Whats New in the 2011 CLSI

Standards for Antimicrobial

Susceptibility Testing (AST)?
BDDS
Product Specialist

Lynn Hsiao

BY Janet A. Hindler, MCLS MT(ASCP)

CLSI AST Standards

January 2011
M100-S21 Tables (2011)*
M100-S20-U (June 2010)
Revised carbapenem breakpoints
(Enterobacteriaceae)

M02 A10 Disk Diffusion Method (2009)**

M07-A8 MIC Method (2009)**
M11-A7 Anaerobe MIC Testing (2007)
* M100 updated at least yearly
**M02, M07 updated every 3 years

Summary of
Changes

M100-S21. pp. 13.

CLSI AST Standards

Major Changes 2011 (1)
Revisions
Enterobacteriaceae cefazolin breakpoints (again!)
Enterobacteriaceae carbapenem breakpoints (June 2010)
Pseudomonas aeruginosa aztreonam and cephalosporin
breakpoints (reassessed)
Appendix A - Verification (Confirmation) of unusual AST
results

Additions
Table inducible clindamycin resistance Streptococcus spp.
-hemolytic Group
Anaerobe Tables
Intrinsic Resistance Table - Enterobacteriaceae

Listing Information in Boldface Type in

M100-S21

Old comment:
NOTE: Information in boldface type is
considered tentative for one year.
Revised comment:
NOTE: Information in boldface type is
new or modified since the previous
edition.
M100-S21 Table 1A. pp. 32
and throughout.

To Be used with
CLSI M11-A7

Enterobacteriaceae

Enterobacteriaceae - Carbapenems
Revised Breakpoints (MIC g/ml)

*FDA breakpoint
Corresponding disk diffusion breakpoints also revised
M100-S21 Table 2A. pp. 45.
First published M100-S20-U (June 2010)

New CLSI Specific Carbapenem

Dosage Comment
Because of limited treatment options for
infections caused by organisms with
carbapenem MICs or zone diameters in
the intermediate range clinicians may
wish to range, design carbapenem
dosage regimens that use maximum
recommended doses and possibly
prolonged intravenous infusion
regimens as has been reported in the
literature.
CLSI M100-S21. pp. 45.
References for this suggestion in M100-S21. pp. 58.

Will tests for carbapenemases (e.g.,

Modified Hodge Test) be needed with the
revised breakpoints?
No. For patient management, tests for
carbapenemases are not necessary
If requested, tests for carbapenemases
may be done for infection control and
epidemiological surveillance purposes
Modified Hodge Test phenotypic test for
carbapenemase activity
PCR for known carbapenemases
M100-S21 Table 2A-S2. pp. 50.

Revised breakpoint

Exmp. OLD Breakpoints - Meropenem

S, I, R Reporting Strategy

Perform MHT if MIC 2-8 g/ml (imipenem or meropenem) or

2-4 g/ml (ertapenem) and R to at least one 3rd gen
cephalosporin
2 Recommendation changed from CLSI M100-S20 January 2010;
now report all carbapenems R if MHT positive

OLD Meropenem
Breakpoints (
g/ml)

CLSI M100-S21. Tables

2A-S2, 2A-S3. pp. 54.

Exmp. NEW Breakpoints - Meropenem

S, I, R Reporting Strategy

1 MHT not needed for routine patient reporting; may perform

for Infection Control or Epidemiological Surveillance but DO
NOT change S or I to R on patient report if MHT positive

NEW Meropenem
Breakpoints (
g/ml)
CLSI M100-S21
Table 2A-S2. pp. 50.

Carbapenem Resistant
Enterobacteriaceae (CRE)
Two mechanisms of resistance
Carbapenemase - -lactamase that hydrolyzes
carbapenems
Cephalosporinase combined with porin loss
Some cephalosporinases (e.g., AmpC -lactamases
or ESBLs) have low-level carbapenemase activity
Porin loss limits entry of the carbapenem into the
cell
Identification of CRE is important from an
infection control perspective regardless of the
mechanism of resistance

What criteria can we use to categorize an

isolate of Enterobacteriaceae as CRE
for infection control purposes?

1 isolate must fulfill criteria for at least one drug

Revised
breakpoints (
g/ml)
Not in M100-S21.
JH comment.

What about Proteus / Providencia /

Morganella and imipenem?
New comment:
(21) Imipenem MICs for Proteus spp.,
Providencia spp., and Morganella morganii
tend to be higher (eg, MICs in the new I or
R range) than meropenem or doripenem
MICs.These isolates may have elevated MICs
by mechanisms other than production of
carbapenemases.

