Whats New in the 2005

Standards for Antimicrobial

Susceptibility Testing
Janet Hindler, MCLS MT(ASCP)
UCLA Medical Center
jhindler@ucla.edu
working as a consultant with the Association of
Public Health Laboratories with support from CDC,
Division of Laboratory Systems

At the conclusion of this talk,

you will be able to
Outline the major changes found in the
CLSI/NCCLS tables (M100-S15).
Discuss ESBL testing of Proteus mirabilis.
List specific drugs suggested for
testing/reporting with Acinetobacter spp.,
Stenotrophomonas maltophilia and Burkholderia
cepacia.
Describe polymyxin B / colistin MIC testing.
Discuss the standard reference method for
2 MIC testing of Neisseria meningitidis.

At the conclusion of this talk,

you will be able to(cont)
State the latest recommendations for detecting
oxacillin resistance and/or vancomycin
resistance in staphylococci.
Explain the performance of the D zone test for
inducible clindamycin resistance in Group B
and other streptococci.
Identify the use of ATCC reference strains for
routine quality control (QC) versus quality
assessment (QA) purposes.
3

CLSI/NCCLS Standards - 2005

M100-S15 Tables (2005)*
..to be used with text documents
explaining how to perform the tests.
M2-A8 Disk Diffusion (2003)**
M7-A6 MIC (2003)**
* M100 updated yearly
**M2, M7 updated every 3 years
4

Reference Terminology
.when I refer to.
M100 -- this means the new tables (M100-S15)
M2 -- this means the disk diffusion method
(described in M2-A8)
M7 -- this means the MIC method (described
in M7-A6)
CLSI = former NCCLS
5

Changes 2005
CLSI/NCCLS M100-S15

Updated information in
M100-S15

General Changes
ADDITIONS
Clarification of incubation temperature range
Daptomycin testing / reporting
Telithromycin reporting
Testing ATCC strains for quality assessment (QA) vs.
quality control (QC)

NCCLS 2005 Changes

Incubation Temperature
Range
Staphylococcus spp.
33-35 C (do not exceed 35 C)
Potential problems detecting MRSA and MRcoagulase-negative staphylococci (MRCoNS)
at >35 C

All other organism / antimicrobials

35 C +/- 2 C
9

Daptomycin
FDA approval for Rx (package insert):
Complicated skin/skin structure infections
due to:
S. aureus
Streptococcus, Groups A, B, C, G
E. faecalis vancomycin susceptible

10

Daptomycin Testing
Susceptibility testing media requirements
Cation-adjusted Mueller-Hinton broth with 50 g/ml
calcium

Disks (30 g) available from Cubist (free)

1-888-RX-DAPTO

MIC Tests check with Cubist or seek

Reference Lab assistance (free)
Laboratory Specialists Inc., Westlake, OH (800) 520-4890
11

Daptomycin Breakpoints
Method
Staphylococcus spp.
Disk diffusion 30 g (mm)
MIC ( g/ml)
Enterococcus spp.
Disk diffusion 30 g (mm)
MIC ( g/ml)

Susc

Int

Res

16
1

11
4

Disk diffusion may fail to detect isolates with reduced

susceptibility [e.g., MICs >1 g/ml (staphylococci) or > 4
g/ml (enterococci)]. Clinical failures may occur with some
disk diffusion S results.
12

Rezai et al. 2004. ICAAC abstract #97a.

Jevitt et al. 2004. ICAAC abstract #48.

Excerpt from:
Suggestions for Verification of AST Results
and Confirmation of Organism Identification
Organism or Group

Category I
Verify at all labs

Enterococcus spp.
Enterococcus faecalis
Enterococcus faecium

Daptomycin-NS

Staphylococcus aureus
Coagulase-negative staphylococci

Daptomycin-NS

Streptococcus, beta group

Streptococcus, viridans group

Daptomycin-NS

NS, not susceptible (only S interpretive criteria); resistance uncommon

13

NCCLS M100-S15 Tables 4 (M2) and 8 (M7)

Daptomycin
When Test/Report?
Obtain input from Medical Staff when
developing your test/report protocol
From CLSI / NCCLS M100-S15
Staphylococcus spp.
Enterococcus spp.
For vancomycin-susceptible E. faecalis only

