationan for G of NOTE: NOTE:

for Values Cutoff Epidemiological 2J-2. Table (1) 2J-2 for Table References 1 2 3 4

116 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 116 ©Clinical and Laboratory Standards Institute. All rights reserved. M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 117 M100S,M100S, 26th ed.ed. For Use With M02-A12 and M07-A10 g/mL g/mL   Proteus Proteus and me, ceftazidime, ceftazidime, me, g/mL g/mL g/mL   Table 3A Table 2°C; ambient air

Tests for ESBLs for Tests 

35°C and Cefotaxime 0.25–64 Cefotaxime-clavulanate 0.25/4–64/4 (Testing necessitates use of both cefotaxime and ceftazidime, alone and in combination clavulanate.)with procedure Ceftazidime 0.25–128Ceftazidime Ceftazidime-clavulanate 0.25/4–128/4 16–20 hours Broth microdilution g g to resistant). However, ESBL testing g g     and cefoperazone) not evaluated.were ESBL Test 30 30 . Cefuroxime (parenteral) alsowas evaluated; 30/10 a -1 Klebsiella oxytoca, Escherichia coli, Escherichia oxytoca, Klebsiella

2°C; ambient air

revised interpretive criteria for cefazolin, cefotaxi 

lactam, cefonicid, cefamandole, Ceftazidime Standard disk diffusion procedure Standard broth dilution and Cefotaxime (Testing necessitates use of both cefotaxime and ceftazidime, alone and in combination with clavulanate.)

MHA CAMHB MHA Ceftazidime-clavulanate Cefotaxime-clavulanate 30/10 16–18 hours Disk diffusion g/mL g/mL g/mL or g/mL or g/mL g/mL or g/mL or g/mL or g/mL or    :      : Klebsiella pneumoniae, Klebsiella spp., ESBLtesting should be performed.If isolates ESBLtest positive, forresults the E. coli the dosage.When using the current interpretivecriteria, routine ESBLtesting longerisno and 2°C; ambient air 35°C to edit results for cephalosporins, aztreonam, or penicillins

poses. For laboratories that not implemented have the current interpretive criteria, ESBL testing 

P. mirabilis K. pneumoniae, K. Proteus or ty in many countries (eg, moxa (eg, countries many in ty

35°C

Cefotaxime 1 Cefotaxime Ceftazidime 1 Ceftazidime For 1 Cefpodoxime (The use of more than one antimicrobial agent improves the sensitivity of ESBL detection.) procedure Ceftriaxone 1 Cefotaxime 1 Aztreonam 1 Ceftazidime 1 For oxytoca, Cefpodoxime 4 16–20 hours Broth microdilution in January2010 (M100-S20) andarelisted in Table2A mited clinicaldata, and MIC distributions, -Lactamases in -Lactamases β

foperazone should be reported as resistant. g or g or g g or g or g or g or g g or :         E. coli, Klebsiella, coli, E. detection.) E. coli : Criteria for PerformanceESBL of Test and 2°C; ambient air



P. mirabilis K. pneumoniae, For 10 Cefpodoxime 30 Ceftazidime 30 Cefotaxime (The use of more than one antimicrobial agent improves the sensitivity of ESBL For K. oxytoca, Cefpodoxime 10 35°C Ceftazidime Aztreonam 30 Cefotaxime 30 Ceftriaxone 30 30 Disk diffusion CAMHB MHA Standard disk diffusion procedure Standard broth dilution 16–18 hours

Following evaluation of PK-PD properties, li

Test Method Test Medium Antimicrobial Concentration Inoculum Incubation Conditions Incubation Length

moxalactam, cefonicid, cefamandole, and ce however,no change in interpretive criteria necessary was with necessary before reporting results (ie, it is no longer necessary should be performed as described in this table. Note that interpretive criteria for drugs limitedwith availabili consideringIf these of use for drugs mirabilis for Extended-Spectrum Table 3A. Tests NOTE: ceftizoxime, ceftriaxone, and aztreonam were published may stillmay be useful for epidemiological or infection control pur

118 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 118 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With M02-A12 M02-A12 and andM07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed. 1

=

g/mL; when when

 8

=

ESBL (eg, (eg, ESBL

=

Table 3A Table Tests for ESBLs for Tests 3 twofold concentration

 g/mL). decrease in an MIC for either antimicrobial agent tested in combination clavulanatewith vs the MIC of the agent A tested alone ceftazidime MIC  ceftazidime-clavulanate MIC Broth microdilution cephalosporin and aztreonam 21).

ESBL ESBL Test

=

phalosporins, and aztreonam. =

16;

=

when tested alonewhen

5-mm increase in a zone

≥ diameter for either antimicrobial agent tested in combination with clavulanate vs the zone diameter of the agent A ceftazidime-clavulanate zone laboratoriesIf usenot do current interpretive criteria, the test interpretation should be reported as resistant for all penicillins, ce laboratoriesIf currentuse cephalosporin and aztreonaminterpretive criteria, then test interpretations for these agents do not need to be changed from susceptible to resistant. (eg, ceftazidime zone For all confirmed ESBL-producing strains: Disk diffusion 2

8

MIC 

MIC  cefotaxime). cefotaxime). g/mL for g/mL  2

 K. oxytoca, E. coli, K. pneumoniae, g/mL for cefpodoxime or g/mL for cefpodoxime, Growth at or above the Growth concentrations listed may indicate ESBL production (ie, for and  MIC  ceftazidime, or ceftazidime, aztreonam, or ceftriaxone; cefotaxime, and for P. mirabilis, Broth microdilution

22 mm 27 mm 27 mm

25 mm 27 mm 17 mm 22 mm

   22 mm

    

: Criteria for Performance of ESBL Test of for Performance Criteria : K. pneumoniae, K. oxytoca, P. mirabilis E. coli Ceftazidime zone Ceftazidime zone Ceftazidime zone For Cefpodoxime zone Zonesabove may indicateESBL production. Cefotaxime zone zone Cefotaxime For and Cefpodoxime zone Disk diffusion Aztreonam zone zone Cefotaxime zone Ceftriaxone Test Test Method Method Test Results Reporting (Continued) 3A. Table

©Clinical and Laboratory Standards Institute. All rights reserved. 119 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 119 M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10

®

® 3

700603: ® ATCC ATCC 25922: < ® E. coli ATCC Table 3A Table ATCC -lactamase; MHA, Mueller- Tests for ESBLs for Tests  , K. pneumoniae 3 twofold concentration

twofold concentration decrease in MIC for antimicrobial agent tested in combination with clavulanate vs the MIC of agent tested alone. when K. pneumoniae 25922 should be tested routinely (eg, or daily).weekly QC: Acceptable E. coli  When performing the ESBL test 700603 and decrease in MIC for an antimicrobial agent tested in combination clavulanatewith vs the MIC of agent when tested alone. Broth microdilution

ESBL Test 2-mm

700603 700603: ≤ ® ® when testedwhen 25922 should

® ATCC ATCC 25922: ® ATCC ATCC E. coli ton broth; ESBL, extended-spectrum 5-mm increase in zone 3-mm increase in zone

increase in zone diameter for antimicrobial agent tested in combination clavulanatewith vs the zone diameter alone. K. pneumoniae When performing the ESBL test, K. pneumoniae ≥ and be used for routine QC (eg, weekly or daily). QC: Acceptable E. coli diameter of ceftazidime- clavulanate vs ceftazidime alone; ≥ diameter of cefotaxime- clavulanate vs cefotaxime alone. Disk diffusion K. g/mL g/mL g/mL g/mL g/mL g/mL   

No  

® 2 2 2

=

2

8

700603 or     ®

ATCC 25922, may 25922 ® ® ATCC 700603 is provided as ® ATCC ATCC growth (seegrowth acceptable QC ranges listed inTable 5A) K. pneumoniae E. coli MIC Cefotaxime a supplemental QC strain (eg, for training, competence assessment, or test evaluation). Either strain, pneumoniae then be used for routine QC daily). or (eg, weekly E. coli 700603 = Growth: Cefpodoxime MIC  When testing antimicrobial agents used for ESBL detection, K. pneumoniae ATCC Ceftazidime MIC Ceftazidime MIC Aztreonam MIC Ceftriaxone Broth microdilution CAMHB, cation-adjusted Mueller-Hin

in Table 700603:

® E. coli ATCC 25922 (see K. pneumoniae ® Criteria for Performance of ESBL Test of for Performance Criteria 700603 is provided as 700603 or then be 25922, may ®b ® ® ATCC ATCC ATCC acceptable QC ranges Disk diffusion When testing antimicrobial agents used for ESBL detection, K. pneumoniae ATCC used for routine QC (eg, weekly or daily). E. coli Cefpodoxime zone 9–16 mm Ceftazidime zone 10–18 mm Aztreonam zone 9–17 mm Cefotaxime zone 17–25 mm Ceftriaxone zone 16–24 mm 4A) K. pneumoniae a supplemental QC strain (eg, for training, competence assessment, or test evaluation). Either strain, , American Type Culture Collection; ® Test Test Method Method Test QC Recommendations Hinton agar; MIC, minimal inhibitory concentration; PK-PD, pharmacokinetic-pharmacodynamic; QC, quality control. Abbreviations:ATCC Table 3A. (Continued) (Continued) 3A. Table

120 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 120 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use WithWith M02-A12 M02-A12 and and M07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed. g) and  Table 3A Table Tests for ESBLs for Tests L of clavulanate to ceftazidime (30  g) disks: Using disks: g) solutionstock a of clavulanate at 1000  70°C), add 10 g/10 − 

Footnotes Footnotes avulanate to absorb and the disks to be dry enough for application. Use disks L of stock solution to the ceftazidime and cefotaxime disks one hourwithin before they  g/10 µg)g/10 and cefotaxime-clavulanate (30  om small aliquots that have been frozen at he American Type Culture Collection. or discard; do not store. g) disks. Use a micropipette the 10 to apply  is a registered trademark of t ® g/mL (either freshly prepared or taken fr  are applied to the plates, allowing about 30 minutes for the cl cefotaxime (30 cefotaxime immediately after preparation

(Continued) 3A. Table a. Preparation ofceftazidime-clavulanate (30 b. ATCC

©Clinical and Laboratory Standards Institute. All rights reserved. 121 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 121 M100S,M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

spp. more more and -lactamase.  Acinetobacter Acinetobacter Enterobacteriaceae, P. P. aeruginosa,

rbapenemase gene present ve criteria for carbapenems for criteria ve and spp. that are nonsusceptible to oducing Tests for Carbapenemases for Tests Introduction to Tables 3B and 3C Tables to Introduction Other (eg, molecular assays) on), and usually test resistant to one or Acinetobacter one or more carbapenems to determine the presence of a carbapenemase, or to determine carbapenemase type in isolates positive MHT by or Carba NP Enterobacteriaceae, Determines type of carbapenemase in additionabsenceto presenceor the of enzyme Special reagents and equipment are needed. Specific to targeted genes; false-negative result if specific ca is not targeted. and Pseudomonas aeruginosa, Pseudomonas

-S20 (January 2010) should perform the MHT, the Carba NP to one or more carbapenems using the current interpretive criteria MHT, modified Hodge test; NDM, New Delhi metallo- MHT, modified Hodge test; NDM, New P. aeruginosa,

Carba NP (Table 3C) spp. that are nonsusceptible y necessitatey identification of carbapenemase-pr Enterobacteriaceae, nsitive indicator of carbapenemase producti Enterobacteriaceaeare suspicious carbapenemasefor production based on imipenem or Acinetobacter to one or more carbapenems Enterobacteriaceae, Rapid Special reagents are needed, some of which necessitate in-house preparation (and have a short shelf life). Invalid results occur some isolates. with Certain carbapenemase types (eg, OXA- type, chromosomally encoded) are not detected.consistently xime, ceftazidime, ceftizoxime, and ceftriaxone). some i solates that produce However, ceftazidime, ceftizoxime, xime, ly recommendedly for routine use. usually test intermediate or resistant

Tests Used for Epidemiological or Infection Control–Related Testing st susceptible to these cephalosporins. -lactamase; MIC, minimal inhibitory concentration; β MHT MIC interpretive criteria for carbapenems described in M100 that are nonsusceptible to Enterobacteriaceae (Table 3B) Enterobacteriaceae. Ertapenem nonsusceptibility is the most se spp. Such testing is not currentnot is testing Such spp. procedures or epidemiological investigations ma bclass III (eg, cefoperazone, cefota ( NOTE: -1 False-positive results can occur in isolates that Enterobacteriaceae one or more carbapenems Simple to perform No special reagents or media necessary produce ESBL or AmpC enzymes coupled with porin loss. False-negative results are occasionally noted (eg, some isolates producing NDM carbapenemase). applies to Only Enterobacteriaceae Acinetobacter and Organisms Strengths Limitations

in Carbapenemases for Tests 3C. and 3B Tables to Introduction Institutional infection control aeruginosa, Carbapenemase-producing isolates of as listed in Table 2A agents in cephalosporin su carbapenemases such as SME or IMI often te Laboratories using isolatesof below and/or a molecularwhen assayas described test, meropenem MICs of 2–4 µg/mL or ertapenem MIC of 2 µg/mL. Refer to Tables 3B-1 or 3C-1 for specific steps to use interpretiwith 2010). (January M100-S20 listed in Abbreviations: ESBL, extended-spectrum

122 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 122 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12 and M07-A10 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 123 M100S,M100S, 26th26th ed. For Use With M02-A12 and M07-A10 a 25922 25922 n Table n Table ® diffusion Table 3B Table rbapenemsusceptibility isresults test The Modified Hodge Test for Suspected Test The Modified Hodge

Carbapenemase Production in Enterobacteriaceae Production Carbapenemase opriate number of ertapenem or meropenem disks on the plate as organism grown overnightblooda on plateagar and inoculate in MHT line or broth. Inoculate an MHA plate as for the routine disk colonydirect suspension growthor method) of E. coli ATCC No change inthe interpretation ca of ed in M100-S20 (January 2010), please refer to modifications i modifications to refer please 2010), (January M100-S20 in ed NOTE: (100-mm 150-mm respectively): or diameter, the disk. Thethe disk. streak should of isolatesin length.Test per plate be at least 20–25 the number mm as Carbapenemase Production in Enterobacteriaceae

g or g g   2°C; ambient air

±

straight line out from the edge of Forepidemiological or infection control purposes. Prepare(1) a McFarland0.5 standardsuspension (using either MHT MHA Ertapenem disk 10 (the indicator organism) in broth or saline, and dilute 1:10 in sa noted below and shown in Figures 1 and 2. Capacity of small and large MHA plates Disks Test isolates QC isolates 35°C 1 16–20 hours 2 1 1–6 2 1–4 Small Large Small necessary for carbapenemase-positive isolates. procedure. Allow the plate to dry 3–10 minutes. Place the appr noted below and shown in Figures 1 and 2. (2)Using a10-µL loop or swab,pick 3–5 colonies of test or QC Meropenem disk 10

Test If using FORMER MIC interpretive criteria for carbapenems describ for carbapenems criteria MIC interpretive FORMER If using NOTE: NOTE: 3B-1 below. When to Do This Test: Test: This Do to When Method Test Medium Antimicrobial Concentration Inoculum Conditions Incubation Length Incubation Suspected for Test Hodge Modified The 3B. Table

124 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 124 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With With M02-A12 and and M07-A10 M07-A10 M100S,M100S, 26th ed.26th ed. e J Clin Clin J 90%)

. Table 3B Table Enterobacteriaceae. The sensitivity and specificity of 1 The Modified Hodge Test for Suspected Test The Modified Hodge Carbapenemase Production in Enterobacteriaceae Production Carbapenemase carbapenemase in and provide for a high level of sensitivity (> 25922. When this occurs,cleara area be seen will ® ATCC are MHT positive, and MHT-positive be results may

MHT modified Hodgemodified minimal test; MIC, inhibitoryconcentration; Klebsiellapneumoniae Enterobacteriaceae, ility test results is necessary for MHT-positive isolates. Enterobacteriaceae e mechanisms other than carbapenemase production. is uninterpretable for these isolates. for enhancedfor organismaround growth streak at the intersectionQC or test the of th or those requesting epidemiological information. carbapenemase–type carbapenemases in these isolates. for the detection of carbapenemase production in nonfermenting gram-negative bacilli d following testing of US isolates of BAA-1705—MHT positive BAA-1706—MHT negative negative for carbapenemase production.

® ® =

positive for carbapenemase production.

=

Klebsiella pneumoniae ATCC ATCC Not all carbapenemase-producing isolates of Report results of the MHTto infection control No change in the interpretation of carbapenem susceptib K. pneumoniae

No enhanced growth Followingincubation, examine platethe MHA streak and the zone of inhibition (see Figures 1 and 2). Enhanced growth Test positive and negative QC organisms each day of testing. K. pneumoniae around the streak (see Figure 3), and the MHT encountered in isolates carbapenemwith resistanc NOTE: isolates test Some may produce substances inhibitthat growthcoliof E. 90%) in detecting

, American Type American , CultureCollection; Mueller-HintonMHA, agar; MHT, ®

2007;45(8):2723-2725.

Test andspecificity (> the test for detecting other carbapenemase production can vary. No data exist on the usefulness of the MHT Anderson KF,Lonsway DR, RasheedJK, et Evaluational. methodsof to identify the Microbiol. Results and Testing Additional Reporting Recommendations QC

QC, quality control. (Continued) 3B. Table Abbreviations:ATCC Test recommendations largelywere derive NOTE 1: Reference for Table 3B 1 NOTE 2:

©Clinical and Laboratory Standards Institute. All rights reserved. 125 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 125 M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10 ry ternative test for test ternative Table 3B-1 Table , this test (or an al an (or test this , MIC of 2–8 µg/mL,2–8 of MIC meropenemor ofMIC as Tablein listed M100-S20in 2A (Janua are suspicious for carbapenemase production based Carbapenems Described in M100-S20 (January Described in M100-S20 2010) Carbapenems Modifications of Table 3B When Using Interpretive Criteria for Criteria When Using Interpretive Table 3B of Modifications

MHT Enterobacteriaceae Enterobacteriaceae and are MHT MHT-positive be positive results may e mechanisms other than carbapenemase production. ent carbapenem MIC interpretive criteria nem MICs usingMICs nem interpretiveCLSI criteria eertapeneman µg/mL,2–4 of MIC imipenem µg/mL or ertapenem MIC of 2 µg/mL. MIC, minimal inhibitory concentration. Not all carbapenemase-producing isolates of

Until laboratoriesUntil can implement currthe carbapenemases) should be performed isolateswhen of on imipenem or meropenem MICs of 2–4 Forisolates that are MHT positive and hav 2–8 µg/mL, report all carbapenems as resistant. MHTinterpretthe If negative, is carbapethe 2010). NOTE: encountered in isolates carbapenemwith resistanc Test When to Do This This Do When to Test: Reporting Table 3B-1. Modifications of Table 2010) (January in M100-S20 Described Carbapenems 3B Criteria for When Using Interpretive Abbreviations: MHT, modified Hodge test;

126 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 126 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With M02-A12 M02-A12 and andM07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed.

K. E. ® Tables 3B and 3B-1 Tables 25922 25922 ATCC ® BAA-1705 BAA-1705 E.coli ® ATCC 25922 ATCC E. coli ® 25922 and an indentation of an and 25922 indentation ® ATCC ATCC Inhibition of Inhibition by ertapenem Enhanced growth of growth Enhanced by Carbapenemase produced 25922. pneumoniae the zone is noted. is noted. zone the inactivated ertapenem that diffused into into diffused ertapenem that inactivated is longer no there Thus, media. the to ertapeneminhibit here sufficient coli E. coli The Modified Hodge Confirmatory Test for Suspected Carbapenemase Production and Carbapenemase for Suspected Test Confirmatory The Modified Hodge Modifications When Using Interpretive Criteria Described in M100-S20 (January Criteria Described in M100-S20 2010) When Using Interpretive Modifications 2 BAA-1705, positive result; result; positive BAA-1705, result; negative BAA-1706, 3 ® ® 1 ATCC ATCC K. pneumoniae K. K. pneumoniae K. (2) result. positive (3) and a isolate, clinical Figure 1. The MHT Performed on a Small MHA Plate. Plate. MHA a on Small Performed 1. MHT The Figure (1)

3B-1. (Continued) and Tables 3B

©Clinical and Laboratory Standards Institute. All rights reserved. 127 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 127 M100S,M100S, 26th 26th ed. For Use With M02-A12 and M07-A10 Tables 3B and 3B-1 Tables

(1) A clinical The Modified Hodge Confirmatory Test for Suspected Carbapenemase Production and Carbapenemase for Suspected Test Confirmatory The Modified Hodge Modifications When Using Interpretive Criteria Described in M100-S20 (January Criteria Described in M100-S20 2010) When Using Interpretive Modifications

BAA-1705, positive result; ® ATCC BAA-1706, negative result; (3–8) ® ATCC K. pneumoniae (1) K. pneumoniae With Plate MHA Large a on Performed MHT The 2. Figure Ertapenem. Result. Indeterminate an of Example 3. Figure An isolate an with indeterminate result; and (2) a clinical isolate with a negative result. clinical isolates;7, 8) positive result.(3, 4, 5, (6) negative result; (2) (2)

3B-1. (Continued) and Tables 3B

128 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 128 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12 and M07-A10 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 129 M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10 spp. spp. “b.” “b.” and Acinetobacter and Table 3C Table Pseudomonas aeruginosa, Pseudomonas , results before 2 hours can be reported as ontaining antibiotics or other agents that select for Carba NP Test for Suspected Carbapenemase Production in Production Suspected Carbapenemase for Test NPCarba h patientisolate, QC organism,and uninoculatedreagent Enterobacteriaceae, Pseudomonas aeruginosa, Pseudomonas Enterobacteriaceae, tubes shouldtubes contain only bacterialprotein extraction reagent, Enterobacteriaceae tructions for preparation are provided below this table): No change in the interpretation of carbapenem susceptibility test results Carba NP Test sting is recommendednot currently for routine use. NOTE: traction reagent in Tris HCl buffer, pH 7.4 cribed in M100-S20 (January 2010), please refer to modifications modifications to refer please 2010), (January M100-S20 in cribed a1-µL loopful ofbacteria from an overnight bloodagar plate in tubesboth “a” and 2 hours. Isolates that demonstrate positive imipenem)

+

Do not use growth from selective media or plates c 2°C for up to

±

NOTE: L of bacterial protein extraction reagent to each tube. L of Solution A to tube “a.” L of Solution B to tube “b.” μ μ μ

L inoculation loops μ no organism.) control. carbapenemase producers. Vortex each tube each Vortex 5 seconds.for (Uninoculated reagent control certain bacteria. certain Imipenem reference standard powder Commercially available bacterial protein ex Microcentrifuge tubes 1.5 mL, clear Containers to store prepared solutions 10 mM zinc sulfate heptahydrate solution 2. Add 100 Colorimetric microtube assay  1-   Use reagents above to prepare the following solutions (ins   0.5% phenol red solution  0.1 N sodium hydroxide solution  Carba NP Solution A Carba NP Solution B (solution A 3. Foreach isolateto be tested, emulsify is necessary for Carba NP–positive isolates. Such te For epidemiological or infection control purposes.   Clinical laboratory reagent water   Zinc sulfate heptahydrate  Phenol red powder  1 N NaOH solution  10% HCl solution  1. Label twomicrocentrifuge tubes (one “a” andone for “b”) eac 4. Add 100 5. Add 100 6. tubes Vortex well. 7. Incubate at 35°C

1-7 spp. Test If using FORMER MIC interpretive criteria for carbapenems des carbapenems for criteria MIC interpretive FORMER If using NOTE: NOTE: below.in Table 3C-1 Test: This Do to When Method Test Test Reagents and Materials Test Procedure

Acinetobacter Table 3C. Carba in Production Carbapenemase NP for Suspected Test

130 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 130 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use WithWith M02-A12 M02-A12 and and M07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed. spp. spp. Acinetobacter and Table 3C Table Interpretation Negative, no Invalid Invalid carbapenemase detected Positive, carbapenemase producer Carba NP Test for Suspected Carbapenemase Production in Production Suspected Carbapenemase for Test NPCarba Enterobacteriaceae, Pseudomonas aeruginosa, Pseudomonas Enterobacteriaceae, Tube “b”: “b”: Tube Solution B B Solution Carba NP Test Light orange, dark or yellow, Red or red-orange Orange yellow colorAny Results for Patient and QC Tubes QC and for Patient Results positive

=

negative

Tube “a”: Tube Solution A A Solution =

(serves as internal control) invalid invalid

Red or red-orange Red or red-orange Red or red-orange Orange, light orange, dark yellow, or yellow =

tube other “a” is any If color, the test is invalid.  Both tubes must be red or red-orange.   Tubebe red “a” or red-orange. must   Red or red-orange Light orange, dark or yellowyellow,  Orange  If either tube is color,other any the test is invalid.

1. Read uninoculated reagent tubes “a” and “b” (ie, “blanks”).control 2. Read inoculated tube “a.” 4. Interpret results as follows: as results Interpret 4. Strategy for readingStrategy (see Figure 1, below): 3. Read inoculated tube “b.” Test Test Interpretation Test Interpretation (Continued) 3C. Table

©Clinical and Laboratory Standards Institute. All rights reserved. 131 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 131 M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10 spp. spp.

,

spp. es all ting other other ting Acinetobacter and Acinetobacter and Table 3C Table 7.8, prepare fresh Solution A and

carbapenemase (KPC), New Delhi metallo- each day each day of testing. ity and specificity of the test for detec Carba NP Test for Suspected Carbapenemase Production in Production Suspected Carbapenemase for Test NPCarba Enterobacteriaceae, Pseudomonas aeruginosa, Pseudomonas Enterobacteriaceae, of imipenemof Solutionto CompareA. patient tubes the to negative (ie, red or red-orange). Any other result invalidat result for an uninoculated reagent control test indicates a susceptible by MIC to all three carbapenems and one E. Klebsiella pneumoniae

Carba NP Test Enterobacteriaceae, Pseudomonas aeruginosa, “b” to appear red-orange tube “a” is red. when E. cloacae ated reagent control tubes 90%) in detecting

enem and ertapenem) not detected thiswere test. by en interpretingen questionable results. inhibitory concentration; QC, quality control. lid, perform molecular assay. rbapenemases in these isolates. The sensitiv ple, the sensitivity of the Carba NP test for detecting OXA-48-type carbapenemases (ie, 11%). is low carbapenemase detected.” BAA-1705—Carbapenemase positive BAA-1706—Carbapenemase negative following testing of US isolates of ® ® 90%) and specificity (>

ATCC ATCC Reagent deterioration can cause invalid results. An invalid problem Solution A and/orwith Solution Check the pH B. of Solution A. If pH is < Solution B. Check reagents for QC strains and uninoculated reagent controls.

  Repeat the test, including the uninoculated reagent controls.  If the repeat test is inva Results for uninoculated reagent control tubes “a” and “b” must be The addition of imipenem to tube “b” might cause tube K. pneumoniae colorslight A 1. change observedbe may the addition with uninoculated reagent control tubes wh Report positive as “Carbapenemase producer.” Report negative as “No tests performed on that day lotsame the reagents.of with 2. For invalid results: Test positive and negative QC strains and uninocul K. pneumoniae

, American Type Culture Collection; MIC, minimal ® Test -lactamase, VIM, IMP, SPM, and SME-type ca Test recommendations largelywere derived and provide for a high level of sensitivity (> carbapenemase production can vary. For exam  In CLSI studies, KPC-positive two strains carbapenem low with MICs (one

NOTES: Reporting Recommendations QC

NOTE 2: susceptible coli that to meropenemwas and intermediate to imip NOTE 1:

(Continued) 3C. Table Abbreviations: ATCC

132 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 132 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use With With M02-A12 M02-A12 and M07-A10and M07-A10 M100S,M100S, 26th 26th ed. ed. st

an alternative confirmatory te criteria as listed in Table 2A in M100- Tables 3C and 3C-1 Tables are suspicious for carbapenemase production are Carba NP positive. retive criteria, this test (or Enterobacteriaceae When Using Interpretive Criteria Described in M100-S20 (January Criteria Described in M100-S20 2010) When Using Interpretive Carba NP Test for Suspected Carbapenemase Production and Modifications and Modifications Production Suspected Carbapenemase for Test NPCarba Carba NP Test Enterobacteriaceae all carbapenems as resistant, regardless of MIC. 2–4 µg/mL or ertapenem MIC of 2 µg/mL. he carbapenem MICs using CLSI interpretive bitory bitory Concentration Interpretive Criteria for Carbapenems

1-7 Not all carbapenemase-producing isolates of Until laboratories can implement the revised carbapenem MIC interp for carbapenemases) should be performed when isolates of based on imipenem or meropenem MICs of If the Carba NP test is negative, interpret t For isolates that are Carba NP positive, report S20 (January 2010). NOTE: expirationindividualof components expirationindividualof components O. 2 7H

•

4 Test This solution does not remain in solution. Mix before use. well

When to Do This Test: Test: This Do to When Reporting Table 3C-1. Modifications of Table 3C When Using Minimal Inhi 2010) (January M100-S20 in Described Abbreviation: MIC, minimal inhibitory concentration. Components Test of Preparation for Instructions – 3C-1 and 3C Tables 10 mM Zinc Sulfate Heptahydrate Solution: 1. Weigh out 1.4 g ZnSO 2. Add to 500 mL clinical laboratory reagent (CLRW). water 3. Mix. 4. Store at room temperature. Expiration: 1 year or not to exceed 0.5% Phenol Red Solution: 1. Weigh out 1.25 g phenol red powder. 2. Add to 250 mL CLRW. 3. Mix. 4. Store at room temperature. Expiration: 1 year or not to exceed NOTE:

©Clinical and Laboratory Standards Institute. All rights reserved. 133 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 133 M100S,M100S, 26th ed.ed. For Use With M02-A12 and M07-A10 if solution turns any if solutionother color) turns any Tables 3C and 3C-1 Tables L of Solution B is needed. of powder.of Divide actualthe to6 by weight in, and uninoculated reagent control. When Using Interpretive Criteria Described in M100-S20 (January Criteria Described in M100-S20 2010) When Using Interpretive Carba NP Test for Suspected Carbapenemase Production and Modifications and Modifications Production Suspected Carbapenemase for Test NPCarba d an uninoculated reagent control, 500 μ It is advisable to weigh out at least 10 mg L per tube for each patient, QC stra μ NOTE: e, and protect from prolonged light exposure. ration of individual components (solution should remain red or red-orange; do not use

3 mL of Solution A, is sufficient for 30 tubes.which

= es, positive andpositive es, negative controls an

6 expirationindividualof components

6 mg/mL Imipenem):

/

+

0.1 0.1 N NaOH solutionwith (or 10% HCl solution if pH is too high).

±

L of 10 mM zinc sulfate solution. μ

Example: To test 2 patient isolat determine the amount (in mL) of Solution A to add to the powder. Example: 18 mg of imipenem 3. Adjust pH to 7.8

3C-1. (Continued) and Tables 3C 0.1 N Sodium Hydroxide Solution: 1. Add 20 mL 1 N NaOH to 180 mL CLRW. 2. Store at room temperature. Expiration: 1 year or not to exceed Carba NP Solution A: 1. In a 25- to 50-mL beaker, add 2 mL 0.5% phenol red solution to 16.6 mL CLRW. 2. Add 180 3. Store at 4 to 8°C for up 3 days. Carba NP Solution B (Solution A Expiration: 2 or not to exceedweeks expi 1. Determine the amount of Solution B needed, allowing 100 2. Weigh out approximately 10–20 mg of imipenem powder.

4. Store at 4 to 8°C in a small vial or bottl

134 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 134 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use WithWith M02-A12 M02-A12 and andM07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed.

Tables 3C and 3C-1 Tables When Using Interpretive Criteria Described in M100-S20 (January Criteria Described in M100-S20 2010) When Using Interpretive Carba NP Test for Suspected Carbapenemase Production and Modifications and Modifications Production Suspected Carbapenemase for Test NPCarba

3C-1. (Continued) and Tables 3C FigureInterpretation 1. of Reactions Color

©Clinical and Laboratory Standards Institute. All rights reserved. 135 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 135 M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10 Klebsiella carbapenemase J ClinJ Microbiol.

production in the modified Hodge test spp. by spp. by using a biochemical test. Enterobacteriaceae. Klebsiella pneumoniae Tables 3C and 3C-1 Tables 2012;18(9):1503-1507. 2012;50(11):3773-3776. Pseudomonas and J Clin Microbiol. 2013;51(4):1269-1271.

