m10033 Samplepages-1
m10033 Samplepages-1
m10033 Samplepages-1
M100
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Performance Standards for Antimicrobial
Susceptibility Testing
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The Clinical and Laboratory Standards Institute (CLSI) is a not-for-profit membership organization that brings
together the varied perspectives and expertise of the worldwide laboratory community for the advancement of a
common cause: to foster excellence in laboratory medicine by developing and implementing medical laboratory
standards and guidelines that help laboratories fulfill their responsibilities with efficiency, effectiveness, and global
applicability.
Consensus Process
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Consensus—the substantial agreement by materially affected, competent, and interested parties—is core to the
development of all CLSI documents. It does not always connote unanimous agreement but does mean that the
participants in the development of a consensus document have considered and resolved all relevant objections
and accept the resulting agreement.
Commenting on Documents
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CLSI documents undergo periodic evaluation and modification to keep pace with advances in technologies,
procedures, methods, and protocols affecting the laboratory or health care.
CLSI’s consensus process depends on experts who volunteer to serve as contributing authors and/or as participants
in the reviewing and commenting process. At the end of each comment period, the committee that developed
the document is obligated to review all comments, respond in writing to all substantive comments, and revise the
draft document as appropriate.
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Comments on published CLSI documents are equally essential and may be submitted by anyone, at any time, on
any document. All comments are managed according to the consensus process by a committee of experts.
Appeal Process
When it is believed that an objection has not been adequately considered and responded to, the process for
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Sharon K. Cullen, BS, RAC Michael Satlin, MD, MS
Tanis Dingle, PhD, D(ABMM), FCCM Audrey N. Schuetz, MD, MPH, D(ABMM)
Marcelo F. Galas, BSc Susan Sharp, PhD, D(ABMM), F(AAM)
Romney M. Humphries, PhD, D(ABMM), FIDSA Patricia J. Simner, PhD, D(ABMM)
Abstract
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The data in the tables are valid only if the methodologies in CLSI documents M02,1 M07,2 and M113 are followed.
These standards contain information about disk diffusion (M021) and dilution (M072 and M113) test procedures for
aerobic and anaerobic bacteria. Clinicians depend heavily on information from the microbiology laboratory for
treating their seriously ill patients. The clinical importance of antimicrobial susceptibility test results demands
that these tests be performed under optimal conditions and that laboratories have the capability to provide results
for the newest antimicrobial agents. The tables presented in M100 represent the most current information for drug
selection, interpretation, and quality control using the procedures standardized in M02,1 M07,2 and M11.3 Users
should replace previously published tables with these new tables. Changes in the tables since the previous edition
appear in boldface type.
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Clinical and Laboratory Standards Institute (CLSI). Performance Standards for Antimicrobial Susceptibility Testing.
33rd ed. CLSI supplement M100 (ISBN 978-1-68440-170-3 [Print]; ISBN 978-1-68440-171-0 [Electronic]). Clinical and
Laboratory Standards Institute, USA, 2023.
The Clinical and Laboratory Standards Institute consensus process, which is the mechanism for moving a
document through two or more levels of review by the health care community, is an ongoing process. Users
should expect revised editions of any given document. Because rapid changes in technology may affect the
procedures, methods, and protocols in a standard or guideline, users should replace outdated editions with the
current editions of CLSI documents. Current editions are listed in the CLSI catalog and posted on our website at
www.clsi.org.
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If you or your organization is not a member and would like to become one,
or to request a copy of the catalog, contact us at:
P: +1.610.688.0100; F: +1.610.688.0700; E: customerservice@clsi.org; W: www.clsi.org.
M100-Ed33
Copyright ©2023 Clinical and Laboratory Standards Institute. Except as stated below, any
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Suggested Citation
CLSI. Performance Standards for Antimicrobial Susceptibility Testing. 33rd ed.
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CLSI supplement M100. Clinical and Laboratory Standards Institute; 2023.
