Antimicrobial Susceptibility Testing: The Basics

Antimicrobial Susceptibility Testing: The Basics Susan E. Sharp, Ph.D., DABMM, FAAM Director, Airport Way Regional Laboratory Director, Regional Microbiology and Molecular Infectious Diseases Laboratories Kaiser Permanente, Department of Pathology Portland, OR Romney Humphries, Ph.D., DABMM Section Chief, Clinical Microbiology University of California Los Angeles Lost Angeles, CA

Objectives Discuss the basic components of the CLSI M100 S24 document, including Tables 1A and 1B (antimicrobials suggested for routine testing and reporting) and Tables 2 (interpretive criteria). Review key susceptibility testing issues for commonly encountered, clinically relevant organisms, including Staphylococcus, the Enterococcus, Streptococcus pneumoniae Enterobacteriaceae, Pseudomonas aeruginosa and the Nonfermenting GNRs. Examine quality control issues commonly encountered by the clinical laboratory, and define how to resolve these. Review M45 guideline on susceptibility testing for fastidious or infrequently encountered bacteria.

Basic Components Discuss the basic components of the CLSI M100 S24 document Tables 1A & 1B (antimicrobials suggested for routine testing and reporting) Tables 2 (interpretive criteria) Other tables and guidance

CLSI AST Standards January 2014 M100-S24 Tables (2014)* M02-A11 Disk Diffusion Method (2012)^ M07-A9 MIC Method (2012)^ * M100 updated every year ^ M02, M07 updated every 3 years 4

Summary of Major Changes Changes to CLSI documents are summarized in the front of each document. Recent breakpoint addition/revision with dates are listed in the front of M100 document. Information listed in boldface type throughout is new or modified since the previous edition of M100 document. 5

M100: Instructions for Use of Tables I. Selecting Antimicrobial Agents for Testing and Reporting II. Reporting Results III. Therapy-Related Comments IV. Confirmation of Patients Results V. Development of Resistance and Testing of Repeat Isolates VI. Warning VII. Screening Tests VIII. QC and Verification IX. Abbreviations and Acronyms

I. Selecting Antimicrobial Agents for Testing and Reporting Tables 1A & 1B These tables contain suggested groupings of antibiotics that should be considered for routine testing and reporting by clinical microbiology laboratories. The guidelines are based on drugs with clinical indications approved by the FDA.

Tables 1 Table 1A Enterobacteriaceae P.aeruginosa Staphylococcus spp Enterococcus spp Acinetobacter spp Burkholderia cepacia Stenotrophomonas maltophilia Other Nonenterobacteriaceae Table 1B Haemophilus influenzae and H. parainfluenzae Neisseria gonorrhoeae Streptococus pneumoniae Streptococcus spp, b- hemolytic Group Streptococcus spp, Viridans Group

Tables 2A through 2I For each organism group, an additional tables contain: Recommended testing conditions Routine QC recommendations General comments for testing Suggested agents that should be considered for routine testing and reporting Additional drugs that have an approved indication Zone diameters and MIC interpretative criteria

Other tables Tables 1C and 2J Address specific recommendations for testing and reporting results on anaerobes Tables 3: A through I Describe screening tests for other tests to detect particular types of resistance

Table 1A These tables contain suggested groupings of antibiotics that should be considered for routine testing and reporting by clinical microbiology laboratories.