When Using Interpretive Criteria Described in M100-S20 (January Criteria Described in M100-S20 2010) When Using Interpretive Carba NP Test for Suspected Carbapenemase Production and Modifications and Modifications Production Suspected Carbapenemase for Test NPCarba Enterobacteriaceae 2013;51(9):3097-3101. Pseudomonas spp. Enterobacteriaceae. Emerg Infect Dis. 2010;65(2):249-251. J Clin Microbiol. Cloverleaf test (modified Hodge test) for detecting carbapenemase l R. Rapid and simultaneous detection of genes encoding Hodge test for detectionof emergingcarbapenemases in ) in Gram-negative bacilli. J Clin Microbiol. NDM J Antimicrob Chemother. d identification of carbapenemase types in d detection of carbapenemase-producing oducing Gram-negative bacilli. -lactamase (bla apid detection of carbapenemase-producing β 2012;56(12):6437-6440. be aware of false positive results. ) and DelhiNew metallo- KPC 2012;50(2):477-479. Antimicrob Agents Chemother. Agents Antimicrob for detection of carbapenemase-pr (bla

pneumoniae:

Carvalhaes CG, Picão RC, Nicoletti AG, Xavier DE, Gales AC. Poirel Girlich D, L, NordmannValueP. of modifiedthe Nordmann P, Poirel L, Dortet L. Rapi Dortet L, Poirel L, Nordmann P. R Dortet L, Poirel L, Nordmann P. Rapi Cunningham SA, Noorie T, Meunier D, Woodford N, Pate Vasoo S, Cunningham SA, Kohner PC, et al. Comparison of a novel, rapid chromogenic biochemical assay, the Carba NP test, with 3C-1. (Continued) and Tables 3C and 3C-1 3C for Tables References 1 2 3 4 5 6 7

136 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 136 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12 and M07-A10 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 137 M100S,M100S, 26th26th ed. For Use With M02-A12 and M07-A10 0.12 0.12 0.12

≤

=

Table 3D Table ) with penicillin) with MICs ≤ ) with ) penicillinwith MICs b b but negativebut resultsshould be spp. in Staphylococcus Test for β -Lactamase Production for Test the zone margin surrounding a penicillin S. lugdunensis ed test or follow manufacturer’sed test or follow directions 29 mm 29 mm

≥ ≥ andCoNS (includinglugdunensis S. and CoNS (including a a species species -lactamase positive. -lactamase-positivestaphylococci are resistant penicillin,to amino-, carboxy-, Up to 1 hour for nitrocefin-bas N/A S. aureus S. S. aureus β µg/mL or zones Nitrocefin-basedbe can tests aureus,for S. used confirmed the penicillinwith zone-edge test before reporting penicillin as susceptible. β and ureidopenicillins.

Nitrocefin-based test Induced growth taken (ie, growth from or cefoxitin disk test on either MHA or a blood agar plate after 16–18 hours of incubation) Nitrocefin-based test µg/mL or zones Room temperature Nitrocefin-based test: conversion from yellow to red/pink -Lactamase Production -Lactamase β Staphylococcus

a a

-lactamase negative β -lactamase positive (see β 29 mm 29 mm 29

≥ ≥ 25923 for routine QC of penicillin ® -Lactamase Production in Production -Lactamase β 2°C; ambient air

±

0.12 µg/mL or zones 0.12 µg/mL or zones -lactamase-positive staphylococci are resistant to

penicillin, amino-, carboxy-, and ureidopenicillins. disk to include examination of zone edge test (fuzzy edge = “beach”) Disk diffusion (Penicillin zone-edge test) N/A MHA 10 units penicillin disk Standard disk diffusion procedure 35°C 16–18 hours Sharp zone edge (“cliff”) = penicillinMICs S. aureus with ≤ Disk diffusion (Penicillin zone-edge test) β with penicillinMICs S. aureus with ≤

S. aureus ATCC Figure 1 below this table). zoneFuzzy edge (“beach”) = (see Figure 2 below this table).

c Test Organism Group Organism Method Test Medium Antimicrobial Concentration Inoculum Incubation Conditions Length Incubation Results Group Organism Method Test Testing Additional Reporting and QC Recommendations Routine –

138 of Detection for Table 3D. Test ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 138 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use With With M02-A12 M02-A12 and M07-A10 and M07-A10 M100-S25M100S, M100S, 26th 26th ed. ed ore g/mLand zone

μ The zone- penicillin 0.12 first and, if this test is is test this if and, first

Table 3D Table S. aureus.S. 2008;14(6):614-616. spp. in Staphylococcus Test for β -Lactamase Production for Test not been metbeen not Clin Microbiol Infect. Clin . Microbiol -lactamase production in production -lactamase β 29213 – positive 25923 – negative ® ® -lactamase will test penicillin resistant (MIC > (MIC resistant penicillin test will -lactamase β is negative, the penicillin zone-edge test shouldtest performedbe zone-edge penicillin the bef negative, is Staphylococcus aureus trocefin assay or assay trocefin other CLSI method referenceon penicillin test that isolates ivestaphylococci; Mueller-HintonMHA, agar; minimalMIC, S. aureus ATCC (or see local regulations and manufacturers’ recommendations)

S. aureus ATCC -Lactamase Production -Lactamase β

sk diffusion or MIC reference method and is unsure if the method can reliably detect penicillin detect penicillin reference can reliably method and is unsure if the sk diffusion or MIC Footnotes ssary because isolates producing a producing isolates because ssary criteriato from converting for daily weekly havetesting QC ia for to ia from converting weekly beenhave testing QC Subchapters(see daily met 4.7.2.1 in 4.7.2.2 and M02- more tests nitrocefin-based than sensitive of detection for

minimum inhibitory concentrations appearanceedge zone inhibitory penicillin minimum and staphylococcal production.beta-lactamase with the laboratorythe performshould inducedan ni -lactamase detection. However, some laboratories may choose to perform a nitrocefin-based test to choose may laboratories some However, detection. -lactamase β where penicillin may be may for used penicillin therapy where endocarditis).(eg, “cliff”)

=

on of phenotypic methods for penicillinase detection in on detection penicillinase phenotypicfor of methods 29213 – positive penicillin zone- with testing of lot/shipment new with each materials. -lactamase (or penicillin resistant). If the nitrocefin test nitrocefin the If resistant). penicillin (or -lactamase ® β S. lugdunensis,S. ATCC ate as penicillin susceptible. susceptible. penicillin as ate -lactamase detection are not nece not are detection -lactamase β S. aureus edge test (sharp edge tests for for tests , American TypeAmerican , Culture Collection; coagulase-negatCoNS, ® 1981;14(4):437-440.

e 29 mm). If a laboratory is using a method other than the CLSI di d

Test A12 and M07-A10)and A12 S. lugdunensis,S.

the if performedis test per once than less Daily weekif and/or lot/shipment materials testing of new each With testthe if leastat performed is a once Weekly criter and week  resistance with contemporary with resistance of isolates thereporting before susceptible isol  Test negative (susceptible)negative Test strain:QC  positive, report the results as positive for positive as results the report positive, edge test is recommended if only if edge test is recommended onetest is used for diameters < reporting the isolate as penicillin susceptible in cases cases in susceptible thereporting penicillin as isolate Microbiol. Clin J

QC – Recommendations Lot/shipment QC – Recommendations Supplemental

c. c. recommendations QC Routine – inhibitory concentration;quality control. QC, d. d. recommendations QC Lot/shipment – strain QC (resistant) positive Test minimum at (Continued) 3D. Table Abbreviations:ATCC a. shown test zone-edge diffusion be to disk penicillin The was References: References: Lenga M, Kaase etS, Friedrich S, Comparis al. of Correlation CM. Ingalls CB, Manning VJ, penicillin Gill

b. For

©Clinical and Laboratory Standards Institute. All rights reserved. 139 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 139 M100S,M100S, 26th26th ed. For Use With M02-A12 and M07-A10 Table 3D Table spp. in Staphylococcus Test for β -Lactamase Production for Test -lactamaseproduction. β -lactamase production.-lactamase β The zone edge is fuzzy or like a “beach” indicating no indicating “beach” a like or zone The edgefuzzy is The zone edgezone The “cliff”a like or sharp is indicating

r training personnel, and for competence assessment. It is not necessary to include supplementalr training QC strains personnel, It is not necessary and for competence assessment. -LactamaseDetection. -LactamaseDetection. β β susceptibility testing QC programs. See AppendixSee programs. QC testing describes footnoteC, of use susceptibility strains.QC which supplemental i, in routine daily or weekly antimicrobial weekly or daily routine in test, fo new Supplemental QC strains can be used to assess a

 (Continued) 3D. Table QC e. recommendationsSupplemental– Figure Positive1. Penicillin A Disk Zone-Edge Testfor NegativeZone-EdgePenicillin Disk Figure 2. A Test for

140 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 140 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12 and M07-A10 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 141 M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10 Staphylococcus Staphylococcus

Table 3E Table Except species, and S. lugdunensis

Test for Methicillin Resistance (Oxacillin Resistance) Resistance) (Oxacillin Methicillin Resistance for Test S. aureus S. 4 µg/mL cefoxitinµg/mL 4 Broth microdilution Broth CAMHB Standard broth microdilution procedure 35°C;to 33 ambient air temperaturesat (Testing above 35°C may detectnot MRSA.) hours16–20 Staphylococcus pseudintermedius Staphylococcus Except spp., in Staphylococcus Using Cefoxitin Mediated OxacillinResistance mecA-

a after 18 hours,18 after resistant) if 24 hours 24 (may reportedbe CoNS and S.

Disk diffusion Disk MHA 30 µg cefoxitin disk cefoxitin µg 30 hours 16–18 33 to 35°C;to 33 ambient air (Testing at temperatures above 35°C may not detect MRSA.) S. aureus lugdunensis Standard disk diffusion disk Standard procedure

on of Methicillin Resistance (Oxacillin Resistance) in Staphylococcus L loopL that was 

OxacillinResistance g/mL oxacillin g/mL oxacillin

6  transmittedread light with Agar dilution Agar NaCl4% MHA with to suspension colony Direct McFarland0.5 obtain turbidity. 1- a Using (Testing at temperatures above may35°C detectnot MRSA.) S.aureus hours; 24 dipped in the suspension, spot suspension, the in dipped 10–15area an mm diameter. in using swab a Alternatively, and suspension the in dipped expressed,spot asimilar area or entire an streak quadrant. 33 to 35°C;to 33 ambient air

Test Test MethodTest Medium Inoculum Organism Group Antimicrobial Concentration Incubation Conditions Incubation Length Table 3E. Detecti for Test pseudintermedius

142 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 142 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use WithWith M02-A12 M02-A12 and andM07-A10 M07-A10 M100S,M100S, 26th ed. 26th ed.

- β mecA ueller- mediated oxacillin oxacillin mediated mecA- negative (cefoxitin MIC 1–4 isolates that test as test that isolates ence of oxacillin resistance resistance ence of oxacillin

positive asreported be should mecA positive (MIC (MIC mecA positive Table 3E Table mecA, negativestaphylococci; M MHA, 29213 – positive 43300 – 43300 negative ® ® mecA mecA

= =

ATCC ATCC and S. lugdunensis

Test for Methicillin Resistance (Oxacillin Resistance) Resistance) (Oxacillin Methicillin Resistance for Test 4 µg/mL 4 µg/mL) 4 4 µg/mL 4 reportedbe should µg/mL), 4 as resistant. oxacillin

µg/mL) > S. aureus Broth microdilution Broth S. aureus S. ≤ > Cefoxitin is used as a surrogate fora as used is Cefoxitin resistance. as mecAtest that Isolates testing of other resistant; routine cefoxitin) (not oxacillin lactam agents, except those with anti-MRSA activity, is notis exceptagents, those lactam activity, anti-MRSA with advised. occurr Because of the rare than other mechanisms negative, but for the oxacillin MICs are resistant which (MIC ≥ Staphylococcus pseudintermedius Staphylococcus Except spp., in Staphylococcus

aureus S. zone Using Cefoxitin Mediated OxacillinResistance 21 mm) 21 positive positive negative

≤ -lactamagents, r-Hintonbroth; coagulase-CoNS, QC, quality control.QC, quality mecA mecA β

mecA- -mediated oxacillin = =

a mecA negative (cefoxitinnegative

CoNS mm 25 ≥ 24 mm 24 ≤ S. aureus; mecA

positive should be reported as reported be should positive positive (zone positive mecA mecA 25923 – ® 43300 – 43300 ® positive positive negative mecA mecA ATCC

ATCC and S. lugdunensis = =

21 mm 21 mm 22

Disk diffusion Disk ≤ Cefoxitin is used as a surrogate for as a Cefoxitin is used S. aureus S. S. aureus S.

S. aureus S. 23–29 mm)23–29 resistance. resistance. as test that Isolates ≥ oxacillin (not cefoxitin) (not other oxacillin resistant; thoseexcept should be anti-MRSA activity, with reported as reported.be not should or resistant

-lactam β ncentration; MRSA, methicillin-resistant 1 colony or colony 1

29213 – 43300 – ® ® >

-lactam agents β oxacillin resistant resistant oxacillin

ATCC ATCC =

OxacillinResistance ,American Type CultureCollection; CAMHB, cation-adjusted Muelle ® 1 colony 1

S. aureus S. aureus S. staphylococci Oxacillin-resistant

S. aureus light film of growth. growth. of film light > Agar dilution Agar carefullyExamine with for light transmitted are resistant to all agents; other be should reportedresistantas be not should or reported. Resistant Susceptible (with each test day)test each (with Susceptible

c

b Test Organism Group MethodTest Results Additional Testingand Reporting QC Recommend- ations– Routine QC Recommend- ations– Lot/shipment Hinton agar; MIC, minimal inhibitory co Table 3E. (Continued) Abbreviations:ATCC

©Clinical and Laboratory Standards Institute. All rights reserved. 143 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 143 M100S,M100S, 26th26th ed. For Use With M02-A12 and M07-A10 (see Subchapters 4.7.2.1 and Table 3E Table Test for Methicillin Resistance (Oxacillin Resistance) Resistance) (Oxacillin Methicillin Resistance for Test Staphylococcus pseudintermedius Staphylococcus Except spp., in Staphylococcus

Footnotes Footnotes ia for converting from daily QC testing to haveweekly been met

group. th each new th each new lot/shipment of testing materials. S. aureus per and/or if criteria for convertingweek from to daily QC testing have notweekly been met is includedwhich in the S. lugdunensis, 4.7.2.2 in M02-A12 and M07-A10) Test positive (resistant) QC strain at minimum at Test (resistant) strain QC positive wi Daily if the test is performed less than once With each new lot/shipment of testing materials Weekly if the test is performed at least once and a criterweek QC recommendations – Lot/shipment  Test negative (susceptible) QC strain:  

c. b. QC recommendations – Routine Table 3E. (Continued) a. Except

144 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 144 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12 and M07-A10 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 145 M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10 ,E. g/mL ) from those ), such vanC ), which often which and vanB spp. that growspp. that on BHI– Table 3F Table spp. and Enterococcus

Enterococcus Enterococcus with vancomycin 8–16  of MICs with and casseliflavus, Enterococcus aureus Staphylococcus for Screen Agar Vancomycin 29212 – Susceptible– 29212 – 51299 Resistant

® ® g/mL  spp. E. gallinarum E. and 8

 ATCC ATCC agar a Enterococcus gallinarum Enterococcus g/mL vancomycing/mL  species species grow on the vancomycinthe on enterococci other to grow contrast In plate. screen casseliflavus (intermediate) differ from vancomycin-resistant enterococcus for infection purposes. control Enterococcus Enterococcus (eg, l resistance to vancomycin intermediate-leve intrinsic, with 1–10µL ofa 0.5McFarland suspensionspotted onto agar surface. dipped in using a swab the suspension and excessAlternatively, liquid expressed, spot an area 10–15 mm in diameter or streak a portion of the plate. Perform vancomycinMIC on and screening agar and test pigment productionvancomycin for motility to acquired distinguish species with resistance (eg, vanA as > 1 colony = Presumptive vancomycin resistance Presumptive= colony 1 > vancomycin E. faecalis E. 35°C ± 2°C;± 35°C ambient air BHI hours24 E. faecalis E. Agar dilution Agar 6 Vancomycin MICVancomycin C, minimal inhibitory concentration; QC, quality control. S. aureusS. 1 colony or1 colony L ontodrop

 Enterococcus that grow on that grow  and

aureus 29212 – Susceptible – 29212

 ATCC 51299 – Resistant – 51299 Presumptive reduced susceptibility toPresumptive reduced susceptibility 

=

Staphylococcus 2°C; air ambient 

g/mL vancomycing/mL 1 colony g/mL will fail to grow. grow. to fail g/mL will

Enterococcus faecalis Enterococcus S. aureus S. 6  Preferably,using amicropipette, spot a10- dipped in the using a swab agar surface. Alternatively, suspension and the excess liquid expressed, spot an area 10–15mm in diameter orstreak a portion of the plate. 35°C MICs on S. aureus to determine vancomycin Testing on BHI–vancomycin screening agar does not detect vancomycin-intermediate all reliably MICs are 4 the vancomycin for which strains. Some strains  E. faecalis ATCC E. light film of growth. growth. of film light  Agar dilution Agar agar BHI obtainto suspension turbidity. McFarland 0.5 colony Direct hours24 transmitted light for with Examine carefully Perform a vancomycin MIC using a validated method vancomycin BHI–vancomycin screening agar.screening BHI–vancomycin

b

, American Type Culture Collection; BHI, Brain Heart Infusion; MI ®

c Screen TestScreen

Organism Group MethodTest Medium Concentration Antimicrobial Inoculum IncubationConditions IncubationLength Results AdditionalTesting and Reporting QC Recommendations– Routine RecommendationsQC – Lot/shipment Abbreviations: ATCC Agarfor Screen Table 3F. Vancomycin

146 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 146 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With M02-A12 M02-A12 and andM07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed. Table 3F Table spp. and Enterococcus omparably. aureus Staphylococcus for Screen Agar Vancomycin

ia for converting from daily QC testing to haveweekly been (see Subchapters 4.7.2.1 met Footnotes Footnotes per and/or if criteria for convertingweek from to daily QC testing have notweekly been met mum with each new eachmum new lot/shipment with of testing materials. able, dextrose phosphate agar and broth have been shown in limited testing to perform c and 4.7.2.2 in M02-A12 and M07-A10) Daily if the test is performed less than once With each new lot/shipment of testing materials Weekly if the test is performed at least once and a criterweek  Test negative (susceptible) QC strain:   a. a. BHI: even though not as widely avail b. b. QC recommendations – Routine c. c. QC recommendations – Lot/shipment mini at Test (resistant) strain QC positive Table 3F. (Continued)

©Clinical and Laboratory Standards Institute. All rights reserved. 147 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 147 M100S,M100S, 26th26th ed. For Use With M02-A12 and M07-A10 and spp. - β and Streptococcus

1 µg/mL erythromycin and 0.5 µg/mL clindamycin in same well hemolytic S. pneumoniae CAMHB with CAMHB to (2.5% LHB 5% with v/v) 20–24 hours Table 3G Table

2°C; ambient air

b ±

Broth Microdilution Broth Microdilution 35°C inducible clindamyc in resistance.

and CoNS no inducible clindamycin resistance.

=

=

Standard broth microdilution procedure species, pneumoniae, Streptococcus S. aureus, lugdunensis, CAMHB 4 µg/mL erythromycin and 0.5 µg/mL clindamycin in same well Any growth Any No growth 18–24 hours spp., spp., in Staphylococcus Resistance Inducible Clindamycin for Test

spp. β -Hemolytic Group spp. and Streptococcus pneumoniae, Streptococcus

=

spp. - β

2 Staphylococcus and Inducible Clindamycin Resistance Resistance Clindamycin Inducible Streptococcus 2°C; 5% CO



S. pneumoniae hemolytic supplementedMHA with sheepblood (5% TSAor v/v) supplemented sheepwith blood (5% v/v) 15-µg erythromycin disk and 2-µg clindamycin disk spaced 12 mm apart Standard disk diffusion procedure 35°C 20–24 hours inducible clindamycin resistance.

=

and (D-zone test) Disk Diffusion

a 2°C; ambient air

±

16–18 hours

S. aureus, lugdunensis, CoNS orMHA blood agarpurity plate used MIC tests with 15-µg erythromycin and 2-µg clindamycin disks spaced 15– 26 mm apart Standard disk diffusion procedure or heavilyinoculated ofarea platepurity 35°C Flattening of the zone inhibi tion adjacent to the erythromycin disk (referred to as a D-zone) Hazy growth the zone ofwithin inhibition around clindamycin clindamycin resistance, even if no D-zone is apparent. -Hemolytic Group -Hemolytic β

spp. Test

Test Method Method Test only Group (applies Organism to organismsresistant to erythromycin and susceptible to intermediate or clindamycin) Medium Antimicrobial Concentration Inoculum Conditions Incubation Length Incubation Results in Resistance Inducible Clindamycin of for Detection Table 3G. Test Streptococcus

148 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 148 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use WithWith M02-A12 M02-A12 and and M07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed. ysed ysed 49619 or  -hemolytic β BAA-976 – no  and ATCC spp.

ATCC

ested for inducible clindamycin Streptococcus S. pneumoniae S. pneumoniae growth S. aureus Table 3G Table

® ® ith 2010 guidance from the Centers for Broth Microdilution

BAA-977 – growth BAA-976 (no growth) BAA-977 (growth)  ® ®

and ATCC ATCC ATCC

b CoNS S. aureus, lugdunensis, S. aureus ATCC BAA-976 or S. aureus 29213 – no growth S. aureus S. aureus S. aureus ATCC spp., spp., in Staphylococcus Resistance Inducible Clindamycin for Test isolate is presumed to be resistant based on detection of spp. β -Hemolytic Group spp. and Streptococcus pneumoniae, Streptococcus

spp. 49619  r-Hinton broth; CoNS, coagulase-n egative staphylococci; LHB, l - β disks

ATCC and Inducible Clindamycin Resistance Clindamycin Inducible

Streptococcus ci from penicillin-allergic pregnant shouldwomen be t Footnotes Footnotes

S. pneumoniae S. pneumoniae hemolytic for routine QC of erythromycin and clindamycin SeeAppendix Cfor use of supplemental QC strains.

(D-zone test) Disk Diffusion ry concentration;ry QC, quality control; TSA, agar. tryptic soy -hemolytic streptococci need not be performed routinely (see comment [4] in Table 2H-1). When β cin resistance.” 25923 for BAA-976 (D-zone test negative) BAA-977 (D-zone test positive) ® ® ® olates of group B streptococ

ed, it should include testing for inducible clindamycin resistance. In accordance w routine QC of erythromycin clindamycinand disks S. aureus ATCC S. aureus ATCC S. aureus, lugdunensis, and CoNS Report inducible isolates with clindamycin resistance as “clindamycin resistant.” The comment may following be included the report: “This with Use of unsupplemented MHA is acceptable for these strains.

S. aureus ATCC

inducible clindamy inducible

– – –

, American Type Culture Collection; CAMHB, cation-adjusted Muelle ®

d Test c

Antimicrobial susceptibility testing (AST) of b NOTE: susceptibilitytesting clinicallyis indicat Disease Control and Prevention, colonizing is resistance (see comment [11] in Table 2H-1).

Test Method Method Test only Group (applies Organism to organismsresistant to erythromycin and susceptible or intermediate to clindamycin) and Testing Additional Reporting Recommendations QC Routine Recommendations QC Lot/shipment Recommendations QC Supplemental

(Continued) 3G. Table Abbreviations: ATCC horse blood; MHA, Mueller-Hinton agar; MIC, minimal inhibito a.

©Clinical and Laboratory Standards Institute. All rights reserved. 149 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 149 M100S,M100S, 26th26th ed. For Use With M02-A12 and M07-A10 (see (see rs for MMWR MMWR Table 3G Table ootnote i, which describes use of spp., spp., in Staphylococcus Resistance Inducible Clindamycin for Test spp. β -Hemolytic Group spp. and Streptococcus pneumoniae, Streptococcus

QC programs. See Appendix C, f tional Center for Immunization and Respiratory Diseases, Cente for training for personnel,and competencefor assessment.necessary not is It to per and/or if criteria for convertingweek from to daily QC testing have notweekly been met ofperinatal groupBstreptococcal disease revised– guidelines from 2010.CDC, m with each new each new lot/shipmentm with of testing materials. 2.2 in M02-A12 and M07-A10) 2010;59(RR-10):1-36. Subchapters 4.7.2.1 and 4.7. include supplemental QC strains in routine daily or AST weekly supplemental QC strains.

lot/shipment With each new of testing materials Weekly if the test is performed at least once a and criteria for convertingweek to from daily weekly QC testing have been met Daily if the test is performed less than once Supplemental canstrains QC usedbe assessto test, new a DiseaseControl and Prevention. Prevention Recomm Rep. Test negative (susceptible) QC strain:     Reference Verani JR, McGee L, Schrag SJ; Division of Bacterial Diseases, Na

b. QC recommendations – Routine c. QC recommendations – Lot/shipment QC recommendations d. – Supplemental (Continued) 3G. Table

minimu at Test (resistant) strain QC positive

150 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 150 ©Clinical and Laboratory Standards Institute. All rights reserved. M100S, 26th ed. For Use With M02-A12 and M07-A10 M100S, 26th ed. (see (see rs for MMWR MMWR ootnote i, which describes use of

This page is intentionally left blank. tional Center for Immunization and Respiratory Diseases, Cente m with each new each new lot/shipmentm with of testing materials. 2010;59(RR-10):1-36. Subchapters 4.7.2.1 and 4.7.2.2 in M02-A12 and M07-A10) include supplemental QC strains in routine daily or ASTQC programs. weekly See Appendix C, f supplemental QC strains.

DiseaseControl and Prevention. Prevention ofperinatal groupBstreptococcal disease revised– guidelines from 2010.CDC, Recomm Rep. Test negative (susceptible) QC strain:  lot/shipment With each new of testing materials  Weekly if the test is performed at least once a and criteria for convertingweek to from daily weekly QC testing have been met  Daily if the test is performed less than once per and/or if criteria for convertingweek from to daily QC testing have notweekly been met  Supplemental canstrains QC usedbe assessto test, new a training for personnel,and competencefor assessment.necessary not is It to Reference Verani JR, McGee L, Schrag SJ; Division of Bacterial Diseases, Na b. QC recommendations – Routine c. QC recommendations – Lot/shipment QC recommendations d. – Supplemental (Continued) 3G. Table

minimu at Test (resistant) strain QC positive

150 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 151 M100S,For Use 26th With ed. M02-A12 and M07-A10 For Use With M02-A12M100S, and 26th M07-A10 ed.

Table 3H. Test for Detection of High-Level Mupirocin Resistance in Staphylococcus aureus High-Level Test Mupirocin Resistancea,b Organism Group S. aureus Test Method Disk diffusion Broth microdilution Medium MHA CAMHB

Antimicrobial 200-µg mupirocin disk Single mupirocin 256-g/mL well Concentration Inoculum Standard disk diffusion procedure Standard broth microdilution procedure

Table 3H Table Incubation 35°C  2°C; ambient air 35°C  2°C; ambient air Conditions Incubation Length 24 hours; read with transmitted light 24 hours Staphylococcus aureus Staphylococcus

Results Examine carefully with transmitted For single 256-µg/mL well: light for light growth within the zone

Test for High-Level Mupirocin Resistance in Resistance Mupirocin High-Level for Test of inhibition. Growth = high-level mupirocin resistance.

No zone = high-level mupirocin No growth = the absence of high-level mupirocin resistance. resistance.

Any zone = the absence of high-level mupirocin resistance. Additional Testing Report isolates with no zone as Report growth in the 256-µg/mL well as high-level mupirocin and Reporting high-level mupirocin resistant. resistant.

Report any zone of inhibition as the Report no growth in the 256-µg/mL well as the absence of high- absence of high-level resistance. level resistance. QC S. aureus ATCC® 25923 (200-µg S. aureus ATCC® 29213 – mupA negative (MIC 0.06–0.5 µg/mL) Recommendations disk) – mupA negative (zone 29–38 – Routinec mm) or

E. faecalis ATCC® 29212 – mupA negative (MIC 16–128 µg/mL)

QC S. aureus ATCC® BAA-1708 – S. aureus ATCC® BAA-1708 – mupA positive (growth in 256-µg/mL Recommendations mupA positive (no zone) well) – Lot/shipmentd

Abbreviations: ATCC®, American Type Culture Collection; CAMHB, cation-adjusted Mueller Hinton broth; MHA, Mueller-Hinton agar; MIC, minimal inhibitory concentration; QC, quality control.

Footnotes

a. Although not formally validated by CLSI document M23–based analyses, some studies have linked a lack of response to mupirocin-based decolonization regimens with isolates for which the mupirocin MICs are  512 µg/mL. Although this document does not provide guidance on interpretive criteria for mupirocin, disk-based testing and the MIC test described here identify isolates for which the mupirocin MICs are  512 µg/mL.

b. References:

Simor AE, Phillips E, McGeer A, et al. Randomized controlled trial of chlorhexidine gluconate for washing, intranasal mupirocin, and rifampin and doxycycline versus no treatment for the eradication of methicillin-resistant Staphylococcus aureus colonization. Clin Infect Dis. 2007;44(2):178-185.

Harbarth S, Dharan S, Liassine N, Herrault P, Auckenthaler R, Pittet D. Randomized, placebo-controlled, double-blind trial to evaluate the efficacy of mupirocin for eradicating carriage of methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother. 1999;43(6):1412-1416.

Walker ES, Vasquez JE, Dula R, Bullock H, Sarubbi FA. Mupirocin-resistant, methicillin-resistant Staphylococcus aureus; does mupirocin remain effective? Infect Control Hosp Epidemiol. 2003;24(5):342-346.

©Clinical and Laboratory Standards Institute. All rights reserved. 135 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 152 ©Clinical and Laboratory Standards Institute. All rights reserved. ForM100S, Use With 26th M02-A12 ed. and M07-A10 M100S, 26th ed.

Table 3H. (Continued)

c. QC recommendations – Routine

Test negative (susceptible) QC strain:

 With each new lot/shipment of testing materials

 Weekly if the test is performed at least once a week and criteria for converting from daily to weekly QC testing have been met (see Subchapters 4.7.2.1 and 4.7.2.2 in M02-A12 and M07-A10)

 Daily if the test is performed less than once per week and/or if criteria for converting from daily to weekly QC testing have 3H Table not been met

d. QC recommendations – Lot/shipment aureus Staphylococcus

Test positive (resistant) QC strain at minimum with each new lot/shipment of testing materials.

in Resistance Mupirocin High-Level for Test

136 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 153 M100S,M100S, 26th26th ed. ed. For Use With M02-A12 and M07-A10

29212 – 51299 – ® ® agar; MIC, Resistant

ATCC ATCC =

g/mL g/mL 2°C; ambient air ambient 2°C;

 ±

agar agar L of a 0.5 McFarland McFarland a 0.5 L of h doses of penicillin or b  1 colony

Table 3I Table > BHI Streptomycin, 2000 10 suspension spotted onto surface agar at susceptible (if hours 24–48 reincubate) 24 hours, faecalis E. Susceptible faecalis E. Resistant g/mL) resistance may not be may resistance g/mL)

 spp. Enterococcus

64

® ® Resistant

=

ATCC ATCC 2°C; ambient air air ambient 2°C; 35°C

±

broth broth b Streptomycin HLAR Test for High-Level Aminoglycoside Resistance in Resistance Aminoglycoside High-Level for Test

E. faecalis E. faecalis E. 1000 µg/mL µg/mL 1000 dilution broth Standard procedure 24 at susceptible reincubate) hours, growth Any – Susceptible 29212 – Resistant 51299 BHI Broth microdilution microdilution Broth dilution Agar 24–48 hours (if hours 24–48 (Includes Disk Diffusion) Diffusion) Disk (Includes a

® g/mL) or ampicillin (MICs ≥  species ATCC Susceptible Inconclusive Inconclusive

= =

128 128 Resistant Resistant

2°C; ambient air air ambient 2°C; 35°C

≥ = 2000 µg/mL (agar) (agar) 2000 µg/mL

1000 µg/mL (agar) (agar) µg/mL 1000 500 µg/mL (broth) (broth) 500 µg/mL

±

1000 µg/mL (broth) (broth) 1000 µg/mL

> ≤ ≤

>

=

=

10 mm

mm 7–9 E. faecalis E. mm 14–20 29212: 300-µg streptomycin disk disk streptomycin 300-µg Streptomycin, diffusion disk Standard procedure 6 mm ≥ correlates: MIC R and S and MHA Disk diffusion diffusion Disk 16–18 hours hours 16–18

Enterococcus ® ® HLAR, high-level aminoglycoside resistance; MHA, Mueller-Hinton ATCC ATCC 16 µg/mL are categorized as resistant. However, enterococci with low levels of penicillin (MICs (MICs of penicillin with levels low enterococci However, as resistant. 16 µg/mL are categorized = Resistant

≥ 2°C; ambient air air ambient 2°C; 35°C

±

agar agar L of a 0.5 a 0.5 L of b  1 colony E. faecalis E. – Susceptible 29212 faecalis E. – Resistant 51299

Gentamicin, Gentamicin, 500 µg/mL 10 suspension McFarland agar onto spotted surface > BHI 24 hours 24 hours

Physicians’ requests to determinethe actual MIC of penicillin or ampicillin for blood and CSF isolates of g/mL) resistance may be susceptible to synergistic killing by these penicillins in combination with gentamicin or with gentamicin combination in penicillins these by killing synergistic to susceptible be may resistance g/mL)

1,2 ® ®  Resistant

=

ATCC ATCC 2°C; ambient air air ambient 2°C; 35°C

±

broth broth g/mL  g/mL ampicillin and penicillin MICs MICs penicillin and ampicillin b Gentamicin HLAR Gentamicin 29212 – Susceptible – Susceptible 29212 – Resistant 51299 BHI Gentamicin, 500 dilution broth Standard procedure 35°C growth Any faecalis E. faecalis E. 24 hours 24 hours Broth microdilution microdilution Broth dilution Agar

® ATCC Susceptible Inconclusive Inconclusive

= = g/mL) or ampicillin (MICs 16–32 16–32 (MICs ampicillin or g/mL)

Resistant Resistant

 2°C; ambient

= 500 µg/mL 500 µg/mL

500 µg/mL 500 µg/mL

±

> ≤

= =

10 mm

streptomycin (in the absencehigh-level of resistance to gentamicin or streptomycin, see Subchapter 3.13.2.4M07-A10) in if hig (MICs penicillin of levels higher possessing Enterococci are used. ampicillin synergistic effect. to the susceptible 16–64 16–64 Disk diffusion diffusion Disk MHA gentamicin 120-µg disk disk Standard procedure diffusion 35°C air hours 16–18 6 mm mm 7–9 ≥ correlates: MIC R S vancomycin). and penicillin, ampicillin, (eg, agent wall–active cell with synergistic not is Resistant: susceptible. also that is and vancomycin) penicillin, (eg, ampicillin, agent wall–active cell with is synergistic Susceptible: If disk diffusion result is inconclusive:perform an agar dilution or brothdilution test MIC to confirm. with of enterococci Strains enterococci should be considered. faecalis E. 29212: mm 16–23

– – , American Type Culture Collection; BHI, Brain Heart Infusion; ®

d Test Test

c Test Method Medium Antimicrobial Concentration Inoculum Incubation Conditions Incubation Length Results Additional and Testing Reporting QC Recommendations Routine QC Recommendations Lot/shipment Table 3I. Test for Detection of High-Level Aminoglycoside Resistance in Resistance Aminoglycoside of High-Level for Detection Table 3I. Test Abbreviations: ATCC minimal inhibitory concentration; QC, quality control.