Streptococcus spp.
Beta-hemolytic streptococcus only
14

NCCLS M100-S15 Tables 1 and 1A (M2,M7)

Telithromycin
FDA approval for Rx (package insert):
Bronchitis, sinusitis, community-acquired
pneumonia due to S. pneumoniae, H.
influenzae, M. catarrhalis
Also
S. aureus (sinusitis)
Mycoplasma pneumoniae, Chlamydophila
pneumoniae, MDRSP* (pneumonia)
*multi-drug resistant S. pneumoniae (includes macrolide-R)
15

Telithromycin
When Test/Report?
Obtain input from Medical Staff when
developing your test/report protocol
From CLSI / NCCLS M100-S15
Staphylococcus spp.
Haemophilus spp.
Footnote f may be used for empiric therapybut test
results often not useful for management of individual
patients.

Streptococcus pneumoniae
16

NCCLS M100-S15 Tables 1 and 1A (M2,M7)

Quality Assessment (QA) vs. Quality

Control (QC) Using ATCC Strains
Using ATCC Strains for QA, e.g., for
Training demonstrate techniques and learn how to do
test to ensure accurate results
Competency make sure each operator performs test
correctly
Test evaluation determine accuracy of results during
test implementation, modification, etc.

Example: D zone Test QA strains

17

Negative S. aureus ATCC BAA-976 (msrA)

Positive S. aureus ATCC BAA-977 (ermA)

Quality Assessment (QA) vs. Quality

Control (QC) Using ATCC Strains
(cont)
Using ATCC Strains for QC, e.g., for
Routine daily or weekly testing to ensure
accurate results. Acceptable results imply the
following are satisfactory:
Equipment
Reagents / media / supplies
Test procedure - operator

Example: D zone Test QC strain

18

QC disks with S. aureus ATCC 25923

Changes 2005
CLSI/NCCLS M100-S15

Gram Negatives

19

Enterobacteriaceae
ADDITIONS
Proteus mirabilis ESBL testing
ESBL testing QC recommendations
(clarification)

20

NCCLS 2005 Changes

Proteus mirabilis
ESBL Testing
Routine screening not recommended
Perform ESBL test when clinically
relevant (e.g., bacteremia)
Consult with medical staff to determine when to
test
Practical approach, test sterile body site
isolates

Use standard ESBL screen test with

21 slight modification

Proteus mirabilis
ESBL Screen Test
Drug

22

Disk Screen
(mm)

MIC Screen
(g/ml)

Cefpodoxime

17

2*

Ceftazidime

22

Aztreonam

NA

NA

Cefotaxime

27

Ceftriaxone

NA

NA

*unique breakpoint for P. mirabilis (as compared to 8 g/ml

for E. coli and Klebsiella spp.); NA, not applicable

Proteus mirabilis
ESBL Testing (cont)
Use standard ESBL phenotypic
confirmatory test without
modification

23

Proteus mirabilis
ESBL Producers
Uncommon in USA
Schwaber et. al. JCM 2004. 42:294
1/171 ESBL positive
TEM -lactamase gene

Have caused significant problems in

some locations (e.g., Europe, South
America)
Nosocomial outbreaks
24

ESBL Test QC Frequency

Disk Diffusion and MIC Methods
Screen Test

Phenotypic Confirmatory
Test

Daily / Weekly QC
K. pneumoniae ATCC 700603*
OR
E. coli ATCC 25922

Daily / Weekly QC
K. pneumoniae ATCC 700603*
AND
E. coli ATCC 25922

QA
K. pneumoniae ATCC 700603*
25 *ESBL gene on plasmid; must store QC strain at -60C or lower

Non-Enterobacteriaceae
ADDITIONS
Table 1 - specific drugs to test/report for:
Acinetobacter spp.
Burkholderia cepacia
Stenotrophomonas maltophilia

MIC testing for polymyxin B / colistin

Disk diffusion interpretive criteria for
trimethoprim-sulfamethoxazole and B. cepacia
26

NCCLS 2005 Changes

CLSI/NCCLS Table 1
M100-S15
M2, disk diffusion

M7, MIC testing

27

CLSI/NCCLS Table 1
M100-S15
M2, disk diffusion and M7, MIC

28

CLSI/NCCLS Table 1
M100-S15 MIC
Pseudomonas aeruginosa and
Other Non-Enterobacteriaceae k
k

