CLSI 2012 AST Update

2/1/2012 Speaker Janet A. Hindler, MCLS, MT(ASCP), F(AAM), Senior Specialist, Clinical Microbiology, UCLA Medical Center, Los Angeles, CA Ms. Hindler has worked as a clinical microbiologist for over 30 years, the past 29 at UCLA Medical Center, Los Angeles, CA. She has written and taught extensively in the area of antimicrobial susceptibility testing. From 2000-2004 she held a contract with the Centers for Disease Control and Prevention (CDC) where her focus was to develop and conduct training programs in antimicrobial susceptibility testing. Ms. Hindler is now working as a consultant with the Association of Public Health Laboratories with support from the CDC to continue in this role. She is a fellow in the American Academy of Microbiology, member of the Clinical and Laboratory Standards Institute (CLSI, formerly NCCLS) Subcommittee on Antimicrobial Susceptibility testing, member of ASMs International Committee, Past Chair of ASM Division C and Past President of the Southern California Branch of the American Society for Microbiology. Ms. Hindler was the 2006 recipient of ASMs bioMerieux Sonnenwirth award for leadership in clinical microbiology and in 2007 she received an award from the Clinical and Laboratory Standards Institute for Excellence in Standards Development. Ms. Hindler has served as a consultant to the World Health Organization and assisted in teaching individuals in developing countries about antimicrobial susceptibility testing and antimicrobial resistance. One of Ms. Hindler's primary professional goals is to provide antimicrobial susceptibility testing information to clinical laboratory scientists and clinician Objectives At the conclusion of this program, participants will be able to: Identify the major changes found in the new CLSI documents M02-A11, M07-A9, and M100-S22. Design a strategy for implementing the new practice guidelines into their laboratory practices. Develop a communication strategy for informing clinical staff of updates. Continuing Education Credit The Association of Public Health Laboratories (APHL) is approved as a provider of continuing education programs in the clinical laboratory sciences by the ASCLS P.A.C.E. Program. Participants who successfully complete this program will be awarded 1 contact hour of continuing education credit. Florida CEU credit will be offered based on 1 contact hour. Continuing education credits are available to individuals who successfully complete the program and evaluation by March 2, 2012. The evaluation password is 601bd. Detailed directions for completing the evaluation and printing your certificate are on www.aphl.org/courses/pages/webinarevaluation.aspx. Archived Program The archived streaming video will be available within two weeks. Anyone from your site can view the Web archived program and/or complete the evaluation and print the CEU certificate for free. To register for the archive program go to www.aphl.org/courses/Pages/590-601-12.aspx. and use the complementary discount code 601bd in the discount box during registration. Comments, opinions, and evaluations expressed in this program do not constitute endorsement by APHL or CLSI. The APHL and CLSI do not authorize any program faculty to express personal opinion or evaluation as the position of APHLor CSLI. The use of trade names and commercial sources is for identification only and does not imply endorsement by the program sponsors. This program is copyright protected by the speaker(s), CLSI and APHL. The material is to be used for this APHL program only. It is strictly forbidden to record the program or use any part of the material without permission from the author or APHL. Any unauthorized use of the written material or broadcasting, public performance, copying or re-recording constitutes an infringement of copyright laws.

Whats New in the 2012 CLSI Standards for Antimicrobial Susceptibility S tibilit T Testing ti (AST) ?

At the conclusion of this talk, you will be able to

List the major cha anges found in the new 2012 AST do ocuments: M02 M02A11; M07M07-A9; and d M100 M100-S22. Describe a strateg gy for implementation p o the new practice of p guidelines in your laboratory, as appropriate. app op ate

Janet A. Hindler, MCLS MT(ASCP) UCLA Medical Center jhi dl @ l d jhindler@ucla.edu

and working as a consultant with the Association of Public Health Laborator ries

CLSI AST Standards Januar ry 2012

M100 M100-S22 Tables (201 12)* M02 M02-A11 Disk Diffusion Method ( (2012)** ) M07 M07-A9 MIC Method (2012)** M11 M11-A7 Anaerobe MI IC Testing (2007)
* M100 updated at least yearly y **M02, M07 updated every 3 years

M100M100 -S22 Partial Table of Contents

M100M100 -S22. Page 9.

Major j Cha anges g 2012

Enterobacteriaceae
Revised ertapenem breakp points (again!) Added ciprofloxacin break kpoints for use with S. typhi and extraintestinal isolates s of Salmonella spp.

Summary of Changes

More Breakpoints!

Pseudomonas aerugin nosa

Lowered breakpoints for piperacillin iperacillin, , piperacillinpiperacillintazobactam, tazobactam , ticarcillin, ticarcillin, tica arcillinarcillin -clavulanic acid Lowered breakpoints for im mipenem, mipenem , meropenem; meropenem; added breakpoints for doripenem m

Staphylococcus St h l spp.
M100M100 -S22. Page 13.

Added penicillin disk zone edge test for -lactamase production in S. aureus Breakpoints = interpretive criteria

CLSI Breakpoint Additions / Revisions Since 2010

Breakpoint Revi ision Reminders!