Previous Editions:
December 1986, December 1987, December 1991, December 1992, December 1994, December
1995, January 1997, January 1998, January 1999, January 2000, January 2001, January 2002,
January 2003, January 2004, January 2005, January 2006, January 2007, January 2008,
January 2009, January 2010, June 2010, January 2011, January 2012, January 2013, January
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2014, January 2015, January 2016, January 2017, January 2018, January 2019, January 2020,
March 2021, February 2022
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M100-Ed33
ISBN 978-1-68440-170-3 (Print)
ISBN 978-1-68440-171-0 (Electronic)
ISSN 1558-6502 (Print)
ISSN 2162-2914 (Electronic) Volume 43, Number 3
ii
Table of Contents
Contents
viii
M100-Ed33
Abstract .................................................................................................................................................... i
Committee Membership................................................................................................................................. iii
e
Overview of Changes ................................................................................................................................... xiv
CLSI Breakpoint Additions Since 2010 .............................................................................................................. xxx
CLSI Breakpoint Revisions Since 2010 ............................................................................................................. xxxiii
CLSI Archived Resources ........................................................................................................................... xxxvii
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Summary of CLSI Processes for Establishing Breakpoints and Quality Control Ranges ................................................... xxxviii
CLSI Reference Methods vs Commercial Methods and CLSI vs US Food and Drug Administration Breakpoints ........................ xxxix
Subcommittee on Antimicrobial Susceptibility Testing Mission Statement ..................................................................... xl
Instructions for Use of Tables .......................................................................................................................... 1
References ............................................................................................................................................... 22
Introduction to Tables 1A–1P. Antimicrobial Agents That Should Be Considered for Testing and Reporting by Microbiology
Laboratories .......................................................................................................................................... .. 24
m Table 1A. Enterobacterales (not including inducible AmpC producers and Salmonella/Shigella) ......................................... 26
Table 1B. Salmonella and Shigella spp. ............................................................................................................. 28
Table 1C. Pseudomonas aeruginosa.................................................................................................................. 30
Table 1D. Acinetobacter spp. ......................................................................................................................... 32
Table 1E. Burkholderia cepacia complex ........................................................................................................... 34
Table 1F. Stenotrophomonas maltophilia .......................................................................................................... 36
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Table 1G. Other Non-Enterobacterales ............................................................................................................ . 38
Table 1H. Staphylococcus spp. ....................................................................................................................... 40
Table 1I. Enterococcus spp. ............................................................................................................................ 42
Table 1J. Haemophilus influenzae and Haemophilus parainfluenzae ......................................................................... 44
Table 1K. Neisseria gonorrhoeae ...................................................................................................................... 46
Contents (Continued)
Table 1L. Streptococcus pneumoniae .............................................................................................................. 48
Table 1M. Streptococcus spp. β-Hemolytic Group ................................................................................................ 50
Table 1N. Streptococcus spp. Viridans Group ..................................................................................................... 52
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Table 1O. Gram-Negative Anaerobes .............................................................................................................. 54
