Transcribed by Erica Manion 7/29/2014

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Microbiology - Lecture 17 Antibiotics Lab I by Dr. Tierno

[Slide 1] Antibiotics Lab
[Dr. Tierno] I guess we can start now. Ok now that you have a handle on, well at least a general
concept. This in not for you to be practitioners of the medical arts of antibiotic administration,
meant to intro you to the concepts of antibiotic therapy, how they work against organisms, what are
the mechanisms, what are the groups, the classes, and the five things I told you to know about every
group of antibiotics is what you have to come away with. Now, in your practice, eventually you will
have an op to submit a culture to a laboratory, we talked about this last week. And you will want to
have identified the etiologic agent of an infectious process in the oral cavity, in this case. And
besides identifying the agent that is causing the problem, when you submit that specimen the
laboratory will provide you with whats called an antibiotic susceptibility pattern, or an
antibiogram, it is called by some. In other words, it will tell you that patients bug is susceptible to
such-and-such antibiotic but is resistant to others. And of course, as good practicing dentists, you
will look at the lesion and prescribe a particular drug empirically based on your knowledge, your
accumulated knowledge and the history of the patient, and the site of the infection. You say this
drug I will prescribe to you now. You may make a change when you get back the antibiotic
susceptibility pattern. And that may be the case. When you get it back, sometimes it will take a
couple of days, but as I told you in our first two lectures on diagnostic microbiology, that you are
fortunate in that you are living at a time and practicing at a time when real time microbiology is at
hand. As I told you, the MALDI TOF can identify a bacteria in 10 minutes. Thats a far cry from three
days. There are PCR systems that can probe the genes of resistance chromosomally and
extrachromosomally in one hour. So you can literally have same day results at some point in the
future.. Right now things are a little expensive to do that, and it may or may not be justified So
there may be selective cases where the lab may get involved especially in hospital environments
where you are dealing with critically ill patients whose lives are dependent on a quick assessment
of what they have. But eventually that will be common place. So as I said, classic methodologies
have to be learned anyway. You have to be aware of it as educated dentists. And what we are going
to talk about now is some classic ways antibiotic susceptibility patterns are provided to a clinician,
such as yourself, and how to use it for interpreting results, for treatment in a patient. We are
hoping for good results.


[Slide #2] Antibiotic usage
Now unfortunately, I always preface this with this little, the last time I looked, there are about 4
billion prescriptions written annually. I think that number has increased. 60% of these are for
antibiotics. The CDC 8 to 10 years ago came out with this statement: 50% are unnecessary or
inappropriate. And that is still the case in this country unfortunately. The agriculture, we but 23
million pounds, thats 70% of the antibiotics into the agricultural industry where we only use 3
million pounds to treat disease. That is livestock feed as well as other agricultural areas, to fatten
up herds and whatnot. That creates problems by exposing people to sublethal doses over time.
Youre getting it in your foods, in your meats, in your vegetables. The US government is now doing
what some Europeans have done many years ago. They are limiting the use of antibiotic drugs in
the agricultural industry. Antibiotic resistance cost tax payers when I wrote this a few years ago, 5
billion dollars. Its nearer to 12 billion annually and growing.


[Slide #3] WHO Report, 2003
Now this is an old report. I just want to show you what they did in 1999. Denmark. World health
report. They used to have antibiograms, antibiotic susceptibility patterns against Enterococcus
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faecium that were resistant to 5 or more drugs, 60 to 80%. It had been reduced to 5 to 35%. Now,
currently, that is 2003. Currently, 2014, less than 1%. They eliminated drugs in agriculture and they
propitiously used, they specifically used or defined the use of antibiotics in treating patients.

[Slide #4] Antibiotics
So I just preface this with that. So you should be aware when you administer a drug, its gotta be for
a good reason. Proper dosing, proper time, so that you dont have a chance of developing
resistance. These are the words that you should become familiar with after we finish this, I think
one of these lectures today, and we finish up Thursday at 3:00 I believe, I forget when the lecture is.
Kirby-Bauer, zone of inhibition, what we mean by susceptible, intermediate, and resistant. The
concept of bacteriostasis, bacteriocidal, bacteriolytic, as it applies to how organisms grow or are
affected by those processes. You have to be familiar with the Schlicter test, the E test, the MICs and
MBCs, whats the difference? Antagonism and synergy, tolerance and antibiotic blood levels. You
will be familiar with those terms. As we go along we will deal with each of them.