Both CLSI and FDA se et breakpoints for USA Criteria for establishin ng breakpoints differ slightly between CLSI I and FDA Commercial AST syst tems MUST use FDA breakpoints Clinical laboratories can c use either CLSI or FDA breakpoints
Acceptable to accrediting agencies If using FDA FDA-cleared comm mercial AST system, clinical laboratory must verify CLS SI breakpoints on that system before using them

Newer breakpoints now referred to as current!

Previous breakpoints can be found in the version of M100 that precedes the document listed here, eg, previous breakpoints for aztreonam are listed in M100M100-S19 (January 2009). 2009) M100-S22. Page 22.

Setting / Revisin ng Breakpoints Data Used d by CLSI

MIC distributions of f wild wild type type or normal populations of bacte eria
Wild type = no acquired R mechanism

10

PiperacillinPiperacillin -tazobactam MIC distribution example

Blue = wild type is solates Red = isolates wit th acquired q R mechanism

Pharmacokinetic Pharmacokinetic-ph harmacodynamic (PK/PD) analysis MICs associated wit th clinical outcome
Very limited new data d for older drugs
CLSI M23M23-A3 (2008) Development of In Vitro Susceptibility Testing Criteria and QC Param meters; Approved Guideline Guideline describes CLSI process for se etting / revising breakpoints

www.eucast.org g

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What is PK/PD?
PK: pharmacokinetic p cs - the p process by y which a drug is abso orbed, distributed, metabolized, and elim minated by the body
Relates to drug concentration over time

PK/PD Goal (Targe et) for -lactams = % of time during dosing interval i that drug level in patients serum exceeds organisms o MIC (%T > MIC)
Cmax (peak concentration) Serum Conc centratio on (g/m ml)

PD: pharmacodynam mics - the relationship between b t concentrati t tion of fd drug and d its it antimicrobial effects over time in vivo PK/PD can project j t po otential t ti l efficacy ffi of f antimicrobial agents in vivo
Key reference = Cra aig WA. 1998. Clin Infect Dis. 26:126:1-10.

(hypothetical)

MIC Time abov ve MIC

dose

Time (hours)

dose

13

What PK/PD target value v (% Time > MIC) i desired is d i d for f carbap b penems to t attain tt i a bactericidal respons se*?
Organism Enterobacteriaceae Pseudomonas aeruginos sa
*reduction in colony colony-forming g units

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What is the status of o FDA breakpoint revisions related to recent CLSI M100 breakpoint revisions?
FDA breakpoints rece ently revised that now match current CLSI br reakpoints
Ceftriaxone Enteroba acteriaceae (late 2010)

% Time > MIC 35% 30%

Bactericidal activity of -lac ctams depends on length of time free (unbound) levels of o drug in the patients serum exceed MIC ( (% T > MIC) M )
CLSI Agenda Book June 2011

Remember we will not see revised CLSI breakpoints on comme ercial AST devices until FDA revises those breakpoints AST manufacturers MUST use FDA breakpoints!

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Check with manufacturer to determine which i t interpretive ti criteria it i are used with your AST system. y

Resources for Imp plementing g Current CLSI Brea akpoints

CLSI teleconference 2011 (Jean Patel, PhD) archive here
http://eo2.commpartners.com/us sers/clsi/registernow.php?id=10788 sers/clsi/registernow.php?id 10788

Infectious Diseases Soc ciety of America (IDSA) website

http://www.idsociety.org/Antimic crobial_Susceptibility_Testing/

CAP BIT (Breakpoint Im mplementation Tool) available ~Spring 2012

www.cap.org M100-S22. Page 21.

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I Introduct Introducti d tion i

Instructions for Tables 1 and 2

Note: deleted redundant instructions in Tables 1A1A-1C

A few gener ral issues re: M100M100 -S22, S22 M02 2-A11, A11 M07 M07-A9 A9

M100M100 -S22. Page 24.

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Reporting Pro otocol for MDR (M ltid (Multidrug Resis R istant t tO i ) Organisms)
Section I.D. Selective Rep p porting g
. . .

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Specimen: Tracheal As spirate Diagnosis: Pneumonia a Klebsiella pneumoniae

amikacin ampicillin cefazolin cefepime ceftriaxone ciprofloxacin ertapenem gentamicin meropenem piperpiper -tazobactam tobramycin trimethtrimeth -sulfa MIC ( (g/ml) >32 R >32 R >32 R >32 R >32 R >4 R >4 R >16 R >8 R >128 R >16 R >4/76 R SOP should include steps: Discuss with MD MD to suggest additional drugs (e.g., colistin, tigecycline) g y ) to test, if appropriate Indicate how testing will be done ( (e.g., g , in in-house or send to reference lab)

In In addition, addition each laborato ory should develop a protocol to address isolat tes that are confirmed as resistant to all agents on their t routine test panels panels. . This protocol should inclu ude options for testing additional agents inin-house e or sending the isolate to a reference laboratory laboratory. (Now a CAP requirement r - MIC.21944)
M100-S22. Page 26.

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CLSI AST Standards for Routine AST

Added doripenem: doripenem Boldface type No OR with other carbapenems - cannot extrapolate Breakpoints added for several organism groups

The Tables

Disk Diff Diffusion sion

Table 1A Drugs to Test/Report

M100M100 -S22. Page 34.

