ry

ra
b
EUCAST and susceptibility itesting
L
r e
c
Europe and beyondtu
Le r
e t ho
l i n u
n a
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C M
ES
Gunnar Kahlmeter
EUCAST, ESCMID
 ry
Antimicrobial susceptibility testing
a
i b r
•
e L
r
To guide therapy and predict clinical outcome in individual patients
(clinical breakpoints)
c tu
•
Le
To obtain a basis for empirical therapy
r
(clinical breakpoints)
e t h o
•
l i n u
To screen for organisms with exceptional resistance (ECOFFs) for
n
intervention in health care and a
community
O by
– MRSA, VRE, ESBL, KPC, NDM, MDRTB etc

ID ©
•
C
To determineM the rate of resistance development

E S
(ECOFF and clinical breakpoints)
– To understand and predict resistance development
– To form strategies to counteract resistance development
– Measure success and failure of strategies
 Methods for susceptibility testing
r y
r a
based on antimicrobial activity (MIC) and breakpoints ib
• Phenotypic test methods

e L
r
– MIC, disk diffusion, automated systems like Phoenix, Vitek2, Microscan
– Predict susceptibility and resistance
tu
• Genotypic test methods ec
– Quantifiable

L r
gene oroits product (PCR, WGS)
n e
based on the detection of a resistance
i t h
Tof)
n l a u
– mecA, vanA, vanB, ….PBP2, … betalactamase detection (enzyme detection, Maldi

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– Predict resistance, not sensitivity

D ©
– Not quantifiable

M
• By deduction
I
– Useful for epidemiological purposes.

C
– ”expert rules”

E S
– If MRSA then report all betalactam antibiotics R – or soon not?
If ESBL-positive, then report betalactam antibiotics R – but not any longer!
If erythromycin-resistant, then report all macrolide antibiotics as R;
– Some rules predict susceptibility, others resistance.
– Not quantifiable.
– Unreliable !
 ry
Phenotypic susceptibility testing
ra
is based on Lib
r e
c tu
Le r
e t ho
l i n u
n a
O by
ID ©
CM
E S
 y
MIC tu
e
r
Li b ra r

c
MIC
n
MIC
l
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i ne L
a
e r
u t ho

MIC
E
MIC
SCM ID ©

MIC
 MIC
ry
ra
Li b
e r
c tu
Le r
e t ho
l i n
MIC is a relative measure,
u
influenced by
inoculum, pH,ncations,
y a incubation time,
O b
ID
temperature,
© and more -
C M
S
E can be standardised to the extent
which
where we start believing it is absolute!
Methods for MIC determination
ry
ra
Broth dilution
Li b
r e
c tu
Le r
e t ho
i
MIC is l0.5nmg/L u
n y a
O b
ID
Broth microdilution (BMD)
©
C M 16 8 4 2 1 .5 .25 .12 .06 .03 C

E S
 Surrogate MIC determination
ry
ra
Agar dilution
b
Disk diffusion

Li
r e
c tu
Le r
e t ho
l i n u
n a
O by
Gradient MIC test

D ©
Several manufacturers:

M I bioMerieux (Etest)
Oxoid (M.I.C.E.)

C
Liofilchem (MIC-strip)

E S
 Breakpoints ry
ra
Li
Accepting that the basis for phenotypic AST bis the MIC

r e
(and surrogate quantitative measurements)…

c tu
L ereport rnot only the MIC
and that the ambition is to
e t ho
i n
but also an interpretation
l u (recommendation),
a
phenotypicntests require
O by
breakpoints.

ID ©
C M
E S
 ry
Clinical breakpointsbra
Li
r e
c tu
Le r
e t ho
l i n u
n a
O by
ID ©
CM
E S
 ry
Susceptibility Testing Categorisation
a
i b r
L
e values
Epidemiological cutoff
tu r
c
e r
(ECOFF)
e L o
i
WT≤X mg/L n u t
NWT>Yh mg/L
n l a
mmy NWT<Y
O b
WT≥X mm
ID ©
C M
S
EClinical breakpoints (EUCAST):
S≤X mg/L R>Ymg/L (CLSI R> )
S≥X mm R<Y mm (CLSI < )
 ry
ra
Li b
r e
tu
Clinical breakpoints - MIC-concentrations defined

