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«Ε μ υ α α Gram α α»
Δου ου α Ανα ο
Επ μ ’ μ μα, μ ί αί « . & . υ α »
E μ υ ί α α α υ μα : - E α (π S. saprophyticus NOVOR) - π φα υπ α (S. aureus VANR, LINR, DPR ) - Expert rules = E μ ία μ α μ α
Έ υα ία αφυ , DD Β υπ υ α αφ μ α α μ M ο:
- ueller-Hinton α - pH 7.2-7.4 - π υπα ATCC 29213 EUCAST α 25923 CLSI
Eνα μα: - 0.5 McF α - μ α μ , φα μ α ί α π α
Επ α : - 35±1°C α α α 16-20 h EUCAST AST EUCAST disk diffusion method version 3.0 January 2013
- 35±2°C 16-18 h (24h α FOX, CNS / Θ>350C ί μ α MRS) CLSI Twenty-Second Information Supplement, M100-S23 2013
αφυ , α :
Z π υ α α , 30cm απ μ μ α α μ φ μ (reflected light) α φ • πί α π υ α EUCAST • μπ α α CLSI
FOX: α π υ απ ,
υπ α μ ί
LIN, MUP (CLSI) μ φ μ
(transmitted light) SXT: α ί α αφ α π υ
α μ α π φα α α
α μ φ μ
Β μ φ μ
αφ α α Gram(+) α α α CLSI 2013 (i)
• Group A: πα αί , υπ α αφ Ο π μ α αμμα
- Staphylococci: PEN, OXA (FOX), ERY CLARI AZITHRO, CLIN, SXT
- Enterococci: AM, PEN
- S.pneumoniae: PEN, ERY, SXT
- Strep. -α μ υ ί: PEN AMP, ERY, CLIN
• Group B: Γί α , α α αφ α υπ α Group A
- Staphylococci: VAN, DP, LIN, RIF, TETRA
- Enterococci: VAN, DP, LIN
- S. pneumoniae: CTX, CLIN, FQNs, MEM, TETs, VAN
•Group C: Eπ α α αφ α μ υμ πίπ ίμ
-Staphylococci: CHLOR, FQNs, GEN, QD
-Enterococci: GT (HL), STR (HL)
- S. pneumoniae: AMX, AMC, CXM, CHLORA, LIN, RIFA,
CEFTAR •Group O: υ , α α α αφ α α αμμα Η
-Staphylococci: Ό α α - α αμ OXA α PEN, AMGs
CLSI: υ α υ ί α α S. saprophyticus
CNS: υπ α π μ α ί υ π
FOXR α ί α MRSA
ΔΕ Α Α Ε ΕΓΧ ΕΦΑ Ω
• Pen 10 units: S ≥29mm, R ≤28 mm • α μ α PEN ≥29mm C
≤0.12 mg/l π π α ί α zone-edge test PCR-blaz
A ί υ MRSA/MRS CLSI 2013
DD mm MIC mg/l
ε≥ I δ≤ ε≤ δ≥ FOX S.aureus, S.lugdunensis 22 21
FOX CNS 25 24
OXA S. aureus, S. lugdunensis 2 4
OXA CNS 0.25 0.5
CEFTAROLINE 30 μg 24 21-23 20 1 4
ΔΕ Α Α Ε ΕΓΧ ΕΦΑ Ω
ΧΑ: MIC≥4mg/l α CLS = C>2mg/l α EUCAST
CLSI MIC mg/l breakpoints
S I R
VA S. aureus ≤2 4-8 (VISA/GISA)
≥16 (VRSA/GRSA)
VACNS ≤4 8-16 ≥32 TEC S. aureus +CNS ≤8 16 ≥32
•Ό GPs μ ί •S. aureus MICTEC/VAN>2mg/l α R, α ί
α μ α GPs α μ α αυ μ ί α απ μα
Staphylococci: Γ υ π π ί α
DD mm MIC mg/l
ε≥ I δ≤ ε≤ I δ≥ ERYTHROMYCIN 23 14-22 13 0.5 1-4 8 CLINDAMYCIN 21 15-20 14 0.5 1-2 4
QUIN/DALFO(MSSA) 19 16-18 15 1 2 4
Η ERY φ μα ί (DD)
Staphylococci: α ί / αμί
EUCAST: « , αμυ ί μπ ί α ί π α α μ α α α SSTIs α μ μα, α ί ί α απί α μφ π υ α »
CLSI: «A μ πα μ α αμυ ί . Ε μπ ί α ί α απ μα μ υ α ί »