154 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 154 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With M02-A12 M02-A12 and andM07-A10 M07-A10 M100S,M100S, 26th 26th ed .ed. Enterococcus n n

Table 3I Table t (see Subchapters 4.7.2.1 spp. Enterococcus not been met streptomycin. m comparably. entamicin synergy i entamicin synergy Test for High-Level Aminoglycoside Resistance in Resistance Aminoglycoside High-Level for Test

e been shown in limited testing to perfor Footnotes Footnotes eriaconvertingfor from daily to QC weekly testing havebeen me 1997;102(3):284-293. vities against enterococci are not superior to gentamicin and Am J Med. with each new each new lot/shipmentwith of testing materials. es MJ, Baquero F. High-level penicillin resistance resistance penicillin-g and penicillin High-level F. Baquero MJ, es ailable, dextrose phosphate agar and broth hav Chemother. 1993;37(11):2427-2431.Chemother. Antimicrob Agents . and 4.7.2.2 in M02-A12 and M07-A10) With each new lot/shipment of testing materials Weekly if the test is performed at least once a andweek crit Daily if the test is performed less than once per and/or if criteria for convertingweek from to daily QC testing have weekly    faecium

Test negative (susceptible) QC strain: Torres C, Tenorio C, Lantero M, Gastañar BE. Vancomycin-resistant Murray enterococci. b. BHI: even though not as av widely b. QC recommendations d. – Lot/shipment minimum at Test (resistant) strain QC positive c. QC recommendations c. – Routine Table 3I. (Continued) a. Other aminoglycosides need not be tested, because their acti References for Table 3I 1 2

©Clinical and Laboratory Standards Institute. All rights reserved. 155 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 155 M100S,For Use 26th With ed. M02-A12—Disk Diffusion For Use With M02-A12—DiskM100S, 26th Diffusion ed.

Table 4A. Disk Diffusion: Quality Control Ranges for Nonfastidious Organisms (Unsupplemented Mueller-Hinton Medium) Klebsiella Escherichia Staphylococcus Pseudomonas Escherichia pneumoniae Antimicrobial Disk coli aureus aeruginosa coli ATCC® Agent Content ATCC®a 25922 ATCC® 25923 ATCC® 27853 ATCC® 35218b,c 700603 Amikacin 30 g 19–26 20–26 18–26 – – Amoxicillin-clavulanate 20/10 g 18–24 28–36 – 17–22 – Ampicillin 10 g 15–22 27–35 – 6 – Ampicillin-sulbactam 10/10 g 19–24 29–37 – 13–19 – Azithromycin  – 21–26 – – –

M02 15 g

Table 4A Table Azlocillin 75 g – – 24–30 – – Aztreonam 30 g 28–36 – 23–29 31–38 10–16 Aztreonam-avibactam 30/20 g 32–38 – 24–30 31–38 26–32d Carbenicillin 100 g 23–29 – 18–24 – – Cefaclor 30 g 23–27 27–31 – – – Nonfastidious Quality Control Nonfastidious Cefamandole 30 g 26–32 26–34 – – – Cefazolin 30 g 21–27 29–35 – – – Cefdinir 5 g 24–28 25–32 – – – Cefditoren 5 g 22–28 20–28 – – – Cefepime 30 g 31–37 23–29 24–30 – – Cefetamet 10 g 24–29 – – – – Cefixime 5 g 23–27 – – – – Cefmetazole 30 g 26–32 25–34 – – – Cefonicid 30 g 25–29 22–28 – – – Cefoperazone 75 g 28–34 24–33 23–29 – – Cefotaxime 30 g 29–35 25–31 18–22 – 17–25 Cefotetan 30 g 28–34 17–23 – – – Cefoxitin 30 g 23–29 23–29 – – – Cefpodoxime 10 g 23–28 19–25 – – 9–16 Cefprozil 30 g 21–27 27–33 – – – Ceftaroline 30 g 26–34 26–35 – – – Ceftaroline-avibactam 30/15 g 27–34 25–34 17–26 27–35 21–27d Ceftazidime 30 g 25–32 16–20 22–29 – 10–18 Ceftazidime-avibactam 30/20 g 27–35 16–22 25–31 28–35 21–27d Ceftibuten 30 g 27–35 – – – – Ceftizoxime 30 g 30–36 27–35 12–17 – – Ceftobiprole 30 g 30–36 26–34 24–30 – – Ceftolozane-tazobactam 30/10 g 24–32 10–18 25–31 25–31 17–25 Ceftriaxone 30 g 29–35 22–28 17–23 – 16–24 Cefuroxime 30 g 20–26 27–35 – – – Cephalothin 30 g 15–21 29–37 – – – Chloramphenicol 30 g 21–27 19–26 – – – Cinoxacin 100 g 26–32 – – – – Ciprofloxacin 5 g 30–40 22–30 25–33 – – Clarithromycin 15 g – 26–32 – – – Clinafloxacin 5 g 31–40 28–37 27–35 – – Clindamycine 2 g – 24–30 – – – Colistin 10 g 11–17 – 11–17 – – Delafloxacin 5 g 2835h 3240h 2329h – – Dirithromycin 15 g – 18–26 – – – Doripenem 10 g 27–35 33–42 28–35 – – Doxycycline 30 g 18–24 23–29 – – – Enoxacin 10 g 28–36 22–28 22–28 – – Eravacycline 20 g 16–23 19–26 – – – Ertapenem 10 g 29–36 24–31 13–21 – – Erythromycine 15 g – 22–30 – – – Faropenem 5 g 20–26 27–34 – – – Fleroxacin 5 g 28–34 21–27 12–20 – – Fosfomycinf 200 g 22–30 25–33 – – – Fusidic acid 10 g – 24–32 – – – Garenoxacin 5 g 28–35 30–36 19–25 – – Gatifloxacin 5 g 30–37 27–33 20–28 – – Gemifloxacin 5 g 29–36 27–33 19–25 – – Gentamicing 10 g 19–26 19–27 17–23 – – Gepotidacin 10 g 18–26 23–29 – – – Grepafloxacin 5 g 28–36 26–31 20–27 – – Iclaprim 5 g 14–22 25–33 – – – Imipenem 10 g 26–32 – 20–28 – –

©Clinical and Laboratory Standards Institute. All rights reserved. 139 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 156 ©Clinical and Laboratory Standards Institute. All rights reserved. ForM100S, Use With 26th M02-A12—Disk ed. Diffusion For Use With M02-A12—DiskM100S, Diffusion 26th ed.

Table 4A. (Continued) Klebsiella Escherichia Staphylococcus Pseudomonas Escherichia pneumoniae Antimicrobial Disk coli aureus aeruginosa coli ATCC® Agent Content ATCC® 25922 ATCC® 25923 ATCC® 27853 ATCC® 35218b,c 700603 Kanamycin 30 g 17–25 19–26 – – – Lefamulin 20 g – 26–32 – – – Levofloxacin 5 g 29–37 25–30 19–26 – – Levonadifloxacin 10 g 27–33h 32–39h 17–23h – – Linezolid 30 g – 25–32 – – –

Linopristin-flopristin 10 g – 25–31 – – – M02 Lomefloxacin 10 g 27–33 23–29 22–28 – – 4A Table Loracarbef 30 g 23–29 23–31 – – – Mecillinam 10 g 24–30 – – – – Meropenem 10 g 28–34 29–37 27–33 – –

Methicillin 5 g – 17–22 – – – Quality Control Nonfastidious Mezlocillin 75 g 23–29 – 19–25 – – Minocycline 30 g 19–25 25–30 – – – Moxalactam 30 g 28–35 18–24 17–25 – – Moxifloxacin 5 g 28–35 28–35 17–25 – – Nafcillin 1 g – 16–22 – – – Nalidixic acid 30 g 22–28 – – – – Netilmicin 30 g 22–30 22–31 17–23 – – Nitrofurantoin 300 g 20–25 18–22 – – – Norfloxacin 10 g 28–35 17–28 22–29 – – Ofloxacin 5 g 29–33 24–28 17–21 – – Omadacycline 30 g 22–28 22–30 – – – Oxacillin 1 g – 18–24 – – – Pefloxacin 5 g 25–33 – – – – Penicillin 10 units – 26–37 – – – Piperacillin 100 g 24–30 – 25–33 12–18 – Piperacillin-tazobactam 100/10 g 24–30 27–36 25–33 24–30 – Plazomicin 30 g 21–27 19–25 15–21 – – Polymyxin B 300 units 13–19 – 14–18 – – Quinupristin-dalfopristin 15 g – 21–28 – – – Razupenem 10 g 21–26 – k – – – Rifampin 5 g 8–10 26–34 – – – Solithromycin 15 g – 22–30 – – – Sparfloxacin 5 g 30–38 27–33 21–29 – – Streptomycing 10 g 12–20 14–22 – – – Sulfisoxazolej 250 g or 15–23 24–34 – – – 300 g Tedizolid 20 g – 22–29 – – – Teicoplanin 30 g – 15–21 – – – Telavancin 30 g – 16–20 – – – Telithromycin 15 g – 24–30 – – – Tetracycline 30 g 18–25 24–30 – – – Ticarcillin 75 g 24–30 – 21–27 6 – Ticarcillin-clavulanate 75/10 g 24–30 29–37 20–28 21–25 – Tigecycline 15 g 20–27 20–25 9–13 – – Tobramycin 10 g 18–26 19–29 20–26 – – Trimethoprimj 5 g 21–28 19–26 – – – Trimethoprim- 1.25/23.75 23–29 24–32 – – – sulfamethoxazolej g Trospectomycin 30 g 10–16 15–20 – – – Trovafloxacin 10 g 29–36 29–35 21–27 – – Ulifloxacin 5 g 32–38 20–26 27–33 – – (prulifloxacin)i Vancomycin 30 g – 17–21 – – – Abbreviation: ATCC®, American Type Culture Collection.

NOTE: Information in boldface type is new or modified since the previous edition.

Footnotes

a. ATCC® is a registered trademark of the American Type Culture Collection.

b. QC strain recommended when testing β-lactam/β-lactamase inhibitors.

140 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 157 M100S,For Use 26th With ed. M02-A12—Disk Diffusion For Use With M02-A12—DiskM100S, 26th Diffusion ed.

Table 4A. (Continued)

c. It is essential that E. coli ATCC® 35218 maintains its ability to produce β-lactamase in order to adequately perform QC for β-lactam/β-lactamase inhibitor agents. If stored at temperatures above −60°C or if repeatedly subcultured, E. coli ATCC® 35218 may lose its plasmid containing the genes that code for β-lactamase production. To ensure E. coli ATCC® 35218 maintains its β-lactamase production integrity, when the organism is first subcultured from a frozen or lyophilized stock culture, test by disk diffusion or a dilution test with either ampicillin, piperacillin, or ticarcillin. In-range QC results for these agents confirm that the subculture of E. coli ATCC® 35218 is reliable for QC of the β-lactam/β-lactamase inhibitor agents (refer to M02- A12, Chapter 4 and M100 Appendix C). Testing performed during the rest of the month may then include only the combination drugs.

M02 ®

Table 4A Table d. K. pneumoniae ATCC 700603 must be used for routine QC of ceftaroline-avibactam, ceftazidime-avibactam, and aztreonam- avibactam. Either K. pneumoniae ATCC® 700603 or E. coli ATCC® 35218 can be used for routine QC of ceftolozane- tazobactam.

e. When disk approximation tests are performed with erythromycin and clindamycin, S. aureus ATCC® BAA-977 (containing Nonfastidious Quality Control Nonfastidious inducible erm(A)-mediated resistance) and S. aureus ATCC® BAA-976 (containing msr(A)-mediated macrolide-only efflux) are recommended as supplemental QC strains (eg, for training, competence assessment, or test evaluation). S. aureus ATCC® BAA-977 should demonstrate inducible clindamycin resistance (ie, a positive D-zone test), whereas S. aureus ATCC® BAA-976 should not demonstrate inducible clindamycin resistance. S. aureus ATCC® 25923 should be used for routine QC (eg, weekly or daily) of erythromycin and clindamycin disks using standard Mueller-Hinton agar.

f. The 200-g fosfomycin disk contains 50 g of glucose-6-phosphate.

g. For control limits of gentamicin 120-g and streptomycin 300-g disks, use E. faecalis ATCC® 29212 (gentamicin: 16–23 mm; streptomycin: 14–20 mm).

h. QC ranges for delafloxacin and levonadifloxacin were established using data from only one disk manufacturer. Disks from other manufacturers were not available at the time of testing.

i. Ulifloxacin is the active metabolite of the prodrug prulifloxacin. Only ulifloxacin should be used for antimicrobial susceptibility testing.

j. These agents can be affected by excess levels of thymidine and thymine. See M02-A12, Subchapter 3.1.4 for guidance, should a problem with QC occur.

k. Razupenem tested with S. aureus ATCC® 25923 can often produce the double or target zone phenomenon. For accurate QC results, use S. aureus ATCC® 29213 (no double zones) with acceptable limit 33–39 mm.

©Clinical and Laboratory Standards Institute. All rights reserved. 141 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 158 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12—Disk Diffusion M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 159 M100S, 26th 26th ed. ed. For Use WithFor Use M02-A12—Disk With M02-A12—Disk Diffusion Diffusion

Table 4B. Disk Diffusion: Quality Control Ranges for Fastidious Organisms

Haemophilus Haemophilus Neisseria Streptococcus Antimicrobial influenzae influenzae gonorrhoeae pneumoniae Agent Disk Content ATCC® 49247 ATCC® 49766 ATCC® 49226 ATCC® 49619a Amoxicillin-clavulanateb 20/10 g 15–23 – – – Ampicillin 10 g 13–21 – – 30–36 Ampicillin-sulbactam 10/10 g 14–22 – – – Azithromycin 15 g 13–21 – – 19–25 Aztreonam 30 g 30–38 – – – M02

Table 4B Table Cefaclor 30 g – 25–31 – 24–32 Cefdinir 5 g – 24–31 40–49 26–31 Cefditoren 5 g 25–34 – – 27–35 Cefepime 30 g 25–31 – 37–46 28–35

Fastidious Quality Control Fastidious Cefetamet 10 g 23–28 – 35–43 – Cefixime 5 g 25–33 – 37–45 16–23 Cefmetazole 30 g 16–21 – 31–36 – Cefonicid 30 g – 30–38 – – Cefotaxime 30 g 31–39 – 38–48 31–39 Cefotetan 30 g – – 30–36 – Cefoxitin 30 g – – 33–41 – Cefpodoxime 10 g 25–31 – 35–43 28–34 Cefprozil 30 g – 20–27 – 25–32 Ceftaroline 30 g 29–39 – – 31–41 Ceftaroline-avibactamc 30/15 g 30–38 – – – Ceftazidime 30 g 27–35 – 35–43 – Ceftazidime-avibactamc 30/20 g 28–34 – – 23–31 Ceftibuten 30 g 29–36 – – – Ceftizoxime 30 g 29–39 – 42–51 28–34 Ceftobiproled 30 g 28–36 30–38 – 33–39 Ceftolozane-tazobactamc 30/10 g 23–29 – – 21–29 Ceftriaxone 30 g 31–39 – 39–51 30–35 Cefuroxime 30 g – 28–36 33–41 – Cephalothin 30 g – – – 26–32 Chloramphenicol 30 g 31–40 – – 23–27 Ciprofloxacin 5 g 34–42 – 48–58 – Clarithromycin 15 g 11–17 – – 25–31 Clinafloxacin 5 g 34–43 – – 27–34 Clindamycin 2 g – – – 19–25 e Delafloxacin 5 g 4051 – – 2836 Dirithromycin 15 g – – – 18–25 Doripenem 10 g 21–31 – – 30–38 Doxycycline 30 g – – – 25–34 Enoxacin 10 g – – 43–51 – Eravacycline 20 g – – – 23–30 Ertapenemd 10 g 20–28 27–33 – 28–35 Erythromycin 15 g – – – 25–30 Faropenem 5 g 15–22 – – 27–35 Fleroxacin 5 g 30–38 – 43–51 – Fusidic acid 10 g – – – 9–16 Garenoxacin 5 g 33–41 – – 26–33 Gatifloxacin 5 g 33–41 – 45–56 24–31 Gemifloxacin 5 g 30–37 – – 28–34 Gepotidacin 10 g – – – 22–28 Grepafloxacin 5 g 32–39 – 44–52 21–28 Iclaprim 5 g 24–33 – – 21–29 Imipenem 10 g 21–29 – – – Lefamulin 20 g 22–28 – – 19–27 Levofloxacin 5 g 32–40 – – 20–25 Levonadifloxacin 10 g 33–41e – – 24–31e Linezolid 30 g – – – 25–34 Linopristin-flopristin 10 g 25–31 – – 22–28 Lomefloxacin 10 g 33–41 – 45–54 – Loracarbef 30 g – 26–32 – 22–28 Meropenem 10 g 20–28 – – 28–35 Moxifloxacin 5 g 31–39 – – 25–31 Nitrofurantoin 300 g – – – 23–29 Norfloxacin 10 g – – – 15–21 Ofloxacin 5 g 31–40 – 43–51 16–21 Omadacycline 30 g 21–29 – – 24–32 f Oxacillin 1 g – – –  12

142 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 160 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M02-A12—Disk M02-A12—Disk Diffusion Diffusion M100S,M100S, 26th 26th ed. ed.

Table 4B. (Continued)

Haemophilus Haemophilus Neisseria Streptococcus Antimicrobial influenzae influenzae gonorrhoeae pneumoniae Agent Disk Content ATCC® 49247 ATCC® 49766 ATCC® 49226 ATCC® 49619a Penicillin 10 units – – 26–34 24–30 Piperacillin-tazobactam 100/10 g 33–38 – – – Quinupristin-dalfopristin 15 g 15–21 – – 19–24 Razupenem 10 g 24–30 – – 29–36 Rifampin 5 g 22–30 – – 25–30  Solithromycin 15 g 16–23 – 33–43 25–33 M02

Sparfloxacin 5 g 32–40 – 43–51 21–27 4B Table Spectinomycin 100 g – – 23–29 – Tedizolid 20 g – – – 24–30 Telavancin 30 g – – – 17–24 Telithromycin 15 g 17–23 – – 27–33 Quality Control Fastidious Tetracycline 30 g 14–22 – 30–42 27–31 Tigecycline 15 g 23–31 – 30–40 23–29 Trimethoprim- 1.25/23.75 g 24–32 – – 20–28 sulfamethoxazole Trospectomycin 30 g 22–29 – 28–35 – Trovafloxacin 10 g 32–39 – 42–55 25–32 Vancomycin 30 g – – – 20–27

Disk Diffusion Testing Conditions for Clinical Isolates and Performance of QC Streptococci and Organism Haemophilus influenzae Neisseria gonorrhoeae Neisseria meningitidis Medium HTM GC agar base and 1% defined MHA supplemented with 5% growth supplement. The use of defibrinated sheep blood a cysteine-free growth supplement is not required for disk diffusion testing.

Inoculum Direct colony suspension Direct colony suspension Direct colony suspension

Incubation 5% CO2; 16–18 hours; 35°C 5% CO2; 20–24 hours; 35°C 5% CO2; 20–24 hours; 35°C Characteristics

Abbreviations: ATCC®, American Type Culture Collection; HTM, Haemophilus Test Medium; MHA, Mueller-Hinton agar; QC, quality control.

NOTE: Information in boldface type is new or modified since the previous edition.

Footnotes

a. Despite the lack of reliable disk diffusion interpretive criteria for S. pneumoniae with certain -lactams, Streptococcus pneumoniae ATCC® 49619 is the strain designated for QC of all disk diffusion tests with all Streptococcus spp.

b. When testing Haemophilus on HTM incubated in ambient air, the acceptable QC limits for E. coli ATCC® 35218 are 17–22 mm for amoxicillin-clavulanate.

c. QC limits for E. coli ATCC® 35218 in HTM: ceftaroline-avibactam 26–34 mm; ceftazidime-avibactam 27–34 mm; ceftolozane- tazobactam 25–31 mm.

d. Either H. influenzae ATCC® 49247 or 49766 may be used for routine QC testing.

e. QC ranges for delafloxacin and levonadifloxacin were established using data from only one disk manufacturer. Disks from other manufacturers were not available at the time of testing.

f. Deterioration in oxacillin disk content is best assessed with QC organism S. aureus ATCC® 25923, with an acceptable zone diameter of 18–24 mm.

©Clinical and Laboratory Standards Institute. All rights reserved. 143 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 161 M100S, 26th 26th ed. ed. For Use WithFor Use M02-A12—Disk With M02-A12—Disk Diffusion Diffusion

Table 4C. Disk Diffusion: Reference Guide to Quality Control Frequency

Conversion From Daily to Weekly QC

Routine QC is performed each day the test is performed unless an alternative plan has been established (see CLSI document EP23™).1 When developing a strategy for QC, the requirements of accrediting organizations should be considered, as these may differ from the recommendations described in this document. M02-A12, Subchapter 4.7.2.1 describes a 20- or 30-day plan that, if successfully completed, allows a user to convert from daily to weekly QC. An alternative option using a two-phase, 15- M02

Table 4C Table replicate (3 × 5 day) plan is described as follows:

QC Testing Frequency QC Testing  Test 3 replicates using individual inoculum preparations of the appropriate QC strains for 5 consecutive test days.

 Evaluate each QC strain/antimicrobial agent combination separately using acceptance criteria and following recommended actions as described in the flow diagram below.

 Upon successful completion of either the 20- or 30-day plan or the 15-replicate (3 × 5 day) plan, the laboratory can convert from daily to weekly QC testing. If unsuccessful, investigate, take corrective action as appropriate, and continue daily QC testing until either the 20- or 30-day plan or 15-replicate (3 × 5 day) plan is successfully completed. At that time weekly QC testing can be initiated.

* 15-Replicate (3 × 5 Day) Plan: Acceptance Criteria and Recommended Action Number Out of Range With Initial Testing Conclusion From Initial Number Out of Range After (based on 15 Testing (based on 15 Repeat Testing (based on Conclusion After replicates) replicates) all 30 replicates) Repeat Testing Plan is successful. 0–1 Convert to weekly QC N/A N/A testing. Test another 3 replicates Plan is successful. 2–3 for 5 days. 2–3 Convert to weekly QC testing. Plan fails. Investigate and Plan fails. Investigate and ≥ 4 take corrective action as ≥ 4 take corrective action as appropriate. Continue QC appropriate. Continue QC each test day. each test day. * Assess each QC strain/antimicrobial agent combination separately. Abbreviations: N/A, not applicable; QC, quality control.

144 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 162 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M02-A12—Disk M02-A12—Disk Diffusion Diffusion M100S,M100S, 26th 26th ed. ed.

Table 4C. (Continued)

Test Modifications

This table summarizes the suggested QC frequency when modifications are made to antimicrobial susceptibility test systems. It applies only to antimicrobial agents for which satisfactory results have been obtained with either the 15-

replicate (3 × 5 day) plan or 20 or 30 consecutive test day plan. Otherwise QC is required each test day.

Required QC Frequency

15-Replicate M02 Plan or 4C Table 20- or 30-Day

Test Modification 1 Day 5 Days Plan Comments Frequency QC Testing Disks Use new shipment or lot X number. Use new manufacturer. X Addition of new antimicrobial In addition, perform in-house verification X agent to existing system. studies. Media (prepared agar plates) Use new shipment or lot X number. Use new manufacturer. X Inoculum Preparation Convert inoculum preparation/ Example: standardization to use of a Convert from visual adjustment of X device that has its own QC turbidity to use of a photometric device protocol. for which a QC procedure is provided. Convert inoculum preparation/ Example: standardization to a method Convert from visual adjustment of X that depends on user turbidity to another method that is not technique. based on a photometric device. Measuring Zones Change method of measuring Example: zones. Convert from manual zone measurements to automated zone X reader.

In addition, perform in-house verification studies. Instrument/Software (eg, automated zone reader) Software update that affects Monitoring all drugs, not just those X AST results implicated in software modification Repair of instrument that Depending on extent of repair (eg, affects AST results critical component such as the X photographic device), additional testing may be appropriate (eg, 5 days). Abbreviations: AST, antimicrobial susceptibility testing; QC, quality control.

©Clinical and Laboratory Standards Institute. All rights reserved. 145 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 163 M100S, 26th 26th ed. ed. For Use WithFor Use M02-A12—Disk With M02-A12—Disk Diffusion Diffusion

Table 4C. (Continued)

NOTE 1: QC can be performed before or concurrent with testing patient isolates. Patient results can be reported for that day if QC results are within the acceptable limits.

NOTE 2: Manufacturers of commercial or in-house-prepared tests should follow their own internal procedures and applicable regulations.

NOTE 3: For troubleshooting out-of-range results, refer to M02-A12, Subchapter 4.8.1 and M100 Table 4D.

M02 Additional information is available in Appendix C, Quality Control Strains for Antimicrobial Susceptibility Table 4C Table Tests (eg, QC organism characteristics, QC testing recommendations).

QC Testing Frequency QC Testing NOTE 4: Broth, saline, and/or water used to prepare an inoculum does not need routine QC.

Reference for Table 4C

1 CLSI. Laboratory Quality Control Based on Risk Management; Approved Guideline. CLSI document EP23-A™. Wayne, PA: Clinical and Laboratory Standards Institute; 2011.

146 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 164 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12—Disk Diffusion M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 165 ForM100S, Use 26th With ed. M02-A12—Disk Diffusion For Use With M02-A12—DiskM100S, 26th Diffusion ed.

Table 4D. Disk Diffusion: Troubleshooting Guide

This table provides guidance for troubleshooting and corrective action for out-of-range QC, primarily using antimicrobial susceptibility tests with MHA. Refer to M02-A12 (disk diffusion), Chapter 4, Quality Control and Quality Assurance for additional information. Out-of-range QC tests should first be repeated. If the issue is unresolved, this troubleshooting guide should be consulted regarding additional suggestions for troubleshooting out-of-range QC results. In addition, if unresolved, manufacturers should be notified of potential product problems.

M02

Table 4D Table General Comment

(1) QC organism maintenance: Avoid repeated subcultures. Retrieve new QC strain from stock. If using lyophilized strains, follow

QC Troubleshooting the maintenance recommendations of the manufacturer. Store E. coli ATCC® 35218 and K. pneumoniae ATCC® 700603 stock cultures at −60C or below and prepare working cultures weekly (refer to M02-A12, Subchapter 4.4).

Antimicrobial Agent QC Strain Observation Probable Cause Comments/Action Aminoglycosides Any Zone too small pH of media too low Acceptable pH range = 7.2–7.4 Avoid CO2 incubation, which lowers pH. Aminoglycosides Any Zone too large pH of media too high Acceptable pH range = 7.2–7.4 Aminoglycosides P. aeruginosa Zone too small Ca++ and/or Mg++ Use alternative lot of media. ATCC® 27853 content too high Aminoglycosides P. aeruginosa Zone too large Ca++ and/or Mg++ Use alternative lot of media. ATCC® 27853 content too low Amoxicillin-clavulanate E. coli ATCC® Zone too small Clavulanate is labile. Disk Use alternative lot of disks. 35218 has lost potency. Check storage conditions and package integrity. Ampicillin E. coli ATCC® Zone too large Spontaneous loss of the See general comment (1) on 35218 (should be no plasmid encoding the β- QC organism maintenance. zone—resistant) lactamase β-Lactam group Any Zone initially Disk has lost potency. Use alternative lot of disks. acceptable, but Check storage conditions and decreases and package integrity. possibly out of Imipenem, clavulanate, and range over time cefaclor are especially labile. Aztreonam K. pneumoniae Zone too large Spontaneous loss of the See general comment (1) on Cefotaxime ATCC® 700603 plasmid encoding the β- QC organism maintenance. Cefpodoxime lactamase Ceftazidime Ceftriaxone Cefotaxime-clavulanate K. pneumoniae Negative ESBL Spontaneous loss of the See general comment (1) on Ceftazidime-clavulanate ATCC® 700603 test plasmid encoding the β- QC organism maintenance. lactamase Penicillins Any Zone too large pH of media too low Acceptable pH range = 7.2–7.4 Avoid CO2 incubation, which lowers pH. Penicillins Any Zone too small pH of media too high Acceptable pH range = 7.2–7.4 Carbenicillin P. aeruginosa Zone too small QC strain develops See general comment (1) on ATCC® 27853 resistance after repeated QC organism maintenance. subculture. Ticarcillin-clavulanate E. coli ATCC® Zone too small Clavulanate is labile. Disk Use alternative lot of disks. 35218 has lost potency. Check storage conditions and package integrity. Clindamycin S. aureus Zone too small pH of media too low Acceptable pH range = 7.2–7.4 ® ATCC 25923 Avoid CO2 incubation, which lowers pH. Clindamycin S. aureus Zone too large pH of media too high Acceptable pH range = 7.2–7.4 ATCC® 25923 Macrolides S. aureus Zone too small pH of media too low Acceptable pH range = 7.2–7.4 ® ATCC 25923 Avoid CO2 incubation, which lowers pH. Macrolides S. aureus Zone too large pH of media too high Acceptable pH range = 7.2–7.4 ATCC® 25923

©Clinical and Laboratory Standards Institute. All rights reserved. 147 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 166 ©Clinical and Laboratory Standards Institute. All rights reserved. M100S,For Use With 26th M02-A12—Disk ed. Diffusion For Use With M02-A12—DiskM100S, Diffusion 26th ed.