MIC MIC

23

Good time for yo ou to review. review

M02 M02-A11 and/or M07M07-A9 if using disk diffusion or reference e MIC methods to ensure your procedu ures match current recommendations d ti uct instructions if Manufacturers produ using i commercial i l AS ST
Follow precisely! Use manufacturers QC r ranges! (Verify current CLSI breakpoints, if appropriate for your laboratory)

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Discussion of GNR Resistance Mechanisms M02-A11 - Section 11.3 11 3 M07-A9 - Section 12.3

Upd dated

Descriptions of Drugs M02 A11 - Section 6 M02-A11 M07-A9 - Section 6

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M02-A11 / M07M02M07-A9 S Some Updated U d t d Technical T h i l Tips! Ti !

Read cefoxitin disk with reflecte ed light; oxacillin disk with transmitted light Ceftaroline cephalosporin wit th anti anti-MRSA activity (no CLSI breakpoints, b k i t must t use FDA bre b eakpoints) k i t ) Vancomycin (6 g/ml in BHI) ag gar screen many VISA with MICs of 4 g/ml do not grow on this medium

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QC Range Revisions
Pseudomonas aerug ginosa ATCC 27853 g
Cefepime MIC (now 0.5 0 -4 g/ml) 0.5-

Staphylococcus spp.

E. coli ATCC 25922

Colistin MIC (now 0.2 2525 -2 g/ml)

Streptococcus S pneumon niae i

If oxacillin disk screen is 19mm m, do not report as R without doing penicillin MIC

D zone test
Clarified distance for placemen nt of erythromycin and clindamycin disks (edge to edge)
Staphylococcus 15 15-26 mm -hemolytic Streptococcus 12 2 mm

Added QC ranges for several new agents agents, most of which are in developmental stages
M100-S22. Pages 126-144.

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Enterobacteriace eae - Ertapenem CLSI Breakp point History

CLSI Document MIC ( (g/ml) Susc 2 0.25 0.5 05 Int 4 0.5 10 1.0 Res 8 1 2 Disk Diffusion (mm) Susc 19 23 22 Int 16 16-18 20 20-22 19 19-21 Res 15 19 18

E Enterobac Enterobact t b cteriaceae t i

M100-S20 M100(Jan. 2010)* M100-S20U M100(June 2010) M100M100 -S22 (Jan 2012)**

New N

*same as curre ent FDA breakpoints

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Why did CLSI revise ertapenem breakpoints for Enter robacteriaceae again?
MIC distributions PK/PD (conservatively went with 0.25 g/ml) Very limited clinical data (no patie ents with MICs at 0.5 g/ml)

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2011 breakpoints p primarily p y based on:

2012 breakpoints primarily y based on:

Additional surveillance data show wed isolates with MICs of 0.5 g/ml did not have carbapenemases Further review of PK/PD Additional clinical data (including g ESBLESBL-producing E. coli with 0.5 g/ml MICs suggested clinical res sponse) Also, lowest ertapenem concentr ration on some commercial panels is 0.5 g/ml thus allowing labs to us se CLSI ertapenem breakpoints (following verification) if breakpo oint is 0.5 0.5 g/ml but not if 0.25 0.25 g/ml CLSI Agenda Book June 2011

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32

Ertapenem - Cumulat tive % Inhibited at MIC

(N 356 KPC P d ing E t b t i ) (N= Produci Enterobacteriaceae)
90 80 70 60 50 40 30 20 10 0 89.3 Cumulative % In nhibited

Susc

Int

Res

0 <=0.25

0.3 0.5

0.8

2.2

7.3

1 2 MIC (m mcg/ml)

>=8.0

CLSI Agenda Book June 2011

CLSI Agenda Book June 2011 (Sentry Surveillance Program)

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Table 2A. Ent terobacteriaceae

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Table 2A. Ent terobacteriaceae

when using g the current cephem breakpointsESBL testing g may y still be useful for epidemiological or r infection control purposes. For laboratories that have not imple emented the current interpretive criteria, ESBL testing should be pe erformed as described in this table.
M100M100 -S22. Table 2A. Page 45.

U til l Until laboratories b t i can implement i l t the th current t carbapenem b interpretive i t ti criteria, it i the the Modified Hodge Test (MHT) sho ould be performed as described in the updated Table 2A Supplemental Table 3. After implementation of the current interpretive p criteria, , MHT does not need n to be p performed other than for epidemiological or infec ction control purposes. M100M100 -S22. Table 2A. Page 45.

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Modified Hodge Test for Carbapenemases

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Modified Hodge Test (MHT) (Table 2A Suppleme ental Table 2 and 3)

NOTE: Not all carbapenemase enemase-producing teriaceae are MHT isolates of Enterobact positive and MHT MHT-posi itive results may be encountered in isolate es with carbapenem resistance mechanism ms other than carbapenemase p produ p uction.

(old breakpoints)

M100M100 -S22. Table 2A Supplemental T bl 2 and Tables d 3. 3 Pages 5252-60.

(current breakpoints)

M100M100 -S22. Table 2A Supplemental Tables 2 and 3. Pages 53 and 57.