M100-S21 Table 2A. pp. 45.

Why not use ertapenem to categorize an

isolate of Enterobacteriaceae as CRE
for infection control purposes?
Most isolates I or R to ertapenem but S to
other carbapenems may not pose the same infection
control risk as isolates I or R to other
carbapenems
Substantial number of Enterobacteriaceae are I or
R to ertapenem only and would be flagged as
CRE
Enterobacteriaceae with chromosomal -lactamase + porin
loss often I or R to ertapenem and S to other
carbapenems

Bennett et al. 2010. DMID. 66:445.

Woodford et al. 2007. Int J Antimicrob Agents. 29:456.
Not in M100-S21.
JH comment.

Why should we try to implement revised

carbapenem breakpoints for
Enterobacteriaceae?
Increasing numbers of isolates of
Enterobacteriaceae with decreased
carbapenem susceptibility due to a variety of
resistance mechanisms
New information suggests old susceptible
breakpoints may not reliably predict drug
efficacy
Will allow identification of CRE which can be
communicated to infection control with
minimal delay

Enterobacteriaceae
Revised (again!) Cefazolin Breakpoints

a Breakpoints are based on a dosage regimen of 2 g every 8 h.

b Cephalothin interpretive criteria should only be used to
predict results of the oral agents, cefadroxil, cefpodoxime,
cephalexin, and loracarbef. Older data which suggest that
cephalothin results could predict susceptibility to some other
cephalosporins may still be correct but there are no recent data
to confirm this.
CLSI M100-S21 Table 2A. pp. 43.
T/R = test/report group

What are the test / report issues for

cefazolin and cephalothin with urine
isolates of Enterobacteriaceae?
Most labs do not test both cephalothin and
cefazolin
If results from testing cefazolin (with new
breakpoints) are used to predict activity of
oral narrow-spectrum cephalosporins for
uncomplicated urinary tract infections
resistance will be overcalled in many
isolates
Revised cefazolin breakpoints are based on
serum and not urine concentrations of drug

Best to test / report cephalothin

Pseudomonas aeruginosa

Pseudomonas aeruginosa
Beta-lactam Breakpoints (1)
Reevaluation but no change in breakpoints for
cefepime, ceftazidime, aztreonam
Added dosage information (ceftazidime and
aztreonam dosages are different than those for
Enterobacteriaceae)

M100-S21 Table 2B-1. pp. 61.

Pseudomonas aeruginosa
Beta-lactam Breakpoints (2)
Deleted breakpoints for:
Ceftriaxone, cefotaxime - limited indications (e.g.,
urinary tract infections)
Ceftizoxime, cefoperazone, moxalactam - no
longer available in USA

Currently reexamining breakpoints for:

Carbapenems
Extended-spectrum penicillins
-lactam / -lactamase inhibitor combinations

Gram-positive bacteria

Staphylococcus spp. (Table 2C)

Enterococcus spp. (Table 2D)
Streptococcus spp. -hemolytic Group (Table 2H-1)
Streptococcus spp. Viridans Group (Table 2H-2)

Added comment:
Daptomycin should not be reported
for isolates from the lower respiratory
tract

Staphylococcus spp.

Staphylococcus spp.
Test/Report
Added minocycline
Therapy option for
MRSA
New (2011) IDSA
Guidelines for treatment
of MRSA at
http://www.idsociety.org)

M100-S21 Table 1A. pp. 30.

Staphylococcus spp.
Penicillin and -lactamase Testing (1)
Revised comment:
(11) .. Perform an induced -lactamase test on all
S. aureus isolates for which the penicillin MICs are
0.12 g/mL or zone diameters 29 mm before
reporting the isolate as penicillin susceptible. Rare
isolates of staphylococci that contain genes for
lactamase production may not produce a positive
induced -lactamase test. Consequently, for serious
infections requiring penicillin therapy, laboratories
should perform MIC tests and induced -lactamase
testing on all subsequent isolates from the same
patient. PCR testing of the isolate for the blaZ lactamase gene may be considered.
M100-S21 Table 2C.pp. 70.