GROUP U SUPPLEMENTAL FOR URINE ONLY GROUP C SUPPLEMENTAL REPORT SELECTIVELY GROUP B PRIMARY TEST REPORT SELECTIVELY GROUP A PRIMARY TEST AND REPORT Table 1A. Suggested Groupings of Antimicrobial Agents With FDA Clinical Indications That Should Be Considered for Routine Testing and Reporting on Nonfastidious Organisms by Clinical Microbiology Laboratories in the United States Enterobacteriaceae Pseudomonas aeruginosa Staphylococcus spp. Enterococcus spp. m Ampicillin d Ceftazidime Azithromycin b or clarithromycin b or erythromycin b Ampicillin n Penicillin o Cefazolin e Gentamicin Tobramycin Amikacin Amikacin Ceftaroline h *Daptomycin j *Daptomycin j Aztreonam Linezolid Linezolid Amoxicillin-clavulanate Ampicillin-sulbactam Piperacillin-tazobactam Ticarcillin-clavulanate Cefuroxime Gentamicin Tobramycin Piperacillin Cefepime Clindamycin b *, Oxacillin i,k Cefoxitin i,k (surrogate test for oxacillin) Penicillin i Trimethoprimsulfamethoxazole Doxycycline Minocycline b Tetracycline a Vancomycin Cefepime Cefotetan Cefoxitin Ciprofloxacin Levofloxacin Doripenem Imipenem Meropenem Piperacillin-tazobactam Ticarcillin *, Vancomycin Rifampin g Cefotaxime d,e or ceftriaxone d,e Ciprofloxacin d Levofloxacin d Doripenem Ertapenem Imipenem Meropenem Piperacillin Trimethoprim-sulfamethoxazole d Aztreonam Ceftazidime Ceftaroline Chloramphenicol b,d Tetracycline a Enterobacteriaceae Pseudomonas aeruginosa Staphylococcus spp. Enterococcus spp. m Chloramphenicol b Gentamicin (high-level resistance screen only) Ciprofloxacin or Streptomycin levofloxacin or (high-level ofloxacin resistance screen only) Moxifloxacin Gentamicin l Cefazolin c (surrogate test for uncomplicated UTI) Lomefloxacin or ofloxacin Lomefloxacin or ofloxacin Norfloxacin Lomefloxacin Norfloxacin Ciprofloxacin Levofloxacin Norfloxacin Norfloxacin Nitrofurantoin Nitrofurantoin Nitrofurantoin Sulfisoxazole Sulfisoxazole Trimethoprim Trimethoprim Tetracycline a

I. Selecting Antimicrobial Agents for Testing and Reporting Should be a decision made at each individual laboratory in consultation with infectious diseases practitioners, pharmacy, P&T, etc. Recommendations for each group include agents of proven efficacy that show acceptable in vitro test performance Considerations for inclusion of agents into the Table include clinical efficacy, prevalence of R, minimizing emergence of R, cost, FDA indications, current consensus for first-choice and alternative drugs.

Tables 1A & 1B Drugs listed together in a single box are agents for which interpretive results (SIR) and clinical efficacy are similar. Within each box an OR between agents indicates those agents for which cross-r and cross-s are nearly complete. Can be used to predict the results of the other EX: Enterobactericacae: ceftriaxone & cefotaxime When there is no OR connecting agents within a box, testing of one agent can not be used to predict results of the other

Tables 1A & 1B Test/Report Groups Group A: Primary Test and Report Considered appropriate for inclusion in a routine, primary testing panel, as well as for routine reporting of results for the specific organism group.

GROUP A PRIMARY TEST AND REPORT Tables 1A: Group A Enterobacteriaceae Pseudomonas aeruginosa Staphylococcus spp. Ampicillin d Ceftazidime Azithromycin b or clarithromycin b or erythromycin b Cefazolin e Gentamicin Tobramycin Gentamicin Tobramycin Piperacillin Clindamycin b *, Oxacillin i,k Cefoxitin i,k (surrogate test for oxacillin) Penicillin i Trimethoprimsulfamethoxazole Enterococcus spp. m Ampicillin n Penicillin o d. WARNING: For Salmonella spp. and Shigella spp., 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 trimethoprimsulfamethoxazole 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. e. Cefotaxime or ceftriaxone should be tested and reported on isolates from CSF in place of cefazolin.

GROUP A PRIMARY TEST AND REPORT Tables 1A: Group A Enterobacteriaceae Pseudomonas aeruginosa Staphylococcus spp. Ampicillin d Ceftazidime Azithromycin b or clarithromycin b or erythromycin b Cefazolin e Gentamicin Tobramycin Gentamicin Tobramycin Piperacillin Clindamycin b *, Oxacillin i,k Cefoxitin i,k (surrogate test for oxacillin) Penicillin i Trimethoprimsulfamethoxazole Enterococcus spp. m Ampicillin n Penicillin o 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.

GROUP A PRIMARY TEST AND REPORT Tables 1A: Group A Enterobacteriaceae Pseudomonas aeruginosa Staphylococcus spp. Ampicillin d Ceftazidime Azithromycin b or clarithromycin b or erythromycin b Cefazolin e Gentamicin Tobramycin Gentamicin Tobramycin Piperacillin Clindamycin b *, Oxacillin i,k Cefoxitin i,k (surrogate test for oxacillin) Penicillin i Trimethoprimsulfamethoxazole Enterococcus spp. m Ampicillin n Penicillin o 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 penicillinasestable penicillins, cloxacillin, dicloxacillin, flucloxacillin, methicillin, and nafcillin.