Include
Pseudomonas spp.
Nonfastidious glucose-nonfermenting GNB
except

Acinetobacter
spp.
29

Burkholderia
cepacia

Stenotrophomonas
maltophilia

Pseudomonas aeruginosa and

Other Non-Enterobacteriaceae
The following may be indicated for (routine) testing
of some Pseudomonas spp. and other
nonfastidious, glucose-nonfermenting, gramnegative bacilli (not P. aeruginosa)

30

Ticarcillin-clavulanic acid
Trimethoprim-sulfamethoxazole
Cefotaxime or ceftriaxone
Chloramphenicol
Ceftizoxime - urine isolates only
Tetracycline - urine isolates only
CLSI/NCCLS M100-S15 Table 1 (M7)

Acinetobacter baumannii
amikacin
ampicillin-sulbactam
cefepime
ceftazidime
doxycycline
ciprofloxacin
gentamicin
imipenem
piper-tazobactam
trimeth-sulfa

31

R
R
R
R
R
R
R
R
R
R

What should we do when all are R?

Consult with MD
Suggest ID consult
Other drugs to test?
Is isolate important to patient management?
Use reference lab?
Colistin / polymyxin B??
Cystic Fibrosis Referral Center for Susceptibility
and Synergy Testing
http://synergy.columbia.edu/

32

Testing
Colistin / Polymyxin B
MIC and disk diffusion QC ranges for both
MIC breakpoints for polymyxin B only

Polymyxin B MIC result can predict colistin MIC

S 2 g/ml
R 4 g/ml
Can report polymyxin B MIC with comment re:
colistin

Reevaluation of disk diffusion test pending

Disk diffusion failed to identify some R isolates

(primarily S. maltophilia and Acinetobacter spp.);
Gales et al. 2001. J JCM. 39:183-190

Rare resistance in P. aeruginosa

33

Standard MIC Method for

Neisseria meningitidis!

34

NCCLS 2005 Changes

Neisseria meningitidis
Broth Microdilution MIC Testing
Inoculum:

direct colony suspension from

chocolate agar (20-24h growth)
Incubation: 35 C; CO2; 20-24h
Broth:
CAMHB + 2 to 5% LHB
QC:
S. pneumoniae ATCC 49619
E. coli ATCC 25922 (select drugs)
Biosafety Level 2 (BSL 2) safety practices; use biosafety cabinet
35

Neisseria meningitidis
Therapeutic agents
Penicillin
Ampicillin
Cefotaxime
Ceftriaxone
Meropenem
Chloramphenicol
36

Neisseria meningitidis
Breakpoints may be appropriate only for
prophylaxis of meningococcal case
contacts

37

Azithromycin
Ciprofloxacin
Levofloxacin
Minocycline
Rifampin
Sulfisoxazole
Trimethoprim-sulfamethoxazole

Neisseria meningitidis
Resistance Issues
Rare -lactamase producing isolates
6 to date; most recent 1996 (Spain)

Penicillin I or R isolates
Mechanism altered PBP
MICs to extended-spectrum cephalosporins remain low

Resistance to prophylactic agents:

Sulfonamides (common)
Ciprofloxacin (rare)
Rifampin (uncommon)

38

Changes 2005
CLSI/NCCLS M100-S15

Gram Positives
39

Staphylococcus spp.
ADDITIONS
Oxacillin testing/reportingmore on

mecA and PBP2a testing

Use of cefoxitin disk diffusion test
Reporting -lactam results on OX-S staphylococci
Testing Staphylococcus lugdunensis

S. aureus reduced vancomycin susceptibility

BHI vancomycin screen agar
40

NCCLS 2005 Changes

Staphylococcus spp. (cont)

ADDITIONS
Clindamycin induction test QA / QC
recommendations
Fluoroquinolones revised disk diffusion and
MIC breakpoints
Daptomycin disk diffusion and MIC breakpoints
and test / report suggestions (Table 1)
Telithromycin added to Table 1
41