Table 1P. Gram-Positive Anaerobes ................................................................................................................ 56
Table 2A. Zone Diameter and MIC Breakpoints for Enterobacterales ......................................................................... 58
Table 2B-1. Zone Diameter and MIC Breakpoints for Pseudomonas aeruginosa .............................................................. 74
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Table 2B-2. Zone Diameter and MIC Breakpoints for Acinetobacter spp...................................................................... 80
Table 2B-3. Zone Diameter and MIC Breakpoints for Burkholderia cepacia complex ....................................................... 84
Table 2B-4. Zone Diameter and MIC Breakpoints for Stenotrophomonas maltophilia ...................................................... 86
Table 2B-5. MIC Breakpoints for Other Non-Enterobacterales .................................................................................. 90
Table 2C. Zone Diameter and MIC Breakpoints for Staphylococcus spp. ...................................................................... 94
Table 2D. Zone Diameter and MIC Breakpoints for Enterococcus spp. ........................................................................ 106
m Table 2E. Zone Diameter and MIC Breakpoints for Haemophilus influenzae and Haemophilus parainfluenzae ....................... 112
Table 2F. Zone Diameter and MIC Breakpoints for Neisseria gonorrhoeae ................................................................... 118
Table 2G. Zone Diameter and MIC Breakpoints for Streptococcus pneumoniae ............................................................. 122
Table 2H-1. Zone Diameter and MIC Breakpoints for Streptococcus spp. β-Hemolytic Group ............................................ 130
Table 2H-2. Zone Diameter and MIC Breakpoints for Streptococcus spp. Viridans Group.................................................. 136
Table 2I. Zone Diameter and MIC Breakpoints for Neisseria meningitidis .................................................................... 140
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Table 2J. MIC Breakpoints for Anaerobes .......................................................................................................... 144
Table 3A. Tests for Extended-Spectrum β-Lactamases in Klebsiella pneumoniae, Klebsiella oxytoca, Escherichia coli,
and Proteus mirabilis ................................................................................................................................. 148
M100-Ed33
Introduction to Tables 3B and 3C. Tests for Carbapenemases in Enterobacterales and Pseudomonas aeruginosa .................... 152
Table 3B. CarbaNP Test for Suspected Carbapenemase Production in Enterobacterales and Pseudomonas aeruginosa ............. 154
ix
Table of Contents
Table of Contents
Contents (Continued)
x
M100-Ed33
Table 3C. Modified Carbapenem Inactivation Methods for Suspected Carbapenemase Production in Enterobacterales and
Pseudomonas aeruginosa ............................................................................................................................. 162
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Table 3D. Tests for Colistin Resistance for Enterobacterales and Pseudomonas aeruginosa .............................................. 174
Table 3E-1. Test for Performing Disk Diffusion Directly From Positive Blood Culture Broth .............................................. 180
Table 3E-2. Zone Diameter Disk Diffusion Breakpoints for Enterobacterales Direct From Blood Culture ............................... 182
Table 3E-3. Zone Diameter Disk Diffusion Breakpoints for Pseudomonas aeruginosa Direct From Blood Culture ..................... 184
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Table 3F. Tests for Detection of β-Lactamase Production in Staphylococcus spp........................................................... 186
Table 3G-1. Test for Detecting Methicillin (Oxacillin) Resistance in Staphylococcus aureus and Staphylococcus lugdunensis ...... 190
Table 3G-2. Test for Detecting Methicillin (Oxacillin) Resistance in Staphylococcus spp. Except Staphylococcus aureus and
Staphylococcus lugdunensis .......................................................................................................................... 192
Table 3H. Vancomycin Agar Screen for Staphylococcus aureus and Enterococcus spp. .................................................... 194
Table 3I. Tests for Detecting Inducible Clindamycin Resistance in Staphylococcus spp., Streptococcus pneumoniae, and
Streptococcus spp. β-Hemolytic Group ............................................................................................................ 196
mTable 3J. Test for Detecting High-Level Mupirocin Resistance in Staphylococcus aureus ................................................. 200
Table 3K. Test for Detecting High-Level Aminoglycoside Resistance in Enterococcus spp. (includes disk diffusion) ................. 202
Table 4A-1. Disk Diffusion QC Ranges for Nonfastidious Organisms and Antimicrobial Agents Excluding β-Lactam
Combination Agents ................................................................................................................................... 206
Table 4A-2. Disk Diffusion QC Ranges for Nonfastidious Organisms and β-Lactam Combination Agents ................................ 210
Table 4B. Disk Diffusion QC Ranges for Fastidious Organisms .................................................................................. 214
Table 4C. Disk Diffusion Reference Guide to QC Frequency .................................................................................... 218
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Table 4D. Disk Diffusion Troubleshooting Guide .................................................................................................. 220
Table 5A-1. MIC QC Ranges for Nonfastidious Organisms and Antimicrobial Agents Excluding β-Lactam Combination Agents ..... 224
Table 5A-2. MIC QC Ranges for Nonfastidious Organisms and β-Lactam Combination Agents ............................................ 232
Table 5B. MIC QC Ranges for Fastidious Organisms (Broth Dilution Methods) ................................................................ 236
Table 5C. MIC QC Ranges for Neisseria gonorrhoeae (Agar Dilution Method) ................................................................ 240
Contents (Continued)
Table 5D. MIC QC Ranges for Anaerobes (Agar Dilution Method) ............................................................................... 242
Table 5E. MIC QC Ranges for Anaerobes (Broth Microdilution Method) ....................................................................... 244
Table 5F. MIC Reference Guide to QC Frequency ................................................................................................ 246
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Table 5G. MIC Troubleshooting Guide .............................................................................................................. 248
Table 6A. Solvents and Diluents for Preparing Stock Solutions of Antimicrobial Agents ................................................... 254
Table 6B. Preparing Stock Solutions for Antimicrobial Agents Provided With Activity Expressed as Units .............................. 260
Table 6C. Preparing Solutions and Media Containing Combinations of Antimicrobial Agents ............................................. 262
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Table 7. Preparing Dilutions of Antimicrobial Agents to Be Used in Agar Dilution Susceptibility Tests ................................. 268
Table 8A. Preparing Dilutions of Antimicrobial Agents to Be Used in Broth Dilution Susceptibility Tests ............................... 270
Table 8B. Preparing Dilutions of Water-Insoluble Antimicrobial Agents to Be Used in Broth Dilution Susceptibility Tests ........... 272
Appendix A. Suggestions for Confirming Antimicrobial Susceptibility Test Results and Organism Identification for Agents
Approved by the US Food and Drug Administration for Clinical Use ........................................................................... 274
Appendix B. Intrinsic Resistance .................................................................................................................... 282
M100-Ed33
xi
Table of Contents
Table of Contents
Contents (Continued)
xii
M100-Ed33
Glossary I (Part 1). β-Lactams: Class and Subclass Designations and Generic Names ...................................................... 340
Glossary I (Part 2). Non–β-Lactams: Class and Subclass Designations and Generic Names . .............................................. 344
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Glossary II. Antimicrobial Agent Abbreviations, Routes of Administration, and Drug Class................................................ 348
Glossary III. List of Identical Abbreviations Used for More Than One Antimicrobial Agent in US Diagnostic Products ................ 356
The Quality Management System Approach ....................................................................................................... 358
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Overview of Changes
Overview of Changes
xiv
M100-Ed33
M100-Ed33 replaces the previous edition of the supplement, M100-Ed32, published in 2022. The major changes in M100-Ed33 are
listed below. Other minor or editorial changes were made to the general formatting and to some of the table footnotes and
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comments. Changes to the tables since the previous edition appear in boldface type. The following are additions or changes unless
otherwise noted as “Deleted.”
M100 is updated and reviewed annually as new data and new agents become available. Use of outdated documents is strongly
discouraged.