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Classification of Carbapenemases C
Found in: K. pneumonia iae and other riaceae Enterobacter S. marcescen ns P. aeruginosa a Enterobacter riaceae Acinetobacte er S maltophilia S. a Notes Hydrolyze all -lactams Inhibited by b clavulanic cla lanic acid A KPC1

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Value of MHT for Carb bapenemase Detection

(isolates tested included Ente erobacteriaceae suspicious for carbapenemase based on ertapenem MIC 0.5 g/ml)
MHT2 Positive Negative Not interpretable Not Done
1 2 3

Class Carbapenemase

SME B Metallo beta betalactamases (IMP, VIM, GIM, SPM NDM2) SPM,

OXA

Acinetobacte er baumannii riaceae Enterobacter

Hydrolyze all -lactams except aztreonam Somewhat inhibited by clavulanic acid Require zinc for enzymatic activity; inhibited by EDTA Less able to hydrolyze carbapenems

Carbapenemase1 Positive Negative (N=35) (N=19)3 24 11 74 4 7 2

previously characterized d performed using ertapen nem disk AmpC overproducers or r ESBL +/- permeability defect 4 NDM-1 (note: 7/14 NDM-1 producers were MHT negative Sensiti it 77.4%; Sensitivity 77 4% Specificity Specificit 38 38.9% 9% - Good G for KPC and OXA OXA; poor for NDM-1 NDM 1 Gir rlich et al. 2012. J Clin Microbiol. 50:477.

Klebsiella pneumoniae carbapenemase most common carbapenemase in USA USA. New Delhi metallo -lactamase Adapted from Queenan & Bush. 2007. Clin n Microbiol Rev. 20:440.
1 2

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4 Select CRE Examples: Carbapenem MICs & MHT & -Lactam Resistance R Mechanism
Organism MIC ( (g/m ml) 1 Ertap Imip Mero 4R >16 R 4R 0.25 S 8R 1S 8R 2I >16 R 2R MHT Pos4 Pos5
5

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When shoul ld we do MHT?

If using Old Breakpoints and Carbapenemase screen is positive Perform MHT If using Current Breakpoints and MHT test requested for epidemiology Perform MHT

E. coli2 E. K. coli3 pneumoniae3

1 Interpreted 2 Anderson,

R i t Resistance mechanism Plasmid amp pC ESBL blashv NDMNDM -16 IMPIMP -46

K. pneumoniae2 >16 R

>16 R Neg g Pos

with current breakpoints KF et al. 2009. ICAAC C. D-719. 3 Limbago, BM. CLSI Agenda boo ok. January 2011. 4 MHT positive only with ertapen nem disk 5 MHT same result with ertapene em and meropenem (and imipenem) disks 6 Carbapenemases (metallo -lac ctamases)

M100M100 -S2 22. Comment (23) Page 47. Table 2A Suppleme ental Tables 2 and 3. Pages 52 and 56.

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S. typh hi and Extraintestinal Salmonella S spp spp.

S. typhi and Extrain ntestinal Salmonella spp. and Fluo oroquinolones

The story. For F S. S t typhi hi and d extraintestina t i t ti al l infections i f ti with ith Salmonella, S l ll clinical response rates to cipr rofloxacin are poorer for isolates with reduced ciprofl loxacin susceptibility (MICs of 0 12 1.0 0.12 1 0 g/ml)
Crump et al. 2008. Antimicrob Agen nts Chemother. 52:1278. Parry et al. 2010. Antimicrob Agents s Chemother. 54:5201

P Previously i l suggested t d could ld detect d t t with ith nalidixic lidi i acid id test t t Isolates with newer mechanis sms of reduced ciprofloxacin susceptibility p y not readily y dete ected with nalidixic acid test 2012
New ciprofloxacin breakpoints New comment for Intermediate Intermediate e strains e Revised recommendations for nalidixic n acid test

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Table 2A. Ente erobacteriaceae (i l di Sal (including S l lmonella ll spp.) ) Old Ciprofloxac cin Breakpoints
DD (mm) Susc Int 21 16 16-20 Res 15 MIC ( ( g/ml) Susc Int Res 1 2 4

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Salmone ella spp. E t i t ti l Isola Extraintestinal I lates t Nalidixic N lidi i Acid A id Old Recomm mendations
If fluoroquinolonefluoroquinolone-S, test nalidixic acid to detect reduced fluoro oquinolone susceptibility If nalidixic acidacid-R.. Inform clinician that the isolate may not be eradicated by fluoroq quinolone treatment; infectious diseases consult c suggested
M100M100 -S21. Table 2A. Page 46.

M100M100 -S21. Table 2A. Page 46.

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Table 2A. Ente erobacteriaceae Ciprofloxacin n Breakpoints

Organism DD (mm) Susc c 21 31 Int 1616 -20 2121 -30 Res 15 20 Susc 1 MIC ( ( g/ml) Int 2 Res 4 1

Enterobacteriaceae other than S. typhi and extraintestinal S l Salmonella ll spp. S. typhi and extraintestinal Salmonella spp. New

0.06 0.12 0.12-0.5

S. S typhi t hi and d Extraintes E t i t stinal ti l Salmonella spp. and Fluoroq quinolones

M100M100 -S22. Table 2A. Page 48.