GROUP A PRIMARY TEST AND REPORT Tables 1A: Group A Enterobacteriaceae Pseudomonas aeruginosa Staphylococcus spp. Ampicillin d Ceftazidime Azithromycin b or clarithromycin b or erythromycin b Cefazolin e Gentamicin Tobramycin Gentamicin Tobramycin Piperacillin Clindamycin b *, Oxacillin i,k Cefoxitin i,k (surrogate test for oxacillin) Penicillin i Trimethoprimsulfamethoxazole Enterococcus spp. m Ampicillin n Penicillin o m. Warning: For Enterococcus spp., cephalosporins, aminoglycosides (except for high-level resistance screening), clindamycin, and trimethoprim-sulfamethoxazole may appear active in vitro, but are not effective clinically and should not be reported as susceptible. n. 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.

GROUP A PRIMARY TEST AND REPORT Tables 1A: Group A Enterobacteriaceae Pseudomonas aeruginosa Staphylococcus spp. Ampicillin d Ceftazidime Azithromycin b or clarithromycin b or erythromycin b Cefazolin e Gentamicin Tobramycin Gentamicin Tobramycin Piperacillin Clindamycin b *, Oxacillin i,k Cefoxitin i,k (surrogate test for oxacillin) Penicillin i Trimethoprimsulfamethoxazole Enterococcus spp. m Ampicillin n Penicillin o o. Enterococci susceptible to penicillin are predictably susceptible to ampicillin, amoxicillin, ampicillinsulbactam, 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.

Group B: Primary Test, Report Selectively Include drugs that may warrant primary testing but they may be reported only selectively, such as when the organism is resistant to agents of the same class in Group A. For selected specimen sources 3 rd gen cephalosporin for enterics in CSF, or SXT for UTI Polymicrobic infections Multiple site infections Tables 1A & 1B Test/Report Groups Pt allergy, intolerance, failure Infection Control purposes (MRSA, VRE, etc.)

GROUP B PRIMARY TEST REPORT SELECTIVELY Tables 1A: Group B Pseudomonas Staphylococcus Enterococcus Enterobacteriaceae aeruginosa spp. spp. m Amikacin Amikacin Ceftaroline h *Daptomycin j *Daptomycin j Aztreonam Linezolid Linezolid Amoxicillin-clavulanate Ampicillin-sulbactam Piperacillin-tazobactam Ticarcillin-clavulanate Cefuroxime Cefepime Doxycycline Minocycline b Tetracycline a Vancomycin Cefepime Cefotetan Cefoxitin Cefotaxime d,e or ceftriaxone d,e Ciprofloxacin d Levofloxacin d Doripenem Ertapenem Imipenem Meropenem Piperacillin Trimethoprimsulfamethoxazole d Ciprofloxacin Levofloxacin Doripenem Imipenem Meropenem Piperacillintazobactam Ticarcillin *, Vancomycin Rifampin g

GROUP B PRIMARY TEST REPORT SELECTIVELY Tables 1A: Group B Pseudomonas Staphylococcus Enterococcus Enterobacteriaceae aeruginosa spp. spp. m Amikacin Amikacin Ceftaroline h *Daptomycin j *Daptomycin j Aztreonam Linezolid Linezolid Amoxicillin-clavulanate Cefepime Doxycycline Ampicillin-sulbactam h. For S. aureus only including Minocycline methicillinresistant Staphylococcus Tetracycline aureus a (MRSA). b Piperacillin-tazobactam Ticarcillin-clavulanate Cefuroxime Vancomycin Cefepime Cefotetan Cefoxitin Cefotaxime d,e or ceftriaxone d,e Ciprofloxacin d Levofloxacin d Doripenem Ertapenem Imipenem Meropenem Piperacillin Trimethoprimsulfamethoxazole d Ciprofloxacin Levofloxacin Doripenem Imipenem Meropenem Piperacillintazobactam Ticarcillin *, Vancomycin Rifampin g