NCCLS 2005 Changes

Oxacillin-Resistant Staphylococci
mecA = genetic determinant of oxacillin resistance
in classic MRSA and MRCoNS
mecA codes for PBP2a which confers oxacillin
resistance
Tests for mecA or PBP2a detect classic oxacillin
resistance
Rare oxacillin-resistant staphylococci (not classic)
that are mecA or PBP2a negative
MICs or zones in R range
borderline oxacillin resistance

42

Phenotypic Tests for mecA-mediated

Resistance in Staphylococci
Disk diffusion test cefoxitin (30 g)
disk (CX DD)
S. aureus - results comparable to oxacillin disk
(OX DD)
CoNS results better than OX DD
Read with reflected light; easier to read than
oxacillin
Report results for OXACILLIN, not cefoxitin

MIC tests test oxacillin

43

Cefoxitin Disk for mecA-mediated

Resistance in Staphylococci
Cefoxitin zone (mm)
Res
Susc
S. aureus
19*
20**
S. lugdunensis
CoNS

24*

25**

* Report as oxacillin resistant

** Report as oxacillin susceptible
CoNS, coagulase-negative staphylococci

44

CLSI/NCCLS M100-S15 Table 2C (M2, M7)

Why does cefoxitin disk diffusion

test work better than oxacillin disk
in detecting isolates with mecA?
mecA is expressed at higher levels in
presence of cefoxitin as compared to
oxacillin

45

Sensitivity / Specificity
Tests for mecA-mediated Resistant Staphylococci

Sensitivity:
Ability to detect resistance
No. R results / No. mecA positive x 100

Specificity:
Ability not to call false resistance
No. S results / No. mecA negative x 100
*mecA = gold standard
46

Sensitivity/Specificity
Tests for mecA-mediated Resistant S. aureus

Sensitivity:
OX MIC = OX DD = CX DD = PBP2a = mecA*
99%
98%
98%
100%

Specificity:
OX MIC = OX DD = CX DD = PBP2a = mecA
100%
99%
100% 100%
*mecA = gold standard
47

courtesy of Swenson and Tenover

Sensitivity/Specificity
Tests for mecA-mediated Resistant CoNS

Sensitivity:
OX MIC = OX DD = CX DD = PBP2a = mecA*
99%
99%
98%
100%

Specificity:
OX MIC = OX DD < CX DD = PBP2a < mecA*
61%
67%
96%
94%**
48

*mecA = gold standard

**all errors S. warneri

courtesy of Swenson and Tenover

Recap of Tests for

MRSA and MRCoNS
S. aureus
Tests for mecA, PBP2a, CX DD, OX DD or OX MIC work
well
CX DD = OX DD = OX MIC results

CoNS

49

Tests for mecA or PBP2a work well

OX MIC may overcall R in non-epidermidis CoNS
CX DD better than either OX MIC or OX DD
Addition of CX DD for strains with OX-R MICs eliminates
some false OX-R (specificity increased from 61% to 91%)

Reporting -lactam Results on

Staphylococcus spp.
Result
Oxacillin-S

Oxacillin-R

50

Report:
If other -lactams are tested and if
reporting necessary, report results
obtained (do not edit)
Report all -lactams as R
despite any S result in vitro

Do We Need to Perform Multiple

Tests to Confirm MRSA?
Factors to consider:
Technical:

Reliability of your routine test system

Competency of staff
Incidence of errors

Patients / setting

51

Source of specimen
Patient history (including previous MRSA)
Incidence of MRSA
Consequences of reporting or missing MRSA

Staphylococcus - Oxacillin
MIC (g/ml)
Susc
Int
Res
S. aureus
S. lugdunensis
CoNS
52

0.25

0.5

CLSI/NCCLS M100-S15 Table 2C (M7)

Staphylococcus lugdunensis
Coagulase
Slide
pos or neg
Tube coagulase
neg
Ornithine decarboxylase
pos
PYR pos
Penicillin susceptible
Sometimes misidentified as S. aureus
53

CMPH, 2004, ASM Press; MCM, 8th ed, 2003 ASM Press

Staphylococcus lugdunensis
Interpretation
MIC
M100 M100
( g/ml) -S14 -S15
cefazolin
0.5 R*
S
clindamycin 0.5
S
S
erythromycin
0.5
S
oxacillin
0.5 R
S
penicillin
0.06 R*
S
vancomycin 0.5 S
S