[Slide #5] Petri dish with disks
Now, the simplest type of antibiotic susceptibility patterns are generated by something called the
Kirby-Bauer test. This is a large petri dish of Mueller Hinton agar. Its a particular agar that is
transparent that we apply a known inoculation of organism across the whole plate, agar plate. And
usually we do this in three fields. Well do it this way, this way, and then on the sides, this way. 3
fields, 3 planes. So we get a good confluency of organisms growing. Then we drop disks, disks, each
one containing a particular concentration of antibiotic known to occur in the blood with normal
dosing. And thats what each one of those little disks represents. Then we incubate this. After 18
hours we pull it out and look for zones of inhibition. Zones of inhibition. Thats what these clearing
areas are. Its a zone of inhibition around this disk, look, the growth has stopped. Here is the zone
that determines this. Here, this is erythromycin, none. This organism is resistant to erythromycin.
But here is another zone, and you can see the zones on various names of the drugs. Doesnt matter
what the drugs are for now. The idea is, this is how we generate the simplest type of antibiotic
susceptibility pattern. It is called the Kirby-Bauer disk agar test. And this gives you something
called susceptible, intermediate, or resistant. We sometimes call that the SIR pattern. S-I-R.
Susceptible, intermediate, or resistant. Here may be an intermediate, and you have to measure the
zone size to come up with whether it is intermediate or susceptible. Here, there is no zone size so
we know it is resistant or resistant. You can have some zone and it may be resistant. So you have to
measure. So, this deals with a plate of agar called Mueller Hinton, I have that written somewhere,
Mueller Hinton, where we swab the organism in question in three planes with a known
concentration of organism. We know what the concentration is, its about 1x10
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organism across
the plate, in three planes, and we add the disk, incubate overnight and the next day you read the
plate. Ok? Now you may say to yourself oh thats a day to do that test. But by the time you get the
colony growing and purified, and you need pure culture to be able to do this test, it may take
another day or two. Which is true. Thats why this is slow. The new way we do it is by PCR. We
actually have a one-hour test, where we take organism, and we probe the genes of resistance that
are chromosomal and that are extra-chromosomal for the bacterium and identify susceptibility
patterns.

[Slide #6] MIC Minimum Inhibitory Concentration
**[NOTE: Dr. Tierno misspoke at first when describing the MIC. That area is in lighter font,
and I have highlighted in bold and red when he realizes his mistake]**

Now for most cases youre dealing with, urinary tract infections, some simple wound infections, the
Kirby-Bauer method, this method of antibiotic susceptibility is ok. You dont have to worry, you
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dont need any more sophisticated test. Somebody comes in with a urinary tract infection, Im sure
culture of the urine is submitted to the lab, a clinician will prescribe, lets say Septra, its a good
drug, and usually it is E. coli, and usually you have some frame of reference, some thought. But
nevertheless, you want that antibiogram. You want to know if Septra is susceptible. That is your
empiric choice, and then you get back the results and you can change your empiric therapy or not
based on those results. If the patient is doing well, chances are you are going to leave the patient on
the drug regardless of the, it rarely happens that it doesnt coincide with the result, but sometimes
it does because in vivo and in vitro are different. However, there are times when a patient has a
deep seated infection in a particular area of the body. Lets take the gall bladder. The gall bladder,
we have an infected gall bladder. Now, we need more information, rather than just doing a Kirby-
Bauer or SIR test, we need something a little more sophisticated, something called the MIC. The
minimum inhibitory concentration, the MIC. Let us say, we want to use a particular drug, lets say
drug X for this gall bladder infection. And how do we use it if we have no frame of reference to
know whether a particular concentration will be met at the gall bladder site? There is a text called a
PDR that your office will probably have, should have. It is called the Physicians desk reference,
PDR. It is a compendium of all the drugs allowed on the formulary in the United States, and it has a
large reference of anticipated drug concentrations in various organs and body sites based on results
of manufacturers research. So that if I were to pick up the PDR and look at drug X, can I use this
drug at the gall bladder site? The PDR may tell you well, you can use this drug, but susceptibility
strike that. But you will achieve four micrograms of this drug at that site with regular dosing. So
now you know you have a number, four micrograms of antibiotic x can be found at that site using
ordinary dosing. Alright? Now how can I use that information to figure whether my E. coli that we
got isolated from that gall bladder infection will be susceptible? So what you do is what is called a
minimum inhibitory concentration. You take antibiotic X and you start with a high concentration,
in this case it is 64 micrograms, and nowadays we dont do this macrotube method, we have
micromethods of doing this so it is easier. So we just start with 64 and do a 2 fold serial dilution,
downward. And we have 64, 32, 16, 8, 4, and it can go down to 2, 1, 0.5, 0.25 all the way. Of course
you have a negative control and a positive control you use with every test. Alright?