M100M100 -S22. Table 2A. Page 48.

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S. typhi and Extrainte estinal Salmonella spp. N lidixic Nalidix i Acid A id

Strains of Salmonella that test t resistant to nalidixic acid may be associated with clini ical failure or delayed response in fluoroquinolonefluoroquinolone-treated patients p with extraintestinal salmonellosis However However, nalidixic acid may y not detect all mechanisms of fluoroquinolone resistance. resistance. Therefore, Salmonella strains may also be tested with cipr rofloxacin and reported using the Salmonella spp. interpre etive criteria above above

Nalidixic acid test, althoug gh not optimal, remains in M100M100 -S22 S with notes:

S. typhi and Extraintesti inal Salmonella spp. and Ciprofl loxacin

M100M100 -S22. Table 2A. Page 48.

CLSI considered deleting nalidixic acid a test, however, retained it in part due to plea from Latin American cou untries and others where S. typhi more common and sophisticated AS ST lacking M100M100 -S22. Table 2A. Page 48.

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Salmone ella spp.

Fluoroquinolo one Resistance
Genotype
gyrA (single mutation) 1, 2 chromosomal gyrA, gyrB (multiple mutations) chromosomal qnr +/ +/- aac(6) aac(6 ))-lb lb-cr 1, 2 plasmid (newer mechanism) No resistance genes
1 2

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Phenotype
Nalidixic Acid Usually Resistant Resistant Often Susceptible Usually Susceptible Ciprofloxacin MIC ( (g/ml) 0.12 - 1.0 4 0.12 - 1.0 0.06

Salmonella spp. s USA 2009 % S to Ciprofloxacin at MICs*

Organism Salmonella spp. (non(non ( -typhoidal) yp ) Salmonella typhi N 2192 2 361 Ciprofloxacin MIC (g/ml) 0.06 0 06 0.120 12-1.0 0.12 1 0 2.0 20 97.7 39.9 2.2 56.5 0.1 3.6

low level resistance (reduced susc ceptibility); not detected with standard Enterobacteriaceae cip profloxacin breakpoints p p reports of delayed response to cip profloxacin therapy or treatment failure (S. typhi and extraintestinal infecti ions)

* CDCs National Antimicrobial Resistance Monitoring System (NARMS)

http://www.cdc.gov/narms/

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S. typhi and Extrainte estinal Salmonella spp. Ciprofloxa acin Testing

Optimal to do ciprofloxacin MIC Low dilutions reflected in new w breakpoints not on automated systems consider Etest? If doing disk diffusion, diffusion consider testing nalidixic acid and ciprofloxacin disks
Nalidixic acid does best for isola ates with gyrase mutations (gyrA) Ciprofloxacin does best for isola ates with plasmid plasmid-encoded gene mutations

Reduced fluoroquinolone susceptibility due to chromosomal gyrase gene mutations more common c than plasmid plasmid-encoded gene mutations Breakpoints for other fluoroqu uinolones (e.g., levofloxacin) under evaluation
CLSI Agenda Book January 2011

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What drugs are reco ommended for reporting on Salmon nella spp.?
(2) Wh When f fecal l isolate i l tes of f Salmonella S l ll and d Shigella spp. are teste ed, only ampicillin, a fluoroquinolone, fluoroquinolone , and trimethoprim t trimethoprimsulfamethoxazole should be reported routinely In addition, routinely. addition for f extraintestinal isolates of Salmonella a spp., a third thirdgeneration g cephalospo p porin should be tested and reported, and chlo oramphenicol may be tested and reported if requested.
M100M100 -S22. Table 2A. Page 44.

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Strategy for AST of o Salmonella spp. Fecal Isolates

No routine AST in othe erwise healthy patients
Salmonellosis generall ly selfself-limiting and antibiotic therapy not r routinely recommended
Guerrant et al. 2001. Clin Infect Dis. D 32:331. (IDSA Guidelines)

Develop p policies p with medical staff for AST of isolates from patien nts with underlying conditions (e.g. immunosuppression; HIV)
Conservatively, can co onsider highlighting lower (new) ciprofloxacin bre eakpoints

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Strategy for AST of S. . typhi and Salmonella spp. from Extrain ntestinal Sources
Perform AST (new) ) cipro p ofloxacin breakpoints p Use lower ( Apply to fecal isolate es in patients with concomitant isolates s from other body sites
Other than for S. typhi and/o or extraintestinal Salmonella spp infections, spp. infections there are limited data that suggest fluoroquinolones would not be effective for isolates with reduced fluoroquinolone susceptibility (e.g., ciprofloxacin MIC 0.12 MICs 0 12 2 1 g/ml) 2-1 / l)

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Note: optional comment below NOT Specimen: Stool part of new CLSI recommendations Diagnosis: Diarrhea Salmonella spp. (not S. typhi)

ampicillin ciprofloxacin ceftriaxone trimethoprimtrimethoprim -sulfa

MIC (g/ml) >3 32 R 0.5 5 S* 0.5 S 0.5/9.5 S

MD requests q AST on this HIV patient

*Susceptibility testing done pe er Dr. Jones request. Ciprofloxacin MIC of 0.5 g/ml suggests s ciprofloxacin may not be effective in patients with extr raintestinal infections. Infectious f diseases consult sug ggested.