c
to distinguish treatable from non-treatable

Le r
organisms by rendering organisms Susceptible (S

e ho
≤X mg/L), Intermediate (I) or Resistant (R >Y mg/L)

t
l i n u
n a
O by
ECOFF

ID ©
CM
E S
 ry
Susceptibility Testing Categorisation
a
i b r
e L
Epidemiological cutoff values
tu r (ECOFF)
WT≤X mg/L NWT>Y c
e r mg/L
e L o
WT≥X mm
i n u t
NWT<Y h mm
n l a
O by
ID ©
C M
Clinical breakpoints (EUCAST):
E S S≤X mg/L R>Ymg/L (CLSI R> )
S≥X mm R<Y mm (CLSI < )
 ry
ra
Li b
r e
tu
Clinical breakpoints - MIC-concentrations defined

c
to distinguish treatable from non-treatable

Le r
organisms by rendering organisms Susceptible (S

e ho
≤X mg/L), Intermediate (I) or Resistant (R >Y mg/L)

t
l i n u
n a
O by
ID ©
CM
E S
In the beginning there was one table for ry
ra
everything……
L ib
e r
u
One MIC breakpoint and onetzone diameter
c
Le r
breakpoint to fit all
e t ho
l i n u
n a
O by
I D ©
C M
E S
 ry
CLSI S1 (First Supplement, 1981) ra
Li b
r e
c tu
Le r
e t ho
l i n u
n a
O by
ID ©
C M
E S
NCCLS First Supplement, 1981
- “useful for anything that would grow”
 Tools for determining clinicalry
ra
breakpoints ib L
r e
─
tu
Dose and mode of administration
c
─ Clinical targets
Le r
─
e
Target organisms
t ho
─
l i n u
MIC distributions of target organisms
─
n a
Resistance mechanisms of clinical importance in target
O by
organisms
ID ©
─ Pharmacokinetics of agent in target patients

C M
─ Pharmacodynamics of agent in relation to target

E Sorganism
─ Clinical outcome data for target infections
 ry
ra
Breakpoints are determined Li b by:
r e
c tu
L e r
e t ho
l i n u
1. Medicines n a
agencies (EMA, FDA)
2. D O by committees
Breakpoint
M I ©
Pharmaceutical companies

SC AST companies
E Colleagues who know better
 ry
1. Breakpoints by Medicines agencies
a
i b r
(as part of the process for the approval of new drugs)

e L
tu r
• Evaluation is based of the claims of the company
c
e r
e L
• Evaluation performed by different
o
i n t h
experts/rapporteurs for different agents.
u
n l a
• Agents within a group are dealt with individually and
O by
D ©
in sequence with years in between.
I
M
• “No corporate memory”.
C
S
• No systematic review process.
E
 ry
2. Breakpoints by Breakpoint committees ra
Li b
• Committee members with many competences
r e
- in EUCAST there are 60 experts tinunational groups +
c
e r
L
many external expert committees.
e o
h related agents
n utexisting
• When a new agent islievaluated,
n a
O by
are reviewed as part of the process.

IDover time
©
C M
• Consistency – “corporate” memory.

• E S
Breakpoint committees can decide to review, and when
relevant, revise breakpoints independantly of
pharmaceutical companies or agencies.
 Breakpoint committees 1970 -ra ry
2001
Li b
Committee r e
Country tu Disk diffusion
c
e r
BSAC L
United Kingdom
e o Yes

i n u t h
CA-SFM
n l
France
a
Yes
CRG O by
The Netherlands No
ID Germany
©
M
DIN Yes
NWGA C
S
Norway No
E
SRGA Sweden Yes
NCCLS (CLSI) USA Yes
 ry
Enterobacteriaceae 1975 – 2001
a
i b r
Committee Amoxicillin Cefotaxime

e L
Piperacillin-tazob.
BSAC (UK) 8 / 16 2/2
u r 16 / 16

4 / 32t
CA-SFM (F) 4 / 16
e c 8 / 64

L 4 / 8 or
CRG (NL) 2 / 16

2 / 8li ne 2u
t h 0.25 / 4

DIN (D)
n a /8 0.12 / 1

O8 / 16 by 8 / 32
D
NCCLS (USA) 16 / 64

NWGA (N)
M I 0.5 /©8 1/2 8 / 16

S C
E
SRGA (S) 1/8 0.5 / 1 16 / 16

All of us managed to come up with different breakpoints.

 y
The breakpoint committees didrnot
ra
agree… ib L
er
c tu
Le r
• …not because we disagreed
e t ho
l
• …but we were out i n u
n a
of sync
y
O communicate
• …and did not b with each other
ID © best
• …andMwe all knew
SC
E
 ry
ra
Li b
r e
c tu National Breakpoint Committees

e r
D, F, N, NL, S, UK

e L o
i n u t h
n l a
O by
EUCAST General Committee

D ©
All European Countries + Australia + USA

M I
EUCAST Steering Committee

SC BSAC, CA-SFM, CRG, DIN NWGA, SRGA

E
And 2 reps from the General Committee*

Subcommittees
Antifungals
Expert groups
Anaerobes
Expert Rules
Detection of resistance mechanisms
 ry
We decided to find another role model….
a
i b r
e L
tu r
c
e r
e L o
i n u t h
n l a
O by
ID ©
C M
E S
NCCLS/CLSI in session
 ry
…a steering committee with reps from national
ra
i b
breakpoint committees was formed
L
r e
c tu
Le r
e t ho
l i n u
n a
O by
ID ©
C M
E S
 r y
ra
i b
• To determine clinical breakpoints for existing andLnew agents for
r e
u
bacteria and fungi together with EMA and National breakpoint
committees.
c t
L evalues (ECOFFs)
r
e
• To determine epidemiological cut-off
t h o for bacteria
and fungi
l i n u
n a
O by in Europe (methods, QC, education)
• To develop and standardise AST

ID ©
C M
• To act as an expert committee for EMA, ECDC, EFSA and ESCMID.

• ToS
E act as an umbrella organisation for national breakpoint committees
 EUCAST Subcommitteesary
i b r
• Antifungal susceptibility testing L
r e
tu
(Current chair Maiken Arendrup)

c
– Candida species, Aspergillus species
e r
L
– Amfotericin, conazoles, fungins

e ho
– Methods for MIC-testing of Candidae and Aspergillus
t
l i n u
n
• Anaerobe susceptibility a
testing
y resistance
O intrinsic
• Expert rules and b
ID ©
C M
• The detection of resistance mechanisms of

•E
S
clinical and/or public health importance
Antimycobacterial susceptibility testing (AMST)
(in collaboration with ESGMYC)
 Decision process ra ry
L i b
r e
•
tu
Steering Committee evaluates available data and propose
breakpoints (2 – 3 meetings) ec
L o r
Consultation with nationale h
•
proposed breakpoints l i n ut
breakpoint committees on
n a
O by
•
D
(Revision of proposal)
I ©
•
C M
Open consultation via EUCAST webpage
• S
(Revision
E
of proposal and further consultation)
• Final decision and rationale document (4 – 5 meetings = 1
year)
 Breakpoints in EUCAST
r y
ra
i b
– Existing agents - harmonization of European breakpoints
2008) for antibiotics commonly used and availableLin most countries:
(2002 –

r e
u
Penicillins, cephalosporins, carbapenems, aminoglycosides, fluoroquinolones,

c t
tetracyclines, glycopeptides, macrolides etc

L e (2003r - )
– New agents - together with EMA
e t ho
– Daptomycin
l i n u
– Tigecycline
n a
– Doripenem
O by
D ©
– Telavancin
–
–
M I
Ceftaroline
Ceftobiprole
–
S C
Bedaquiline, Delaminid

E– New glycopeptides, cefalosporineinhibitor agents, and more

• Review of established breakpoints (2009 - ): Glycopeptides,

Carbapenems, Colistin, Doripenem
 ry
Why regular review of breakpoints? ra
Li b
r e
• New resistance mechanisms
c tu
• New agent in class Le r
e t ho
l i
• New clinical data n u
• ExtendedO
n y a
ID b
indications

M ©
• Change in dosing or administration
C
•SChange in target organisms
E
 EUCAST Websites ry
ra
free access
Li b
r e
c tu
Le r
e t ho
l i n u
n a
O by
ID ©
C M
S
EUCAST General website
E
The EUCAST MIC and zone
diameter distribution website