Now lets see, how do we get an MIC out of this? Well, we inoculate those concentrations in the 2
fold diluted tube with different concentration of antibiotic. Nowadays we have lyophilized tubes,
they already have these concentrations, we just reconstitute with lets say half a cc of fluid. We add
the bug, a known concentration, to each tube, same amount. And you look for the tube, over night
incubation, you look for the tube with no visible growth. In this example, those dots represent
growth. Turbidity. You have 4, 2 micrograms and the control positive is also positive, and that is
good. The control negative is not here, but the negative would be the broth with no organism. So
now what do you do? You know it is higher than 4, the dilution, the concentration you need,
because 4 is positive, 2 is positive. Anything lower than 2 would still be positive, in other words
growth. So it is not useful. In those that you cant see visible growth, you subculture to a plate, agar
plate for growth. You sub-culture the 8g, the 16g, the 32 g. Incubate it overnight and take it out.
Here is growth in the 8g so you know the MIC is 16. The highest concentration with no growth, or
the lowest concentration with no growth is the minimum inhibitory concentration (MIC). So the
lowest would be 16. Here you have growth, 7 colonies grew out. So now MIC in this case is 16. And
we said you need 4ug at the site to be able to irradiate the organism. The MIC of the organism is
usually around 1. In this case, in this example it is 16. So can you use that drug? Can you get 16g
at the site with regular dosing? No. You can only get 4. So in this case, what if the MIC was 1? Can
you use it? If the minimum inhibitory concentration of E. coli against drug X is 1g, could you use it?
Yeah, you can use it. Because youre gonna get 4 of the drug at the site. So if your bug will succumb
to 1ug, the MIC, lets say is 1 instead of 16, you can use it. Youre having 4 times the concentration
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needed to inhibit the organism at the site. You follow how that works? It sounds complicated but
really it is not. And this example is unfortunately a high MIC but the whole idea is to show you that
if the MIC is too high, you cant use that particular drug. So what would you do? You go to an
alternative drug and check the organism. And by the way these MICs are done against a whole
panel of drugs so you dont have to do them day by day. Its done all at once.
Now, there is another, oh no! Im giving you the MBC. I misspoke and nobody corrected me.
The MIC turns out to be 8. That is the visible tube, right? 8, 16, and 32 you dont see any growth. So
that the lowest tube with no growth is your MIC, and therefore it is 8. So strike what I said about it
being 16. 16 is the MBC.
[inaudible student question]
[Dr. Tierno] Say that again? Spit it out.
[another student asks a question] You said there was growth overnight?
[Dr. Tierno] Yeah I know, we are going to get to that, its the MBC. Its the second component of the
MIC. I got to it too quickly. There are times when you need both MIC and MBC and Im going to
touch on when you need the MBC.

But right now, backtrack. The visible, no visible growth. MIC is just visible, what you can see with
your eye in the tube. And it turns out to be 8. Now when you subculture those, you can get what is
called the MBC minimum bactericidal concentration. This is the concentration that kills just about
everything. So you can see why, in this tube 8, it didnt kill everything, you had growth. So you go
to this tube, which is 16, and that is the MBC. So in this case the MIC is 8, the MBC is 16. Why do you
need an MBC? Well, you need the MBC because in some cases where the antibiotic fails, remember I
gave the example of the elderly man and the football player. The elderly man succumbed, mostly
because of immunologic reasons. The younger man got well pretty quickly and left the hospital.
There is one other reason why antibiotics may not work, and that is something called tolerance.
And thats why you need an MBC. The tolerance is defined as the difference between the MIC and
the MBC to be greater than 5 dilutions or 4 dilutions off. As a matter of fact, I think I have an
example somewhere. In other words, the disparity between the MIC and the MBC is greater than
four dilutions. If you look at the MIC and the MBC here, the MIC of 8, the MBC of 16, that is one
dilution off. So if the MIC were 8, and the MBC were 64, thats said to be a tolerant organism. In
other words, many organisms like Pneumococci may be tolerant by just not being killed but
elongating in the tube. So when you take the antibiotic away, the organism comes right back to
where it was and continues the infection. Thats tolerance. These are sometimes tough terms to
grasp. But tolerant bacteria do occur and have to be treated and usually you have to switch to
another drug. Even though you may be exquisitely susceptible to penicillin, lets say, just like in the
example with that football player. Exquisitely susceptible. Lets say he didnt get better on
penicillin. We know it is not his immune response, he is perfectly normal. We know the drug seems
to be susceptible based on MIC, but if we do an MBC we find we are greater than 4-5 dilutions off.
And sometimes even more dilutions off, and that is said to be a tolerant organism and youd have to
shift to another antibiotic. So this is why you sometimes need an MIC and an MBC. MIC to determine
the effectiveness of the drug at a particular site when you are given certain information like from
the PDR in your total(?) 4ug concentration usually occur at the gall bladder with this drug.