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Breakpoint (MIC g/ /ml) Revisions

Agent Old (M100(M100-S21) Susc 64 64/4 64 64/2 Int Res 128 128/4 128 128/2 Susc 16 16/4 16 16/2 New M100 M100-S221 Int 3232 -64 32/4 32/4-64/4 3232 -64 32/2 32/2-64/2 Res 128 128/4 128 128/2

Pseudomonas a aeruginosa

P Pseudomonas d s aeruginosa i

Piperacillin PiperacillinPiperacillin tazobactam Ticarcillin TicarcillinTicarcillin clavulanate

1

Corresponding disk diffusion bre eakpoints also revised

M100M100 -S22. Table 2B 2B-1. Page 63.

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Pseudomona as aeruginosa

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Section III. III

Therapy y-Related Comments

In In cases where sp pecific dosage regimens are impo ortant for proper application of brea akpoints the dosage akpoints, regimen is listed. These T dosage regimen comments s are not intended for use on individu ual patient reports reports. .
Dosage comments Dosage t (3 g every 6 h also for pip peracillin and for ticarcillin)
M100M100 -S22. Table 2B 2B-1. Page 63. M100M100 -S22. Instructions. Page 28.

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Pseudomonas aeruginosa Penicillins +/ +/- -lac ctamase Inhibitors

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Outcomes of bacteremia (N=34 episodes) due to P. aeruginosa with re educed susceptibility to piperacillinpiperacillin -tazobactam m

P P. aeruginosa breakpoints originally set higher than those for Enterobacteriaceae based in part on FDA label noting that these drugs should be co onsidered in combination therapy with aminoglycoside Deleted comment from Table 2B 2 -1 - Rx: The susceptible 2Bcategory for penicillins, -lact tam/-lactamase inhibitors implies the need for highhigh-dose e therapy for serious infections caused by P. aeruginosa. For these infections, monotherapy has been associated with clinical failure P. P aer aeruginosa ginosa MIC breakpoints s are no now the same as those for Enterobacteriaceae (slight t differences in disk diffusion breakpoints)

85.7%

Clinical data suggest gg former breakpoints too high!

30.0% 20.5%

22.2%

Tam et e al. 2008. Clin Infect Dis. 46:862.

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Pseudomonas ae eruginosa B Breakpoint k i t (MIC g/ / l) Revisions R i i /ml)

Agent Doripenem2 Imipenem3 Meropenem3 4 4 Old (M100(M100-S21) Susc Int None 8 8 16 16 Res Susc 2 2 2 New M100 M100-S221 Int 4 4 4 Res 8 8 8

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Why is S breakpoint t for P. aeruginosa and carbapenems higher th han S S breakpoint for Enterobacteriaceae?
Animal models studies have de emonstrated The Time above MIC (T>MIC) required for an antibacterial effect is lower (ie, 30% vs. 35 5%). This means the percentage of time the serum levels mus st stay above the MIC of the isolate to kill P. aeruginosa is s less than that for Enterobacteriaceae. The Th amount t of f drug d required i d to t kill P. P aeruginosa i i less is l than that required for Enterobacteriaceae. After the drug g is gone, g , there continues to be a post p antibiotic effect which mean ns there is still some antibacterial effect occurring g against P. aeruginosa. This is not as apparent pp in Enterobac cteriaceae.
Fantin et al.. 1991. Antimicrob Agents Chemother. 35:1413. W. Craig, MD. Personal communication.

1 2 3

corresponding p g disk diffusion breakpoints p also revised Interpretive criteria are based on dosage d regimens of 500 mg every 8 h Interpretive criteria are based on dosage d regimens of 1 g every 8 h

M100M100 -S22. Table 2B 2B-1. Page 63.

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P. aeruginosa a - Penicillins 46 Sentry 20052005-09) % at MIC (N=7,84

60 50 %a at MIC 40 30 20 10 0 8 <=8 6 16 3 32 MIC (mcg/ml) 6 64 8 >=128

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P. aeruginosa - Carbapenems 46 Sentry 20052005-09) % at MIC (N=7,84

Susc Int Res
Doripenem p Imipenem Meropenem 40

Susc

Int t

Res
Piperacillin p Pip-tazobactam Ticar-clavulanate

35 30 %a at MIC 25 20 15 10 5 0 0 5 <=0.25 0 5 0.5 1 2 4 8 >=8 MIC (mcg/ml)

*imipenem, meropenem

CLSI Agenda Book June 2011

CLSI Agenda Book June 2011

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P. aeruginosa
% S Using Old vs. New Breakpoints

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(N=7,846 Sentry Su urveillance 20052005-09)

Agent Piperacillin PiperacillinPiperacillin -tazobactam TicarcillinTicarcillin -clavulanate Doripenem Imipenem Meropenem M Breakpoints ( MIC (g/ml) M100 0-S21 2011 M100 M100-S22 2012 78 83 68 74 79 64 70 16 76 70 72