Both available at www.eucast.org

 www.eucast.org
ry
ra
Li b
e
r
c tu
Le r
e t ho
l i n u
n a
O by
ID ©
CM
E S
 ry
ra
Li b
The rationale for breakpoint
r e
decisions is published
c tu
Le r
e t ho
l i n u
n a
O by
ID ©
CM
E S
 ry
EUCAST ra
i b
encourages countries toL form a
r e
National AST Committee
c tu (NAC).
L e r
e t ho
l i n u
n a

E SC M I NAC
D ©
O by

A document describing a prototype NAC

is available on website.
 NAC ra ry
• Antimicrobial susceptibility testing
Li b
r
– Coherent strategy at national level e
– Implementation of breakpoints
c tu and methods

Le
– Education (national workshops,
r
websites)
e
– Translation of documents
t ho
l i n u
n anda
– Liaison and consultation with EUCAST – via the
O
General Committee
b y open consultations

ID stewardship
– Liaison with other national groups involved in
©
C
– QA
M
antimicrobial or surveillance of resistance.

E S
• (Antimicrobial Policies)
• (Antimicrobial Resistance Surveillance)
• (Antimicrobial Consumption and Stewardship)
 y
National AST Committees (NACs), August 2014

a r
Yes
i b r
L
Finland

In the process of forming a NAC

No
r e
u
Norway
Russia

t
Sweden Estonia

c
No information

e r
Latvia

L o
Denmark Lithuania

e t h
Ireland Belarus

i n
Great Britain Nether-

l u
lands Poland

n a
Germany Ukraine
Belgium

O by
Czech
Luxembourg Republic
Slovakia Moldova

ID © France Switzer-
Austria Hungary
Romania

M
land Slovenia
Croatia

C
Bosnia- Serbia
Herze-

S
govina Monte- Bulgaria
negro Mace-

E
Italy
donia Turkey
Portugal
Spain Albania

Greece

Malta

Countries not on this map: Australia Iceland Israel South Africa USA Brazil Morocco
 ry
ra
Li b
e
r
c tu
Le r
e t ho
l i n u
n a
O by
ID ©
CM
E S
 guidelines in EARS-Net ra ry
Trends in antimicrobial susceptibility testing

100
Li b
r e
90

c tu
80
Le r
e t ho
n
70

i u
Percent participants

60
n l a
EUCAST

O by
D ©
50

40
M I
C
CLSI
30

20 E S
10

0
2010 2011 2012 2013
 y
Implementation of EUCAST breakpoints, August 2014

a r
% Laboratories
>50%
i b r
L
Finland

e
10-50%

r
Norway

u
Russia
<10%

t
Sweden Estonia

No information
c
e r
Latvia

L o
Denmark Lithuania

e t h
Ireland Belarus

i n
Great Britain Nether-

l u
lands Poland

n a
Germany Ukraine

O by
Belgium
Czech
Luxembourg Republic
Slovakia Moldova

ID © France Switzer-
Austria Hungary
Romania

M
land
Slovenia

C
Croatia Serbia
Bosnia-

S
Herze- Bulgaria
govina Monte-
negro Mace-

E
Portugal Italy
donia Turkey
Spain Albania

Greece

Malta

Countries not on this map: Australia Iceland Israel South Africa USA Brazil Morocco
 y
Adoption of the EUCAST disk diffusion method, August 2014

a r
% Laboratories
>50%
i b r
L
Finland

e
10-50%

r
Norway

u
Russia
<10%

t
Sweden
Estonia

No information
c
e r
Latvia

L o
Denmark Lithuania

e t h
Ireland Belarus

i n
Great Britain Nether-

l u
lands Poland

n a
Germany Ukraine

O by
Belgium
Luxembourg Czech
Republic
Slovakia Moldova

ID © France Switzer-
Austria Hungary
Romania

M
land
Slovenia

C
Croatia Serbia
Bosnia-

S
Herze- Bulgaria
govina Monte-
negro

E
Portugal Italy Mace-
donia Turkey
Spain Albania

Greece

Malta

Countries not on this map: Australia Iceland Israel South Africa USA Brazil Morocco
 EUCAST in summary ry
ra
•
L b
Tasked to determine clinical breakpoints and iECOFFs and to
standardise methodology in Europe.
r e
c t u
•
e r
External expert committee with regulatory
L
agreements
(ECDC, EMA and EFSA)
Steering committee and aeGeneral h
t o
•
l i n u
Committee with European

n a
and across-oceans representation.
•
O per byear.
Financed by ESCMID
y
and ECDC.
•
ID by Steering
5 two-day meetings
©
•
C M
Decisions taken
consultation.
Committee following open