Continuing issues for Staphylococcus

spp. that test penicillin-S(1)
Perform an induced -lactamase test on
penicillin-S Staphylococcus spp.
An induced -lactamase test does not always
detect S. aureus capable of producing lactamase
Revised comment in CLSI M100- S21 suggests
blaZ PCR may be considered
Very recently determined blaZ PCR not optimal
Variations of gene and need multiple primers
Some blaZ do not produce functional -lactamase

CLSI exploring other phenotypic -lactamase

methods
CLSI January 2011 Agenda Book.

Continuing issues for Staphylococcus

spp. that test penicillin-S(2)
For now, a lab strategy might be to:
Report penicillin if R
Suppress penicillin if S (except for S.
lugdunensis) and add note Contact lab if
penicillin results needed needed
May get requests to test isolates from serious
infections as endocarditis, osteomyelitis
Upon request, test:

Induced -lactamase test

?blaZ PCR
?Other
and test subsequent isolates on the patient

Streptococcus spp.
Beta-hemolytic Group

Streptococcus spp.
Beta-hemolytic Group Penicillin
Revised comment:
(3) Penicillin and ampicillin are drugs of choice for treatment
of beta-hemolytic streptococcal infections. Susceptibility
testing of penicillins and other
-lactams approved by the
FDA for treatment of
-hemolytic streptococcal infections
need not be performed routinely, because nonsusceptible
isolates (ie, penicillin MICs > 0.12 and ampicillin MICs > 0.25
g/mL) are extremely rare in any
-hemolytic streptococcus
and have not been reported for Streptococcus pyogenes. If
testing is performed, any
-hemolytic streptococcal isolate
found to be nonsusceptible should be re-identified, retested,
and, if confirmed, submitted to a public health laboratory.

M100-S21 Table 2H-1. pp. 100.

Group B Streptococcus spp.

Penicillin Non-susceptible
Japan - 1995-2005
14 isolates w/ penicillin MICs 0.25-1 g/ml
Modified penicillin binding proteins (PBP2X and others)
Elevated MICs to other
-lactams
Kimura, et al, 2008. AAC 52:2890.
USA CDC - 1999-2005 (n=5631)
Four isolates with PBP2X mutations in hot spot similar to
Streptococcus pneumoniae
Dahesh, et al. 2008. AAC 52:2915.
Penicillin MICs for isolates from a patient on long term penicillin
therapy went from 0.06-0.25 g/ml
Gaudreau et al. 2010. J Antimicrob Chemother. 65:594.

Streptococcus spp.
Beta-hemolytic Group*
Erythromycin / Clindamycin

* Groups A, B, C, G (large colony types)

**requires induction to show resistance

Inducible Clindamycin Resistance

Streptococcus spp. -hemolytic Group
D Zone Test:
Routine disk diffusion
method
Place 2 g clindamycin 12
g
mm from edge of 15
erythromycin disk.

Broth microdilution test:

1 g/mL erythromycin and
0.5 g/mL clindamycin in
same well
Bowling et al. 2010. JCM.
48:2275.

Recommendations for Prevention of Perinatal

Group B Streptococcal (GBS) Disease

from CDC GBS

Guidelines
Check CDC GBS
website for additional
guidelines for AST

Check for inducible

clindamycin R if.
erythromycin-R and
clindamycin-S
website for additional
guidelines for AST

Revised Appendix A

M100-S21 App. A. pp.144-145

Actions to take for 3 categories of

results.

Example: Confirm vancomycin-NS

(MIC >32 g/ml) Streptococcus mitis

Example: Confirm ceftriaxone-R

(MIC >32 g/ml) Salmonella spp.

M100-S21 App. B. pp.147

What do we mean by intrinsic vs.

acquired resistance?
Intrinsic resistance = inherent or innate (not
acquired) resistance, which is reflected in
wildtype antimicrobial patterns of all or almost
all representatives of a species. Intrinsic
resistance is so common that susceptibility
testing is unnecessary.
M100-S21 App. B. pp. 147.
Acquired resistance = antimicrobial resistance
in a bacterium that was previously susceptible
that occurs as a result of:
Chance gene mutation
Acquisition of R genes from another bacterium

Morganella morganii (outpatient urine)

ampicillin
R
Cephalothin
R
Cefuroxime
S??
Ciprofloxacin R
Nitrofurantoin S??
trim-sulfa
R
Refer to intrinsic resistance profiles to evaluate the
accuracy of testing methods
Results inaccurate?? - M. morganii are intrinsically
R to cefuroxime and nitrofurantoin

What should we do?

What should we do when AST results

do not match intrinsic R profile?
Check for any obvious errors
Consider impact to patient care: