principles and practice of antimicrobial susceptibility testing...
TRANSCRIPT
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Principles and Practice of
Antimicrobial Susceptibility Testing
Microbiology Technical Workshop
25th September 2013
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Scope
• History
• Why Perform Antimicrobial Susceptibility Testing?
• How to Perform an Antimicrobial Susceptibility Test– Isolate
– Method (phenotypic, special tests, genotypic)
– Drug
– Standards (how breakpoints are derived; CLSI, EUCAST, BSAC, CDS)
• Understanding An Antimicrobial Susceptibility Test– Categorical interpretation
– 90-60 rule
• Summary
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History
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Source: http://www.biography.com/
Source: http://www.s1darvel.com/
Sir Alexander Fleming
(1881-1955)
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“When I woke up just after dawn on
September 28, 1928, I certainly didn't plan
to revolutionize all medicine by discovering
the world's first antibiotic, or bacteria killer.
But I suppose that was exactly what I did.”
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Why Perform Antimicrobial
Susceptibility Testing?
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Empiric Therapy
InvestigationsDefinitive Therapy
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Patient LAM
• 89 year old Chinese female
• Previously hospitalized 2 months ago for cystitis– Urine culture – ESBL positive E. coli
– Blood cultures – negative
• Now admitted from the A&E with fever, dysuria and increased urinary frequency for 3 days– Urine microscopy – RBC 3, WBC > 2000, EC 0
– Urine culture – no bacterial growth
• Started empirically on IV Piperacillin/tazobactam
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• Predict treatment outcome
• Guide selection of most appropriate agent
• Provide alternatives – drug allergy, oral option
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How to Perform an Antimicrobial
Susceptibility Test
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Results
Standards
Method Drug
Isolate
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Isolate
• Identity of bacterial isolate
• Normal flora
• Clinically significant number of colonies
• Predictable antibiotic susceptibility profile
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Method
• Phenotypic
– Zone diameter
– Minimum inhibitory concentration (MIC)
• Special tests
• Genotypic
Source: CLSI M100-S23E Performance Standards for Antimicrobial Susceptibility Testing - 23rd Informational Supplement
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Source: http://www.cdc.gov/
Source: http://www.cdc.gov/
Disk Diffusion
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Source: http://bacterioweb.univ-fcomte.fr/
Etest (Epsilometer test)
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Source: http://www.cdc.gov/
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Broth Macrodilution
Source: http://web.carteret.edu/ Source: http://web.carteret.edu/
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Automated (Vitek2)
Source: www.biomerieux.com
Source: www.biomerieux.com
Source: www.biomerieux.com
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Source: http://microblog.me.uk/
D-Test for inducible clindamycin resistance
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Clavulanic acid Cephalosporin
ESBL Detection (double-disk approximation)
Cephalosporin
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Source: http://www.cepheid.com/
Source: http://www.pih.org/ Source: http://www.pih.org/
Source: http://www.ahsoman.com/
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Drug
• Species to be tested
• Institution formulary
• Commonly used antimicrobials
• Availability of antimicrobial agent for testing
• Tailored to specific needs of institution
– Infectious disease physicians
– Clinical microbiologists
– Pharmacists
– Committees concerned with institutional formulary
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Source: http://www.eucast.org/
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Standards
• MIC distribution
– Wild-type
– Epidemiological cut-off (ECOFF)
• Pharmacokinetic
• Pharmacodynamic
• Clinical data
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0
10
20
30
40
50
60
70
80
0.125 0.25 0.5 1 2 4 8 16 32 64 128 256
increasing concentration of antibiotic
susceptible resistant
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0
10
20
30
40
50
60
70
80
0.125 0.25 0.5 1 2 4 8 16 32 64 128 256
increasing concentration of antibiotic
susceptible resistant
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Source: http://mic.eucast.org/
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Source: http://mic.eucast.org/
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Source: http://mic.eucast.org/
???
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Standard Location Media Inoculum
CLSI America, several
areas of Europe,
Asia, Australia
Mueller-Hinton agar
Mueller-Hinton agar with 5% sheep blood
0.5 McFarland
EUCAST Europe Mueller-Hinton agar
Mueller-Hinton agar with 5% defibrinated horse
blood + 20 mg/L β-NAD
0.5 McFarland
BSAC United Kingdom Iso-Sensitest agar
Iso-Sensitest agar with 5% defibrinated horse
blood + 20 mg/L NAD
0.5 McFarland
then dilute
(refer to Table)
CDS Australia Sensitest agar
Sensitest agar with 5% horse blood
Refer to Figure
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Source: http://bsac.org.uk/ (Version 12 May 2013)
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Source: http://bsac.org.uk/ (Version 12 May 2013)
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Source: http://bsac.org.uk/ (Version 12 May 2013)
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Source: http://web.med.unsw.edu.au/ (Sixth Edition)
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Source: http://web.med.unsw.edu.au/ (Sixth Edition)
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Source: CLSI M100-S23E Performance Standards for Antimicrobial Susceptibility Testing - 23rd Informational Supplement
CLSI
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Source: CLSI M100-S23E Performance Standards for Antimicrobial Susceptibility Testing - 23rd Informational Supplement
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Source: http://www.eucast.org/
EUCAST
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Source: http://www.eucast.org/
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Source: http://bsac.org.uk/ (Version 12 May 2013)
BSAC
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CDS
Source: http://web.med.unsw.edu.au/ (Sixth Edition)
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Source: http://web.med.unsw.edu.au/ (Sixth Edition)
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Source: http://web.med.unsw.edu.au/ (Sixth Edition)Source: http://web.med.unsw.edu.au/ (Sixth Edition)
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Understanding An Antimicrobial
Susceptibility Test
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Identify
Test
Report
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Categorical Interpretation
Category Interpretation
Susceptible • High likelihood of therapeutic success
Resistant • High likelihood of therapeutic failure
Intermediate • Uncertain therapeutic effect
• Drug concentration at body sites
• Buffer zone
Susceptible-dose dependent (S-DD) • Antifungal susceptibility testing
• Susceptibility dependent on achieving
maximal possible blood level
Nonsusceptible • Often seen with new antimicrobial
agents
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Source: Rex and Pfaller CID 2002 - Has Antifungal Susceptibility Testing Come of Age?
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Summary
• Antimicrobial susceptibility tests allows us to– Predict treatment outcome
– Guide selection of most appropriate agent
– Provide alternatives
• Factors to consider – Isolate
– Method
– Drug
– Standards
• Understanding the results
– Categorical interpretation
– 90-60 rule
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Thank you for your attention!
Dr Jamie Tan ([email protected])
Registrar
Department of Pathology
Singapore General Hospital
Source: http://www.channelnewsasia.com/