NoS
•
E membership fees, No charge for documents, Openly and
freely available on internet.
• Results of consultation published.
• Rationale for decisions published.
 Are we in need of even morery
ra
ib
standardisation/harmonisation?
L
re
across borders.
c tu
• Medicine and health care is international – patients move

L e r
e ho
• Comparable resistance data (surveillance)
t
– resistance moves
across borders.
l i n u
n y a
O ofbefficacy.
• Comparable evaluation
ID ©
C M
• Simplify and make procedure
breakpoints,
less costly (determining
AST manufacturing, package inserts, education,

E S
etc)

• Less confusion.
 Needs for Breakpoint Harmonization ry
ra
i b
(Summary of agreement between CLSI and EUCAST breakpoint criteria for 2013)

L
r e
c
No. assessed
tu Same breakpoints Overall
Compoun
Le r
Criteria Susceptible Resistant agreement
Organisms ds

e t ho (%)
Enterobacteriaceae 30

l i n u
60 10 4 23.3%
P. aeruginosa
n 17
a 34 9 3 35.3%
Acinetobacter spp.
O by
10 20 5 3 40.0%
Staphylococci
ID © 25 50 11 5 32.0%

C
Enterococci
M 5 10 2 2 40.0%

E S
S. pneumoniae
All results
27
-
60
234
11
48
11
28
36.7%
32.5%

70 % disagreement between EUCAST and CLSI

Ron Jones, IDSA 2013
Breakpoint Harmonization Needs in USA ry
ra
L
(Summary of agreement between CLSI and USA-FDA PI criteria for 2013)
i b
r e
c tu
Fluoroquinolone a

L e r
• 82 breakpoints across 13 e
t h o
organism groups and six drugs
• Agreement l i n u
n to 100.0% a
O by
– 33.3% (moxifloxacin) (NA) by drug

D © pathogens
– 61.7% forI Gram-negative
– 54.3% for Gram-positive cocci

M
C % disagreement between CLSI and FDA
–S40
Ea. Most commonly used agents (ciprofloxacin, levofloxacin, moxifloxacin, norfloxacin,
ofloxacin and nalidixic acid [NA]).

Ron Jones, IDSA 2013

 ry
ra
International standardisation? Li b
r e
c tu
Le r
t ho
1. Clinicale breakpoints
l i n u
n
2. MIC distributions a and ECOFFs
O by
ID3. Methodology
©
C M
E S
 1. Clinical breakpoints
ry
- international standardisation ra
Li b
• If as a concerted action – who rtakes e the initiative?
– WHO, UN, ISO?
c tu
Le r
– EUCAST or CLSI?
e
model? th
o
– Financing? Business
l i n u
n y a
O b
•
ID
If by evolution and “survival of the fittest”
©
•C
M
– is it then EUCAST or CLSI when judged on…
S Science/credibility?
E • Decision model?
• Influence/transparence?
• Availability to the international community?
 ry
2. Wild type MIC distributions and ECOFFs
a
– international standardisation
i b r
• MIC- (and zone diameter) distribution e L
tu r database is

– >25 000 MIC distributions ec

based on large quantities of MIC (and zone) data

– 100 – 100 000 isolates e

L o r
i
– Data from all partslofn t h
per distribution
u
n a
the world
y
Oand inclusion
– Standardisation
b criteria for how to define
I D © under development
distribution and ECOFF

C M
• TheS
EInternational MIC- and Zone diameter distribution
EUCAST database is being transformed to “the

database” and ECOFFs.

 3. Methodology ry
ra
- international standardisation
Li b
• ISO-standard MIC broth microdilution r e
c tu
ISO 20776-1; 2006.
L e r
e t ho
l i n u
• EUCAST and CLSI n a
recommendations
y identical.
for disk
diffusion areO b
now almost
D Inoculum,
+ MediumI(MH), ©
C M incubation

E S
– MH-F, a few disk potencies
 ry
Conclusion ib ra
e L
We are well on our tu r way to
e c
L o r
international estandardisation….
i n u t h
n l a
O by
ID ©
C M
E S Thank you