Table 4D. (Continued) Antimicrobial Agent QC Strain Observation Probable Cause Comments/Action Quinolones Any Zone too small pH of media too low Acceptable pH range = 7.2–7.4 Avoid CO2 incubation, which lowers pH. Quinolones Any Zone too large pH of media too high Acceptable pH range = 7.2–7.4 Tetracyclines Any Zone too large pH of media too low Acceptable pH range = 7.2–7.4 Avoid CO2 incubation, which lowers pH. M02

Tetracyclines Any Zone too small pH of media too high Acceptable pH range = 7.2–7.4 4D Table Tetracyclines Any Zone too small Ca++ and/or Mg++ content Use alternative lot of media. too high Tetracyclines Any Zone too large Ca++ and/or Mg++ content Use alternative lot of media. QC Troubleshooting too low Sulfonamides E. faecalis Zone ≤ 20 mm Media too high in thymidine Use alternative lot of media. Trimethoprim ATCC® 29212 content Trimethoprim- sulfamethoxazole Various Various Zone too small Contamination Measure zone edge with visible growth detected with Use of magnification to unaided eye. Subculture to read zones determine purity and repeat if necessary. Various Any Many zones too Inoculum too light Repeat using McFarland 0.5 large turbidity standard or Error in inoculum standardizing device. Check preparation expiration date and proper storage if using barium sulfate Media depth too thin or latex standards. Use agar with depth MHA nutritionally approximately 4 mm. unacceptable Recheck alternate lots of MHA. Various Any Many zones too Inoculum too heavy Repeat using McFarland 0.5 small turbidity standard or Error in inoculum standardizing device. Check preparation expiration date and proper storage if using barium sulfate Media depth too thick or latex standards. Use agar with depth MHA nutritionally approximately 4 mm. unacceptable Recheck alternate lots of MHA. Various Any One or more zones Measurement error Recheck readings for too small or too measurement or transcription Transcription error large errors. Random defective disk Retest. If retest results are out of range and no errors are Disk not pressed firmly detected, initiate corrective against agar action. Various Various Zone too large Did not include lighter Measure zone edge with growth in zone visible growth detected with measurement (eg, double unaided eye. zone, fuzzy zone edge) Various S. pneumoniae Zones too large. Inoculum source plate too Subculture QC strain and ATCC® 49619 Lawn of growth old and contains too many repeat QC test or retrieve new scanty. nonviable cells. Plate used QC strain from stock. to prepare inoculum should be 18–20 hours.

148 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 167 M100S,For Use 26th With ed. M02-A12—Disk Diffusion For Use With M02-A12—DiskM100S, 26th Diffusion ed.

Table 4D. (Continued) Antimicrobial Agent QC Strain Observation Probable Cause Comments/Action Various Any One QC strain is out One QC organism may be a Retest this strain to confirm of range, but other better indicator of a QC reproducibility of acceptable QC organism(s) are problem. results. in range with the Evaluate with alternative same antimicrobial strains with known MICs. agent. Initiate corrective action with problem QC

M02 strain/antimicrobial agents.

Table 4D Table Various Any Two QC strains are Indicates a problem with the Use alternative lot of disks. out of range with the disk Check storage conditions and same antimicrobial package integrity. QC Troubleshooting agent. Various Any Zones overlap. Too many disks per plate Place no more than 12 disks on a 150-mm plate and 5 disks on a 100-mm plate; for some fastidious bacteria that produce large zones, use fewer. Abbreviations: ATCC®, American Type Culture Collection; ESBL, extended-spectrum -lactamase; MHA, Mueller-Hinton agar; MIC, minimal inhibitory concentration; QC, quality control.

©Clinical and Laboratory Standards Institute. All rights reserved. 149 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 168 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12—Disk Diffusion M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 169 M100S, 26th 26th ed. ed. For Use WithFor UseM02-A12—Disk With M07-A10—MIC Diffusion Testing

Table 5A. MIC: Quality Control Ranges for Nonfastidious Organisms (Unsupplemented Mueller- Hinton Medium [Cation-Adjusted if Broth]) Escherichia Escherichia Klebsiella Staphylococcus Enterococcus coli Pseudomonas coli pneumoniae ® Antimicrobial aureus faecalis ATCC® aeruginosa ATCC ATCC® Agent ATCC®a 29213 ATCC® 29212 25922 ATCC® 27853 35218b,c 700603 Amikacin 1–4 64–256 0.5–4 1–4 – – Amikacin-fosfomycin 0.5/0.24/1.6 32/12.8128/51.2 0.25/0.1 1/0.48/3.2   (5:2)d 2/0.8 Amoxicillin – – – – – > 128

M07 Amoxicillin-clavulanate 0.12/0.06–0.5/0.25 0.25/0.12–1.0/0.5 2/1–8/4 – 4/2–16/8 4/2–16/8 Table 5A Table (2:1) Ampicillin 0.5–2 0.5–2 2–8 – > 32 >128 Ampicillin-sulbactam – – 2/1–8/4 – 8/4–32/16 8/4–32/16 (2:1) Azithromycin 0.5–2 – – – – – Nonfastidious Quality Control Nonfastidious Azlocillin 2–8 1–4 8–32 2–8 – – Aztreonam – – 0.06–0.25 2–8 0.03–0.12 8–64 Aztreonam-avibactam – – 0.03/4– 2/4–8/4 0.015/4–0.06/4 0.06/4–0.5/4g 0.12/4 Besifloxacin 0.015–0.06 0.06–0.25 0.06–0.25 1–4 – – Biapenem 0.03–0.12 – 0.03–0.12 0.5–2 0.03–0.12 0.03–0.12 Cadazolid 0.060.5 0.060.25 – – – – Carbenicillin 2–8 16–64 4–16 16–64 – – Cefaclor 1–4 – 1–4 – – – Cefamandole 0.25–1 – 0.25–1 – – – Cefazolin 0.25–1 – 1–4 – – – Cefdinir 0.12–0.5 – 0.12–0.5 – – – Cefditoren 0.25–2 – 0.12–1 – – – Cefepime 1–4 – 0.015–0.12 0.5–4 – – Cefepime-tazobactame 1/84/8  0.03/8 0.5/84/8  0.12/80.5/8 0.12/8 Cefetamet – – 0.25–1 – – – Cefixime 8–32 – 0.25–1 – – – Cefmetazole 0.5–2 – 0.25–1 > 32 – – Cefonicid 1–4 – 0.25–1 – – – Cefoperazone 1–4 – 0.12–0.5 2–8 – – Cefotaxime 1–4 – 0.03–0.12 8–32 – – Cefotetan 4–16 – 0.06–0.25 – – – Cefoxitin 1–4 – 2–8 – – – Cefpodoxime 1–8 – 0.25–1 – – – Cefprozil 0.25–1 – 1–4 – – – Ceftaroline 0.12–0.5 0.25–2f 0.03–0.12 – – 2–8 Ceftaroline-avibactam 0.12/4–0.5/4 – 0.03/4– – 0.015/4–0.06/4f 0.25/4–1/4g 0.12/4 Ceftazidime 4–16 – 0.06–0.5 1–4 – 16–64 Ceftazidime-avibactam 4/4–16/4 – 0.06/4–0.5/4 0.5/4–4/4 0.03/4–0.12/4 0.25/4–2/4g Ceftibuten – – 0.12–0.5 – – – Ceftizoxime 2–8 – 0.03–0.12 16–64 – – Ceftobiprole 0.12–1 0.06–0.5 0.03–0.12 1–4 – – Ceftolozane-tazobactam 16/4–64/4 – 0.12/4–0.5/4 0.25/4–1/4 0.06/4–0.25/4 0.5/4–2/4g Ceftriaxone 1–8 – 0.03–0.12 8–64 – – Cefuroxime 0.5–2 – 2–8 – – – Cephalothin 0.12–0.5 – 4–16 – – – Chloramphenicol 2–16 4–16 2–8 – – – Cinoxacin – – 2–8 – – – Ciprofloxacini 0.12–0.5 0.25–2 0.004–0.015 0.25–1 – – Clarithromycin 0.12–0.5 – – – – – Clinafloxacin 0.008–0.06 0.03–0.25 0.002–0.015 0.06–0.5 – – Clindamycinj 0.06–0.25 4–16 – – – – Colistin – – 0.25–2 0.5–4 – – Dalbavancinl 0.03–0.12 0.03–0.12 – – – – Daptomycinm 0.12–1 1–4 – – – – Delafloxacin 0.0010.008 0.0150.12 0.0080.03 0.120.5   Dirithromycin 1–4 – – – – – Doripenem 0.015–0.06 1–4 0.015–0.06 0.12–0.5 – – Doxycycline 0.12–0.5 2–8 0.5–2 – – – Enoxacin 0.5–2 2–16 0.06–0.25 2–8 – – Eravacycline 0.015–0.12 0.015–0.06 0.03–0.12 2–16 – – Ertapenem 0.06–0.25 4–16 0.004–0.015 2–8 – – Erythromycinj 0.25–1 1–4 – – – –

150 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 170 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M07-A10—MIC M07-A10—MIC Testing Testing M100S,M100S, 26th 26th ed. ed.

Table 5A. (Continued) Klebsiella Staphylococcus Enterococcus Escherichia Pseudomonas Escherichia pneumoniae Antimicrobial aureus faecalis coli aeruginosa coli ATCC® Agent ATCC®a 29213 ATCC® 29212 ATCC® 25922 ATCC® 27853 ATCC® 35218b,c 700603 Faropenem 0.03–0.12 – 0.25–1 – – – Fidaxomicin 2–16 1–4 – – – – Finafloxacin 0.03–0.25 0.25–1 0.004–0.03 1–8 – – Fleroxacin 0.25–1 2–8 0.03–0.12 1–4 – – Fosfomycinn 0.5–4 32–128 0.5–2 2–8 – –

Fusidic acid 0.06–0.25 – – – – – M07

Garenoxacin 0.004–0.03 0.03–0.25 0.004–0.03 0.5–2 – – 5A Table Gatifloxacin 0.03–0.12 0.12–1.0 0.008–0.03 0.5–2 – – Gemifloxacin 0.008–0.03 0.015–0.12 0.004–0.015 0.25–1 – – Gentamicino 0.12–1 4–16 0.25–1 0.5–2 – – Gepotidacin 0.12–1 – 1–4 – – – Nonfastidious Quality Control Nonfastidious Grepafloxacin 0.03–0.12 0.12–0.5 0.004–0.03 0.25–2.0 – – Iclaprim 0.06–0.25 0.004–0.03 1–4 – – – Imipenem 0.015–0.06 0.5–2 0.06–0.25 1–4 – – Imipenem-relebactam 0.008/4–0.03/4 0.5/4–2/4 0.06/4–0.25/4 0.25/4–1/4 0.06/4–0.25/4 – Kanamycin 1–4 16–64 1–4 – – – Lefamulin 0.06–0.25      Levofloxacin 0.06–0.5 0.25–2 0.008–0.06 0.5–4 – – Levonadifloxacin 0.0080.03 – 0.030.25 0.54 – – Linezolid 1–4 1–4 – – – – Linopristin-flopristin 0.06–0.25 0.5–2 – – – – Lomefloxacin 0.25–2 2–8 0.03–0.12 1–4 – – Loracarbef 0.5–2 – 0.5–2 > 8 – – Mecillinam – – 0.03–0.25p – – – Meropenem 0.03–0.12 2–8 0.008–0.06 0.25–1 – – Methicillin 0.5–2 > 16 – – – – Mezlocillin 1–4 1–4 2–8 8–32 – – Minocyclinei 0.06–0.5 1–4 0.25–1 – – – Moxalactam 4–16 – 0.12–0.5 8–32 – – Moxifloxacin 0.015–0.12 0.06–0.5 0.008–0.06 1–8 – – Nafcillin 0.12–0.5 2–8 – – – – Nalidixic acidi – – 1–4 – – – Netilmicin  0.25 4–16  0.5–1 0.5–8 – – Nitrofurantoin 8–32 4–16 4–16 – – – Norfloxacin 0.5–2 2–8 0.03–0.12 1–4 – – Ofloxacin 0.12–1 1–4 0.015–0.12 1–8 – – Omadacyclinek 0.12–1 0.06–0.5 0.25–2 – – – Oritavancinl 0.015–0.12 0.008–0.03 – – – – Oxacillin 0.12–0.5 8–32 – – – – Penicillin 0.25–2 1–4 – – – – h Piperacillin 1–4 1–4 1–4 1–8 > 64 – Piperacillin-tazobactam 0.25/4–2/4 1/4–4/4 1/4–4/4 1/4–8/4 0.5/4–2/4 8/4–32/4 Plazomicin 0.25–2 32–128 0.25–2 1–4 – – Polymyxin B – – 0.25–2 0.5–2 – – Quinupristin-dalfopristin 0.25–1 2–8 – – – – Razupenem 0.008–0.03 0.25–1 0.06–0.5 – – – Rifampin 0.004–0.015 0.5–4 4–16 16–64 – – Solithromycin 0.03–0.12 0.015–0.06 – – – – Sparfloxacin 0.03–0.12 0.12–0.5 0.004–0.015 0.5–2 – – Sulfisoxazolei,r 32–128 32–128 8–32 – – – Sulopenem 0.015–0.12 2–8 0.015–0.06 – – – Tedizolid 0.25–1 0.25–1 – – – – Teicoplanin 0.25–1 0.25–1 – – – – Telavancinl 0.03–0.12 0.03–0.12 – – – – Telithromycin 0.06–0.25 0.015–0.12 – – – – Tetracycline 0.12–1 8–32 0.5–2 8–32 – – Ticarcillin 2–8 16–64 4–16 8–32 > 128 > 256 Ticarcillin-clavulanate 0.5/2–2/2 16/2–64/2 4/2–16/2 8/2–32/2 8/2–32/2 32/2–128/2 Tigecyclinek 0.03–0.25 0.03–0.12 0.03–0.25 – – – Tobramycin 0.12–1 8–32 0.25–1 0.25–1 – – Trimethoprimr 1–4 0.12–0.5 0.5–2 > 64 – – Trimethoprim-  0.5/9.5  0.5/9.5  0.5/9.5 8/152–32/608 – – sulfamethoxazole (1:19) Trospectomycin 2–16 2–8 8–32 – – –

©Clinical and Laboratory Standards Institute. All rights reserved. 151 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 171 M100S, 26th 26th ed. ed. For Use WithFor UseM02-A12—Disk With M07-A10—MIC Diffusion Testing

Table 5A. (Continued) Klebsiella Staphylococcus Enterococcus Escherichia Pseudomonas Escherichia pneumoniae Antimicrobial aureus faecalis coli aeruginosa coli ATCC® Agent ATCC®a 29213 ATCC® 29212 ATCC® 25922 ATCC® 27853 ATCC® 35218b,c 700603 Trovafloxacin 0.008–0.03 0.06–0.25 0.004–0.015 0.25–2 – – Ulifloxacin – – 0.004–0.015 0.12–0.5 – – (prulifloxacin)q Vancomycins 0.5–2 1–4 – – – – Abbreviations: ATCC®, American Type Culture Collection; MIC, minimal inhibitory concentration. M07 Table 5A Table NOTE 1: These MICs were obtained in several reference laboratories by dilution methods. If four or fewer concentrations are tested, QC may be more difficult.

NOTE 2: Information in boldface type is new or modified since the previous edition.

Nonfastidious Quality Control Nonfastidious Footnotes

a. ATCC® is a registered trademark of the American Type Culture Collection.

b. QC strain recommended when testing β-lactam/β-lactamase inhibitors.

c. It is essential that E. coli ATCC® 35218 maintains its ability to produce β-lactamase in order to adequately perform QC for β- lactam/β-lactamase inhibitor agents. If stored at temperatures above −60°C or if repeatedly subcultured, E. coli ATCC® 35218 may lose its plasmid containing the genes that code for β-lactamase production. To ensure E. coli ATCC® 35218 maintains its β-lactamase production integrity, when the organism is first subcultured from a frozen or lyophilized stock culture, test by disk diffusion or a dilution test with either ampicillin, piperacillin, or ticarcillin. In-range QC results for these agents confirm that the subculture of E. coli ATCC® 35218 is reliable for QC of the β-lactam/β-lactamase inhibitor agents (refer to M07-A10, Subchapter 4.4 and M100 Appendix C). Testing performed during the rest of the month may then include only the combination drugs.

d. QC ranges reflect MICs obtained when medium is supplemented with 25 g/mL of glucose-6-phosphate.

e. QC range for E. coli NCTC (National Collection of Type Cultures) 13353 with cefepime-tazobactam is 0.06–0.25 µg/mL. This strain is considered supplemental QC only and is not required as routine user QC. This CTX-M-15-producing strain provides proper evaluation of the tazobactam inhibition effect because CTX-M-15 is inhibited by tazobactam and cefepime is hydrolyzed by CTX-M-15.

f. Testing this strain with this antimicrobial agent is considered supplemental QC only and is not required as routine user QC testing.

g. K. pneumoniae ATCC® 700603 must be used for routine QC of ceftazidime-avibactam, ceftaroline-avibactam, aztreonam- avibactam, and ceftolozane-tazobactam. Either K. pneumoniae ATCC® 700603 or E. coli ATCC® 35218 can be used for routine QC of other β-lactam/β-lactamase inhibitor combination agents.

K. pneumoniae ATCC® 700603 should be tested against ceftazidime-avibactam and ceftazidime alone, ceftaroline-avibactam and ceftaroline alone, or aztreonam-avibactam and aztreonam alone to confirm the activity of avibactam in the combination and to ensure that the plasmid encoding the β-lactamase has not been lost in this QC strain. Currently, there are no MIC QC ranges for ceftolozane without tazobactam. Either aztreonam, ceftaroline, or ceftazidime can be tested to ensure K. pneumoniae ATCC® 700603 has not lost its β-lactamase resistance plasmid.

h. No range recommended due to off-scale results on the low end.

i. QC limits for E. coli ATCC® 25922 with ciprofloxacin, nalidixic acid, minocycline, and sulfisoxazole when tested in cation- adjusted Mueller-Hinton broth (CAMHB) with 2.5% to 5% lysed horse blood incubated either in ambient air or 5% CO2 (when testing N. meningitidis) are the same as those listed in Table 5A.

j. When the erythromycin/clindamycin combination well for detection of inducible clindamycin resistance is used, S. aureus ATCC® BAA-977 (containing inducible erm(A)-mediated resistance) and S. aureus ATCC® 29213 or S. aureus ATCC® BAA-976 (containing msr(A)-mediated macrolide-only efflux) are recommended for QC purposes. S. aureus ATCC® BAA-977 should demonstrate inducible clindamycin resistance (ie, growth in the well), whereas S. aureus ATCC® 29213 and S. aureus ATCC® BAA-976 should not demonstrate inducible clindamycin resistance (ie, no growth in the well).

k. For broth microdilution testing of omadacycline and tigecycline, when MIC panels are prepared, the medium must be prepared fresh on the day of use. The medium must be no more than 12 hours old at the time the panels are made; however, the panels may then be frozen for later use.

l. QC ranges reflect MICs obtained when CAMHB is supplemented with 0.002% polysorbate-80.

m. QC ranges reflect MICs obtained when Mueller-Hinton broth is supplemented with calcium to a final concentration of 50 g/mL. Agar dilution has not been validated for daptomycin.

152 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 172 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M07-A10—MIC M07-A10—MIC Testing Testing M100S,M100S, 26th 26th ed. ed.

Table 5A. (Continued)

n. The approved MIC susceptibility testing method is agar dilution. Agar media should be supplemented with 25 g/mL of glucose-6-phosphate. Broth dilution should not be performed.

o. For control organisms for gentamicin and streptomycin high-level aminoglycoside tests for enterococci, see Table 3I.

p. This test should be performed by agar dilution only.

q. Ulifloxacin is the active metabolite of the prodrug prulifloxacin. Only ulifloxacin should be used for antimicrobial susceptibility testing. M07

5A Table r. Very medium-dependent, especially with enterococci.

s. For QC organisms for vancomycin screen test for enterococci, see Table 3F. Nonfastidious Quality Control Nonfastidious

©Clinical and Laboratory Standards Institute. All rights reserved. 153 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 173 M100S, 26th 26th ed. ed. For Use WithFor UseM02-A12—Disk With M07-A10—MIC Diffusion Testing

Table 5B. MIC: Quality Control Ranges for Fastidious Organisms (Broth Dilution Methods) Haemophilus Haemophilus Streptococcus influenzae influenzae pneumoniae Antimicrobial Agent ATCC® 49247 ATCC® 49766 ATCC® 49619 Amikacin-fosfomycin (5:2)a 0.5/0.2–4/1.6 – 8/3.2–64/25.6 Amoxicillina – – 0.03–0.12 Amoxicillin-clavulanate (2:1)b 2/1–16/8 – 0.03/0.015–0.12/0.06 Ampicillin 2–8 – 0.06–0.25 Ampicillin-sulbactam (2:1) 2/1–8/4 – – Azithromycin 1–4 – 0.06–0.25 M07 Aztreonam 0.12–0.5 – – Table 5B Table Besifloxacin 0.015–0.06 – 0.03–0.12 Cefaclor – 1–4 1–4 Cefamandole – 0.25–1 – Cefdinir – 0.12–0.5 0.03–0.25 Cefditoren 0.06–0.25 – 0.015–0.12 Cefepime 0.5–2 – 0.03–0.25 Cefepime-tazobactam 0.5/8–2/8 – 0.03/8–0.12/8 Fastidious Quality Control Broth Dilution Broth Quality Control Fastidious Cefetamet 0.5–2 – 0.5–2 Cefixime 0.12–1 – – Cefmetazole 2–16 – – Cefonicid – 0.06–0.25 – Cefotaxime 0.12–0.5 – 0.03–0.12 Cefotetan – – – Cefoxitin – – – Cefpirome 0.25–1 – – Cefpodoxime 0.25–1 – 0.03–0.12 Cefprozil – 1–4 0.25–1 Ceftaroline 0.03–0.12 – 0.008–0.03 Ceftaroline-avibactam 0.015/4–0.12/4 – – Ceftazidime 0.12–1 – – Ceftazidime-avibactamc 0.06/4–0.5/4 0.015/4–0.06/4 0.25/4–2/4 Ceftibuten 0.25–1 – – Ceftizoxime 0.06–0.5 – 0.12–0.5 Ceftobiproled 0.12–1 0.016–0.06 0.004–0.03 Ceftolozane-tazobactam 0.5/4–2/4 – 0.25/4–1/4 Ceftriaxone 0.06–0.25 – 0.03–0.12 Cefuroxime – 0.25–1 0.25–1 Cephalothin – – 0.5–2 Chloramphenicol 0.25–1 – 2–8 Ciprofloxacine 0.004–0.03 – – Clarithromycin 4–16 – 0.03–0.12 Clinafloxacin 0.001–0.008 – 0.03–0.12 Clindamycin – – 0.03–0.12 Dalbavancing – – 0.008–0.03 Daptomycinh – – 0.06–0.5 Delafloxacin 0.00025–0.001 – 0.004–0.015 Dirithromycin 8–32 – 0.06–0.25 Doripenem – 0.06–0.25 0.03–0.12 Doxycycline – – 0.015–0.12 Enoxacin – – – Eravacycline 0.06–0.5 – 0.004–0.03 Ertapenem – 0.015–0.06 0.03–0.25 Erythromycin – – 0.03–0.12 Faropenem – 0.12–0.5 0.03–0.25 Finafloxacin – 0.002–0.008 0.25–1 Fleroxacin 0.03–0.12 – – Fusidic acid – – 4–32 Garenoxacin 0.002–0.008 – 0.015–0.06 Gatifloxacin 0.004–0.03 – 0.12–0.5 Gemifloxacin 0.002–0.008 – 0.008–0.03 Gentamicin – – – Gepotidacin 0.25–1 – 0.06–0.25 Grepafloxacin 0.002–0.015 – 0.06–0.5 Iclaprim 0.12–1 – 0.03–0.12 Imipenem – 0.25–1 0.03–0.12 Imipenem-relebactam – 0.25/4–1/4 – Lefamulin 0.5–2 – 0.06–0.5

154 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 174 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M07-A10—MIC M07-A10-MIC Testing Testing M100S,M100S, 26th 26th ed. ed.

Table 5B. (Continued) Haemophilus Haemophilus Streptococcus influenzae influenzae pneumoniae Antimicrobial Agent ATCC® 49247 ATCC® 49766 ATCC® 49619 Levofloxacin 0.008–0.03 – 0.5–2 Levonadifloxacin 0.008–0.06 – 0.12–0.5 Linezolid – – 0.25–2 Linopristin- 0.25–2 – 0.12–0.5 flopristin Lomefloxacin 0.03–0.12 – – Loracarbef – 0.5–2 2–8 M07

Meropenem – 0.03–0.12 0.03–0.25 5B Table Metronidazole – – – Minocyclinee – – – Moxifloxacin 0.008–0.03 – 0.06–0.25 Nalidixic acide – – – Nitrofurantoin – – 4–16 Norfloxacin – – 2–8 Ofloxacin 0.015–0.06 – 1–4 Dilution Broth Quality Control Fastidious Omadacyclinef 0.5–2 – 0.015–0.12 Oritavancing – – 0.001–0.004 Penicillin – – 0.25–1 Piperacillin- 0.06/4–0.5/4 – – tazobactam Quinupristin- 2–8 – 0.25–1 dalfopristin Razupenem – 0.008–0.03 0.008–0.06 Rifampin 0.25–1 – 0.015–0.06 Solithromycin 1–4 – 0.004–0.015 Sparfloxacin 0.004–0.015 – 0.12–0.5 Spectinomycin – – – Sulfisoxazolee – – – Sulopenem – 0.06–0.25 0.03–0.12 Tedizolid – – 0.12–0.5 Telavancing – – 0.004–0.015 Telithromycin 1–4 – 0.004–0.03 Tetracycline 4–32 – 0.06–0.5 Tigecyclinef 0.06–0.5 – 0.015–0.12 Trimethoprim- 0.03/0.59– – 0.12/2.4– sulfamethoxazole (1:19) 0.25/4.75 1/19 Trospectomycin 0.5–2 – 1–4 Trovafloxacin 0.004–0.015 – 0.06–0.25 Vancomycin – – 0.12–0.5

Testing Conditions for Clinical Isolates and Performance of QC Streptococcus Organism Haemophilus influenzae pneumoniae and streptococci Neisseria meningitidis Medium Broth dilution: Broth dilution: CAMHB with LHB Broth dilution: CAMHB with LHB HTM broth (2.5% to 5% v/v) (2.5% to 5% v/v) Inoculum Direct colony suspension Direct colony suspension Direct colony suspension

Incubation Ambient air; 20–24 hours; 35°C Ambient air; 20–24 hours; 35°C 5% CO2; 20–24 hours; 35°C Characteristics (for QC with S. pneumoniae ® ATCC 49619, 5% CO2 or ambient air, except for azithromycin, ambient air only) Abbreviations: ATCC®, American Type Culture Collection; CAMHB, cation-adjusted Mueller-Hinton broth; HTM, Haemophilus Test Medium; LHB, lysed horse blood; MIC, minimal inhibitory concentration; QC, quality control.

©Clinical and Laboratory Standards Institute. All rights reserved. 155 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 175 M100S, 26th 26th ed. ed. For Use WithFor UseM02-A12—Disk With M07-A10—MIC Diffusion Testing

Table 5B. (Continued)

NOTE 1: Information in boldface type is new or modified since the previous edition.

NOTE 2: For four-dilution ranges, results at the extremes of the acceptable ranges should be suspect. Verify validity with data from other QC strains.

Footnotes

a. QC ranges reflect MICs obtained when medium is supplemented with 25 g/mL of glucose-6-phosphate.

M07

Table 5B Table ® b. QC limits for E. coli ATCC 35218 when tested on HTM are 4/2–16/8 g/mL for amoxicillin-clavulanate and  256 g/mL for amoxicillin; testing amoxicillin may help to determine if the isolate has maintained its ability to produce -lactamase.

c. QC limits for K. pneumoniae ATCC® 700603 with ceftazidime-avibactam when testing in HTM are 0.25/4–1/4 µg/mL. K. pneumoniae ATCC® 700603 should be tested against ceftazidime-avibactam and ceftazidime alone to confirm the activity of avibactam in the combination and to ensure that the plasmid encoding the β-lactamase has not been lost in this strain. The acceptable range for ceftazidime alone is > 16 µg/mL. Fastidious Quality Control Broth Dilution Broth Quality Control Fastidious d. Either H. influenzae ATCC® 49247 or 49766 may be used for routine QC testing.

e. QC limits for E. coli ATCC® 25922 with ciprofloxacin, nalidixic acid, minocycline, and sulfisoxazole when tested in CAMHB with 2.5% to 5% LHB incubated either in ambient air or 5% CO2 (when testing N. meningitidis) are the same as those listed in Table 5A.

f. For broth microdilution testing of omadacycline and tigecycline, when MIC panels are prepared, the medium must be prepared fresh on the day of use. The medium must be no more than 12 hours old at the time the panels are made; however, the panels may then be frozen for later use.

g. QC ranges reflect MICs obtained when CAMHB is supplemented with 0.002% polysorbate-80.

h. QC ranges reflect MICs obtained when Mueller-Hinton broth is supplemented with calcium to a final concentration of 50 g/mL. Agar dilution has not been validated for daptomycin.

156 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 176 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M07-A10—MIC Testing M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 177 M100S,For Use 26th With ed. M07-A10-MIC Testing For Use With M07-A10—MICM100S, 26th Testing ed.

Table 5C. MIC: Quality Control Ranges for Neisseria gonorrhoeae (Agar Dilution Method)

Neisseria gonorrhoeae Antimicrobial Agent ATCC® 49226 Azithromycin 0.25–1 Cefdinir 0.008–0.03 Cefepime 0.015–0.06 Cefetamet 0.015–0.25 Cefixime 0.004–0.03 Cefmetazole 0.5–2 M07 Cefotaxime 0.015–0.06 Table 5C Table Cefotetan 0.5–2 Agar Dilution Agar Cefoxitin 0.5–2 Cefpodoxime 0.03–0.12 Ceftazidime 0.03–0.12 Ceftizoxime 0.008–0.03 Ceftriaxone 0.004–0.015 Cefuroxime 0.25–1 Quality Control for Neisseria gonorrhoeae for Quality Control Ciprofloxacin 0.001–0.008 Enoxacin 0.015–0.06 Fleroxacin 0.008–0.03 Gatifloxacin 0.002–0.015 Grepafloxacin 0.004–0.03 Lomefloxacin 0.008–0.03 Moxifloxacin 0.008–0.03 Ofloxacin 0.004–0.015 Penicillin 0.25–1 Solithromycin 0.030.25 Sparfloxacin 0.004–0.015 Spectinomycin 8–32 Tetracycline 0.25–1 Trospectomycin 1–4 Trovafloxacin 0.004–0.015 Testing Conditions for Clinical Isolates and Performance of QC Organism Neisseria gonorrhoeae Medium Agar dilution: GC agar base and 1% defined growth supplement. The use of a cysteine- free supplement is necessary for agar dilution tests with carbapenems and clavulanate. Cysteine-containing defined growth supplements do not significantly alter dilution test results with other drugs. Inoculum Direct colony suspension, equivalent to a 0.5 McFarland standard Incubation 36°C  1°C (do not exceed 37°C); 5% CO2; Characteristics 20–24 hours Abbreviations: ATCC®, American Type Culture Collection; MIC, minimal inhibitory concentration; QC; quality control.

NOTE 1: Information in boldface type is new or modified since the previous edition.

NOTE 2: For four-dilution ranges, results at the extremes of the acceptable ranges should be suspect. Verify validity with data from other QC strains.

©Clinical and Laboratory Standards Institute. All rights reserved. 157 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 178 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M07-A10—MIC Testing M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 179 M100S,M100S, 26th 26th ed. ed. For Use With M02-A12—DiskFor Use With Diffusion M11-A8

Table 5D. MIC: Quality Control Ranges for Anaerobes (Agar Dilution Method) Eggerthella lenta Bacteroides Bacteroides (formerly fragilis thetaiotaomicron Clostridium difficile Eubacterium lentum) Antimicrobial Agent ATCC® 25285 ATCC® 29741 ATCC® 700057 ATCC® 43055b Amoxicillin-clavulanate 0.25/0.125–1/0.5 0.5/0.25–2/1 0.25/0.125–1/0.5 – (2:1) Ampicillin 16–64 16–64 1–4 – Ampicillin-sulbactam (2:1) 0.5/0.25–2/1 0.5/0.25–2/1 0.5/0.25–4/2 0.25/0.125–2/1 Cadazolid – – 0.12–0.5 – M11

Table 5D Table Cefmetazole 8–32 32–128 – 4–16

Agar Dilution Agar Cefoperazone 32–128 32–128 – 32–128 Cefotaxime 8–32 16–64 – 64–256 Cefotetan 4–16 32–128 – 32–128 Anaerobe Quality Control Quality Control Anaerobe Cefoxitin 4–16 8–32 – 4–16 Ceftaroline 4–32 16–128 2–16 8–32 Ceftaroline-avibactam 0.12/4–0.5/4 4/4–16/4 0.5/4–4/4 4/4–16/4 Ceftizoxime – 4–16 – 16–64 Ceftolozane-tazobactam 0.12/4–1/4 16/4–128/4 – – Ceftriaxone 32–128 64–256 – – Chloramphenicol 2–8 4–16 – – Clinafloxacin 0.03–0.125 0.06–0.5 – 0.03–0.125 Clindamycin 0.5–2 2–8 2–8 0.06–0.25 Doripenem – – 0.5–4 – Eravacycline 0.06–0.25 0.12–1 0.06–0.25 – Ertapenem 0.06–0.25 0.25–1 – 0.5–2 Faropenem 0.03–0.25 0.12–1 – 1–4 Fidaxomicin – – 0.06–0.25 – Finafloxacin 0.12–0.5 1–4 1–4 0.12–0.5 Garenoxacin 0.06–0.5 0.25–1 0.5–2 1–4 Imipenem 0.03–0.125 0.125–0.5 – 0.125–0.5 Linezolid 2–8 2–8 1–4 0.5–2 Meropenem 0.03–0.25 0.125–0.5 0.5–4 0.125–1 Metronidazole 0.25–1 0.5–2 0.125–0.5 – Mezlocillin 16–64 8–32 – 8–32 Moxifloxacin 0.125–0.5 1–4 1–4 0.125–0.5 Nitazoxanide – – 0.06–0.5 – Omadacycline 0.25–2 0.5–4 0.25–2 0.25–2 Penicillin 8–32 8–32 1–4 – Piperacillin 2–8 8–32 4–16 8–32 Piperacillin-tazobactam 0.125/4–0.5/4 4/4–16/4 4/4–16/4 4/4–16/4 Ramoplanin – – 0.125–0.5 – Razupenem 0.015–0.12 0.06–0.25 0.06–0.25 0.06–0.5 Rifaximin – – 0.004–0.015 – Secnidazole 0.25–1 0.5–2 0.06–0.5 0.25–2 Sulopenem – 0.06–0.5 1–4 0.5–2 Surotomycina – – 0.12–1 2–8 Tetracycline 0.125–0.5 8–32 – – Ticarcillin 16–64 16–64 16–64 16–64 Ticarcillin-clavulanate – 0.5/2–2/2 16/2–64/2 16/2–64/2 Tigecycline 0.12–1 0.5–2 0.125–1 0.06–0.5 Tinidazole – – 0.125–0.5 – Tizoxanide – – 0.06–0.5 – Vancomycin – – 0.5–4 – Abbreviations: ATCC®, American Type Culture Collection; MIC, minimal inhibitory concentration.