GROUP B PRIMARY TEST REPORT SELECTIVELY Tables 1A: Group B Pseudomonas Staphylococcus Enterococcus Enterobacteriaceae aeruginosa spp. spp. m Amikacin Amikacin Ceftaroline h *Daptomycin j *Daptomycin j Aztreonam Linezolid Linezolid Amoxicillin-clavulanate Ampicillin-sulbactam Piperacillin-tazobactam Ticarcillin-clavulanate Cefuroxime Cefepime Doxycycline Minocycline b Tetracycline a j. Daptomycin should not be reported for isolates from the respiratory Vancomycin tract. Cefepime Cefotetan Cefoxitin Cefotaxime d,e or ceftriaxone d,e Ciprofloxacin d Levofloxacin d Doripenem Ertapenem Imipenem Meropenem Piperacillin Trimethoprimsulfamethoxazole d Ciprofloxacin Levofloxacin Doripenem Imipenem Meropenem Piperacillintazobactam Ticarcillin *, Vancomycin Rifampin g

GROUP B PRIMARY TEST REPORT SELECTIVELY Tables 1A: Group B Pseudomonas Staphylococcus Enterococcus Enterobacteriaceae aeruginosa spp. spp. m Amikacin Amikacin Ceftaroline h *Daptomycin j *Daptomycin j Aztreonam Linezolid Linezolid Amoxicillin-clavulanate Ampicillin-sulbactam Piperacillin-tazobactam Ticarcillin-clavulanate Cefuroxime Cefepime Doxycycline Minocycline b Tetracycline a Vancomycin a. Organisms that are susceptible to tetracycline are also considered susceptible to doxycycline and minocycline. Ciprofloxacin *, Vancomycin Levofloxacin Cefepime However, some organisms Doripenem that are Rifampin intermediate g or Imipenem resistant to tetracycline Meropenem may be susceptible to doxycycline, minocycline, or both. Cefotetan Cefoxitin Cefotaxime d,e or ceftriaxone d,e Ciprofloxacin d Levofloxacin d Doripenem Ertapenem Imipenem Meropenem Piperacillin Trimethoprimsulfamethoxazole d Piperacillintazobactam Ticarcillin

GROUP B PRIMARY TEST REPORT SELECTIVELY Tables 1A: Group B Pseudomonas Staphylococcus Enterococcus Enterobacteriaceae aeruginosa spp. spp. m Amikacin Amikacin Ceftaroline h *Daptomycin j *Daptomycin j Aztreonam Linezolid Linezolid Amoxicillin-clavulanate Ampicillin-sulbactam Piperacillin-tazobactam Ticarcillin-clavulanate Cefuroxime Cefepime Doxycycline Minocycline b Tetracycline a Vancomycin Ciprofloxacin Levofloxacin *, Vancomycin Cefepime Cefotetan Cefoxitin Cefotaxime d,e or ceftriaxone d,e Ciprofloxacin d Levofloxacin d Doripenem Ertapenem Imipenem Meropenem Piperacillin Piperacillintazobactam Ticarcillin Trimethoprimsulfamethoxazole d Doripenem Imipenem Meropenem Rifampin g g. Rx: Rifampin should not be used alone for antimicrobial therapy.

Table 2A. Zone Diameter and Minimal Inhibitory Concentration (MIC) Interpretive Standards for Enterobacteriaceae Testing Conditions Medium: Inoculum: Incubation: Disk diffusion: Mueller-Hinton agar (MHA) Broth dilution: cation-adjusted Mueller-Hinton broth (CAMHB) Agar dilution: MHA Growth method or direct colony suspension, equivalent to a 0.5 McFarland standard 35 2 C; ambient air; Disk diffusion: 16 to 18 hours Dilution methods: 16 to 20 hours Routine QC Recommendations (See Tables 4A and 5A for acceptable QC ranges.) Escherichia coli ATCC * 25922 Pseudomonas aeruginosa ATCC 27853 (for carbapenems) Escherichia coli ATCC 35218 (for -lactam/ -lactamase inhibitor combinations) General Comments (1) For disk diffusion, test a maximum of 12 disks on a 150-mm plate and up to 6 disks on a 100-mm plate; disks should be placed no less than 24 mm apart, center to center (M02, Section 9.2 will be updated during its next scheduled revision to include this recommendation). Each zone diameter should be clearly measurable; overlapping zones prevent accurate measurement. Measure the diameter of the zones of complete inhibition (as judged by the unaided eye), including the diameter of the disk. Hold the Petri plate a few inches above a black background illuminated with reflected light. The zone margin should be considered the area showing no obvious, visible growth that can be detected with the unaided eye. Ignore faint growth of tiny colonies that can be detected only with a magnifying lens at the edge of the zone of inhibited growth. Strains of Proteus spp. may swarm into areas of inhibited growth around certain antimicrobial agents. With Proteus spp., ignore the thin veil of swarming growth in an otherwise obvious zone of growth inhibition. With trimethoprim and the sulfonamides, antagonists in the medium may allow some slight growth; therefore, disregard slight growth (20% or less of the lawn of growth) and measure the more obvious margin to determine the zone diameter. (2) 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. (3) The dosage regimens shown in the comment column below are those required to achieve plasma drug exposures (in adults with normal renal and hepatic functions) on which breakpoints were based. When implementing new breakpoints, it is strongly recommended that laboratories share this information with infectious disease practitioners, pharmacists, pharmacy and therapeutics committees, and infection control committees. NOTE: Information in boldface type is new or modified since the previous edition.