* Edited to R because of oxacillin-R result

54

NCCLS Interpretive Criteria

Vancomycin - Staphylococcus spp.
VISA
Method
MIC (g/ml)
Disk (30 g)
(mm)

55

Susceptible Intermediate
8-16
4
15

VRSA
Resistant
32
-

Detection of VISA / VRSA

Method
Disk diffusion

VRSA

Not detected May show subtle

growth in zone

NCCLS broth microdilution

reference MIC

Detected

Detected

NCCLS agar dilution

reference MIC

Detected

Detected

Etest (use 0.5 McFarland,

24h incubation)

Detected

Detected

Inconsistent

Inconsistent

Automated systems
56

VISA

VRSA
(3 isolates encountered to date)
Isolate
1
2
3
1
2

57

Vanco MIC (g/ml) 1

1024
32 2
64 2

Reference broth microdilution MIC

Missed or inconsistent results (some < 2 g/ml ) with

automated methods
4/04 CDC recommendation: add vancomycin agar screen
if using automated method

Algorithm for Testing S. aureus with Vancomycin (VA)

Acceptable
Primary Test Methods
Include:

MIC method1 plus VA screen plate

(BHIA with 6 g/ml of VA)
VA MIC <2 g/ml
And NO growth on
VA screen plate

Report as VSSA3

VA MIC <2 g/ml

AND GROWTH on
VA screen plate
(rare)

VA MIC >4 g/ml

AND GROWTH on
VA screen plate

April 2004
Disk diffusion2 plus VA screen plate
(BHIA with 6 g/ml of VA)

VA zone <14 mm
AND GROWTH on
VA screen plate

VA zone >14 mm
AND GROWTH on
VA screen plate

Possible VISA/VRSA

Possible VISA/VRSA

VA zone >14 mm
and NO growth on
VA screen plate

Report as VSSA3

CHECK purity
CONFIRM isolate ID

RETEST using non-automated MIC method4

SAVE ISOLATE

NOTIFY infection control, physician, local health department and CDC5 of possible VISA/VRSA

SEND to reference laboratory for confirmation

Important Footnotes
Laboratories using automated susceptibility test methods should add a commercial vancomycin agar screen plate.
2
Disk diffusion alone is not sufficient to detect VISA.
3
If a laboratory is concerned about a result based on a patients history, MIC testing can be performed at CDC.
4
Non-automated methods: reference broth microdilution, agar dilution, agar gradient diffusion (Etest; use a 0.5 McFarland inoculum and Mueller-Hinton agar).
5
Report to CDC by email: SEARCH@cdc.gov
More VISA/VRSA info: www.cdc.gov/ncidod/hip/vanco/vanco.htm
1

58

Clindamycin Disk Diffusion

Induction Test QA/QC
Daily / Weekly QC
S. aureus ATCC 25923 to QC
erythromycin and
clindamycin disks

QA
S. aureus ATCC BAA-976
(msrA; not inducible)
S. aureus ATCC BAA 977
(ermA; inducible)
59

New MIC Breakpoints ( g/ml)

Staphylococci and Fluoroquinolones*
Old
S
1

I
2

Gatifloxacin

0.5

Levofloxacin

0.5

Ciprofloxacin

Moxifloxacin

60

New

none

R
4

S
No

change

*check M100-S15 for corresponding disk diffusion

breakpoint changes

New Breakpoints - Staphylococci

Gatifloxacin and Levofloxacin
Current commercial systems do not have
modifications; lowest concentration generally 2
g/ml.
Testing strategy:
Test on MD request
Use method that will detect lower level resistance
(e.g., disk diffusion, extended dilution panel, Etest)
It is likely that ciprofloxacin will predict results for
gatifloxacin and levofloxacin
OK to report MICs of 4 or 8 g/ml as R
61

Streptococcus pneumoniae
CHANGE
Table 1A remove or from
fluoroquinolone box

62

NCCLS 2005 Changes

Streptococcus pneumoniae
Table 1A
M100-S14
gatifloxacin or
levofloxacin or
moxifloxacin