NOTE: Information in boldface type is new or modified since the previous edition.

Footnotes

a. QC ranges reflect MICs obtained when media are supplemented with calcium to a final concentration of 50 g/mL.

b. MIC variability with some agents has been reported with Eggerthella lenta (formerly E. lentum) ATCC® 43055; therefore, QC ranges have not been established for all antimicrobial agents with this organism.

158 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 180 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M11-A8 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 181 M100S,For Use 26th With ed. M07-A10-MIC Testing ForM100S, Use With 26th M11-A8 ed.

Table 5E. MIC: Quality Control Ranges for Anaerobes (Broth Microdilution Method) Eggerthella lenta (formerly Bacteroides Bacteroides Clostridium Eubacterium fragilis thetaiotaomicron difficile lentum) Antimicrobial Agent ATCC® 25285 ATCC® 29741 ATCC® 700057 ATCC® 43055c Amoxicillin-clavulanate (2:1) 0.25/0.125–1/0.5 0.25/0.125–1/0.5 – – Ampicillin-sulbactam (2:1) 0.5/0.25–2/1 0.5/0.25–2/1 – 0.5/0.25–2/1 Cadazolid – – 0.06–0.25 – Cefotetan 1–8 16–128 – 16–64

M11 Cefoxitin 2–8 8–64 – 2–16

Table 5E Table Ceftaroline 2–16 8–64 0.5–4 – Ceftaroline-avibactam 0.06/4–0.5/4 2/4–8/4 0.25/4–1/4 4/4–16/4 Ceftizoxime – – – 8–32 Broth Microdilution Broth Ceftolozane-tazobactam 0.12/4–1/4 16/4–64/4 – – Anaerobe Quality Control Quality Control Anaerobe Chloramphenicol 4–16 8–32 – 4–16 Clindamycin 0.5–2 2–8 – 0.06–0.25 Doripenem 0.12–0.5 0.12–1 – – Doxycycline – 2–8 – 2–16 Eravacycline 0.015–0.12 0.06–0.25 0.015–0.06 – Ertapenem 0.06–0.5 0.5–2 – 0.5–4 Faropenem 0.015–0.06 0.12–1 – 0.5–2 Garenoxacin 0.06–0.25 0.25–2 – 0.5–2 Imipenem 0.03–0.25 0.25–1 – 0.25–2 Linezolid 2–8 2–8 – 0.5–2 Meropenem 0.03–0.25 0.06–0.5 – 0.125–1 Metronidazole 0.25–2 0.5–4 – 0.125–0.5 Moxifloxacin 0.12–0.5 1.0–8 – 0.12–0.5 Omadacyclinea 0.12–1 0.25–1 0.06–0.25 0.06–5 Penicillin 8–32 8–32 – – Piperacillin 4–16 8–64 – 8–32 Piperacillin-tazobactam 0.03/4–0.25/4 2/4–16/4 – 8/4–32/4 Razupenem 0.03–0.25 0.12–0.5 0.06–0.5 0.12–0.5 Sulopenem – 0.03–0.25 0.5–2 0.25–1 Surotomycinb – – 0.12–1 1–4 Ticarcillin-clavulanate 0.06/2–0.5/2 0.5/2–2/2 – 8/2–32/2 Tigecyclinea 0.06–0.5 0.25–1 0.03–0.12 – Abbreviations: ATCC®, American Type Culture Collection; MIC, minimal inhibitory concentration.

NOTE 1: Information in boldface type is new or modified since the previous edition.

NOTE 2: For four-dilution ranges, results at the extremes of the acceptable range(s) should be suspect. Verify validity with data from other QC strains.

Footnotes

a. For broth microdilution testing of tigecycline and omadacycline, when MIC panels are prepared, the medium must be prepared fresh on the day of use. The medium must be no greater than 12 hours old at the time the panels are made; however, the panels may then be frozen for later use.

b. QC ranges reflect MICs obtained when broth is supplemented with calcium to a final concentration of 50 g/mL.

c. MIC variability with some agents has been reported with Eggerthella lenta (formerly E. lentum) ATCC® 43055; therefore, QC ranges have not been established for all antimicrobial agents with this organism.

©Clinical and Laboratory Standards Institute. All rights reserved. 159 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 182 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M11-A8 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 183 M100S, 26th ed. For Use With M07-A10—MICM100S, 26th Testing ed.

Table 5F. MIC: Reference Guide to Quality Control Frequency

Conversion From Daily to Weekly QC

Routine QC is performed each day the test is performed unless an alternative plan has been established (see CLSI document EP231). When developing a strategy for QC, the requirements of accrediting organizations should be considered, as these may differ from the recommendations described in this document. M07-A10, Subchapter 4.7.2.1 describes a 20- or 30-day plan that, if successfully completed, allows a user to convert from daily to weekly QC. An alternative option using a two-phase, 15- M07

Table 5F Table replicate (3 × 5 day) plan is described as follows:

QC Testing Frequency QC Testing  Test 3 replicates using individual inoculum preparations of the appropriate QC strains for 5 consecutive test days.

 Evaluate each QC strain/antimicrobial agent combination separately using acceptance criteria and following recommended actions as described in the flow diagram below.

 Upon successful completion of either the 20- or 30-day plan or the 15-replicate (3 × 5 day) plan, the laboratory can convert from daily to weekly QC testing. If unsuccessful, investigate, take corrective action as appropriate, and continue daily QC testing until either the 20- or 30-day plan or 15-replicate (3 × 5 day) plan is successfully completed. At that time weekly QC testing can be initiated.

* 15-Replicate (3 × 5 Day) Plan: Acceptance Criteria and Recommended Action Number Out of Range With Initial Testing Conclusion From Initial Number Out of Range After (based on 15 Testing (based on 15 Repeat Testing (based on Conclusion After replicates) replicates) all 30 replicates) Repeat Testing Plan is successful. 0–1 Convert to weekly QC N/A N/A testing. Test another 3 replicates Plan is successful. 2–3 for 5 days. 2–3 Convert to weekly QC testing. Plan fails. Investigate and Plan fails. Investigate and ≥ 4 take corrective action as ≥ 4 take corrective action as appropriate. Continue QC appropriate. Continue QC each test day. each test day. * Assess each QC strain/antimicrobial agent combination separately. Abbreviations: N/A, not applicable; QC, quality control.

©Clinical and Laboratory Standards Institute. All rights reserved. 160 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 184 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M07-A10—MIC M07-A10-MIC Testing Testing M100S,M100S, 26th 26th ed. ed.

Table 5F. (Continued)

Test Modifications

This table summarizes the suggested QC frequency when modifications are made to antimicrobial susceptibility test systems. It applies only to antimicrobial agents for which satisfactory results have been obtained with either the 15-

replicate (3 × 5 day) plan or 20 or 30 consecutive test day plan. Otherwise QC is required each test day.

Required QC Frequency

15-Replicate M07 Plan or 5F Table 1 5 20- or 30-Day

Test Modification Day Days Plan Comments Frequency QC Testing MIC Tests(s) Use new shipment or lot number. X Expand dilution range. X Example: Convert from breakpoint to expanded range MIC panels. Reduce dilution range. X Example: Convert from expanded dilution range to breakpoint panels. Use new method (same X Examples: company). Convert from visual to instrument reading of panel.

Convert from overnight to rapid MIC test.

In addition, perform in-house verification studies. Use new manufacturer of MIC X In addition, perform in-house verification test. studies. Use new manufacturer of broth X or agar. Addition of new antimicrobial X In addition, perform in-house verification agent to existing system studies. Inoculum Preparation Convert inoculum preparation/ Example: standardization to use of a Convert from visual adjustment of turbidity X device that has its own QC to use of a photometric device for which a protocol. QC procedure is provided. Convert inoculum preparation/ Example: standardization to a method that Convert from visual adjustment of turbidity X is dependent on user technique. to another method that is not based on a photometric device. Instrument/Software Software update that affects AST Monitor all drugs, not just those implicated X results in software modification. Repair of instrument that affects Depending on extent of repair (eg, critical AST results X component such as the optics), additional testing may be appropriate (eg, 5 days). Abbreviations: AST, antimicrobial susceptibility testing; MIC, minimal inhibitory concentration; QC, quality control.

©Clinical and Laboratory Standards Institute. All rights reserved. 161 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 185 M100S, 26th 26th ed. ed. For Use With M07-A10—MIC Testing

Table 5F. (Continued)

NOTE 1: QC can be performed before or concurrent with testing patient isolates. Patient results can be reported for that day if QC results are within the acceptable limits.

NOTE 2: Manufacturers of commercial or in-house-prepared tests should follow their own internal procedures and applicable regulations.

NOTE 3: Acceptable MIC QC limits for US Food and Drug Administration–cleared antimicrobial susceptibility tests

M07 may differ slightly from acceptable CLSI QC limits. Users of each device should use the manufacturer’s Table 5F Table procedures and QC limits as indicated in the instructions for use.

QC Testing Frequency QC Testing NOTE 4: For troubleshooting out-of-range results, refer to M07-A10, Subchapter 4.8.1 and M100 Table 5G. Additional information is available in Appendix C, Quality Control Strains for Antimicrobial Susceptibility Tests (eg, organism characteristics, QC testing recommendations).

NOTE 5: Broth, saline, and/or water used to prepare an inoculum does not need routine QC.

Reference for Table 5F

1 CLSI. Laboratory Quality Control Based on Risk Management; Approved Guideline. CLSI document EP23-A™. Wayne, PA: Clinical and Laboratory Standards Institute; 2011.

162 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 186 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M07-A10—MIC Testing M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 187 M100S,For Use 26th With ed. M07-A10-MIC Testing For Use With M07-A10—MICM100S, 26th Testing ed.

Table 5G. MIC: Troubleshooting Guide

This table provides guidance for troubleshooting and corrective action for out-of-range QC primarily using antimicrobial susceptibility tests with CAMHB for broth microdilution. Refer to M07-A10 (MIC), Chapter 4, Quality Control and Quality Assurance. Out-of-range QC tests should first be repeated. If the issue is unresolved, this troubleshooting guide should be consulted regarding additional suggestions for troubleshooting out-of-range QC results and unusual clinical isolate results. In addition, if unresolved, manufacturers should be notified of potential product problems.

M07 General Comment Table 5G Table (1) QC organism maintenance: Avoid repeated subcultures. Retrieve new QC strain from stock. If using lyophilized strains, follow

QC Troubleshooting the maintenance recommendations of the manufacturer. Store E. coli ATCC® 35218 and K. pneumoniae ATCC® 700603 stock cultures at −60C or below and prepare working cultures weekly (refer to M07-A10, Subchapter 4.4).

Antimicrobial Agent QC Strain Observation Probable Cause Comments/Suggested Actions

Aminoglycosides Any MIC too high pH of media too low Acceptable pH range = 7.2–7.4 Avoid CO2 incubation, which lowers pH. Aminoglycosides Any MIC too low pH of media too high Acceptable pH range = 7.2–7.4 Aminoglycosides P. aeruginosa MIC too high Ca++ and/or Mg++ Acceptable range = Ca++ 20–25 mg/L ATCC® 27853 content too high Mg++ 10–12.5 mg/L Aminoglycosides P. aeruginosa MIC too low Ca++ and/or Mg++ Acceptable range = Ca++ 20–25 mg/L ATCC® 27853 content too low Mg++ 10–12.5 mg/L Amoxicillin- E. coli ATCC® MIC too high Clavulanate is labile. Use alternative lot. Check storage and clavulanate 35218 Antimicrobial agent is package integrity. degrading. -Lactam group Any MIC initially Antimicrobial agent is Use alternative lot. Check storage and acceptable, but degrading. package integrity. increases possibly Imipenem, cefaclor, and clavulanate are out of range over especially labile. time Aztreonam K. pneumoniae MIC too low Spontaneous loss of See general comment (1) on QC Cefotaxime ATCC® 700603 the plasmid encoding organism maintenance. Cefpodoxime the -lactamase. Ceftazidime Ceftriaxone Cefotaxime- K. pneumoniae Negative ESBL Spontaneous loss of See general comment (1) on QC clavulanate ATCC® 700603 test the plasmid encoding organism maintenance. Ceftazidime- the -lactamase. clavulanate Carbapenems P. aeruginosa MIC too high Zn++ concentration in Use alternative lot. ATCC® 27853 media is too high. Carbapenems P. aeruginosa MIC too high Antimicrobial agent is Use alternative lot. Check storage and ATCC® 27853 degrading. package integrity. Repeated imipenem results of 4 g/mL with P. aeruginosa ATCC® 27853 may indicate deterioration of the drug. Penicillin S. aureus MIC too high QC strain is a - Repeat with a carefully adjusted ATCC® 29213 lactamase producer; inoculum. overinoculation may yield increased MICs. Penicillins Any MIC too low pH of media too low Acceptable pH range = 7.2–7.4 Avoid CO2 incubation, which lowers pH. Penicillins Any MIC too high pH of media too high Acceptable pH range = 7.2–7.4 Carbenicillin P. aeruginosa MIC too high QC strain develops See general comment (1) on QC ATCC® 27853 resistance after organism maintenance. repeated subculture. Ticarcillin- E. coli MIC too high Clavulanate is labile. Use alternative lot. Check storage and clavulanate ATCC® 35218 Antimicrobial agent is package integrity. degrading. Clindamycin S. aureus MIC too high pH of media too low Acceptable pH range = 7.2–7.4 ® ATCC 29213 Avoid CO2 incubation, which lowers E. faecalis pH. ATCC® 29212

©Clinical and Laboratory Standards Institute. All rights reserved. 163 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 188 ©Clinical and Laboratory Standards Institute. All rights reserved. ForM100S, Use With 26th M07-A10—MIC ed. Testing M100S, 26th ed.

Table 5G. (Continued) Antimicrobial Agent QC Strain Observation Probable Cause Comments/Suggested Actions

Clindamycin S. aureus MIC too low pH of media too high Acceptable pH range = 7.2–7.4 ATCC® 29213 E. faecalis ATCC® 29212 Daptomycin S. aureus MICs too high Ca++ content too low Acceptable Ca++ content 50 µg/mL ATCC® 29213 in CAMHB E. faecalis MICs too low Ca++ content too high Adjust Ca++ concentration in or try

ATCC® 29212 alternative lots. M07 Table 5G Table Macrolides and S. aureus MIC too high pH of media too low Acceptable pH range = 7.2–7.4 ® Ketolides ATCC 29213 Avoid CO2 incubation, which E. faecalis lowers pH. QC Troubleshooting ATCC® 29212 Macrolides and S. aureus MIC too low pH of media too high Acceptable pH range = 7.2–7.4 Ketolides ATCC® 29213 E. faecalis ATCC® 29212 Quinolones Any MIC too high pH of media too low Acceptable pH range = 7.2–7.4 Avoid CO2 incubation, which lowers pH. Quinolones Any MIC too low pH of media too high Acceptable pH range = 7.2–7.4 Tetracyclines Any MIC too low pH of media too low Acceptable pH range = 7.2–7.4 Tetracyclines Any MIC too high pH of media too high Acceptable pH range = 7.2–7.4 Tetracyclines Any MIC too high Ca++ and/or Mg++ content Acceptable range = Ca++ 20–25 too high mg/L Mg++ 10–12.5 mg/L Tetracyclines Any MIC too low Ca++ and/or Mg++ content Acceptable range = Ca++ 20–25 too low mg/L Mg++ 10–12.5 mg/L Omadacycline Any MIC too high CAMHB has not been Reference panels must be used or Tigecycline freshly prepared. frozen within 12 hours of CAMHB preparation. Various Any Many MICs too Inoculum too light; error in Repeat using McFarland 0.5 low inoculum preparation turbidity standard or standardizing device. Check expiration date and proper storage if using barium sulfate or latex standards. Check steps in inoculum preparation and inoculation procedure. Perform colony count check of growth control well immediately after inoculation and before incubation (E. coli ATCC® 25922 closely 5 approximates 5  10 CFU/mL, see M07-A10, Subchapter 3.10). Various Any Many MICs too CAMHB not optimal Use alternative lot. high or too low Various Any Many MICs too Inoculum too heavy Repeat using McFarland 0.5 high turbidity standard or standardizing device. Check expiration date and proper storage if using barium sulfate or latex standards. Check steps in inoculum preparation and inoculation procedure. Perform colony count check of growth control well immediately after inoculation and before incubation (E. coli ATCC® 25922 closely 5 approximates 5  10 CFU/mL, see M07-A10, Subchapter 3.10). Various Any Skipped wells Contamination. Repeat QC test. Improper inoculation of Use alternative lot. panel or inadequate mixing of inoculum. Actual concentration of drug in wells inaccurate. Volume of broth in wells inaccurate.

164 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 189 M100S,For Use 26th With ed. M07-A10-MIC Testing For Use With M07-A10—MICM100S, 26th Testing ed.

Table 5G. (Continued) Antimicrobial Agent QC Strain Observation Probable Cause Comments/Suggested Actions Various Any Several MICs too Possible Recheck readings. high or too low reading/transcription error Use alternative lot. Various Any One QC strain is One QC organism may be Determine if the in-range QC strain out of range, but a better indicator of a QC has an on-scale end point for the other QC strains problem (eg, P. aeruginosa agent in question. Retest this strain are in range with ATCC® 27853 is a better to confirm reproducibility of the same indicator of imipenem acceptable results.

M07 antimicrobial deterioration than E. coli Evaluate with alternative strains Table 5G Table agent. ATCC® 25922). with known MICs. Initiate corrective action with

QC Troubleshooting problem QC strain/antimicrobial agent(s). Various Any Two QC strains Indicates a problem with Initiate corrective action. are out of range the antimicrobial agent. with the same May be a systemic antimicrobial problem. agent. Various Any One QC result is If antimicrobial agent is not out of range, but normally reported, no repeat is the antimicrobial necessary if adequate controls are agent is not an in place to prevent reporting of the agent reported for out-of-range antimicrobial agent. patient results (eg, Carefully check antimicrobial not on hospital agents of the same class for similar formulary). trend toward out-of-control results. If the antimicrobial agent in question is consistently out of control, contact the manufacturer. Abbreviations: ATCC®, American Type Culture Collection; CAMHB, cation-adjusted Mueller-Hinton broth; CFU, colony-forming unit(s); ESBL, extended-spectrum -lactamase; LHB, lysed horse blood; MHB, Mueller-Hinton broth; MIC, minimal inhibitory concentration; QC, quality control.

©Clinical and Laboratory Standards Institute. All rights reserved. 165 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 190 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M07-A10—MIC Testing M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 191 M100S,M100S, 26th 26th ed. ed. For Use With M07-A10—MIC Testing

Table 6A. Solvents and Diluents for Preparation of Stock Solutions of Antimicrobial Agentse Antimicrobial Agent Solvent Diluent Unless otherwise stated, use a minimum amount of the listed solvent to solubilize the antimicrobial Finish diluting the final stock powder. solution as stated below. Amikacin Water Water Amoxicillin Phosphate buffer, pH 6.0, 0.1 mol/L Phosphate buffer, pH 6.0, 0.1 mol/L Ampicillin Phosphate buffer, pH 8.0, 0.1 mol/L Phosphate buffer, pH 6.0, 0.1 mol/L Avibactam Water Water M07

Table 6A Table Azithromycin 95% ethanol or glacial acetic acide,f Broth media Azlocillin Water Water

Solvents and Diluents Solvents Aztreonam Saturated solution sodium bicarbonate Water Besifloxacin Methanol Water Biapenem Salinem Salinem Cadazolid DMSOe Water or broth Carbenicillin Water Water Cefaclor Water Water Cefadroxil Phosphate buffer, pH 6.0, 0.1 mol/L Water Cefamandole Water Water Cefazolin Phosphate buffer, pH 6.0, 0.1 mol/L Phosphate buffer, pH 6.0, 0.1 mol/L Cefdinir Phosphate buffer, pH 6.0, 0.1 mol/L Water Cefditoren Phosphate buffer, pH 6.0, 0.1 mol/L Water Cefepime Phosphate buffer, pH 6.0, 0.1 mol/L Phosphate buffer, pH 6.0, 0.1 mol/L Cefetamet Phosphate buffer, pH 6.0, 0.1 mol/L Water Cefixime Phosphate buffer, pH 7.0, 0.1 mol/L Phosphate buffer, pH 7.0, 0.1 mol/L Cefmetazole Water Water Cefonicid Water Water Cefoperazone Water Water Cefotaxime Water Water Cefotetan DMSOe Water Cefoxitin Water Water Cefpodoxime 0.10% (11.9 mmol/L) aqueous sodium bicarbonate Water Cefprozil Water Water Ceftaroline DMSOe to 30% of total volume Salinem Ceftazidime Sodium carbonated Water Ceftibuten 1/10 volume of DMSOe Water Ceftizoxime Water Water Ceftobiprole DMSO plus glacial acetic acide,h Water, vortex vigorously Ceftolozane Water or salinem Water or salinem Ceftriaxone Water Water Cefuroxime Phosphate buffer, pH 6.0, 0.1 mol/L Phosphate buffer, pH 6.0, 0.1 mol/L Cephalexin Phosphate buffer, pH 6.0, 0.1 mol/L Water Cephalothin Phosphate buffer, pH 6.0, 0.1 mol/L Water Cephapirin Phosphate buffer, pH 6.0, 0.1 mol/L Water Cephradine Phosphate buffer, pH 6.0, 0.1 mol/L Water Chloramphenicol 95% ethanol Water Cinoxacin 1/2 volume of water, then add 1 mol/L NaOH dropwise Water to dissolve Ciprofloxacin Water Water Clarithromycin Methanole or glacial acetic acide,f Phosphate buffer, pH 6.5, 0.1 mol/L Clavulanate Phosphate buffer, pH 6.0, 0.1 mol/L Phosphate buffer, pH 6.0, 0.1 mol/L Clinafloxacin Water Water Clindamycin Water Water Colistina Water Water Dalbavancin DMSOe DMSOe,g

166 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 192 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M07-A10—MIC M07-A10-MIC Testing Testing M100S,M100S, 26th 26th ed. ed.

Table 6A. (Continued) Antimicrobial Agent Solvent Diluent Unless otherwise stated, use a minimum amount of the listed solvent to solubilize the antimicrobial Finish diluting the final stock powder. solution as stated below. Daptomycin Water Water Delafloxacin 1/2 volume of water, then 0.1 mol/L NaOH dropwise to Water dissolve Dirithromycin Glacial acetic acidf Water M07 m m Doripenem Saline Saline 6A Table Doxycycline Water Water

Enoxacin 1/2 volume of water, then 0.1 mol/L NaOH dropwise Water and Diluents Solvents to dissolve Eravacycline Water Water Ertapenem Phosphate buffer, pH 7.2, 0.01 mol/L Phosphate buffer, pH 7.2, 0.01 mol/L Erythromycin 95% ethanol or glacial acetic acide,f Water Faropenem Water Water Fidaxomicin DMSOe Water Finafloxacin Water Water Fleroxacin 1/2 volume of water, then 0.1 mol/L NaOH dropwise Water to dissolve Fosfomycin Water Water Fusidic acid Water Water Garenoxacin Water (with stirring) Water Gatifloxacin Water (with stirring) Water Gemifloxacin Water Water Gentamicin Water Water Gepotidacin DMSOe Water Iclaprim DMSOe Water Imipenem Phosphate buffer, pH 7.2, 0.01 mol/L Phosphate buffer, pH 7.2, 0.01 mol/L Kanamycin Water Water Lefamulin Water Water Levofloxacin 1/2 volume of water, then 0.1 mol/L NaOH dropwise Water to dissolve Levonadifloxacin 27.5 g/mL solution of L-arginine in water Water Linezolid Water Water Linopristin-flopristin DMFk Water Lomefloxacin Water Water Loracarbef Water Water Mecillinam Water Water Meropenem Water Water Methicillin Water Water Metronidazole DMSOe Water Mezlocillin Water Water Minocycline Water Water Moxalactam 0.04 mol/L HCI (let sit for 1.5 to 2 hours) Phosphate buffer, pH 6.0, 0.1 mol/L (diammonium salt)b Moxifloxacin Water Water Mupirocin Water Water Nafcillin Water Water Nalidixic acid 1/2 volume of water, then add 1 mol/L NaOH dropwise to dissolve Netilmicin Water Water Nitazoxanide DMSOe,l DMSOe,l Nitrofurantoinc Phosphate buffer, pH 8.0, 0.1 mol/L Phosphate buffer, pH 8.0, 0.1 mol/L

©Clinical and Laboratory Standards Institute. All rights reserved. 167 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 193 M100S,M100S, 26th 26th ed. ed. For Use With M07-A10—MIC Testing

Table 6A. (Continued) Antimicrobial Agent Solvent Diluent Unless otherwise stated, use a minimum amount of the Finish diluting the final stock listed solvent to solubilize the antimicrobial powder. solution as stated below. Norfloxacin 1/2 volume of water, then 0.1 mol/L NaOH dropwise Water to dissolve Ofloxacin 1/2 volume of water, then 0.1 mol/L NaOH dropwise Water to dissolve Omadacycline Water Water

M07 Oritavancin 0.002% polysorbate-80 in wateri 0.002% polysorbate-80 in wateri Table 6A Table Oxacillin Water Water Penicillin Water Water Solvents and Diluents Solvents Piperacillin Water Water Plazomicin Water Water Polymyxin B Water Water Quinupristin-dalfopristin Water Water Ramoplanin Water Water Razupenem Phosphate buffer, pH 7.2, 0.01 mol/L Phosphate buffer, pH 7.2, 0.01 mol/L Rifampin Methanole (maximum concentration = 640 g/mL) Water (with stirring) Rifaximin Methanole 0.1 M phosphate buffer, pH 7.4 + 0.45% sodium dodecyl sulfonate Secnidazole DMSOe Water Solithromycin Glacial acetic acidf Water Sparfloxacin Water Water Spectinomycin Water Water Streptomycin Water Water Sulbactam Water Water Sulfonamides 1/2 volume hot water and minimal amount of 2.5 mol/L Water NaOH to dissolve Sulopenemj 0.01 M phosphate buffer, pH 7.2, vortex to dissolve 0.01 M phosphate buffer, pH 7.2 Surotomycin Water Water Tazobactam Water Water Tedizolid DMSOe DMSOe,n Teicoplanin Water Water Telavancin DMSOe DMSOe,g Telithromycin Glacial acetic acide,f Water Tetracycline Water Water Ticarcillin Phosphate buffer, pH 6.0, 0.1 mol/L Phosphate buffer, pH 6.0, 0.1 mol/L Ticarcillin-clavulanate Phosphate buffer, pH 6.0, 0.1 mol/L Phosphate buffer, pH 6.0, 0.1 mol/L Tigecycline Water Water Tinidazole DMSOe,l Water Tizoxanide DMSOe,l DMSOe,l Tobramycin Water Water Trimethoprim 0.05 mol/L lactice or hydrochlorice acid, 10% of final Water (may need heat) volume Trimethoprim (if lactate) Water Water Trospectomycin Water Water Ulifloxacin DMSOe Water (prulifloxacin) Vancomycin Water Water Abbreviations: DMF, dimethylformamide; DMSO, dimethyl sulfoxide.

NOTE: Information in boldface type is new or modified since the previous edition.

168 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 194 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M07-A10—MIC M07-A10-MIC Testing Testing M100S,M100S, 26th 26th ed. ed.

Table 6A. (Continued)

Footnotes

a. The formulation of colistin reference standard powder used in antimicrobial susceptibility tests is colistin sulfate and not colistin methane sulfonate (sulfomethate).

b. The diammonium salt of moxalactam is very stable, but it is almost pure R isomer. Moxalactam for clinical use is a 1:1 mixture of R and S isomers. Therefore, the salt is dissolved in 0.04 mol/L HCl and allowed to react for 1.5

to 2 hours to convert it to equal parts of both isomers. M07

6A Table c. Alternatively, nitrofurantoin is dissolved in DMSO.

Solvents and Diluents Solvents d. Anhydrous sodium carbonate is used at a weight of exactly 10% of the ceftazidime to be used. The sodium carbonate is dissolved in solution in most of the necessary water. The antimicrobial agent is dissolved in this sodium carbonate solution, and water is added to the desired volume. The solution is to be used as soon as possible, but it can be stored up to six hours at no more than 25°C.

e. Consult the safety data sheets before working with any antimicrobial reference standard powder, solvent, or diluent. Some of the compounds (eg, solvents such as DMSO, methanol) are more toxic than others and may necessitate handling in a chemical fume hood.

f. For glacial acetic acid, use 1/2 volume of water, then add glacial acetic acid dropwise until dissolved, not to exceed 2.5 µL/mL.

g. Starting stock solutions of dalbavancin and telavancin should be prepared at concentrations no higher than 1600 µg/mL. Intermediate 100× concentrations should then be diluted in DMSO. Final 1:100 dilutions should then be made directly into cation-adjusted Mueller-Hinton broth (CAMHB) supplemented with 0.002% (v/v) polysorbate- 80, so the final concentration of DMSO in the wells is no greater than 1%. See also Table 8B.

h. For each 1.5 mg of ceftobiprole, add 110 L of a 10:1 mixture of DMSO and glacial acetic acid. Vortex vigorously for one minute, then intermittently for 15 minutes. Dilute to 1.0 mL with distilled water.

i. Starting stock solutions of oritavancin should be prepared at concentrations no higher than 1600 g/mL in 0.002% polysorbate-80 in water. Intermediate 100× oritavancin concentrations should then be prepared in 0.002% polysorbate-80 in water. Final 1:100 dilutions should be made directly into CAMHB supplemented with 0.002% polysorbate-80, so the final concentration of polysorbate-80 in the wells is 0.002%.

j. Must be made fresh on the day of use.

k. DMF to 25% of final volume/water.

l. Final concentration of DMSO should not exceed 1%. This may be accomplished as follows: 1) prepare the stock solution at 10 times higher concentration than planned stock solution (ie, prepare at 12 800 g/mL, rather than 1280 µg/mL); 2) add 1.8 mL sterile water to each agar deep; 3) add 0.2 mL of each antibiotic dilution to each agar deep.

m. Saline – a solution of 0.85% to 0.9% NaCl (w/v).

n. Starting stock solutions of tedizolid should be prepared at concentrations no higher than 1600 g/mL. Intermediate 100× concentrations should be diluted in DMSO. Final 1:100 dilutions should be made directly into CAMHB, so that the final concentration of DMSO in the wells is no greater than 1%. See also Table 8B.