α α CLIN αφ α MLSBi :
Staphylococci: μ υ ί
DD mm MIC breakpoints mg/l
μg ε≥ I δ≤ ε≤ I δ≥
GENTAMICIN 10 15 13-14 12 4 8 16
NETILMICIN 30 15 13-14 12 8 16 32
KANAMYCIN 30 18 14-17 13 16 32 64
AMIKACIN 30 17 15-16 14 16 32 64
Β αφ α DD μ α S. aureus/CNS, ί MIC
R α AMIKR
A TOBRAR α KANAR α AMIKR
A GENTR AMGsR
EUCAST: Expert rule α αμ υ ί
CLSI 2013: - Β υπ expert rule, - Β α AMG’s μ αφυ ίμ
Staphylococci, μ υ ί
Screening μ NOR 10μg
DD mm MIC breakpoints mg/l
ε≥ I δ≤ ε≤ I δ≥ CIRPOFLOXACIN5μg 21 16-20 15 1 2 4
LEVOFLOXACIN5μg 19 16-18 15 1 2 4
MOXIFLOXACIN5μg 24 21-23 20 0.5 1 2
NORFLOXACIN(U)10μg 17 13-16 12 4 8 16
Staphylococci:
• ία CLSI α FQs: « αφυ ο ο αναπ ουν αν οχ πα α αμ ν χο νο ον ν, π α υχν χο υα ία » • α α GREP, SPAR, GAT, ENOX (μ α S. saprophyticus α S. epidermidis), υ μ
Expert rule EUCAST α QNs
α CIPR OFLR π π ί α μφ LEVOR α
MOXR
LEVOR MOXR R
FQs
υπ ί :
Βί 200 μg
- DD≥30mm: S
- DD<18mm: R
MIC ε ≤1, δ >256mg/l
« α α α αφ α α ί S. aureus. Tα Ε
α α απ μα , α μα α»
υπ ί :
Βί 200 μg
- DD=6mm: υ α μ α ,
- DD>6mm: απ υ ία υ α
IC R >256 mg/l
Staphylococci: π α
CLSI α DP: α α απ υ
“ υ Σ EUCAST απ CLSI α α π ERY
Antimicrobial agent CLSI susceptibility breakpoint (mg/L)
EUCAST susceptibility breakpoint (mg/L)
Teicoplanin ≤8 ≤2
Gentamicin ≤4 ≤1
Amikacin ≤16 ≤8
Tobramycin ≤4 ≤1
Azithromycin ≤2 ≤1
Clarithromycin ≤2 ≤1
Erythromycin ≤0.5 ≤1
Tetracycline ≤4 ≤1
Doxycycline ≤4 ≤1
Minocycline ≤4 ≤0.5
Clindamycin ≤0.5 ≤0.25
Trimethoprim/sulfamethoxazole ≤2/38 ≤2
Rifampin (CLSI: χ μονο απ ία)
≤1 ≤0.06
Έ υα ία , DD M ο:
MHA
-π υπα Ε. faecalis ATCC 29212 EUCAST α S. aureus 25923 CLSI
Eνα μα:
- 0.5 McFarland α
- μ α μ , φα μ α ί α π α
Επ α :
- 35±1°C α α α 18±20 h, 24h α VA EUCAST
- 35±2°C 16-18 h, 24h α VA CLSI
Αν νω : Z π υ α α , 30cm απ μ μ α α μ φ μ α φ α transmitted light α VA
• πί α π υ EUCAST • μπ α CLSI
DD mm MIC breakpoints mg/l
ε≥ I δ≤ ε≤ I δ≥
PENICILLIN 10units 15 14 8 16
AMPICILLIN 10μg 17 16 8 16
WARNING: α υ υ CEPHS, AMGs, CLIN, SXT Αν PENS AMPS, AMXS, AMCS Α Α AMPS μαίν PENS
E : - α αμ
Γ α α ί α α α ί
DD mm MIC breakpoints mg/l
QC μ E.faecalis 29212
ε≥ I δ≤ ε≤ I δ≥
GENTAMICIN 120μg 10 7-9, Η Β Γ Ω
6 500 500
STREPTOMYCIN 300μg 10 7-9, Η Β Γ Ω
6 1000 2000
Aμ υ ί : screening α HLR υ α
8mm
19mm
DD mm MIC breakpoints mg/l
ε≥ I δ≤ ε≤ I δ≥
VANCOMYCIN 30μg 17 15-16 14 4 8-16 32
TEICOPLANIN 30μg 14 11-13 10 8 16 32
S R R R
sharp fuzzy
E : υ π π ί α
Ε :
DD mm MIC breakpoints mg/l