63

M100-S15
gatifloxacin
levofloxacin
moxifloxacin

Can no longer extrapolate one fluoroquinolone

result to another for S. pneumoniae

Streptococcus spp.
ADDITIONS
D zone test for inducible clindamycin
resistance in beta-hemolytic streptococci
Testing Group B Streptococcus from
anovaginal screen or urine cultures

64

NCCLS 2005 Changes

Beta-hemolytic Streptococci*
Erythromycin / Clindamycin
Mechanism

Determinant Ery

Efflux
Ribosome modification

mef
erm

R
R

S
S**

Ribosome modification

erm

* Groups A, B, C, G
**requires induction to show resistance
65

Clin

constitutive

Group B Streptococcus
clindamycin
erythromycin
penicillin
vancomycin

S
R
S
S

If erythromycin-R and clindamycin-S, do not report

clindamycin-S without performance of D zone Test
66

D Zone Test Beta Streptococci

Inducible
clindamycin resistance
(erm-mediated)

12 mm
E

CC

Routine disk diffusion test:

Place 2 g clindamycin disk
12 mm from edge of 15 g
erythromycin disk.

No induction

CC

Induction
67

D Zone Test positive and optional comment

Group B Streptococcus
clindamycin
erythromycin
penicillin
vancomycin

R
R
S
S

This streptococcus is presumed to be resistant based

on detection of inducible clindamycin resistance.
Clindamycin may still be effective in some patients.

68

MMWR, 2002, Vol 51

(RR-11)

69

Box 2. Recommended regimens for intrapartum antimicrobial prophylaxis for

perinatal GBS disease prevention*
Recommended

Penicillin G, 5 million units IV initial dose,

then 2.5 million units IV every 4 hours until
delivery

Alternative

Ampicillin, 2 g IV initial dose,

then 1 g IV every 4 hours until delivery

If penicillin-allergic #
Patients not at high risk for anaphylaxis
Recommended
Patients at high risk for anaphylaxis

70

Cefazolin, 2 g IV initial dose,

then 1 g IV every 8 hours until delivery
+

GBS susceptible to clindamycin

and erythromycin

Clindamycin, 900 mg IV every 8 hours

until delivery; OR
Erythromycin, 500 mg IV every 6 hours until
delivery

GBS resistant to clindamycin or

erythromycin or susceptibility
unknown

Vancomycin** , 1g IV every 12 hours until

delivery

Group B Streptococcus
Rx: Recommendations for intrapartum prophylaxis
for Group B streptococci are penicillin or ampicillin.
While cefazolin is recommended for penicillinallergic women at low risk for anaphylaxis, those at
high risk for anaphylaxis may receive clindamycin or
erythromycin. Group B streptococci are susceptible
to ampicillin, penicillin, and cefazolin, but may be
resistant to clindamycin and/or erythromycin. When
a group B streptococcus is isolated from a pregnant
woman with severe penicillin allergy (high risk for
anaphylaxis), clindamycin and erythromycin should
be tested and reported.
71

CLSI/NCCLS M100-S15 Table 2H (M2, M7)

Specimen: Anovaginal
Test:
Prenatal screen
Group B Streptococcus
Group B Streptococci are susceptible to
ampicillin, penicillin and cefazolin, but may be
erythromycin and/or clindamycin resistant.
Contact laboratory if erythromycin
and/or clindamycin testing necessary.
72

Beta-hemolytic Streptococcus spp.

Resistance Rates (USA)*
Beta-hemolytic Streptococcus spp.
Ampicillin / penicillin / vancomycin 0%

Group A
Erythromycin up to 10%
Clindamycin up to 7%

Group B
Erythromycin up to 25%
Clindamycin up to 15%
73

*commonly quoted rates; select studies may have

reported higher rates

Changes 2005
CLSI/NCCLS M100-S15

Quality Assessment /
Quality Control

74

QA / QC
ADDITIONS / Changes
New / modified QC ranges in
Boldface type
Clarify QC testing frequency
Follow manufacturers QC ranges for
commercial systems
Verification table expanded
NCCLS 2005 Changes
75

Reference Guide to
Quality Control
Testing Frequency

Table 3B (M2); 3C (M7)

76

Excerpt from: Reference Guide to

QC Testing Frequency
(for ATCC QC strains after 20-30 consecutive days of satisfactory
daily testing)
No. of days of consecutive
Test modification
Use new shipment or
lot number

QC testing requireda
1
5
20 or 30

Comments

Does not eliminate the need for routine weekly

or daily QC testing.

77

CLSI/NCCLS M100-S15 Table 3B (M2) or Table 3C (M7)

Excerpt from: Reference Guide to

QC Testing Frequency
Note 4: Acceptable MIC QC limits for FDAcleared antimicrobial susceptibility tests
may differ slightly from acceptable
CLSI/NCCLS QC limits. Users of each
device should utilize manufacturers
procedures and QC limits as indicated in
the instructions for use.

78

CLSI/NCCLS M100-S15 Table 3C (M7)

Excerpt from:
Suggestions for Verification of AST Results
and Confirmation of Organism Identification
Organism or
Group
Salmonella
spp.

Category I
Verify at all labs

Category II
Verify institution specific
3rd-generation cephalosporin I or R
Fluoroquinolone I or R or nalidixic
acid-R

When submitting to a public health laboratory, include antimicrobial

susceptibility results for Salmonella spp. that are I or R to 3rd generation
cephalosporins and/or I or R to fluoroquinolone or R to nalidixic acid
Cephalosporin I or R results are primarily S. Enterica serotypes
Typhimurium and Newport occur primarily in serotypes typhimurium and
newport

79

CLSI/NCCLS M100-S15 Tables 4 (M2) and 8 (M7)

Table 2K. Potential Agents of Bioterrorism

Bacillus anthracis
Yersinia pestis
Burkholderia mallei
Burkholderia pseudomallei
Francisella tularensis
80

New Antimicrobial Agents in

M100-S15..
Agent

81

Drug class

Route of
administration

FDA
approved

Dalbavancin

glycopeptide

IV

No

Doripenem

carbapenem

IV

No

Oritavancin

glycopeptide

IV

No

Telavancin

glycopeptide

IV

No

Tigecycline

glycylcycline

IV

No

See Glossary in M100-S15

New Antimicrobial Agents in

M100-S15 (cont)..
New glycopeptides
Goal - improved efficacy over vancomycin

Doripenem
Similar activity to meropenem (gram negatives) and
imipenem (gram positives)

Tigecycline
Broad spectrum activity (except P. aeruginosa),
including activity against highly resistant bugs (e.g.,
MRSA, VRE, resistant GNR)
82

See Glossary in M100-S15

Last pages of M2 and M7

sections of M100-S15

Summary of
Comments and
Subcommittee
Responses

83

Issues Under Discussion by

CLSI/NCCLS (cont)
Re-evaluation of -lactam breakpoints
for Enterobacteriaceae
Example: cefotaxime
Current Susceptible at 8 g/ml
Proposed Susceptible at 1 or 2 g/ml

Substantial data needed

Goal is to more accurately detect all lactamase and other -lactam resistance
mechanisms with revised breakpoints
84

Issues Under Discussion by

CLSI/NCCLS
New Guideline for testing bacteria not
currently addressed in NCCLS AST standards
(e.g. Corynebacterium, HACEK, etc.)
Vancomycin testing of staphylococci
Reevaluation of Table 1 (test/report
suggestions)
Disk diffusion for Neisseria meningitidis
85

Material on your CD-ROM

1.
2.
3.
4.
5.
6.
7.
86

Powerpoint presentation
References
M100-S15 Checklist
Procedure - Vancomycin BHI screen for S.
aureus
Group B Streptococcus MMWR
CDC algorithm for VISA/VRSA
CLSI / NCCLS catalogue

Acknowledgements
Boston NLTN Office

Elizabeth Szymczak
Shoolah Escott
Denise Korzeniowski
Denise McFadden

CLSI / NCCLS Staff

Also

Marty Boehme
Ron Jones
Jim Jorgensen
Susan Munro
Jean Patel
Jana Swenson
Fred Tenover
Barbara Zimmer

This program is made possible by an unrestricted

educational grant From Ortho McNeil Pharmaceutical
87

http://www.phppo.cdc.gov/dls/master/default.aspx

88

http://www.phppo.cdc.gov/nltn/default.aspx

NLTN

89

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