©Clinical and Laboratory Standards Institute. All rights reserved. 169 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 195 M100S, 26th 26th ed. ed. For Use With M07-A10—MIC Testing

Table 6B. Preparation of Stock Solutions for Antimicrobial Agents Provided With Activity Expressed as Units

Antimicrobial Pure Agent Agent (Reference) Calculation for µg/mg Example Potassium 0.625 Multiply the activity expressed Activity units/mg × 0.625 µg/unit = Activity µg/mg Penicillin G µg/unit1 in units/mg by 0.625 µg/unit. (eg, 1592 units/mg × 0.625 µg/unit = 995 µg/mg) 1 Sodium 0.6 µg/unit Multiply the activity expressed Activity units/mg × 0.6 µg/unit = Activity µg/mg

M07 Penicillin G in units/mg by 0.6 µg/unit. Table 6B Table (eg, 1477 units/mg × 0.6 µg/unit = 886.2 µg/mg)

Stock Solutions Stock Polymyxin B 10 000 Multiply the activity expressed Activity units/mg × 0.1 µg/unit = Activity µg/mg units/mg = in units/mg by 0.1 µg/unit. (eg, 8120 units/mg × 0.1 µg/unit = 812 µg/mg) 10 units/µg = Divide the activity expressed in Activity units/mg / 10 units/µg = Activity µg/mg 0.1 µg/unit2 units/mg by 10 units/µg. (eg, 8120 units/mg / 10 units/mg = 812 µg/mg)

Colistin 30 000 Multiply the activity expressed Activity units/mg × 0.03333 µg/unit = Activity a sulfate units/mg = in units/mg by 0.03333 µg/unit. µg/mg

30 units/µg = (eg, 20 277 units/mg × 0.03333 µg/unit = 676 µg/mg) 0.03333 Divide the activity expressed in Activity units/mg / 30 units/µg = Activity µg/mg µg/unit2 units/mg by 30 units/mg. (eg, 20 277 units/mg / 30 units/µg = 676 µg/mg)

Streptomycin 785 Divide the number of units ([Potency units/mg] / [785 units/mg]) × (850 µg/mg) 3 units/mg given for the powder by 785. = Potency µg/mg This gives the percent purity of the powder. Multiply the (eg, [751 units/mg / 785 units/mg] × 850 µg/mg = percent purity by 850, which is 813 µg/mg) the amount in the purest form of streptomycin. This result If powder contains 2.8% water: equals the activity factor in µg/mg. 813 × (1 – 0.028) = potency

813 × 0.972 = 790 µg/mg

Footnote

a. Do not use colistin methanesulfonate for in vitro antimicrobial susceptibility tests.

References for Table 6B

1 Grayson ML, Crowe SM, McCarthy JS, et al. Benzylpenicillin (penicillin G). In: Kucers’ The Use of Antibiotics. 6th ed. Boca Raton, FL: Taylor & Francis Group; 2010:5-58.

2 Kucers A, Crowe SM, Grayson ML, Hoy JF. Polymyxins. In: The Use of Antibiotics. 5th ed. Oxford, UK: Butterworth-Heinemann; 1997:667-675.

3 United States Department of Agriculture, Food Safety and Inspection Service, Office of Public Health Science, Laboratory QA/QC Division. Bioassay for the detection, identification and quantitation of antimicrobial residues in meat and poultry tissue. Microbiology Laboratory Guidebook (MLG) 34.03; 2011.

170 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 196 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M07-A10—MIC Testing M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 197 M100S,M100S, 26th 26th ed. For Use With M07-A10—MIC Testing 10 mL of

=

5 mL of 80

+

M07 Table 6C Table 4 in the panel, prepare a 10× Solutions and Media th broth to achieve the final 128/64 in the panel, prepare a a stock concentration of Example 10 mL of 1280/40 µg/mL aztreonam-

=

5 mL of 160 µg/mL tazobactam

+

µg/mL avibactam avibactam. Dilute 1:10 brothwith to achieve the final concentration in microdilution wells. withDilute1:10 broth 1280/80µg/mL cefepime-tazobactam. to the achieve final concentration in the microdilution wells. For a starting concentration of 128/8 in the panel, prepare a 10× stock concentration of cefepime at 2560 µg/mL and serial by twofolddilute increments downfinal theto Preparestocka concentration neededthein panel. Thenanadd concentrationof tazobactam 160at µg/mL. equal ofvolume the tazobactam 160 µg/mL solutioneach to For example,mL of 5 2560 µg/mL diluted tube of cefepime. cefepime For a starting concentration of 10× stock concentration of 2560 µg/mL for amoxicillin and 1280 clavulanate.for µg/mL Then combine equal amounts eachof to the first dilution tube, which then containwill 1280/640 µg/mL of the combination. Dilute 1:10 wi For a starting concentration of 128/ stock concentration of aztreonam at 2560 µg/mL and dilute by serial twofold increments down to the final concentration needed in the panel. Prepare avibactam at 80 µg/mL. Then add an equal volume of the avibactam 80 µg/mL solution to each diluted tube of aztreonam. For example, 5 mL of 2560 µg/mL aztreonam concentration in microdilution wells. Preparation g/mL of glucose-6-  Prepare 10× starting concentration of cefepime at twice the concentration needed serial using usual as dilute and equal an Add dilutions. twofold ofvolume tazobactam 160 µg/mL to each of the diluted tubes. Prepare 10× starting concentration as 5:2 ratio and dilute as needed. NOTE: Media with supplemented be should 25 phosphate. Prepare 10× starting concentration as 2:1 ratio and dilute as needed. Prepare 10× starting concentration of aztreonam at twice the concentration needed and dilute as usual using serial twofold dilutions. Add an equal volume of avibactam 80 µg/mL to each of the diluted tubes. Same as aztreonam-avibactam. Same as aztreonam-avibactam. Same as aztreonam-avibactam. g/mL g/mL 

Combination Tested 5:2 ratio (amikacin:fosfomycin) 2:1 ratio (amoxicillin:clavulanate) at 4 µg/mL of concentration Fixed tazobactam at 8 at 4 µg/mL at 4 µg/mL Fixed concentration of tazobactam at 4 μ 2:1 ratio (ampicillin:sulbactam) Same as amoxicillin-clavulanate. Fixed concentration of avibactam Fixed concentration of avibactam Fixed concentration of avibactam Agent Antimicrobial fosfomycin clavulanate sulbactam avibactam tazobactam avibactam avibactam Amikacin- Amoxicillin- Ampicillin- Aztreonam- Cefepime- Ceftaroline- Ceftazidime- Ceftolozane- tazobactam Agents Antimicrobial of Combinations Media Containing and Solutions of Table 6C. Preparation

198 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 198 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With With M07-A10—MIC Testing Testing M100S,M100S, 26th 26th ed. ed. is the 2 10 mL of

=

M07 Table 6C Table e. Dilute 1:10 broth to with 2 in the panel, prepare a 10× Solutions and Media ration of clavulanate at 40 th broth to achieve the final ethoxazole at 3040 µg/mL. Add im at 160 µg/mL. Prepare a 10× mL trimethoprim and the 3040 8/152 in the panel, prepare a is the concentration of stock solution Example 1 5 mL of 40 µg/mL clavulanate

+

10 mL of 80/1520 trimethoprim-

=

, C where 2 V



2 C

=

1 V



concentration in microdilution wells. sulfamethoxazole. Dilute 1:10 wi 1280/20 µg/mL ticarcillin-clavulanat achieve the final concentration in microdilution wells. For a starting concentration of 128/ stock concentration of ticarcillin at 2560 µg/mL and dilute by serial twofold increments down to the final concentration needed. Prepare a stock concent µg/mL. Then add an equal volume of the clavulanate 40 µg/mL solution to each diluted tube of ticarcillin. For example, 5 mL of 2560 µg/mL ticarcillin For a starting concentration of 10× concentration of trimethopr µg/mL sulfamethoxazole to the first dilution tube, and then dilute serial by twofold dilutions as usual. For example, 5 mL of 160 µg/mL trimethoprim and 5 mL of 3040 µg/mL sulfamethoxazole starting concentration of sulfam an equal volume of the 160 µg/ 1 Preparation multiple of 1520 µg/mL 2 is the unknown volume is the unknown be needed that will to make the intermediate concentration; C 1 Same as aztreonam-avibactam. Same as aztreonam-avibactam. Prepare 10× starting concentration of ticarcillin at twice the concentration needed and dilute as usual using serial twofold dilutions. Add an equal volume of clavulanate 40 µg/mL to each of the diluted tubes. Prepare a 10× starting concentration of trimethoprim at 1600 µg/mL (or at 1280 µg/mL need dilution to 160 that will µg/mL). Prepare a 10× starting concentration of sulfamethoxazole at a log (eg, 1520, 3040, or 6080 µg/mL) depending on the starting concentration needed. al agents, a convenient formula to use is C is the volume of the intermediate stock solution needed. 2 ually 1280 µg/mL or greater); V Combination Tested

Fixed concentration of of concentration Fixed relebactam at 4 µg/mL Fixed concentration of tazobactam at 4 µg/mL Fixed concentration of clavulanate at 2 µg/mL Preparation usually not necessary, because drug powder is received as combination. 1:19 ratio (trimethoprim:sulfamethoxazole) Agent To prepare intermediate dilutions of antimicrobi

Antimicrobial relebactam tazobactam clavulanate sulfamethoxazole Trimethoprim- Imipenem- Piperacillin- Ticarcillin- Quinupristin- dalfopristin Linopristin- flopristin (Continued) 6C. Table NOTE: of the antimicrobial agent (us intermediate concentration needed; and V

©Clinical and Laboratory Standards Institute. All rights reserved. 199 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 199 M100S,M100S, 26th 26th ed. ed. For Use With M07-A10—MIC Testing M07 Table 6C Table Solutions and Media (usually for a final volume of 20 mL of awater) 40 µg/mL solution. mL solution from a 1280 µg/mL stock solution: 20 mL



40 µg/mL

=

20 mL

2 1  V

V





2 C

=

1 V 40 µg/mL 0.625 mL

 = =

1 1 1 C 1280 µg/mL V 1280 µg/mL V

(Continued) 6C. Table For example: To prepare 20 mL of a 40 µg/ Therefore, add 0.625 mL of the µg/mL 1280 stock solution to 19.375 mL of diluent

200 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 200 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M07-A10—MIC Testing M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 201 M100S, 26th 26th ed. ed. For Use With M07-A10—MIC Testing

Table 7A. Scheme for Preparing Dilutions of Antimicrobial Agents to Be Used in Agar Dilution Susceptibility Tests

Antimicrobial Solution

Final Intermediate Concentration Concentration Volume Diluent Concentration at 1:10 Dilution in Step (g/mL) Source (mL) (mL) (g/mL) Agar (g/mL) Log2 M07 5120 Stock – – 5120 512 9 Table 7A Table 1 5120 Stock 2 2 2560 256 8 2 5120 Stock 1 3 1280 128 7 for Agar Dilution Tests Dilution Agar for 3 5120 Stock 1 7 640 64 6 4 640 Step 3 2 2 320 32 5 5 640 Step 3 1 3 160 16 4 Dilution Scheme for Antimicrobial Agents Antimicrobial Dilution Scheme for 6 640 Step 3 1 7 80 8 3 7 80 Step 6 2 2 40 4 2 8 80 Step 6 1 3 20 2 1 9 80 Step 6 1 7 10 1 0 10 10 Step 9 2 2 5 0.5 −1 11 10 Step 9 1 3 2.5 0.25 −2 12 10 Step 9 1 7 1.25 0.125 −3

NOTE: This table is modified from Ericsson HM, Sherris JC. Antibiotic sensitivity testing: report of an international collaborative study. Acta Pathol Microbiol Scand B Microbiol Immunol. 1971;217(suppl):1+.

174 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 202 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M07-A10—MIC Testing M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 203 M100S,For Use 26th With ed. M07-A10—MIC Testing For Use With M07-A10—MICM100S, 26th Testing ed.

Table 8A. Scheme for Preparing Dilutions of Antimicrobial Agents to Be Used in Broth Dilution Susceptibility Tests

Antimicrobial Solution

CAMHBb Final Concentration Volumea Volumea Concentration Step (g/mL) Source (mL) + (mL) = (g/mL) Log2

M07 1 5120 Stock 1 9 512 9 Table 8A Table 2 512 Step 1 1 1 256 8 3 512 Step 1 1 3 128 7 for Broth Dilution Tests Dilution Broth for 4 512 Step 1 1 7 64 6 5 64 Step 4 1 1 32 5 6 64 Step 4 1 3 16 4 Dilution Scheme for Antimicrobial Agents Agents Antimicrobial Dilution Scheme for 7 64 Step 4 1 7 8 3 8 8 Step 7 1 1 4 2 9 8 Step 7 1 3 2 1 10 8 Step 7 1 7 1 0 11 1 Step 10 1 1 0.5 −1 12 1 Step 10 1 3 0.25 −2 13 1 Step 10 1 7 0.125 −3 Abbreviation: CAMHB, cation-adjusted Mueller-Hinton broth.

NOTE: This table is modified from Ericsson HM, Sherris JC. Antibiotic sensitivity testing: report of an international collaborative study. Acta Pathol Microbiol Scand B Microbiol Immunol. 1971;217(suppl):1:+.

Footnotes

a. The volumes selected can be any multiple of these figures, depending on the number of tests to be performed.

b. Adjustment with cations, if necessary, occurs before this step.

Clinical and Laboratory Standards Institute. All rights reserved. 175 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 204 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M07-A10—MIC Testing M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 205 M100S,M100S, 26th 26th ed. ed. For Use With M07-A10—MIC Testing

Table 8B. Scheme for Preparing Dilutions of Water-Insoluble Antimicrobial Agents to Be Used in Broth Dilution Susceptibility Tests

Antimicrobial Solution

Solvent Final (mL) Intermediate Concentration Concentration Volume (eg, Concentration at 1:100 Step (µg/mL) Source (mL) + DMSO) = (g/mL) = (g/mL) Log2 M07

Table 8B Table 1 1600 Stock 1600 16 4 2 1600 Stock 0.5 0.5 800 8.0 3 3 1600 Stock 0.5 1.5 400 4.0 2 4 1600 Stock 0.5 3.5 200 2.0 1

Agents for Broth Dilution Tests Dilution Broth for Agents 5 200 Step 4 0.5 0.5 100 1.0 0 6 200 Step 4 0.5 1.5 50 0.5 −1 7 200 Step 4 0.5 3.5 25 0.25 −2 8 25 Step 7 0.5 0.5 12.5 0.125 −3 Dilution Scheme for Water-Insoluble Antimicrobial Antimicrobial Water-Insoluble Dilution Scheme for 9 25 Step 7 0.5 1.5 6.25 0.0625 −4 10 25 Step 7 0.5 3.5 3.1 0.03 −5 11 3.1 Step 10 0.5 0.5 1.6 0.016 −6 12 3.1 Step 10 0.5 1.5 0.8 0.008 −7 13 3.1 Step 10 0.5 3.5 0.4 0.004 −8 14 0.4 Step 13 0.5 0.5 0.2 0.002 −9 Abbreviation: DMSO, dimethyl sulfoxide.

176 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 206 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M07-A10—MIC Testing M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 207 M100S,M100S, 26th ed.ed. For Use With M02-A12 and M07-A10

a

x x x concern Category III Category epidemiological epidemiological susceptibility if uncommon in the institution. control in facility to determine if special reporting procedures or additional action are needed. Confirm ID and   Check infection with May be common, be May is but generally considered of considered generally Appendix A

a and Organism Identification and Organism

Suggested Test Result Confirmation Confirmation Result Test Suggested Antimicrobial Susceptibility Test Susceptibility Antimicrobial

a x x x x y II Categor y institutions Action Steps:Action Uncommon in most control in the facility to determine if special reporting procedures or additional action are needed. health department to determinewhich isolates should be reported to them and when isolates should be sent to the public health laboratory. susceptibility if uncommon in the institution. Confirm ID and  Check infection with  Check localwith public  Confirmation of Confirmation Results

(NS) Nonsusceptible

a

x

Category I Category

May be May Not reported or only or only Not reported control. laboratory. susceptibility. Occurrence and Significance of Resistance and to Take FollowingActions Confirm ID and rarely reported to date to reported rarely  Report to infection  Send to public health  Save isolate. NOTE: appropriate to notify infection control of preliminary findings before confirmation of results. 

a – I or R c

b Resistance Phenotype Detected Carbapenem – I or R Amikacin, gentamicin, and tobramycin – R Cephalosporin I or R III – Fluoroquinolone – I or R Carbapenem – I or R Colistin/polymyxin – I or R Amikacin, gentamicin, and tobramycin – R Carbapenem – I or R Extended-spectrumcephalosporin Colistin/polymyxin – R

d and and spp .

spp. Organism or or Organism Organism Group Group Organism Enterobacteriaceae Shigella baumannii aeruginosa Any Any Escherichia coli Klebsiella Proteus mirabilis Salmonella Acinetobacter Pseudomonas Results and Organism Identification Organism Identification and Results or (I), Intermediate (R), Resistant of Confirmation for Suggestions A. Appendix

207 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 208 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use With With M02-A12 M02-A12 and M07-A10 and M07-A10 M100S,M100S, 26th 26th e d.ed.

x concern Category III Category epidemiological epidemiological Appendix A May be common, but is is but common, be May generally considered of considered generally

a and Organism Identification and Organism

Suggested Test Result Confirmation Confirmation Result Test Suggested

x x x Category II Category institutions Uncommon in most Confirmation of Confirmation Results

x x x x x x Category I Category Not reported or only or only Not reported Occurrence and Significance of Resistance and to Take FollowingActions rarely reported to date to reported rarely

a

– NS – NS – NS c c c -lactamase negative -lactamase negative β NS – Resistance Phenotype Detected Telavancin – NS Telavancin Extended-spectrum cephalosporin Carbapenem – NS Ceftaroline – NS Extended-spectrum cephalosporin Fluoroquinolone – NS – R Amoxicillin-clavulanate Ampicillin – R and Fluoroquinolone – I or R Ampicillin or penicillin – R Extended-spectrum cephalosporin Meropenem – NS Ampicillin or penicillin – I Azithromycin – NS Chloramphenicol – I or R Fluoroquinolone – I or R Minocycline – NS Rifampin – I or R Daptomycin – NS Linezolid – R NS – Tedizolid High-level aminoglycoside – R Vancomycin – R Trimethoprim-sulfamethoxazole – I or R Oritavancin Oritavancin

spp.

Group Organism or Organism Organism or Organism Stenotrophomonas maltophilia Haemophilus influenzae Neisseria gonorrhoeae Neisseria meningitidis Enterococcus A. (Continued) Appendix

©Clinical and Laboratory Standards Institute. All rights reserved. 208 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 209 M100S,M100S, 26th26th ed. ed. For Use With M02-A12 and M07-A10

x x concern Category III Category epidemiological epidemiological Appendix A May be common, but is is but common, be May generally considered of considered generally

a and Organism Identification and Organism Suggested Test Result Confirmation Confirmation Result Test Suggested

e

x x x x Category II Category institutions Uncommon in most Confirmation of Confirmation Results

x x x x Category I Category Not reported or only or only Not reported Occurrence and Significance of Resistance and to Take FollowingActions rarely reported to date to reported rarely

a – R – NS c c

e

f 4 µg/mL 8 µg/mL

≥ =

NS

– Resistance Phenotype Detected Linezolid – NS Oritavancin – NS NS – Tedizolid – NS Telavancin Vancomycin – NS Daptomycin – NS Linezolid – R Quinupristin-dalfopristin – I or R Vancomycin – I or R Oritavancin Oritavancin – NS Telavancin Vancomycin MIC Ceftaroline – R Daptomycin – NS Linezolid – R Quinupristin-dalfopristin – I or R R – Tedizolid Vancomycin MIC Oxacillin – R Ceftaroline – NS Linezolid – NS Vancomycin – NS Fluoroquinolone – I or R Imipenem or meropenem – I or R Quinupristin-dalfopristin – I or R Rifampin – I or R Using nonmeningitis breakpoints: Amoxicillin or penicillin – R Extended-spectrum cephalosporin Ampicillin or penicillin – NS Ceftaroline – NS Daptomycin – NS Ertapenem or meropenem – NS Extended-spectrum cephalosporin Quinupristin-dalfopristin – I or R

g -

β

Organism or or Organism Organism Group Organism hemolytic group Streptococcus pneumoniae Streptococcus, Staphylococcus aureus Staphylococcus, coagulase-negative A. (Continued) Appendix

209 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 210 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use WithWith M02-A12 M02-A12 and and M07-A10 M07-A10 M100S,M100S, 26th 26th ed. ed. tribution se the se of concern Category III Category the susceptiblethe epidemiological epidemiological Appendix A May be common, but is is but common, be May generally considered of considered generally

a and Organism Identification and Organism Suggested Test Result Confirmation Confirmation Result Test Suggested

itution.) itution.)

ing steps:ing Category II Category institutions Uncommon in most Confirmation of Confirmation Results

y be encounteredbey within the wild-typedis y). The second methodsecond The y). abe might referenceCLSI (eg,method nediameters below indicatedvalue the for

x Category I Category Not reported or only or only Not reported

Occurrence and Significance of Resistance and to Take FollowingActions rarely reported to date to reported rarely ly meanly that the isolate has a resistance mechanism. It is p ossible that y a susceptible interpretive criterion has been designated becau Footnotes organismidentification and antimicrobial susceptibility resultstest should be

a ry testing may not be needed if resistance is common in the inst notthe neededbe may testing ry in common is resistance if eakpoint that lack resistance mechanisms ma if the isolate wasencountered isolate the if andearlier.confirmed rains. Isolates that have MICs above or zo hod performedhod in-house a at or referrallaboratory. al susceptibility tests meth odinitial theyensure to with susceptibility al reproduce.(For cat egoryII,and I and 3 step skip to elect may ion, or defectiveor ion, card. or plate, panel, results with second method second results orin-house (eg, with referral laborator

eptible-only breakpoint is set. disk diffusion) or a US FoodUS a or diffusion) disk and commercial Administration–cleared Drug test. ication; MIC, minimal inhibitory concent ration; NS, nonsusceptible; R, resistant. results and organism identification are accu rateare identification organism and results reproducible.and theConsider follow Resistance Phenotype Detected Daptomycin – NS Ertapenem or meropenem – NS Linezolid – NS Oritavancin – NS Quinupristin-dalfopristin – I or R NS – Tedizolid – NS Telavancin Vancomycin – NS

, viridans

Nonsusceptible (NS): A category used for isolates for onl which absencerare or occurrence of st resistant confirmed (see footnote “a”). breakpoint should be reported as nonsusceptible. isolates with MICs above the susceptible br subsequent to the time susc Group go to steps 4 and4 steps to go categoryFor 5. III, and/orrepeat confirmato ordilution, agar microdilution, broth 4. organism Confirm met second with identification 5. test susceptibility antimicrobial Confirm Ensure antimicrobial susceptibility test susceptibility antimicrobial Ensure 1. transcriptionfor Check contaminaterrors, 2. patientthe on reports previous Check determine to 3. organism Repeat antimicrobi and identification group

Organism or Organism Organism or Organism Streptococcus

A. (Continued) Appendix Abbreviations: I, intermediate; ID, identif NOTE 1:

NOTE 2: An isolate that is interpreted as nonsusceptible does not necessari NOTE 3: Forstrains resultsyielding in the “nonsusceptible” category, a.

©Clinical and Laboratory Standards Institute. All rights reserved. 210 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 211 M100S,M100S, 26th26th ed. ed. For Use With M02-A12 and M07-A10 Appendix A and Organism Identification and Organism productionof Suggested Test Result Confirmation Confirmation Result Test Suggested e range.vancomycin-contrast, In for notifyingpublic for and control infection or resistant category first publishedfirst resistant or category June in d. spp. that are intermediateare that spp. or resistant third- to Salmonella fluoroquinoloneor aci nalidixic to resistant tend to behigher (eg, MICs in the intermediate hese isolates may have elevatedhave mechanisms may isolates hese thanby other MICs morganii ony Groups variants. are variants ony and C thewith colony included small G group.viridans t, include antimicrobial susceptibility test resultstest for antimicrobialinclude t, susceptibility Morganella spp., and in III) and/orIII) in intermediate to resistant or cephalosporin III or IV (see IV I).or III Glossary cephalosporin

=

Providencia spp., Proteus resistantareCoNS rare. When submitting the reportthe submitting When publica to departmen health cephalosporinsgeneration (cephalospor Category encountered. publicand control Rarely follow recommendationsimplications, I health significantof Because infection authorities. health that Confirm GroupsCand are G and colony large col small not 2010 [M100-S20-U])2010 than those ormeropenem with doripenem MICs.T carbapenemases.

e. d. f. are There some (CoNS) vancomycin coagulase-negativestaphylococci of species for mayMICs which intermediatthe test within g. A. (Continued) Appendix b. ImipenemMICs for c. Extended-spectrumcephalosporin

211 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 212 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12 and M07-A10 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 213

M100S,M100S, 26th 26th ed. For Use With M02-A12 and M07-A10

Aminoglycosides Aminoglycosides †

Colistin Colistin Polymyxin B B Polymyxin

dueto method variation, Appendix B Nitrofurantoin Nitrofurantoin Intrinsic Resistance Intrinsic

species are intrinsically resistant Tigecycline Tigecycline

/

Tetracyclines R R R R R R R R R R R R R R R Imipenem Imipenem * * * * *

Cefuroxime Cefuroxime Cephalosporin II: II: Cephalosporin

refer to Cefoxitin, Cefotetan Cefotetan Cefoxitin,

st data. In the tables, an “R” occurring an organism- with Cephamycins: Cephamycins:

results and results identificationare accurate and reproducible. SeeAppendix Cefazolin, Cephalothin Cephalothin Cefazolin,

Cephalosporin I: I: Cephalosporin Ticarcillin Ticarcillin -lactams in these organisms; β -lactams in this organism.

β ve antimicrobial susceptibility te Piperacillin resistant. percentagesmall A (1% to 3%) may appear susceptible idea aidthey in theto recognitionway evaluate commonof the accuracyof testing methods; 2)

ired)antimicrobial resistance, reflectedis which in antimicrobialwild-type patterns of all or almost all antimicrobial susceptibilitytest sulbactam Ampicillin- Ampicillin-

mmon that susceptibility testing is unnecessary. For example, Citrobacter

for reporting.

clavulanate clavulanate

Amoxicillin- Ampicillin Ampicillin R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R

There is no intrinsic resistance to organism. There is no intrinsic resistance to penicillins and cephalosporins in this There is no intrinsic resistance to WARNING belowWARNING

spp. complex Shigella and Antimicrobial Agent Enterobacteriaceae

Organism Citrobacter freundii Citrobacter koseri Enterobacter aerogenes Enterobacter cloacae Escherichia coli Escherichia hermannii alvei Hafnia Klebsiella pneumoniae Morganella morganii Proteus mirabilis Proteus penneri Proteus vulgaris Providencia rettgeri Providencia stuartii Salmonella Serratia marcescens Yersinia enterocolitica antimicrobial agentcombination means that shouldstrains test levelsmutation, or low of resistance expression. “susceptible”A shouldresult viewedbe caution. Ensure with A, footnote “a.” Resistance B. Intrinsic Appendix resistanceIntrinsic definedis inherentas innate or (not acqu representatives of a species. Intrinsic resistance is so co to ampicillin. they 1) prov Thesetables can behelpful in at leastthree ways: phenotypes; can and 3) they verification assist of cumulatiwith B1.

212 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 214 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use With With M02-A12 M02-A12 and M07-A10and M07-A10 M100S,M100S, 26th 26th e d.ed. but are but in vitro, Appendix B lipoglycopeptides Intrinsic Resistance Intrinsic s, and cephamycins may appear may active cephamycins and s, entrationsbythanimipenem other to mechanisms by and macrolides (erythromycin, clarithromycin, and azithromycin). However,

ycin, fusidicteicoplanin), (vancomycin, glycopeptides acid, ycin, spp. with azithromycin). with spp. and Shigella first-and second-generation cephalosporin anate, piperacillin-tazobactam, and the carbapenems are notanate, piperacillin-tazobactam, listed, because there is no intrinsic

icin, netilmicin, and tobramycin but not intrinsically resistant to amikacin. to resistant intrinsically not but tobramycin and netilmicin, icin, quinupristin-dalfopristin, rifampin, Salmonella species may have elevated minimal inhibitory conc have inhibitory minimal elevated may species tedizolid, Morganella spp., aminoglycosides, spp., linezolid, are also intrinsically resistant to clindamycin, daptom resistant clindamycin, to intrinsically also are species, and species, spp. and Shigella spp. Enterobacteriaceae. should be considered resistant to gentam to resistant considered be should Salmonella For resistance in resistance Enterobacteriaceae (oritavancin, telavancin), arethere exceptionssome macrolides (ie, with species, Providencia Cephalosporins III, cefepime, aztreonam, ticarcillin-clavul Proteus Providencia stuartii Providencia production of carbapenemases. Isolates that test as susceptible should be reportedbe should ascarbapenemases. of production susceptible Isolatesas test that susceptible.

NOTE 1: NOTE NOTE 2: B. (Continued) Appendix B1. (Continued) WARNING: should and reportedbe not clinically effective not as susceptible. * †

©Clinical and Laboratory Standards Institute. All rights reserved. 213 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 215

M100S,M100S, 26th 26th ed.ed. For Use With M02-A12 and M07-A10

Fosfomycin Fosfomycin

Chloramphenicol Chloramphenicol

sulfamethoxazole sulfamethoxazole Trimethoprim-

ides Trimethoprim Trimethoprim

R R Tigecycline Tigecycline

cephalothin, Tetracyclines/ Tetracyclines/ R R Appendix B †

Intrinsic Resistance Intrinsic Aminoglycosides Aminoglycosides ifampin.

th this species.

Colistin Colistin

Polymyxin B B Polymyxin

Ertapenem Ertapenem Meropenem Meropenem

R R R R R Imipenem Imipenem

quinupristin-dalfopristin, and r Aztreonam Aztreonam

R R Cefepime Cefepime

penicillin(ie, benzylpenicillin), cephalosporin ( I

Ceftazidime Ceftazidime

Ceftriaxone Ceftriaxone

Cefotaxime Cefotaxime in, cefotetan), clindamycin, daptomycin, fusidic acid, glycopept

Piperacillin-tazobactam Piperacillin-tazobactam azithromycin, clarithromycin), Amoxicillin- clavulanate clavulanate Amoxicillin-

R

Ampicillin-sulbactam Ampicillin-sulbactam tetracycline but not to doxycycline, minocycline, or tigecycline.

*

Ticarcillin Ticarcillin

Piperacillin Piperacillin ppear to be susceptible to ampicillin-sulbactam due to the activity of sulbactam wi Ampicillin, Amoxicillin Amoxicillin Ampicillin,

R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R

is intrinsically resistant is intrinsically to complex nonfermentativegram-negative bacteria are also intrinsically resistantto

Enterobacteriaceae cefazolin), cephalosporin II (cefuroxime), cephamycins (cefoxit (vancomycin, teicoplanin), linezolid, macrolides (erythromycin, These Stenotrophomonas maltophilia Antimicrobial Agent Organism baumannii/ Acinetobacter calcoaceticus Acinetobacter complex cepacia Burkholderia aeruginosa Pseudomonas maltophilia Stenotrophomonas

Acinetobacter baumannii/calcoaceticus may a * † NOTE: B2. Non-

214 B. (Continued) Appendix ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 216 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use With With M02-A12 M02-A12 and M07-A10and M07-A10 M100S,M100S, 26th 26th ed ed..

-lactam

 Fusidic Acid Acid Fusidic -lactam therapy,  Appendix B Intrinsic Resistance Intrinsic

Fosfomycin Fosfomycin R eption of the cephalosporins anti-MRSA [methicillin-with staphylococci [MRS]) are considered resistant to other

ses of documented MRS infections have responded poorly to

There is no intrinsic resistance in these species. species. in these resistance is no intrinsic There Novobiocin Novobiocin R R R R R R R ant to aztreonam, polymyxin B/colistin, and nalidixic acid. ical efficacy for thoseical efficacy agents have not been presented.

-lactamase inhibitor combinations, cephems (with the exc  and coagulase-negative staphylococci (methicillin-resistant -lactam/  ] activity), and carbapenems.This is because most ca

S. aureus

S. aureus resistant These gram-positive bacteria are also intrinsically resist Oxacillin-resistant agents, ie, penicillins, or because convincing clinical data that document clin Agent Antimicrobial Organism lugdunensis S. aureus/S. S. epidermidis S. haemolyticus S. saprophyticus S. capitis S. cohnii S. xylosus B. (Continued) Appendix B3. Staphylococci NOTE 1: NOTE 2:

©Clinical and Laboratory Standards Institute. All rights reserved. 215 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 217 M100S,M100S, 26th26th ed. ed. For Use With M02-A12 and M07-A10

le Fusidic Acid Acid Fusidic Trimethoprim-sulfamethoxazole Trimethoprim-sulfamethoxazole R R R * * *

Appendix B Trimethoprim Trimethoprim

Intrinsic Resistance Intrinsic

Quinupristin-dalfopristin Quinupristin-dalfopristin Clindamycin Clindamycin

R R R R R R R R * * * Aminoglycosides Aminoglycosides R R R * * *

sistance testing), clindamycin, and trimethoprim-sulfamethoxazo

Teicoplanin Teicoplanin

Vancomycin Vancomycin Cephalosporins Cephalosporins R R R R * * * R R R to aztreonam, polymyxin B/colistin, and nalidixic acid. should not be reported as susceptible.