Table 2A. Zone Diameter and Minimal Inhibitory Concentration (MIC) Interpretive Standards for Enterobacteriaceae Antimicrobial Agent Disk Content Zone Diameter Interpretive Criteria (nearest whole mm) MIC Interpretive Criteria (µg/ml) SD D I R S SDD I R Test/Report Group S Comments PENICILLINS A Ampicillin 10 g 17 14 16 13 8 16 32 (4) Results of ampicillin testing can be used to predict results for amoxicillin. See comment (2). B Piperacillin 100 g 21 18 20 17 16 32 64 128 O Mecillinam 10 g 15 12 14 11 8 16 32 (5) For testing and reporting of E. coli urinary tract isolates only. O Ticarcillin 75 g 20 15 19 14 16 32 64 128 β-lactam/β-lactamase INHIBITOR COMBINATIONS B Amoxicillin-clavulanate 20/10 µg 18 14 17 13 8/4 16/8 32/16 B Ampicillin-sulbactam 10/10 µg 15 12 14 11 8/4 16/8 32/16 B Piperacillin-tazobactam 100/10 µg 21 18 20 17 16/4 32/4 64/4 128/4 B Ticarcillin-clavulanate 75/10 µg 20 15 19 14 16/2 32/2 64/2 128/2 CEPHEMS (PARENTERAL) (Including cephalosporins I, II, III, and IV. Please refer to Glossary I.) (6) WARNING: For Salmonella spp. and Shigella spp., first- and second-generation cephalosporins and cephamycins may appear active in vitro, but are not effective clinically and should not be reported as susceptible. (7) Following evaluation of PK-PD properties, limited clinical data, and MIC distributions, revised interpretive criteria for cephalosporins (cefazolin, cefotaxime, ceftazidime, ceftizoxime, and ceftriaxone) and aztreonam were first published in January 2010 (M100-S20) and are listed in this table. Cefuroxime (parenteral) was also evaluated; however, no change in interpretive criteria was required for the dosage indicated below. When using the current interpretive criteria, routine ESBL testing is no longer necessary before reporting results (ie, it is no longer necessary to edit results for cephalosporins, aztreonam, or penicillins from susceptible to resistant). However, ESBL testing may still be useful for epidemiological or infection control purposes. For laboratories that have not implemented the current interpretive criteria, ESBL testing should be performed as described in Table 3A. Note that interpretive criteria for drugs with limited availability in many countries (eg, moxalactam, cefonicid, cefamandole, and cefoperazone) were not evaluated. If considering use of these drugs for E. coli, Klebsiella, or Proteus spp., ESBL testing should be performed (see Table 3A). If isolates test ESBL positive, the results for moxalactam, cefonicid, cefamandole, and cefoperazone should be reported as resistant. (8) Enterobacter, Citrobacter, and Serratia may develop resistance during prolonged therapy with third-generation cephalosporins as a result of derepression of AmpC -lactamase. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. A Cefazolin 30 µg 23 20 22 19 C Ceftaroline 30 µg 23 20 22 19 2 4 8 (9) Interpretive criteria are based on a dosage regimen of 2 g every 8 h. See comment (7). For UTI interpretive criteria, see below under CEPHEMS (ORAL). 0.5 1 2 (10) Interpretive criteria are based on a dosage regimen of 600 mg every 12 h.