St h l Staphylococcus spp. - Penicillin P i illi

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Staphylococcus spp. s Penicillin (1)

The story.. y > 90% of staphylococci are penicillin R Penicillin rarely y conside ered for treatment of staphylococcal infection ns
but might be considere ed for infections requiring lengthy therapy (e (e.g., g end docarditis osteomyelitis) IF docarditis, penicillin S

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Staphylococcus spp. s Penicillin (2)

Previous recommendatio on:
Perform induced nitrocefin n -lactamase test if penicillin zone diameter 29 mm and d/or MIC 0.12 g/ml before reporting penicillin S Test subsequent isolates on o a patient PCR for the blaZ -lactama ase gene may be considered
Penicillin Brea akpoints MIC ( ( g/ml) S 0.12 I R 0.25 Zone (mm) S 29 I R 28

Some Staphylococcus spp. s that test S by MIC or disk diffusion may po ossess a -lactamase and may fail penicillin th herapy

M100M100 -S21. Table 2C. Page 70.

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Induced -lac ctamase Test

Oxacillin n (inducer r)

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Staphylococ ccus aureus -lacta l tamase

Induced nitrocefin -lact tamase test usually but does not always detect staphylococcal s lactamase Other -lactamase tests more sensitive
Cloverleaf test Penicillin disk zone edge test

- Sub isolate to agar (e.g., BAP, MH HA) - Drop -lactam disk (e.g., ( oxacillin n, cefoxitin) - Incubate overnight g - Test cells from periphery of zone - If -lactamase positive (with or without induction), induction) report penicillin R

blaZ gene PCR not optim mal for -lactamase

blaZ codes for -lactamas se production Several types of blaZ genes
Pos Neg

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Staphylococ ccus aureus 3L Lab b* -lactam l t mase Study St d (1)

303 PCR negative (300 blaZ neg; 3 blaZ pos with mutations) ) 45 PCR positive

Bacteria: 348 MSSA (low penicillin p MICs) characterized for f function f nal blaZ by PCR: C

Staphylococcus p y aureus s 3 Lab -lactamase Study (2) (

348 i isolates l t showing h i bla bl Z and d penicillin MIC results: 1 blaZ neg g and penicillin p R 23 blaZ pos and penicillin MIC S S Pen MIC (g/ml) Breakpoints Susc 0.12 Int Res 0.25

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Pen MIC (g/ml) 0.008 0.016 0.032 0.06 0.12 0 25 0.25 0.5 10 1.0 2.0 4.0

blaZ functional Neg 2 15 180 90 15 1 1 5 17 14 4 2 1 303 45 Pos

Methods:
Penicillin MICs C Phenotypic -lactamase tes sts
Nitrocefin - Cefinase Nitrocefin - Dryslide Cloverleaf assay Penicillin disk zone edge

*Statens Serum Institut (Denmark), , CDC (Atlanta), MGH (Boston)

CLSI Agenda Book January 2011.

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Cloverleaf Assay for -lactamase S. aureus

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-lactamase negative

A
5% sheep blood agar 1 unit penicillin disk S. aureus ATCC 25923 as the indicator -lactamase negative (penicillin S) strain Some difficulties reading
CLSI Agenda Book January 2011.

D B C

-lactamase positive

-lactamase negative

Isolates A-D are all -lactamase positive

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Staphylococ ccus aureus

Disk Zone Edge Test (10 U penicillin disk and standard disk diffusion method not va alidated for purity plates)

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Staphylococ ccus aureus 3 Lab -lactamas se Study Results (N=3 348)

Test ensitivity Se (n=45) 77% 88% 100% 96% Specificity (n=303) 100% 100% 100% 100% Cefinase Dryslide Cloverleaf Penicillin disk zone edge

Fuzzy beach = -lactamase negative Penicillin - S

S. aureus QC: Neg - ATCC 25923 Pos - ATCC 29213

(supplemental QC)

Sharp cliff cliff = -lactamase positive Penicillin - R

M100M100 -S22. Tab ble 2C Supplemental Table 1. Page 83.

CLSI Agenda Book January 2011.

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Staphylococ ccus aureus P i illi (MIC 0.1 Penicillin 01 12 g/ml) / l) Reporting R ti

Penicillin MIC 0.12 g/ml

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-lactamase Tests S. au ureus and S. lugdunensis

Note: If doing disk diffusion routinely and zone 29 mm, just examine zone edge!

Nitrocefin -lactamase positive Report penicillin R

Nitrocefin -lactamase negative Perform pe enicillin disk zone-edge test

29 mm fuz zzy Report penicilli in S S

29 mm sharp Report penicillin R M100M100 -S22. Tab ble 2C Supplemental Table 1. Page 80.

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-lactamase Tests CoN NS NOT S. lugdunensis g

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Staphylococcus s spp. Penicillin Optional l Strategy

Report penicillin if R Suppress penicillin if S S and add note Contact laboratory if penicillin re esults needed If penicillin i illi S and d peni i illi results icillin lt needed, needed d d, perform:
S. aureus Nitrocefin -lactamase tes st Penicillin zone edge test if i nitrocefin -lactamase test negative CoNS (including S. lugdune ensis) Induced nitrocefin -lacta amase test Continue to test subsequen nt isolates from patient

M100M100 -S22. Tabl le 2C Supplemental Table 3. Page 88.