Antimicrobial Agent Antimicrobial spp., cephalosporins, aminoglycosides (except for high-level re but are not effective clinically and rum/E. casseliflavusrum/E. spp. spp. in vitro, Enterococcus gram-positive bacteria are also intrinsically resistant For These Enterococcus Warning: Organism Enterococcus faecalis Enterococcus faecium Enterococcus gallina may appearmay active

NOTE: NOTE: * B4. B. (Continued) Appendix

216 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 218 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor UseUse With With M02-A12 M02-A12 and M07-A10 and M07-A10 M100S,M100S, 26th 26th ed ed.. Appendix B

Intrinsic Resistance Intrinsic Quinolones Quinolones

R

Ampicillin Ampicillin

R

Penicillin Penicillin Aminoglycosides Aminoglycosides

Aminoglycosides Aminoglycosides Vancomycin Vancomycin R R R R R

-Negative Bacilli -Negative spp. spp. R spp. Antimicrobial Agent Agent Antimicrobial Antimicrobial Agent Agent Antimicrobial Anaerobic Gram-Positive Bacilli Gram-Positive Anaerobic

Organism Clostridium innocuum Clostridium Organism Bacteroides Fusobacterium canifelinum B. (Continued) Appendix B5. B6. Anaerobic Gram

©Clinical and Laboratory Standards Institute. All rights reserved. 217 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 219 M100S,M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

Other

e cation content in each batch/lot of MHB for daptomycin broth microdilution. medium for sulfonamide or trimethoprim MIC tests. media not optimum Assess suitability of on Brucella Growth  Assess suitability of  Appendix C

 Quality Control Strains Quality Control

Tests mupirocin resistance MIC test agar

Vancomycin Vancomycin agar

 HLAR  HLAR High-level  -

spp. spp. -lactamase -lactamase   MIC Tests -lactam/ -lactam/ Haemophilus (more reproducible selected β with lactams)  inhibitor combinations N. gonorrhoeae negative bacteria N. meningitidis  Haemophilus inhibitor combinations anaerobes positive bacteria ESBL tests All anaerobes All anaerobes Gram-positive Nonfastidious gram- Nonfastidious gram- All anaerobes             

- spp. spp. -lactamase -lactamase   -lactam/ -lactam/ Disk Diffusion Tests negative bacteria N. meningitidis  Haemophilus Haemophilus (more reproducible selected β with lactams)  inhibitor combinations N. gonorrhoeae inhibitor combinations Nonfastidious gram- ESBL tests

       

c,f,g for Antimicrobial Susceptibility Tests Susceptibility for Antimicrobial

-lactamase (non-  b,c,f,g ) and high-level -lactamase negative -lactamase positive -lactamase positive -lactamase negative     Organism Characteristics ESBL) ( vanB aminoglycosides TEM-1 Resistant to vancomycin   plasmid-encoded Contains   BLNAR Ampicillin susceptible  Contains SHV-18 ESBL   CMRNG   

E.

h

25285 (formerly (formerly

29741 700057 29212 51299 25922 35218 43055 49247 49766 700603 49226 ) ®a ® ® ® ® ® ® ® ® ® ® ®

Routine QC Strains B. fragilis ATCC B. thetaiotaomicron ATCC C. difficile ATCC E. faecalis E. faecalis E. coli ATCC E. coli ATCC E. lenta lentum ATCC H. influenzae H. influenzae K. pneumoniae ATCC N. gonorrhoeae ATCC ATCC ATCC ATCC ATCC

Strains Control Appendix C. Quality

© Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine219 Clinical and Laboratory Standards Institute. All rights reserved. Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 220 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor UseUse With With M02-A12 M02-A12 and M07-A10 and M07-A10 M100S,M100S, 26th 26th ed ed..

Other

cation content in each batch/lot of MHB for daptomycin broth microdilution. cation content in each batch/lot of Mueller- Hinton for gentamicin MIC and disk diffusion. Assess suitability of Assess suitability of Appendix C



 Quality Control Strains Quality Control

Tests clindamycin resistance MIC test mupirocin resistance MIC test clindamycin resistance MIC test mupirocin resistance test High-level mupirocin resistance disk diffusion test Inducible clindamycin resistance disk diffusion test (D- zone test) Oxacillin agar Oxacillin agar High-level Inducible

  High-level  Inducible     

spp. MIC Tests positive bacteria S. pneumoniae Streptococcus N. meningitidis negative bacteria Nonfastidious gram- MIC testing Cefoxitin Nonfastidious gram-

    



spp. Disk Diffusion Tests N. meningitidis S. pneumoniae Streptococcus diffusion testing negative bacteria positive bacteria Nonfastidious gram- disk Cefoxitin Nonfastidious gram-      

mecA

gene -lactamase–  negative

negative mupA -lactamase -lactamase negative positive Contains inducible AmpC β Little value in MIC testing due to its extreme to most susceptibility drugs producing strain mecA resistance mediated by the altered penicillin-binding protein  Organism Characteristics mecA

     Weak   Oxacillin-resistant,  High-level mupirocin  Penicillin intermediate by

d

27853 25923 29213 43300 BAA-1708 49619 ® ® ® ® ® ® Routine QC Strains ATCC ATCC ATCC ATCC P. aeruginosa S. aureus S. aureus S. aureus S. aureus S. pneumoniae ATCC ATCC C. (Continued) Appendix

©Clinical and Laboratory Standards Institute. All rights reserved. 220 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 221 M100S,M100S, 26th26th ed. For Use With M02-A12 and M07-A10

® End e

E. faecalis

Other 29212 to assess ® E. faecalis ATCC

CTX-M-15 is inhibited and tazobactam by cefepime is hydrolyzed CTX-M-15. by capabilitiesgrowth of HTM. ATCC 29212. suitability of medium for sulfonamide or trimethoprim MIC and disk diffusion tests. points are the same as for Assess each batch/lot for Alternative to Appendix C    Quality Control Strains Quality Control

Tests

edge test Penicillin zone- 

8-

≥ MIC Tests

Cefepime- tazobactam MIC testing Cefotaxime MICs are testing fold higher higher fold than ceftazidime MICs Ceftaroline MIC

  

Disk Diffusion Tests confirmatory test for confirmatory carbapenemase production (MHT) test for confirmatory carbapenemase production (MHT) approximation tests with erythromycin and clindamycin (D-zone test negative).

Phenotypic Phenotypic Assess disk   

c

j (A)-mediated msr -lactamase–  negative by mechanismsby other than carbapenemase macrolide-only resistance CTX-M-15 ESBL- strain producing producing strain mecA Organism Characteristics

MHT positive   KPC-producing strain Resistant to carbapenems  MHT negative 

 Weak  Contains



i

Strains 29212 33186 10211 BAA-1705 BAA-1706 29213 BAA-976 ® ® ® ® ® ® ® Supplemental QC Supplemental ATCC ATCC E. faecalis E. faecalis ATCC coli E. NCTC 13353 H. influenzae K. pneumoniae ATCC K. pneumoniae ATCC S. aureus S. aureus ATCC ATCC C. (Continued) Appendix

221 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 222 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor UseUse With With M02-A12 M02-A12 and M07-A10 and M07-A10 M100S,M100S, 26th 26th ed ed..

® ® id east

35218 with

K6 (ATCC ® -lactamase or E. coli ATCCE. Other β 2004;42(1):269- National Collection National Collection he plasmid,it be will Test Medium; KPC,

Appendix C E. coli ATCCE. NCTC, Quality Control Strains Quality Control -lactam agent alone (ampicillin, blelevels thymidine.of β J Clin Microbiol. 35218 must be used. Haemophilus



Tests ATCC nate).strain the If losest 700603 cephalosporinswith and aztreonam, ® resistant to many penicillinase-labile drugs but E. coli ATCC t, such as decreasedas such t, for MICs

theQC strain thefor QCbe valid;to test however, the plasm MIC Tests ctamase activity in AmpC-activityctamasein and extended-spectrum beta-lactamase 60  Cor below) is especially important for QC strains K. pneumoniae −

Hodge test; MIC, minimal inhibitory concentration; BAA-1705 because spontaneous loss of the encoding plasmid the lts outside the acceptablethe outside lts limi -lactamase inhibitor combinations, such thoseas containing clavulanate, sulbactam, or ansfers onto laboratory media. Minimize by removing new culture from storage at l ® β

-lactamase negative,ampicillin-resistant; mediated chromosomally CMRNG, penicillin- the QC test is invalid and a new culture of  Footnotes Footnotes in growth as compared the control) ifwith media have accepta ATCC -lactamaseinhibitor agent amoxicillin-clavula(eg, clinical isolates tested by using NCCLS ESBL methodology. β of theof extended-spectrum beta-lactamasereference strain, Klebsiella pneumoniae -lactamase; HLAR, high-level aminoglycoside resistance; HTM, Disk Diffusion Tests approximation tests with erythromycin and clindamycin (D-zone positive).test  Assess disk  -lactamase (non-ESBL); subsequently, the organism is β -lactam/ Antimicrob Agents Chemother. 2000;44(9):2382-2388.Antimicrob Agents Chemother. BAA-1705. β ® (A)- K. pneumoniae cillin, and ticarcillin), decreased MICs for onstrate results outside the acceptable range. erm E, Bush K. Effects of inoculum and beta-la ATCC or freezer temperatures. the plasmid To is present, a test the strain with ensure e (eg, minimal subcultures) and storage (eg, he American Type Culture Collection. and Klebsiella pneumoniae 700603, and ® K. pneumoniae ESBL, extended-spectrum mediated resistance Organism Characteristics -lactamase inhibitorcombinations. The plasmid be must presentin -lactam antimicrobial agents after repeated tr

β  ATCC  Contains inducible -lactam agent tested alone, indicatingwhen that Escherichia coli , American Type Culture American , Collection; BLNAR, carbapenemase; MHB, Mueller-Hinton broth; MHT, modified β ® -lactam/ β QC, quality control. 35218 is recommended only as a control organism for

® i

K. pneumoniae is a registered trademark of t ®

Strains Neisseria gonorrhoeae;

BAA-977 BAA-977 ®

monthly or whenever the strain begins to dem 35218, tazobactam. This strain contains a plasmid-encoded 700603), produceswhich the novel enzyme SHV-18.

and false-negative MHT with enzyme-labile penicillins (eg, ampicillin, pipera (ESBL)-producing susceptible to susceptible amoxicillin,piperacillin, ticarcillin)or in addition to a susceptible to the 275. may be lost duringmay storage at refrigerator carbapenemasehas been documented. Plasmid loss leads to QC resu

E. coli ATCC Supplemental QC Supplemental ATCC S. aureus d. Develops resistance to e. End points should be easy to read (as 80% or greater reduction f. RasheedJK, AndersonGJ, H, Yigit et al.Characterization C. (Continued) Appendix Abbreviations:ATCC resistant Klebsiella pneumoniae a. ATCC c. Carefulattention organismto maintenanc g. Queenan AM, Foleno B, Gownley C, Wira

of Type Cultures; Cultures; Type of b.

© Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicineClinical and Laboratory Standards Institute. All rights reserved. 222 Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 223 M100S,M100S, 26th ed.ed. For Use With M02-A12 and M07-A10 for competence Haemophilus influenzae Appendix C

Quality Control Strains Quality Control xample, ing QC programs. 43055 in CLSI document TierM23 2 ® 43055. Therefore, QC ranges have not been ) ATCC ® producing CTX-M extended-spectrum beta- extended-spectrum CTX-M producing SI reference disk diffusion or MIC testing as described ) ATCC antimicrobial susceptibility test 49766, and is used to ensure HTM can adequately support the ® Escherichia coli (formerly lentum E. llowed for all QC procedures. Supplemental QC strains are used to andworking produces results that fall specifiedwithin limits listed in ATCC y represent alternativey QC strains. For e E. lenta E. (formerly E. lentum (formerly n be used to assess a test,new for training new personnel, and cluded if a laboratory performs CL s in routine daily or weekly Supplemental QC strains may possess susceptibility or resistance characteristics specific for drug development studies (ie, CLSI document M23 Tier 1 QC). (ie, CLSI document drug development studies Eggerthella lenta Eggerthella 49247 or H. influenzae ® ATCC 2004;54(4):735-743. H. parainfluenzae. test system in test system select situations, or ma y or to weekly) ensure the test is system and and H. influenzae s, manufacturer’s recommendations should be fo ts has been reported withts has been reported H. influenzae J. Antimicrob Chemother. Antimicrob J. 10211 is more fastidious than ® one or more special tests listed in M02-A12 and M07-A10. They ca is not necessaryassessment. It to include supplemental QC strain established forantimicrobialall agents and notis it necessary to include MIC variability with some agen MIC variability early in documented is result MIC variability if studies QC growth of clinical isolates of lactamases in the UK. M100. The QC strains recommended in this documentM100. should be in herein. For commercial test system assess particular characteristics of a test or ATCC

j. j. of spread hospital and Community al. et ME, ME, Kaufmann Ward N, Woodford C. (Continued) Appendix h. i. QC strains are tested regularly (eg, dail

223 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 224 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12 and M07-A10 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 225 M100S, 26th 26th ed. ed. For Use With M11-A8

16

Meropenem Meropenem ≥ 4

≤ Number of Strains Strains of Number Appendix D 72 100 0

16 ─

Imipenem Imipenem ≥ Cumulative Susceptibility Cumulative

4

Report for Anaerobic Organisms Anaerobic Report for

─ ≤ Number of Strains Strains of Number

─

16

Ertapenem Ertapenem ≥ 4

a

≤ Number of Strains Strains of Number

64

Cefoxitin Cefoxitin ≥ 16

≤

Number of Strains Strains of Number tazobactam tazobactam 128/4

1 January 2010 – 31 December 2012 2010 – 31 December 1 January

≥ Piperacillin- Isolates collected from selected US hospitals US hospitals from selected Isolates collected 32/4

≤

sceptibility Report for Anaerobic Organisms Organisms Anaerobic for Report sceptibility Strains of Number sulbactam sulbactam

%R %S %R %R %S %S %R %S %R %S %R

32/16

Ampicillin- ≥

8/4

≤ Number of Strains Strains of Number %S

Group 77 88 95 1 77 127 98 0 100 130 0 4 52 58 9 130 95 1 77 94 88 4 6093 128 95 0 70 89 2 11 129 73 60 34 21 9 60 100 0 94 100 0 24100 0 128 99 0 768 90 1497 3 768 98 1503 1 80 98 234 98 99 79 1 470 4 467 1 97 2 349 134 770 87 3 1 96 8 98 1 1403 348 48 8 1 469 70 98 97 0 100 153 5 174 1 106 56 2 99 1 106 82 7 153 22066 20 265 56 906 78 30 8 1231 265 42 15 220 97 81 2 33 11 97 1219 0 53 10 265 97 905 98 1 2 29999 0 1218 98 1 2580 82 3959 6 99 39392580 1 832 98 1 87 98 2580 65 7 7 1 3841

c group group B. fragilis

Anaerobic Anaerobic Organisms Organisms Percent Susceptible (%S) and Percent Resistant (%R) in Breakpoints µg/mL B. fragilis B. thetaiotaomicron B. ovatus B. vulgatus B. uniformis B. eggerthii Parabacteroides distasonis B. fragilis B. fragilis (all 7 species listed) without Antimicrobial Su Appendix D. Cumulative Bacteroides fragilis

224 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 226 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor Use Use With M11-A8 M02-A12 and M07-A10 M100S,M100S, 26th 26th ed. ed. 32

≥

Metronidazole

b b

8

≤ Appendix D

ed the by agar dilution

Cumulative Susceptibility Cumulative Number of Strains Strains of Number Organisms Anaerobic Report for 8 8

≥

Moxifloxacin Moxifloxacin

2

≤ Number of Strains Strains of Number

Footnotes Footnotes raction of %S and %R for each antimicrobial agent from %100. ens submitted to four referral laboratories. Testing perform was 8

≥

Clindamycin Clindamycin

2

≤ %S %R%S %S %R %S %R

Number of Strains Strains of Number

72 29 63 61 25 38 72 100 0 469 32 55 348 47 34 470 129 100 43 46 77 32 0 40 130 99 0 152 47 52 92 20 76 174 100 0 121 44 40 94 27 53 128 99 0 265 25 57 220 69 27 265 100 0 1208 35 53 892 45 40 1239 100 0 1423 72 23 769 65 26 1503 96 2 3839 48 42 2553 51 36 3981 98 1 B. Group (Continued) Group

c

group without group (all 7 Anaerobic Anaerobic Organisms Organisms method.

fragilis Percent Susceptible and Percent (%S) Resistant (%R) Breakpoints in µg/mL B. fragilis B. thetaiotaomicron B. ovatus B. vulgatus B. uniformis B. eggerthii Parabacteroides distasonis B. fragilis B. fragilis species listed)

b. Resistance to metronidazole occurs infrequently. c. Intermediate category is notbut shown, can be derived subt by D. (Continued) Appendix Bacteroides fragilis a. Data generatedwere from unique isolates from patient specim

©Clinical and Laboratory Standards Institute. All rights reserved. 225 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 227 M100S,M100S, 26th ed. ed. For Use With M11-A8 16

≥ Meropenem Meropenem 4

≤

Strains Strains Number of of Number Appendix D

16

Cumulative Susceptibility Cumulative Ertapenem Ertapenem ≥ Report for Anaerobic Organisms Anaerobic Report for 4

≤

Strains Strains Number of of Number

64

≥ a Cefoxitin 16

≤

Strains Strains Number of of Number

tazobactam tazobactam 128/4

≥ Piperacillin- 32/4

Group ≤

1 January 2010 – 31 December 2012 2010 – 31 December 1 January

Strains Strains Number of of Number

Isolates collected from selected US hospitals from selected Isolates collected sulbactam sulbactam %R %S %R %S %R %S %R %S %R 32/16

Bacteroides fragilis

≥ Ampicillin-

8/4

%S ≤

Strains Strains Number of of Number

27 100 0 27 100 0 27 100 0 15 100 0 27 100 0 100 27 0 100 15 0 100 0 100 27 100 27 0 27 34 100 0 494 99 1 930 494 0 100 34 3 9724 31 90 6 32 84 0 8 3297 85 970 16 26 32 71 100 0 266 98 2 0 26699 0 100 7017 77 39 58 100 0 58 100 0 58 100 0 58 100 0 58 100 0 100 58 0 100 58 0 100 0 100 58 100 58 0 58 150 88 9 614 99 981 614 9 83 0 94 150 3 148 108 100 0 348 100 0 108 99 0 69 100 0 348 100 0

b

spp. 229 99 0 800 100 0 806 97 1 196 100 0 234 100 0

c

d e

Anaerobic Anaerobic Organisms Organisms

spp. Percent Susceptible and (%S) Percent Resistant (%R) Breakpoints in µg/mL Prevotella Fusobacterium nucleatum- necrophorum Anaerobic gram-positive cocci Veillonella spp. P. acnes Clostridium perfringens C. difficile Other Clostridium D. (Continued) Appendix Than Other Organisms Anaerobic

226 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 228 ©Clinical and Laboratory Standards Institute. All rights reserved. ForFor UseUse With With M11-A8 M02-A12 and M07-A10 M100S,M100S, 26th 26th ed ed..

32

≥

Metronidazole

8

Appendix D ≤

Cumulative Susceptibility Cumulative

Strains Strains Organisms Anaerobic Report for Number of of Number 8

≥

Moxifloxacin Moxifloxacin

2

≤

Strains Strains Number of of Number Group (Continued) 8

≥

Clindamycin Clindamycin

2

≤ %S %R %S %R %S %R

Bacteroides fragilis Bacteroides

Strains Strains Number of of Number

58 91 58 9 93 3 58 9 91 27 100 0 15 100 0 27 100 0 32 66 3426 81 12 32 97 0 614 79 16150 63 20 611 96 3 493 38 48 17 94 6 494 100 0 266 66 21 45 74 20266 98 1 348 86 7 69 100 0 348 100 0

d

e b spp. spp. 800 72 26196 73 24 571 97 0

c

Clostridium Anaerobic Anaerobic Organisms Organisms

Percent Susceptible (%S) and Percent Resistant (%R) in Breakpoints µg/mL Prevotella Fusobacterium nucleatum- necrophorum Anaerobic gram- positive cocci Veillonella P. acnes Clostridium perfringens C. difficile Other spp. D. (Continued) Appendix Than Other Organisms Anaerobic

©Clinical and Laboratory Standards Institute. All rights reserved. 227 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 229 M100S,M100S, 26th26th ed. For Use With M11-A8 itory concentrations for Appendix D Cumulative Susceptibility Cumulative CLSI documentM39-A4. Wayne, Report for Anaerobic Organisms Anaerobic Report for species. Anaerococcus and referral laboratories.Testing performed the by agar dilutionwas method. s, Finegoldia, Peptoniphilus, Footnotes Footnotes ptibilityTest Data; Approved Guideline—Fourth Edition. ction of %S and %R for each antimicrobial agent from %100. recommendation of 30 isolates. 1 e results do not imply efficacy for intraluminal infections. Vancomycin minimal inhib from patient specimens submitted to four Peptococcus, Peptostreptococcu Standards Institute; 2014. 4 µg/mL.

isolates are from intestinal source; thes Analysis andPresentation Cumulativeof Antimicrobial Susce Data generatedwere from unique isolates than the CLSI documentCalculated from fewer M39 C. difficile Intermediate category is not but shown, can be derived subtra by

CLSI. c. d.

PA: Clinical and Laboratory

D. (Continued) Appendix a. e. Anaerobic gram-positive cocci include 1 Reference for Appendix D for Appendix Reference isolates < were b.

228 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 230 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M11-A8 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 231 M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

Appendix E. Dosing Regimens Used to Establish Susceptible or Susceptible-Dose Dependent Interpretive Criteria

The evolving science of pharmacokinetics-pharmacodynamics has become increasingly important in recent years in determining minimal inhibitory concentration (MIC) interpretive criteria. Recently approved susceptible or susceptible- dose dependent (SDD) interpretive criteria for a number of agents have been based on a specific dosing regimen(s); these dosing regimens are listed in the table below. Proper application of the interpretive criteria necessitates drug exposure at the site of infection that corresponds to or exceeds the expected systemic drug exposure at the dose listed in adult patients with normal renal function. This information should be shared with pharmacists, infectious diseases staff, and others making dosing recommendations for the institution.

Appendix E Interpretive Criteria Antimicrobial Susceptible SDD Agent MIC Dose MIC Dose Table 2A-1. Enterobacteriaceae Aztreonam ≤ 4 μg/mL 1 g every 8 h N/A Cefazolin ≤ 2 μg/mL 2 g every 8 h N/A Ceftaroline ≤ 0.5 μg/mL 600 mg every 12 h N/A Susceptible-Dose Dependent Interpretive Criteria Interpretive Dependent Susceptible-Dose Dosing Regimens Used to Establish Susceptible or Susceptible Establish Used to Dosing Regimens Cefepime ≤ 2 μg/mL 1 g every 12 h 4 µg/mL 1 g every 8 h or 2 g every 12 h

8 µg/mL 2 g every 8 h

or (Because it is not possible to correlate zone diameter: specific zone diameters 19–24 mm with specific MICs, an isolate with a zone diameter in the SDD range should be treated as if it might be an MIC of 8 µg/mL.) Cefotaxime ≤ 1 μg/mL 1 g every 8 h N/A Ceftriaxone ≤ 1 μg/mL 1 g every 24 h N/A Cefoxitin ≤ 8 μg/mL 8 g per day (eg, 2 g every 6 h) N/A Cefuroxime ≤ 8 μg/mL 1.5 g every 8 h N/A Ceftazidime ≤ 4 μg/mL 1 g every 8 h N/A Ceftizoxime ≤ 1 μg/mL 1 g every 12 h N/A Doripenem ≤ 1 μg/mL 500 mg every 8 h N/A Ertapenem ≤ 0.5 μg/mL 1 g every 24 h N/A Imipenem ≤ 1 μg/mL 500 mg every 6 h or 1 g every 8 h N/A Table 2B-1. Pseudomonas aeruginosa Aztreonam ≤ 8 μg/mL 1 g every 6 h or 2 g every 8 h N/A Cefepime ≤ 8 μg/mL 1 g every 8 h or 2g every 12 h N/A Ceftazidime ≤ 8 μg/mL 1 g every 6 h or 2 g every 8 h N/A Doripenem ≤ 2 μg/mL 500 mg every 8 h N/A Imipenem ≤ 2 μg/mL 1 g every 8 h or 500 mg every 6 h N/A Meropenem ≤ 2 μg/mL 1 g every 8 h N/A Piperacillin ≤ 16 μg/mL 3 g every 6 h N/A Piperacillin- ≤ 16/4 μg/mL 3 g every 6 h N/A tazobactam Ticarcillin ≤ 16 μg/mL 3 g every 6 h N/A Ticarcillin- ≤ 16/2 μg/mL 3 g every 6 h N/A clavulanate Table 2B-2. Acinetobacter spp. Doripenem ≤ 2 μg/mL 500 mg every 8 h N/A Imipenem ≤ 2 μg/mL 500 mg every 6 h N/A Meropenem ≤ 2 μg/mL 1 g every 8 h or 500 mg every 6 h N/A Table 2C. Staphylococcus spp. Ceftaroline ≤ 1 μg/mL 600 mg every 12 h N/A Table 2E. Haemophilus influenzae and Haemophilus parainfluenzae Ceftaroline ≤ 0.5 μg/mL 600 mg every 12 h N/A

198 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 232 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M02-A12 M02-A12 and M07-A10 and M07-A10 M100S,M100S, 26th 26th ed ed..

Appendix E. (Continued) Interpretive Criteria Antimicrobial Susceptible SDD Agent MIC Dose MIC Dose Table 2G. Streptococcus pneumoniae Ceftaroline ≤ 0.5 μg/mL 600 mg every 12 h N/A (nonmeningitis) Penicillin ≤ 2 μg/mL 2 million units every 4 h (12 million N/A (nonmeningitis) units per day) Penicillin parenteral ≤ 0.06 μg/mL 3 million units every 4 h N/A (meningitis)

Table 2H-1. Streptococcus spp. β-Hemolytic Group Appendix E Ceftaroline ≤ 0.5 μg/mL 600 mg every 12 h N/A Abbreviations: MIC, minimal inhibitory concentration; N/A, not applicable; SDD, susceptible-dose dependent.

Susceptible-Dose Dependent Interpretive Criteria Interpretive Dependent Susceptible-Dose or Susceptible Establish Used to Dosing Regimens

©Clinical and Laboratory Standards Institute. All rights reserved. 199 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 233 M100S,M100S, 26th26th ed. ed. For Use With M02-A12 and M07-A10

Appendix F. Cefepime Breakpoint Change for Enterobacteriaceae and Introduction of the Susceptible-Dose Dependent Interpretive Category

What Changed?

The CLSI Subcommittee on Antimicrobial Susceptibility Testing revised the cefepime interpretive criteria (breakpoints) in 2014 and introduced the susceptible-dose dependent (SDD) category with this breakpoint revision. Below is a summary of the changes.

Previous – 2013 Appendix F

Interpretive Category Interpretive Method Susceptible Intermediate Resistant

≤ 8 µg/mL 16 µg/mL ≥ 32 µg/mL MIC

Zone Diameter (Disk ≥ 18 mm 15–17 mm ≤ 14 mm Cefepime Breakpoint Change for Enterobacteriaceae for Change Breakpoint Cefepime and Introduction of the Susceptible-Dose Dependent of the Susceptible-Dose and Introduction Diffusion)

Revised – 2014

Method Susceptible Susceptible-Dose Dependent Resistant

≤ 2 µg/mL 4–8 µg/mL ≥ 16 µg/mL MIC

Zone Diameter (Disk ≥ 25 mm 19–24 mm ≤ 18 mm Diffusion) Abbreviation: MIC, minimal inhibitory concentration.

Why were the cefepime breakpoints reconsidered?

The issue of new breakpoints for cefepime became apparent for several reasons:

 Previous breakpoints were based on a higher dose of cefepime than is often used.

 Clinical failures were noted for isolates with cefepime MICs of 4 and 8 µg/mL, especially when lower doses of cefepime were used.

 There are limited new drugs in the pipeline that show activity against multidrug-resistant gram-negative bacteria; thus, there is a need to optimize use of drugs currently available. Designing susceptibility reports to correlate better with dosages of the drug used is one way to help accomplish this goal.

What does “susceptible-dose dependent” (SDD) mean?

The “susceptible-dose dependent” category implies that susceptibility of an isolate is dependent on the dosing regimen that is used in the patient. In order to achieve levels that are likely to be clinically effective against isolates for which the susceptibility testing results (either MICs or disk diffusion) are in the SDD category, it is necessary to use a dosing regimen (ie, higher doses, more frequent doses, or both) that results in higher drug exposure than the dose that was used to establish the susceptible breakpoint. Consideration should be given to the maximum approved dosage regimen, because higher exposure gives the highest probability of adequate coverage of an SDD isolate. The dosing regimens used to set the SDD interpretive criterion are provided in Appendix E. The drug label should be consulted for recommended doses and adjustment for organ function.

200 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 234 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M02-A12 M02-A12 and M07-A10 and M07-A10 M100S,M100S, 26th 26th ed ed..

Appendix F. (Continued)

NOTE: The SDD interpretation is a new category for antibacterial susceptibility testing, although it has been previously applied for interpretation of antifungal susceptibility test results (see CLSI document M27-S4). The concept of SDD has been included within the intermediate category definition for antimicrobial agents. However, this is often overlooked or not understood by clinicians and microbiologists when an intermediate result is reported. The SDD category may be assigned when doses well above those used to calculate the susceptible breakpoint are approved and used clinically, and where sufficient data to justify the designation exist and have been reviewed. When the intermediate category is used, its definition remains unchanged.

SDD is recommended instead of “intermediate” when reporting cefepime results for Enterobacteriaceae isolates because there are multiple approved dosing options for cefepime, and SDD highlights the option of using higher Appendix F doses to treat infections caused by isolates when the cefepime MIC is 4 or 8 µg/mL or the zone is 19 to 24 mm. Category Interpretive Why is SDD being used now?

 It has become apparent that there is a growing need to refine susceptibility reporting to maximize clinicians’ use of available drugs. Cefepime Breakpoint Change for Enterobacteriaceae for Change Breakpoint Cefepime

Dependent of the Susceptible-Dose and Introduction  Intermediate too often means “resistant” to clinicians because they do not appreciate the full definition of “intermediate.”

 SDD is more specific and it conveys what we know—a higher dose can be considered for isolates with MICs (or zones) that fall in this interpretive category.

 SDD is already well established for use in antifungal susceptibility testing.

 It is anticipated that reporting a cefepime SDD result will encourage clinicians to consider the possibility that cefepime may be an option for treatment.

 Antibiotic stewardship programs, which emphasize dosing regimen and duration of therapy options, are increasing awareness of appropriate use of antibiotics. Personnel from these programs should be able to describe the significance to clinicians of an SDD result for cefepime.

How should this change be implemented?

 Meet with the appropriate practitioners at your institution (members of the antimicrobial stewardship team, infectious diseases staff, pathology group, pharmacy, etc.) to inform them of these changes and agree on a plan to inform your clinicians of this change.

 Talk to the manufacturer of your antimicrobial susceptibility testing (AST) device to determine how to implement the revised breakpoints on your device. – NOTE: Because the US Food and Drug Administration (FDA) has not revised the cefepime breakpoints and commercial manufacturers must use FDA breakpoints, the manufacturer cannot adopt the new CLSI cefepime breakpoints. However, for most systems, you can manually change the breakpoints and implement following a verification study.

 Work with your laboratory information system staff to report “SDD” or “D” for Enterobacteriaceae when the cefepime MIC is 4 or 8 µg/mL. Make certain that SDD will be transmitted to the hospital information system and appropriately displayed on reports viewed by clinicians.

 Distribute user-specific educational materials to laboratory staff and clinicians receiving AST results from your laboratory. Examples of these materials can be found on the CLSI Subcommittee on Antimicrobial Susceptibility Testing webpage at www.clsi.org.

©Clinical and Laboratory Standards Institute. All rights reserved. 201 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 235 M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

Appendix F. (Continued)

Additional Questions and Answers:

1. Q: Does CLSI recommend a comment to be reported with the new cefepime breakpoints?

A: If a laboratory chooses to report a comment explaining the SDD range, CLSI recommends the following: “The interpretive criterion for susceptible is based on a dosage regimen of 1 g every 12 h. The interpretive criterion for susceptible-dose dependent is based on dosing regimens that result in higher cefepime exposure, either higher doses or more frequent doses or both, up to approved maximum dosing regimens.” Appendix F

Interpretive Category Interpretive 2. Q: Will all intermediate ranges become SDD?

A: No, the SDD category will be implemented for drug/organism combinations only when there is sufficient evidence to suggest alternative approved dosing regimens may be appropriate for organisms that have MICs or zone diameters between the susceptible and resistant categories.

Cefepime Breakpoint Change for Enterobacteriaceae for Change Breakpoint Cefepime

and Introduction of the Susceptible-Dose Dependent of the Susceptible-Dose and Introduction 3. Q: Will SDD be applied to other antimicrobial agents?