And you have an MIC of 1, you can use that drug. If you have an MIC of 8 or 16, you cant use that
drug unless in the 8 circumstance, you may increase the dosage but that may not give you enough,
and it also jeopardizes the patient when you give megadoses. [To student:] You had a question?
[When youre determining if the drug will be effective in the case of infection and you compare it to the
PDR, do you use MIC or MBC or both?] Both. First you do the MIC to determine whether you are
going to get that concentration to kill it. You may not be dealing with a tolerant organism. Most of
the time youre not. But when you use the drug and it isnt working, that is a red flag. It tells you,
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you better go further. I better do the MBC just in case. And it usually the gram positive organisms
that have this tolerance that occur, in Streptococcus. Especially Pneumococci. Streptococcus
pneumoniae. You follow? So ordinarily, lets sum up a little, so ordinarily Kirby-Bauer, SIR pattern is
sufficient for most ordinary infections. In the classic realm of microbiology. The MIC, when you
have deeper recesses where you have infection. You have to know the concentration of the drug
available at the site, so you have to know the physiologic studies that were done. You go to the PDR
and you see what level you can get. Lets say in the prostate or in the gall bladder or wherever, and
thats how you apply the MIC knowledge. You get the minimum inhibitory concentration
knowledge. But when treatment fails, there may be more than resistance at play. you may have a
condition called tolerance at play, and to determine that, the easiest way is to differentiate the MIC
and MBC, see how far apart they are. Usually they are within one dilution apart, the most, 2. Not
greater than that. 4, 5. Sometimes its 10 dilutions off. Ok so far?

[Slide #7] Pharmacokinetics vs Pharmacodynamics
This is gonna be a little bit tricky but its not if you use a rule of thumb. These are two important
things you have to know about drugs. Pharmacokinetics vs pharmacodynamics. And youll learn
further when you are in an upper class and youll be dealing with prescribing information.

But it is important to understand this. Pharmacokinetics as I defined it says that an antibiotic is only
as good as the concentration it achieves at the site of infection. So the information I gave you said
that the manufacturer told you that there is 4ug at the gall bladder. Thats pharmacokinetics. And
you have pharmacokinetics information in the PDR. Ok, thats understandable. At the site you want
to apply therapy.

So, pharmacodynamics relates to something different. The effect of antibiotic by either inhibiting or
killing the microbe. In other words, is the antibiotic going to kill or inhibit this organism? And that
depends on concentration of drug, or the time the drug is above the MIC. This is another reason
sometimes you need an MIC. We provide to all of our clinicians MIC data in addition to the SIR
interpretation. Susceptible, intermediate, or resistant because they have to understand things
beyond tolerance. MIC and MBC comparison. Ordinary therapy requires you to know certain drugs
are effected by concentration more than time. Or other drugs are affected by the time that the
concentration exceeds the MIC for working, for their efficacy.

[Slide #8] Pharmacodynamic Parameters
Now, it seems complicated but lets try to simplify it. This is the typical graph of the concentration
of the drug over time. And lets start with concentration dependent drugs. These drugs, as the name
implies, require the concentration to exceed the MIC, ok. We are talking about the area under the
curve, you may have heard that concept. Here is the MIC, this dotted line, ok. So this is plotting the
time above the MIC. Well, if you look up to this point of time, this drug is above the MIC. Now it goes
below the MIC. So a concentration dependent MIC is dealing with the area under the curve,
comparing it to the MIC. The MIC should be high, so high it is well above the ordinary MIC on the
curve, the concentration. As opposed to a time dependent antibiotic, and there are classes of
antibiotics, we are going to get to that in a minute. You kill bacteria when the drug concentration
exceeds the MIC but the duration of time over the MIC is important. For example, the penicillins
and cephalosporins fall in this category. They are more time dependent than concentration
dependent. And using those two terms, the keyword time and concentration, you can come to the
conclusion as to whether or not you can get efficacy.

[Slide #9] Time-dependent (non-concentraton dependent)
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And there is a rule of thumb. That you can use, for example: Time dependent, non concentration
dependent, meaning.. So it is time dependent drugs, are the beta lactams, like the penicillins,
cephalosporins, mostly the drugs that would be used by you, the clindamycins, erythromycins, and
related macrolides, vancomycin and linezolid. They kill best when the concentration exceeds the
MIC over time. You saw the graph, pretty big gap of time. So, the duration of time, the MIC, it
exceeds the MIC, rule of thumb is 4x the MIC in this case would be sufficient to fulfill time
dependency. If you have 4x the MIC or higher at a particular site, this would be efficacious for time
dependency.

[Slide #10] Concentration-dependent
If you compare them to concentration dependency, thats a totally different ball of wax. Those are
the quinolones, the aminoglycosides, amphotericin, metronidazole, and other, the azoles, and
another drug called daptomycin which I didnt talk about. Here, they kill best when the
concentration is well above the MIC. In other words, 10x the MIC ordinarily. So, if I were to tell you
you can achieve, lets say the MIC is 1 and at a particular site you can achieve 12 ug. The MIC is 1ug
for an E. coli. And if I said at a particular site you can achieve 12ug. 10 x 1 = 10. So 12 is 2 more
than 10. That is saying that a drug like a quinolone will easily be fulfilled with the concentration
dependency of the drug. Because it is above 10. 10 or higher, so you could use that drug. It gives
you a frame of reference as to how much drug you need to give a patient. You get it?
[Student question] So there would be no time or no duration youd have to take it for?
[Dr. Tierno] No this is a different story. Duration, if you have an antibiotic for 10 days you take it for
10 days. This is time above the MIC. They are talking about your blood level. Your concentration in
your body. They arent talking about the time you are taking the drug. You follow? So these are
important considerations. Any question on this?

[Slide #11] Figure 16-2
I mentioned to you, it can seem baffling, the rule of thumb, the 4 and the10, is really very useful.
The rule of thumb. And by the way that is a rule of thumb, thats not hard and fast. If you can get
10x the MIC then you can fulfill the tenet of the concentration dependent. If you get 4x the MIC that
is time dependent, thats all you need. Thats a rule of thumb and many infectious disease
practitioners utilize that rule of thumb.
So they look at the MIC, thats why its important. So here is another way of doing an MIC. This is
called a microwell or a microtiter tray. Each one of these runs from here to here with a different,
each one is a different antibiotic dilution of drug. So that you have an automated dispenser after this
is reconstituted in diluent that will dispense the bug the same in every well, and you have control
panels also. In fact they are right here. Heres a control positive or negative. Or they can run up and
down. As in this case, it is up and down. Either way, they all have certain numbers of
concentrations to achieve an MIC information. So that certainly beats using test tubes and the
cumbersomeness of the test tubes. This is still used in laboratories. Micro method of generating MIC
data.

[Slide #12] No Title
This is what we currently use in the laboratory instead of the microtubule method. This is called a
VITEK. This system, automated antimcrobial identification

and susceptibility system is nothing more than a Card for each. A card for identification, holding
about 35 substrates so that you get a genus and species. Remember the diagnostic microbiology
talk that we had last week. That is what that does, it gives you miniscule concentrations, and an
automated reader that was first developed by McDonnell Douglas aircraft corporation when
astronauts went into space. This is where this comes from. The early astronauts when they did the
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orbitals would be intibated, catheterized, so the urine could collect in bottles. Unfortunately many
of them developed infection. Because of that, on board, these spaceships they had this machine.
Automated microbic system. Its called a VITEK. Where they could generate the identity of the
organism to genus and another card would give you, susceptible to ampicillin, Cephalin, or
whatever other common drugs there were so the astronaut on board could take it and relieve his
symptoms. So, out of that, NASA came this. Now its owned by a French corporation named
Biomerot. And this generates in a matter of 4 hours to 6 hours identification and antibiograms.
Sometimes longer depending on the generation time. Thats called a VITEK card.

[Slide #13] The E test
Now this E test is another thing you should know. This is a solid plate method of generating MICs.
Its an unusual method, it was developed in Sweden. And E is just E, it stands for nothing
necessarily, but it is an E test. Nobody can define why they wanted E, to be an E test. Maybe if it is
A to E, pick one, pick E! We have here, each strip is unique, and its patented. Its not so easy to
develop a system where you have this top one is 256 micrograms of antibiotic. The next line
represents 192, the next 128. That is a very sophisticated means of getting those concentrations to
exist in a descending order all the way down to one zero here, or 0.12. So what you do with this is
you do the lawn of bacteria like you do for the Kirby-Bauer to do an E test, same thing, 3 planes ,
overnight incubation, and you look at the meniscus. The meniscus that is above the last indicator
here. This is 1ug. The one that is above it is 1.5, so that is its MIC, 1.5. So this is another way of
generating MIC information that can be used for, in special cases where antibiotic therapy is failing.
They have two or three drugs, up to four you can fit on one of the large Mueller Hinton plates. And
you can see the elliptical reading where you can gather MIC data on a few drugs, rather than going
through the whole regimen of doing the microtube or the macrotube method. Sometimes you just
need one or two antibiotics and this is the method they will chose unless you are doing molecular
methods, which as I said is able to be done. We are doing it now on blood cultures at Tisch Hospital
at the Langone Medical Center. If you have an organism that crops up on a blood culture, we take
that organism right there and then and in ten minutes we identify the bug using a MALDI TOF,
which I explained to you. Matrix assisted desorption ionization time of flight. But also we can
generate data using non molecular methods. It is cheaper. In fact there is one other molecular
method Im going to show you later on. We are we use the PCR to identify the enzymes of
resistance rather than doing antibiotic susceptibility testing. If an organism has beta lactamases or
cephalosporinases, or some other ases, enzymes that inactivate antibiotic, we can detect it, if it has
the genes to do that. So that is the ways of the future. But right now we still practice with the classic
methodology to generate data in most cases. And we are combining that with these other methods.

[Slide #14] Relationship between Zones of Inhibition and MIC
Now, this will be the last slide for today. I just want to show you with this slide, the relationships
between the zones of inhibition and MIC. You may have asked yourself the question, well, is MIC
and zone of inhibition similar? Is there a way to correlate them? Or you may not have. Im going to
show you the relationship here by this regression analysis curve.

They are related in fact. And this uses the example of 8ug, this particular organism, that will be the
MIC, let us say. So, anything, 8 or above will be considered susceptible. You have points and dots
and this was done, by the way, the regression analysis curve, on every known antibiotic and on
many micro-organisms, especially the fast growing organisms, to generate this data and to generate
an understanding. Of the correlation between MIC and zone of inhibition. So let us say we do two
things simultaneously. One, we do a petri dish of agar to get the SIR pattern, zone of inhibition, and
we measure in mm the zone. We will record that down here. This is less than lets say, 18mm is
susceptible. It will come up in that range sorry. Less than 18 is resistant. It will come up in that
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range of resistant bugs. And then we do the MIC at the same time and we look at where the
organism sits, and anything above 8 is resistant. So 16, 32, 64, and in between, it is a resistant
quadrant, area.

And if we look at intermediate, remember susceptible, intermediate, and resistant, we correlate the
zones, lets say, make this 18, above 18 to about 26 or so is intermediate. And you can see some
intermediate fall in, some are outliers. you always get outliers also. And 26 or higher is exquisitely
susceptible. You correlate that to the MIC. The MIC in this category of zones of inhibition are
anything from about 0.5 to 2. So there is a correlation between MIC and MBC based on numerous
scientific reports. Do you follow that? So that if I want to be able to identify an MIC, I could
theoretically take the Kirbey-Bauer. Say I get 28. So if I get 28, lets plot. 28 is about here, and go
straight up. 28 is about 2 or so, 2 or.. so it is susceptible on that curve. Is it 2, no, its a little less than
2, 1.8 I guess youd say that is. Because it is a little less than hitting that 2 line. See the red, the
curve? Im trying to hit it, if it hit it up there just on the other side of that dot, it is about 1.8. So that
is the MIC here. In fact there is a machine that does this. It is called a biomic. You take the plate with
Kirbey-Bauer, stick it in this slot, which is connected to a camera which reads all the zones and
reports it to a computer. And it correlates that for every bug and each of the zone sizes. Correlates
it to MIC. And in fact, that machine is used by many countries that are not supporting these half
million dollar machines. They cant put two or three of them in every hospital. But one of these
machines only costs about $2000. Its mostly the camera. So there is a correlation between MIC and
Kirbey-Bauer. SIR. Ok? Well continue this tomorrow. Look over that pharmacokinetics and
pharmacodynamics.