(Urine only) ε≥ I δ≤ ε≤ I δ≥ CIRPOFLOXACIN5μg 21 16-20 15 1 2 4
LEVOFLOXACIN5μg 17 14-16 13 2 4 8
NORFLOXACIN10μg 17 13-16 12 4 8 16
Έ υα ία S. pneumoniae α Streptococci , DD
M ο:
- HA+ 5% απ μ αίμα α υ + 20mg/l NAD (MH-F) EUCAST
- MHA+5% αίμα π υ CLSI
- π υπα S. pneumoniae ATCC 49619 EUCAST/CLSI
Eνα μα:
-0.5 McF απ α μα EUCAST/CLSI, 1.0 απ α α
(EUCAST)
Επ α :
- 35±1°C 5% CO2 α 18±2 h, EUCAST
- 35±2°C 5% CO2 α 20-24h, CLSI
Aν νω : μπ α π υ μ α α μ φ EUCAST/CLSI
EUCAST/CLSI Screening μ OXA 1μg, α ≥20 mm α ί α « », S AM (per os IV), AM/SUL, AMX, AMC, FEP, CTX, CRO, CPR, CEFTARO, CXM, LOR, ERT, IM,
MEM α PEN (per os IV)
S. pneumoniae: - α αμ
MIC breakpoints mg/l S. pneumoniae
ε≤ I δ≥
PENICILLIN IV « » 2 4 8
PENICILLIN IV « » (3millions units x 6)
0.06 0.12
PENICILLIN per os 0.06 0.12-1 2
AMOXYCILLIN « » 2 4 8
ία: Ό α OXA1μg≤19mm, ί α M C CTX, CRO, PEN / α MEM
MIC breakpoints mg/l
ε≤ I R
CEFOTAXIME/CRO « » 1 2 4
CEFOTAXIME/CRO « » 0.5 1 2
CEFTAROLINE 0.5 DD 30μg
S≥ I R
26 - -
CEFACLOR 1 2 4
A μο EUCAST 2014 α screening α μ ν ία υα ία S.pneumoniae α - α αμ
Δί ο Oxacillin 1μg
Αν μ ο α Ε μ ν ία
≥20mm α α - α αμ S, α α υ ί υ ίμ ( CECI)
<20mm BenzylPEN (« ») α PEN-V ( ί )
R
BenzylPEN (π « ») MIC
AMP, AMX, FEP, CTX,CRO
OXA≥8mm S, α MIC α ί α « »
OXA<8mm, MIC α υ μ α μ α
(MICAMX απ MICAMP)
π α αμ MIC
DD mm MIC breakpoints mg/l
ε≥ I δ≤ ε≤ I δ≥ CIRPOFLOXACIN5μg - - - -
LEVOFLOXACIN5μg 17 14-16 13 2 4 8
MOXIFLOXACIN5μg 18 15-17 14 1 2 4
OFLOXACIN5μg 16 13-15 12 2 4 8
O WT-S.pn ίνα CIPI α OFLI
S. pneumoniae:
Screening μ NOR 10μg
α CIPR OFLR π π ί α μφ LEVOR α
MOXR
Expert rules EUCAST α QNs
LEVOR MOXR α
QNs
• ία CLSI α FQs: LEVOS ί α ΧS α GEMS, α ί φ μ .
• α α GREP, SPAR, GAT, TROVA
Leclercq R, Cantón R, Brown DF, et al. EUCAST expert rules in antimicrobial susceptibility testing. Clin Microbiol Infect. 2011 Oct 21
DD mm MIC mg/l
ε≥ I δ≤ ε≤ I δ≥ ERYTHROMYCIN 21 16-20 15 0.25 0.5 1 CLINDAMYCIN 21 15-20 14 0.25 0.5 1
QUIN/DALFO 19 16-18 15 1 2 4
Η ERY φ μα ί (DD)
S. pneumoniae: α ί / αμί
Η ERY φ μα ί (DD)
Επα μ αν οχ ν CLINDAMYCIN (DTEST): EUCAST2014: « ί μ α μ π π α υ CLIN, π α α α π υ π υ α α α απ ία » CLSI: « ί α α CLIN, πα μ α »
μ α μ EUCAST
αφυ :
mpicillin (S. saprophyticus) Fucidic acid Telavancin Tigecycline Fosfomycin IV
Ε :
igecycline
μ α μ CLSI: • αφυ Telithromycin Dirithromycin Grepafloxacin Enoxacin (S. epidermidis, S. sapropyticus) Lomefloxacin Sparfloxacin Ε Tetracycline Fosfomycin (UTI E.faecalis) Daptomycin
Ευ α