A: CLSI will examine the SDD category possibility for additional drug/organism combinations where multiple dosing options exist (eg, other extended-spectrum cephalosporins).

4. Q: How do we perform a verification study before implementing the new cefepime breakpoints on our AST device?

A: Guidelines for performance of such a verification study are provided in the following publication: Clark RB, Lewinski MA, Loeffelholz MJ, Tibbetts RJ. Cumitech 31A: verification and validation of procedures in the clinical microbiology laboratory. Washington, DC: ASM Press; 2009.

5. Q: Does SDD apply to all patients and specimen types (eg, pediatric, geriatric, immunosuppressed)?

A: Yes, in terms of laboratory reporting. Clinicians must decide how to use an SDD result for a specific patient in consideration of all other clinical and physiological parameters for that patient.

6. Q: Do the new cefepime breakpoints apply to Pseudomonas aeruginosa and other gram-negative bacteria also?

A: No, currently they are only applicable to members of the Enterobacteriaceae.

7. Q: Is any special QC needed once the SDD breakpoints are implemented?

A: No, currently recommended routine QC is sufficient.

8. Q: Will it be necessary to report SDD on proficiency testing survey samples?

A: Sponsors of proficiency testing surveys are aware of the difficulties encountered by laboratories in implementing newer CLSI breakpoints. It is highly unlikely that there will be a mandate to report SDD in the near future, but it would be best to check with your proficiency testing survey provider.

9. Q: If we can implement the revised cefepime breakpoints but cannot facilitate reporting of SDD, can we report “intermediate” instead of SDD?

A: A decision related to this question should be made following consultation with your laboratory director, antibiotic stewardship team (if available), infectious diseases practitioners, pharmacists, and infection control practitioners.

10. Q: If we can implement the revised cefepime breakpoints but cannot facilitate reporting of SDD, can we report an MIC or zone diameter without an MIC?

A: A zone diameter should never be reported without an interpretation because there is a high risk of misinterpretation of this value and this poses patient safety issues. There is a lesser danger of reporting an MIC without an interpretation, but this should not be done without an accompanying qualifying comment. See answer to question 9, above.

202 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 236 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M02-A12 M02-A12 and M07-A10 and M07-A10 M100S,M100S, 26th 26th ed ed..

Appendix F. (Continued)

11. Q: If we are still doing extended-spectrum β-lactamase (ESBL) testing and implement the new cefepime breakpoints, do we change a susceptible or SDD result to resistant for ESBL-positive isolates?

A: No. When CLSI changed the other cephem breakpoints in 2010, the recommendation to perform routine ESBL testing was eliminated. When using the new cefepime breakpoints, there is no need to perform routine ESBL testing for patient reporting purposes. However, ESBL testing might be done for infection control or epidemiological purposes.

12. Q: What does the dosing information that is given with breakpoints mean? Appendix F A: The evolving science of pharmacokinetics-pharmacodynamics has become increasingly important in recent years in determining MIC interpretive criteria. Recently approved susceptible or SDD Category Interpretive interpretive criteria for a number of agents have been based on a specific dosing regimen(s); these dosing regimens are listed in Appendix E. Proper application of the interpretive criteria necessitates drug exposure at the site of infection that corresponds to or exceeds the expected systemic drug exposure, at the dose listed, in adult patients with normal renal function. This information should be

shared with pharmacists, infectious diseases staff, and others making dosing recommendations for Enterobacteriaceae for Change Breakpoint Cefepime and Introduction of the Susceptible-Dose Dependent of the Susceptible-Dose and Introduction the institution.

©Clinical and Laboratory Standards Institute. All rights reserved. 203 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 237 M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

Appendix G. Epidemiological Cutoff Values

1. Q: What are epidemiological cutoff values (ECVs)?

A: ECVs are minimal inhibitory concentration (MIC) values that separate bacterial populations into those with and without acquired and/or mutational resistance mechanisms based on their phenotypes (MICs). ECVs are based solely on in vitro data. The term “wild-type” (WT) is used to describe strains with MIC values at or below the ECV that are presumed not to possess acquired and/or mutational resistance mechanisms, while the term “non-wild-type” (NWT) is used to describe strains with MIC values above the ECV that are presumed to possess acquired and/or mutational resistance mechanisms. ECVs are principally used to signal the emergence and evolution of NWT strains. They Appendix G are not the same as clinical breakpoints. The ECV is defined as the MIC value that best defines the estimated upper end of the WT population.

Epidemiological Cutoff Values Epidemiological Cutoff 2. Q: How are ECVs determined?

A: ECVs are determined by collecting and merging MIC distribution data obtained by testing bacteria from a variety of sources, and then applying techniques for estimating the MIC at the upper end of the WT distribution. In order to be reliable, ECVs are estimated by accounting for both biological (strain- to-strain) variation and MIC assay variation within and between laboratories. They are based on the assumption that the WT distribution of a particular antimicrobial agent/organism combination does not vary geographically or over time.

Several conditions must be fulfilled in order to generate reliable ECVs. The most important are:

 An ECV can only be determined within a single species because of the genetic diversity between species within a genus.

 All MIC values included in the merged dataset must have been determined using a recognized reference method such as the CLSI MIC broth dilution method (M07-A121), which is also the methodology outlined in an international reference standard.2

 Data must be sourced from at least three separate laboratories, and there should be at least 100 unique strains included in the merged dataset.

 As much as possible, the MIC values included in an individual laboratory’s dataset must be “on scale.” This condition applies particularly to MICs of the presumptive WT strains. Before merging data for ECV estimation, the MIC distribution from each individual laboratory is inspected, and if the lowest concentration tested is also a mode, then these data cannot be included in the merged dataset.

Once acceptable data are merged, there are several methods that can be used to estimate the ECV. The simplest method is visual inspection. Visual inspection generally works for MIC distributions when there is clear separation of WT and NWT. When there is obvious overlap between WT and NWT strains, visual inspection becomes too subjective. In general, statistical methods are preferred because they remove any potential observer bias from the estimation. The two most widely referenced methods are those of Turnidge et al.3 and Kronvall.4

Estimation of ECVs from MIC distributions may be supplemented with molecular tests for known resistance mechanisms, as a form of validation. The detection of a resistance gene per se in strains with MICs at or below the ECV does not necessarily contradict the choice of ECV, unless it can be accompanied by evidence that the gene is being expressed.

3. Q: How are ECVs used to set clinical breakpoints?

A: Clinical breakpoints are set using many criteria as detailed in CLSI document M23,5 including MIC distributions for the antimicrobial and relevant populations of bacteria, in vitro and in vivo pharmacodynamics, human pharmacokinetics, and clinical outcome. MIC distributions and ECVs are thus just one component of a range of data used to set clinical breakpoints.

204 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 238 ©Clinical and Laboratory Standards Institute. All rights reserved. For UseUse With With M02-A12 M02-A12 and M07-A10 and M07-A10 M100S,M100S, 26th 26th ed ed..

Appendix G. (Continued)

4. Q: How can ECVs be used by the microbiology laboratory?

A: In rare clinical circumstances, experience may suggest an antimicrobial agent for use where no clinical breakpoints exist. For example, vancomycin may be considered for treatment of a P. acnes infection, but there are insufficient data available to establish clinical breakpoints with interpretive criteria. This is due principally to the absence of strains with acquired resistance and a lack of clinical outcome data.

MIC testing using a reference or approved method and ECVs for the drug/organism combination might then be used to determine if the patient’s isolate of P. acnes is a WT or NWT strain. If the Appendix G vancomycin MIC is at or below the ECV (≤ 2 µg/mL) it can be assumed that the isolate is a WT strain. If the vancomycin MIC is > 4 µg/mL, the strain should be retested to confirm the NWT result. The

confirmed MIC result and the ECV data should be discussed with relevant clinicians/pharmacists. A Values Epidemiological Cutoff comment could be added to the report indicating that MIC results were discussed with relevant clinical services (infectious diseases/pharmacists). The MIC result should not be reported with an interpretation.

References for Appendix G

1 CLSI. Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria That Grow Aerobically; Approved Standard—Tenth Edition. CLSI document M07-A10. Wayne, PA: Clinical and Laboratory Standards Institute; 2015.

2 ISO. Clinical laboratory testing and in vitro diagnostic test systems – Susceptibility testing of infectious agents and evaluation of performance of antimicrobial susceptibility test devices – Part 1: Reference method for testing the in vitro activity of antimicrobial agents against rapidly growing aerobic bacteria involved in infectious diseases. ISO 20776-1. Geneva, Switzerland: International Organization for Standardization; 2006.

3 Turnidge J, Kahlmeter G, Kronvall G. Statistical characterisation of bacterial wild-type MIC value distributions and the determination of epidemiological cut-off values. Clin Microbiol Infect. 2006;12(5):418-425.

4 Kronvall G. Normalized resistance interpretation as a tool for establishing epidemiological MIC susceptibility breakpoints. J Clin Microbiol. 2010;48(12):4445-4452.

5 CLSI. Development of In Vitro Susceptibility Testing Criteria and Quality Control Parameters. 4th ed. CLSI guideline M23. Wayne, PA: Clinical and Laboratory Standards Institute; 2016.

©Clinical and Laboratory Standards Institute. All rights reserved. 205 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 239 M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

Glossary I (Part 1). -Lactams: Class and Subclass Designation and Generic Name Antimicrobial Class Antimicrobial Subclass Agents Included; Generic Names Penicillins Penicillinase-labile Penicillin Penicillin penicillinsa Aminopenicillin Amoxicillin Ampicillin Carboxypenicillin Carbenicillin Ticarcillin Ureidopenicillin Azlocillin Mezlocillin Piperacillin Penicillinase-stable Cloxacillin b Glossary I penicillins Dicloxacillin Methicillin Nafcillin Oxacillin Amidinopenicillin Mecillinam -Lactam/-lactamase Amoxicillin-clavulanate inhibitor combinations Ampicillin-sulbactam Aztreonam-avibactam Cefepime-tazobactam Ceftaroline-avibactam Ceftazidime-avibactam Ceftolozane-tazobactam Imipenem-relebactam Piperacillin-tazobactam Ticarcillin-clavulanate Cephems (parenteral) Cephalosporin Ic Cefazolin Cephalothin Cephapirin Cephradine Cephalosporin IIc Cefamandole Cefonicid Cefuroxime (parenteral) Cephalosporin IIIc Cefoperazone Cefotaxime Ceftazidime Ceftizoxime Ceftriaxone Cephalosporin IVc Cefepime Cefpirome Cephalosporins with anti-MRSA activity Ceftaroline Ceftobiprole Cephamycin Cefmetazole Cefotetan Cefoxitin Oxacephem Moxalactam Cephems (oral) Cephalosporin Cefaclor Cefadroxil Cefdinir Cefditoren Cefetamet Cefixime Cefpodoxime Cefprozil Ceftibuten Cefuroxime (oral) Cephalexin Cephradine Carbacephem Loracarbef

206 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 240 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M02-A12 M02-A12 and M07-A10 and M07-A10 M100S,M100S, 26th 26th ed ed..

Glossary I (Part 1). (Continued) Antimicrobial Class Antimicrobial Subclass Agents Included; Generic Names Monobactams Aztreonam Penems Carbapenem Biapenem Doripenem Ertapenem Imipenem Meropenem Razupenem Penem Faropenem Sulopenem Abbreviation: MRSA, methicillin-resistant S. aureus. Glossary I

Footnotes

a. Hydrolyzed by staphylococcal penicillinase.

b. Not hydrolyzed by staphylococcal penicillinase.

c. Cephalosporins I, II, III, and IV are sometimes referred to as first-, second-, third-, and fourth-generation cephalosporins, respectively. Cephalosporins III and IV are also referred to as “extended-spectrum cephalosporins.” This does not imply activity against extended-spectrum -lactamase–producing gram-negative bacteria.

©Clinical and Laboratory Standards Institute. All rights reserved. 207 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 241 M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

Glossary I (Part 2). Non–-Lactams: Class and Subclass Designation and Generic Name Antimicrobial Class Antimicrobial Subclass Agents Included; Generic Names Aminocyclitols Spectinomycin Trospectomycin Aminoglycosides Amikacin Gentamicin Kanamycin Netilmicin Plazomicin Streptomycin Tobramycin

Glossary I Aminoglycoside-fosfomycin Amikacin-fosfomycin Ansamycins Rifampin Rifaximin Folate pathway inhibitors Iclaprim Sulfonamides Trimethoprim Trimethoprim-sulfamethoxazole Fosfomycins Fosfomycin Glycopeptides Glycopeptide Teicoplanin Vancomycin Lipoglycopeptide Dalbavancin Oritavancin Telavancin Ramoplanin Lincosamides Clindamycin Lipopeptides Daptomycin Surotomycin Polymyxins Colistin Polymyxin B Macrocyclic Fidaxomicin Macrolides Azithromycin Clarithromycin Dirithromycin Erythromycin Fluoroketolide Solithromycin Ketolide Telithromycin Nitrofurans Nitrofurantoin Nitroimidazoles Metronidazole Secnidazole Tinidazole Oxazolidinones Linezolid Tedizolid Phenicols Chloramphenicol Pleuromutilin Lefamulin Pseudomonic acid Mupirocin Quinolone Cinoxacin Garenoxacin Nalidixic acid Benzoquinolizine Levonadifloxacin Fluoroquinolone Besifloxacin Ciprofloxacin Clinafloxacin Delafloxacin Enoxacin Finafloxacin Fleroxacin Gatifloxacin Gemifloxacin Grepafloxacin Levofloxacin Lomefloxacin Moxifloxacin Norfloxacin Ofloxacin Pefloxacin Sparfloxacin Trovafloxacin Ulifloxacin (prulifloxacin) Quinolonyl oxazolidinone Cadazolid

208 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 242 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M02-A12 M02-A12 and M07-A10 and M07-A10 M100S,M100S, 26th 26th ed ed..

Glossary I (Part 2). (Continued) Antimicrobial Class Antimicrobial Subclass Agents Included; Generic Names Steroidal Fusidanes Fusidic acid Streptogramins Linopristin-flopristin Quinupristin-dalfopristin Sulfonamides Sulfisoxazole Tetracyclines Doxycycline Minocycline Tetracycline Fluorocycline Eravacycline

Glycylcyclines Tigecycline Glossary I Aminomethylcycline Omadacycline Thiazolide Nitazoxanide Tizoxanide Triazaacenapthylene Gepotidacin

©Clinical and Laboratory Standards Institute. All rights reserved. 209 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 243 M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

Glossary II. Abbreviations/Routes of Administration/Drug Class for Antimicrobial Agents Listed in M100S, 26th ed. Drug Class or Antimicrobial Agent Agent Abbreviationa Routes of Administrationb Subclass PO IM IV Topical Amikacin AN, AK, Ak, X X Aminoglycoside AMI, AMK Amikacin-fosfomycin AKF Xc Aminoglycoside- fosfomycin Amoxicillin AMX, Amx, AMOX, X Penicillin

Glossary II AC Amoxicillin-clavulanate AMC, Amc, A/C, AUG, X -lactam/-lactamase Aug, XL, AML inhibitor Ampicillin AM, Am, AMP X X X Penicillin Ampicillin-sulbactam SAM, A/S, X -lactam/-lactamase AMS, AB inhibitor Azithromycin AZM, Azi, AZI, AZ X X Macrolide Azlocillin AZ, Az, AZL X X Penicillin Aztreonam ATM, AZT, Azt, AT, AZM X Monobactam Aztreonam-avibactam AZA X -lactam/-lactamase inhibitor Besifloxacin BES X Fluoroquinolone Biapenem BPM X Carbapenem Cadazolid CDZ X Quinolonyl oxazolidinone Carbenicillin (indanyl salt) CB, Cb, BAR X Penicillin

Carbenicillin X X Cefaclor CEC, CCL, Cfr, FAC, CF X Cephem Cefadroxil CFR, FAD X Cephem Cefamandole MA, CM, Cfm, FAM X X Cephem Cefazolin CZ, CFZ, Cfz, FAZ, KZ X X Cephem Cefdinir CDR, Cdn, DIN, CD, CFD X Cephem Cefditoren CDN X Cephem Cefepime FEP, Cpe, PM, CPM X X Cephem Cefepime-tazobactam FPZ X -lactam/- lactamase inhibitor Cefetamet CAT, FET X Cephem Cefixime CFM, FIX, Cfe, IX X Cephem Cefmetazole CMZ, CMZS, CMT X X Cephem Cefonicid CID, Cfc, FON, CPO X X Cephem Cefoperazone CFP, Cfp, CPZ, PER, X X Cephem FOP, CP Cefotaxime CTX, TAX, Cft, FOT, CT X X Cephem Cefotetan CTT, CTN, Ctn, CTE, X X Cephem TANS, CN Cefoxitin FOX, CX, Cfx, FX X X Cephem Cefpirome CPO, CPR X X Cephem Cefpodoxime CPD, Cpd, POD, PX X Cephem Cefprozil CPR, CPZ, FP X Cephem Ceftaroline CPT X Cephem Ceftaroline-avibactam CPA X -lactam/-lactamase inhibitor Ceftazidime CAZ, Caz, TAZ, TZ X X Cephem Ceftazidime-avibactam CZA X -lactam/-lactamase inhibitor Ceftibuten CTB, TIB, CB X Cephem Ceftizoxime ZOX, CZX, CZ, Cz, CTZ, X X Cephem TIZ Ceftobiprole BPR X Cephem Ceftolozane-tazobactam C/T X -lactam/-lactamase inhibitor

210 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 244 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M02-A12 M02-A12 and M07-A10 and M07-A10 M100S,M100S, 26th 26th ed ed..

Glossary II. (Continued) Drug Class or Antimicrobial Agent Agent Abbreviationa Routes of Administrationb Subclass PO IM IV Topical Ceftriaxone CRO, CTR, FRX, Cax, X X Cephem AXO, TX Cefuroxime (oral) CXM, CFX, X Cephem ROX, Crm, Cefuroxime (parenteral) FUR, XM X X Cephalexin CN, LEX, CFL X Cephem Cephalothin CF, Cf, CR, CL, CEP, X Cephem CE, KF Glossary II Cephapirin CP, HAP X X Cephem Cephradine RAD, CH X Cephem Chloramphenicol C, CHL, CL X X Phenicol Cinoxacin CIN, Cn X Quinolone Ciprofloxacin CIP, Cp, CI X X Fluoroquinolone Clarithromycin CLR, CLM, X Macrolide CLA, Cla, CH Clinafloxacin CFN, CLX, LF X X Fluoroquinolone Clindamycin CC, CM, CD, Cd, CLI, DA X X X Lincosamide Colistin CL, CS, CT X Lipopeptide Dalbavancin DAL X Glycopeptide Daptomycin DAP X Lipopeptide Delafloxacin DFX X Fluoroquinolone Dicloxacillin DX, DIC X Penicillin Dirithromycin DTM, DT X Macrolide Doripenem DOR X Carbapenem Doxycycline DOX, DC, DOXY X X Tetracycline Eravacycline ERV X X Fluorocycline Ertapenem ETP X X Carbapenem Erythromycin E, ERY, EM X X Macrolide Faropenem FAR, FARO X Penem Fidaxomicin FDX X Macrocyclic Finafloxacin FIN X X X Fluoroquinolone Fleroxacin FLE, Fle, FLX, FO X X Fluoroquinolone Fosfomycin FOS, FF, FO, FM X Fosfomycin Fusidic acid FA, FC X X X Steroidal Garenoxacin GRN X X Quinolone Gatifloxacin GAT X X Fluoroquinolone Gemifloxacin GEM X Fluoroquinolone Gentamicin GM, Gm, CN, GEN X X Aminoglycoside Gentamicin synergy GM500, HLG, Gms Gepotidacin GEP X X Triazaacenapthylene Grepafloxacin GRX, Grx, GRE, GP X Fluoroquinolone Iclaprim ICL X Folate pathway inhibitor Imipenem IPM, IMI, Imp, IP X Carbapenem Imipenem-relebactam X -lactam/-lactamase inhibitor combination Kanamycin K, KAN, HLK, KM X X Aminoglycoside Lefamulin LMU X X Pleuromutilin Levofloxacin LVX, Lvx, X X Fluoroquinolone LEV, LEVO, LE Levonadifloxacin LND X Benzoquinolizine Linezolid LNZ, LZ, LZD X X Oxazolidinone Linopristin- LFE X Streptogramin flopristin Lomefloxacin LOM, Lmf X Fluoroquinolone Loracarbef LOR, Lor, LO X Cephem Mecillinam MEC X Penicillin Meropenem MEM, Mer, MERO, MRP, X Carbapenem MP Methicillin DP, MET, ME, SC X X Penicillin Metronidazole MTZ X X Nitroimidazole Mezlocillin MZ, Mz, MEZ X X Penicillin

©Clinical and Laboratory Standards Institute. All rights reserved. 211 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 245 M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

Glossary II. (Continued) Drug Class or Antimicrobial Agent Agent Abbreviationa Routes of Administrationb Subclass PO IM IV Topical Minocycline MI, MIN, Min, MN, X X Tetracycline MNO, MC, MH Moxalactam MOX X X Cephem Moxifloxacin MXF X X Fluoroquinolone Mupirocin MUP, MOP, MU X Pseudomonic acid Nafcillin NF, NAF, Naf X X Penicillin Nalidixic acid NA, NAL X Quinolone Glossary II Netilmicin NET, Nt, NC X X Aminoglycoside Nitazoxanide NIT X Thiazolide Nitrofurantoin F/M, FD, Fd, FT, X Nitrofurantoin NIT, NI, F Norfloxacin NOR, Nxn, NX X Fluoroquinolone Ofloxacin OFX, OFL, Ofl, OF X X X Fluoroquinolone Omadacycline OMC X X Tetracycline Oritavancin ORI X Lipoglycopeptide Oxacillin OX, Ox, OXS, OXA X X X Penicillin Pefloxacin PEF, PF Fluoroquinolone Penicillin P, PEN, PV X X X Penicillin Piperacillin PIP, PI, PP, Pi X X Penicillin Piperacillin-tazobactam TZP, PTZ, P/T, PTc X -lactam/-lactamase inhibitor combination Plazomicin PLZ X Aminoglycoside Polymyxin B PB X Lipopeptide Quinupristin-dalfopristin SYN, Syn, QDA, RP X Streptogramin Razupenem RZM X Carbapenem Ramoplanin RAM X Lipoglycopeptide Rifampin RA, RIF, Rif, RI, RD X X Ansamycin Rifaximin X Ansamycin Secnidazole SEC X Nitroimidazole Solithromycin SOL X X X Fluoroketolide Sparfloxacin SPX, Sfx, SPA, SO X Fluoroquinolone Spectinomycin SPT, SPE, SC X X Aminocyclitol Streptomycin S, STR, X X Aminoglycoside StS, SM, Streptomycin synergy ST2000, HLS Sulfonamides G, SSS, S3 X X Folate pathway inhibitor (some PO only) Sulopenem SLP, SULO X X Penem Surotomycin SUR X Lipopeptide Tedizolid TZD X X Oxazolidinone Teicoplanin TEC, TPN, Tei, X X Glycopeptide TEI, TP, TPL Telavancin TLV X Lipoglycopeptide Telithromycin TEL X Ketolide Tetracycline TE, Te, TET, TC X X Tetracycline Ticarcillin TIC, TC, TI, Ti X X Penicillin Ticarcillin-clavulanate TIM, Tim, T/C, TCC, X -lactam/-lactamase TLc inhibitor Tigecycline TGC X Glycylcycline Tinoxanide TIN X Thiazolide Tinidazole TNZ X Nitroimidazoles Tobramycin NN, TM, TO, To, TOB X X Aminoglycoside Trimethoprim TMP, T, TR, W X Folate pathway inhibitor Trimethoprim- SXT, SxT, T/S, TS, COT X X Folate pathway inhibitor sulfamethoxazole Trospectomycin TBR X X Aminocyclitol Trovafloxacin TVA, Tva, TRV, TV X X Fluoroquinolone Ulifloxacin (prulifloxacin) PRU X Fluoroquinolone Vancomycin VA, Va, VAN X X Glycopeptide

212 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 246 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use Use With With M02-A12 M02-A12 and M07-A10 and M07-A10 M100S,M100S, 26th 26th ed ed..

Glossary II. (Continued)

Abbreviations: PO, per OS (oral); IM, intramuscular; IV, intravenous.

Footnotes

a. Abbreviations assigned to one or more diagnostic products in the United States. If no diagnostic product is available, abbreviation is that of the manufacturer.

b. As available in the United States.

c. Amikacin-fosfomycin is aerosolized and inhaled. Glossary II

©Clinical and Laboratory Standards Institute. All rights reserved. 213 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 247 M100S, 26th 26th ed. ed. For Use With M02-A12 and M07-A10

Glossary III. List of Identical Abbreviations Used for More Than One Antimicrobial Agent in US Diagnostic Products

Antimicrobial Agents for Which Respective Agent Abbreviation Abbreviation Is Used AZ Azithromycin, Azlocillin AZM Azithromycin, Aztreonam CB, Cb Ceftibuten, Carbenicillin CD, Cd Clindamycin, Cefdinir

Glossary III CF, Cf Cefaclor, Cephalothin CFM, Cfm Cefixime, Cefamandole CFR, Cfr Cefaclor, Cefadroxil CFX, Cfx Cefoxitin, Cefuroxime CH Clarithromycin, Cephradine CL Cephalothin, Chloramphenicol CM Clindamycin, Cefamandole CN, Cn Cephalexin, Cefotetan, Cinoxacin, Gentamicin CP, Cp Cephapirin, Cefoperazone, Ciprofloxacin CPZ Cefprozil, Cefoperazone CZ, Cz Ceftizoxime, Cefazolin DX Doxycycline, Dicloxacillin FO Fleroxacin, Fosfomycin NIT Nitazoxanide, Nitrofurantoin SC Spectinomycin, Methicillin SO Sparfloxacin, Oxacillin TC Tetracycline, Ticarcillin

214 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 248 ©Clinical and Laboratory Standards Institute. All rights reserved. For Use With M02-A12 and M07-A10 M100S, 26th ed.

This page is intentionally left blank.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 249 M100S,For Use 26th With ed. M02-A12 and M07-A10 For Use With M02-A12 M100S, and 26th M07-A10 ed.

The Quality Management System Approach

Clinical and Laboratory Standards Institute (CLSI) subscribes to a quality management system (QMS) approach in the development of standards and guidelines, which facilitates project management; defines a document structure using a template; and provides a process to identify needed documents. The QMS approach applies a core set of “quality system essentials” (QSEs), basic to any organization, to all operations in any health care service’s path of workflow (ie, operational aspects that define how a particular product or service is provided). The QSEs provide the framework for delivery of any type of product or service, serving as a manager’s guide. The QSEs are as follows:

Organization Personnel Process Management Nonconforming Event Management Customer Focus Purchasing and Inventory Documents and Records Assessments Facilities and Safety Equipment Information Management Continual Improvement

M100S does not cover any of the QSEs. For a description of the documents listed in the grid, please refer to the Related CLSI Reference Materials section on the following page.

Safety Process Records Inventory Inventory Personnel Personnel Continual Equipment Equipment Information Assessments Assessments Organization Organization Management Management Management Facilities and Improvement Improvement Purchasing and and Purchasing Documents and Documents Nonconforming Nonconforming Customer Focus Event Management Management Event

EP23 M02 M07 M07 M11 M23

M27 M27S M39 M45 M52

Path of Workflow

A path of workflow is the description of the necessary processes to deliver the particular product or service that the organization or entity provides. A laboratory path of workflow consists of the sequential processes: preexamination, examination, and postexamination and their respective sequential subprocesses. All laboratories follow these processes to deliver the laboratory’s services, namely quality laboratory information.

M100S covers the medical laboratory path of workflow steps indicated by an “X.” For a description of the other documents listed in the grid, please refer to the Related CLSI Reference Materials section on the following page.

Preexamination Examination Postexamination Sample ordering ordering follow-up follow-up Examination Examination Interpretation and archiving Sample transport Results reporting Results reporting Sample collection receipt/processing Results review and Sample management

X X X EP23 EP23 EP23 M02 M02 M02 M02 M07 M07 M07 M07 M11 M11 M11 M11 M27 M27 M27 M27 M27 M27S M27S M27S M27S M27S M39 M45 M45 M45

©Clinical and Laboratory Standards Institute. All rights reserved. 215 Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 250 ©Clinical and Laboratory Standards Institute. All rights reserved. ForM100S, Use With 26th M02-A12 ed. and M07-A10 M100S, 26th ed.

Related CLSI Reference Materials

EP23TM Laboratory Quality Control Based on Risk Management. 1st ed., 2011. This document provides guidance based on risk management for laboratories to develop quality control plans tailored to the particular combination of measuring system, laboratory setting, and clinical application of the test.

M02 Performance Standards for Antimicrobial Disk Susceptibility Tests. 12th ed., 2015. This standard contains the current Clinical and Laboratory Standards Institute–recommended methods for disk susceptibility testing, criteria for quality control testing, and updated tables for interpretive zone diameters.

M07 Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria That Grow Aerobically. 10th ed., 2015. This standard addresses reference methods for the determination of minimal inhibitory concentrations of aerobic bacteria by broth macrodilution, broth microdilution, and agar dilution.

M11 Methods for Antimicrobial Susceptibility Testing of Anaerobic Bacteria. 8th ed., 2012. This standard provides reference methods for the determination of minimal inhibitory concentrations of anaerobic bacteria by agar dilution and broth microdilution.

M23 Development of In Vitro Susceptibility Testing Criteria and Quality Control Parameters. 4th ed., 2016. This guideline discusses the necessary and recommended data for the selection of appropriate interpretive criteria and quality control ranges for antimicrobial agents.

M27 Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts. 3rd ed., 2008. This document addresses the selection and preparation of antifungal agents; implementation and interpretation of test procedures; and quality control requirements for susceptibility testing of yeasts that cause invasive fungal infections.

M27S Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts. 4th ed., 2012. This document provides updated tables for the CLSI antimicrobial susceptibility testing standard M27-A3.

M39 Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data. 4th ed., 2014. This document describes methods for recording and analysis of antimicrobial susceptibility test data, consisting of cumulative and ongoing summaries of susceptibility patterns of clinically significant microorganisms.

M45 Methods for Antimicrobial Dilution and Disk Susceptibility Testing of Infrequently Isolated or Fastidious Bacteria. 3rd ed., 2015. This guideline informs clinical, public health, and research laboratories on susceptibility testing of infrequently isolated or fastidious bacteria that are not included in CLSI documents M02, M07, or M100. Antimicrobial agent selection, test interpretation, and quality control are addressed.

M52 Verification of Commercial Microbial Identification and Antimicrobial Susceptibility Testing Systems. 1st ed., 2015. This guideline includes recommendations for verification of commercial US Food and Drug Administration–cleared microbial identification and antimicrobial susceptibility testing systems by clinical laboratory professionals to fulfill regulatory or quality assurance requirements for the use of these systems for diagnostic testing.

 CLSI documents are continually reviewed and revised through the CLSI consensus process; therefore, readers should refer to the most current editions.

216 Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. ©Clinical and Laboratory Standards Institute. All rights reserved. 251 M100S, 26th 26th ed. ed.

NOTES

217 ©Clinical and Laboratory Standards Institute. All rights reserved. Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015. 252 ©Clinical and Laboratory Standards Institute. All rights reserved. Explore the Latest Offerings From CLSI! As we continue to set the global standard for quality in laboratory testing, we are adding products and programs to bring even more value to our members and customers.

By becoming a CLSI member, your laboratory will join 1,600+ other influential organizations all working together to further CLSI’s efforts to improve health care outcomes. You can play an active role in raising global laboratory testing standards—in your laboratory, and around the world.

Find out which membership option is best for you at www.clsi.org/membership.

Find what your laboratory needs to succeed! CLSI U provides convenient, cost-effective continuing education and training resources to help you advance your professional development. We have a variety of easy-to-use, online educational resources that make eLearning stress-free and convenient for you and your staff.

See our current educational offerings at www.clsi.org/education.

When laboratory testing quality is critical, standards are needed and there is no time to waste. eCLIPSE™ Ultimate Access, our cloud-based online portal of the complete library of CLSI standards, makes it easy to quickly find the CLSI resources you need.

Learn more and purchase eCLIPSE at clsi.org/eCLIPSE.

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015.For more information, visit www.clsi.org today. 950 West Valley Road, Suite 2500, Wayne, PA 19087 USA PRINT ISBN 1-56238-923-8 P: +1.610.688.0100 Toll Free (US): 877.447.1888 F: +1.610.688.0700 ELECTRONIC ISBN 1-56238-924-6 E: [email protected] www.clsi.org

Licensedto:Landspitali-NationalUniversityHospital-DivisionofDiagnosticMedicine Thisdocumentisprotectedbycopyright.CLSIorder#0,Downloadedon12/28/2015.