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www w.clsi.org l i
next next

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What are some of the issues i are currently being addressed by CL CLSI S AST S S Subcommittee? ?
Fluoroquinolone breakpoints for several organism groups Quality Q lit control t l Intrinsic resistance tables for r non non-Enterobacteriaceae and for gram gram-positive bacteria Enterobacteriaceae
Levofloxacin breakpoints for S. S typhi and extraintestinal Salmonella spp. spp Cefepime breakpoints Colistin / polymyxin B breakpoints Eliminate oxacillin disk diffusion test for S. aureus Doxycycline y y and tetracycline y breakpoints p Inducible clindamycin resistance Frequency for screen tests; frequen ncy for MIC and disk diffusion tests QC ranges for colistin / polymyxin B; B optimal medium for testing

Staphylococcus spp.

Streptococcus pneumoniae

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Summ mary y( (1) )

CLSI updates AST tables (M1 100) each January. CLSI updates documents tha at describe how to perform reference disk diffusion (M02 2) and reference MIC (M07) tests every 3 years. Changes to CLSI documents are summarized in the front of each document. Information listed in boldface e type is new or modified since i the th previous i edition diti of f M100 M100. Recent breakpoint addition/revision dates are listed in the front of M100M100-S22. Manufacturers of commercia al AST systems systems, , by law, MUST use FDA breakpoints.

And thanks to: APHL Staff CLSI Staff CLSI Subcommittee on AST espec p cially: y William Craig Mary Jane Ferraro Susan Munro Jean Patel

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Summ mary y( (2) )

FDA breakpoints for -lactam ms with Enterobacteriaceae or Pseudomonas aeruginosa or for Salmonella spp. and ciprofloxacin have not yet bee en revised (except for ceftriaxone with Enterobacter riaceae). Clinical laboratories can implement current CLSI breakpoints on a commercial AST system following verification. The director of th he clinical microbiology laboratory must consider multiple factors when deciding if this is appropriate for his/her r laboratory. sage regimens on which It is important to mention dos breakpoints were revised whe en discussing new breakpoints with Infectious Diseases, Pha armacy, etc., however these should not be routinely listed d on patient reports.

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Summ mary y( (3) )

Clinical laboratories should develop a protocol for testing additional agents on n isolates resistant to all drugs on their routine test panel, p when appropriate. This might include inin-house testi ing or sending an isolate to a reference laboratory. y Doripenem breakpoints hav ve been added to M100M100-S22. Results from testing other carbapenems c cannot be used to predict results for doripenem. QC ranges for P. aeruginosa a ATCC 27853 with cefepime and E. coli ATCC 25922 with h colistin have been revised. Ertapenem Et b k i t for breakpoints f Enterobacteriaceae E t b t i have h been revised.

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Summ mary y( (4) )

Clinical laboratories that hav ve not implemented current CLSI breakpoints for cephem ms and aztreonam for Enterobacteriaceae should continue c to perform ESBL testing. testing . C Clinical ca laboratories abo ato es t that at hav ave e not ot yet implemented p e e ted current CLSI breakpoints for r carbapenems and Enterobacteriaceae should continue c to perform Modified Hodge g test test. . MHT is neither 100% sensitiv ve nor 100% specific in NDM-1 producers are detecting carbapenemases; NDM generally MHT negative. New ciprofloxacin breakpoin nts have been added to Enterobacteriaceae tables be e used for S. typhi and Salmonella spp. spp from extrain ntestinal sources. sources.

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Summ mary y( (5) )

Testing low concentrations of o ciprofloxacin and applying new breakpoints for S. typhi i and Salmonella spp. from extraintestinal sources is pre eferred to nalidixic acid testing to detect reduced fluoroquinolone susceptibility. It t is s ge generally e a y not ot necessary ecessa y to perform pe o AST S o on nonnon o typhoidal Salmonella spp. fr rom fecal sources as salmonellosis confined to th he GI tract is generally self limiting. g Breakpoints for piperacillin, piperacillin piperacillin-tazobactam, ticarcillin, ticarcillinticarcillin-clavulan nic acid, imipenem, and meropenem have been revis sed for P. aeruginosa. Over 90% of staphylococci are a penicillin resistant and penicillin therapy for staphylococcal infections would only be considered in unusu ual cases. cases

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Summ mary y( (6) )

For S. aureus isolates where e penicillin zones are 29 mm or penicillin MICs are 0.12 g/ /ml, a penicillin disk zone edge test should be performed be efore reporting penicillin susceptible. For CoNS (including S. S lugd dunensis) isolates where penicillin zones are 29 mm m or penicillin MICs are 0.12 g/ml, g/ml, an induced beta beta-lacta amase test with nitrocefin should be performed before e reporting penicillin susceptible. ommittee meetings and other Minutes of CLSI AST Subco materials are available at ww ww ww.clsi.org ww.clsi.org. clsi org. CLSI and other groups welc come help with improving susceptibility testing!

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