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Section/Table Changes
General
Throughout Revised text for testing and reporting to clarify relevant institutional stakeholders
CLSI Breakpoint Revised to create 2 separate tables:
Additions/Revisions Since 2010 CLSI Breakpoint Additions Since 2010
CLSI Breakpoint Revisions Since 2010
CLSI Breakpoint Additions Added:
Since 2010 Plazomicin disk diffusion and MIC breakpoints for Enterobacterales (p. xxx)
CLSI Breakpoint Revisions Revised:
Since 2010 Amikacin
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Disk diffusion and MIC breakpoints for Enterobacterales (p. xxxiii)
Disk diffusion and MIC breakpoints for Pseudomonas aeruginosa (p. xxxiv)
Gentamicin disk diffusion and MIC breakpoints for Enterobacterales (p. xxxiii)
Piperacillin disk diffusion and MIC breakpoints for P. aeruginosa (p. xxxiv)
Piperacillin-tazobactam disk diffusion and MIC breakpoints for P. aeruginosa (p. xxxiv)
Tobramycin
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Disk diffusion and MIC breakpoints for Enterobacterales (p. xxxiv)
Disk diffusion and MIC breakpoints for P. aeruginosa (p. xxxiv)
Deleted:
Gentamicin disk diffusion and MIC breakpoints for P. aeruginosa (p. xxxiv)
Overview of Changes (Continued)
Section/Table Changes
General (Continued)
CLSI Archived Resources Added:
Former Tables 1A–1C regarding suggested groupings of antimicrobial agents approved by the US
Food and Drug Administration for clinical use that should be considered for testing and reporting
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by microbiology laboratories, which have been replaced by new Tables 1A through 1P (p. xxxvii)
Instructions for Use of Tables Added:
Test/Report Tiers and Additional Designations (pp. 3–5)
Selective and Cascade Reporting (pp. 6–7)
Revised:
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Introductory section to include new Tables 1A through 1P and to update test/report tiers and
designations (p. 1)
Appropriate Agents for Routine Testing (p. 2)
Equivalent Agents (pp. 2–3)
Susceptible-dose dependent definition to include extended infusion in the dosage regimen
information (p. 9)
Organisms Excluded from Table 2 to clarify Aeromonas spp. (p. 11)
Tables 2 Added (where applicable):
Urine-only (U) designation and associated footnote
Inv. designation for investigational agents
Deleted:
Test/Report column
Tables 1. Antimicrobial Agents That Should Be Considered for Testing and Reporting by Microbiology Laboratories
Introduction to Tables 1A–1P. Added:
Introductory text and warning box for Tables 1A-1P (p. 24)
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Table 1A. Enterobacterales Added:
(not including inducible AmpC Antimicrobial agents for Enterobacterales (not including inducible AmpC producers and
producers and Salmonella/Shigella) Salmonella/Shigella) (pp. 26–27)
(new table)
M100-Ed33
Table 1B. Salmonella and Shigella Added:
spp. (new table) Antimicrobial agents for Salmonella and Shigella spp. (p. 28)
xv
Overview of Changes
Overview of Changes
M100-Ed33
Section/Table Changes
Tables 1. (Continued)
Table 1C. Pseudomonas aeruginosa Added:
(new table) Antimicrobial agents for P. aeruginosa (p. 30)
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Table 1D. Acinetobacter spp. Added:
(new table) Antimicrobial agents for Acinetobacter spp. (p. 32)
Table 1E. Burkholderia cepacia Added:
complex (new table) Antimicrobial agents for B. cepacia complex (p. 34)
Table 1F. Stenotrophomonas Added:
maltophilia (new table) Antimicrobial agents for S. maltophilia (p. 36)
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Table 1G. Other Non- Added:
Enterobacterales (new table) Antimicrobial agents for other non-Enterobacterales (p. 38)
Table 1H. Staphylococcus spp. Added:
(new table) Antimicrobial agents for Staphylococcus spp. (pp. 40–41)
Table 1I. Enterococcus spp. Added:
(new table) Antimicrobial agents for Enterococcus spp. (pp. 42–43)
Table 1J. Haemophilus influenzae Added:
and Haemophilus parainfluenzae Antimicrobial agents for H. influenzae and H. parainfluenzae (pp. 44–45)
(new table)
Table 1K. Neisseria gonorrhoeae Added:
m (new table)
Table 1L. Streptococcus
pneumoniae (new table)
Table 1M. Streptococcus spp.
β-Hemolytic Group (new table)
Table 1N. Streptococcus spp.
Viridans Group (new table)
Table 1O. Gram-Negative
Anaerobes (new table)
Antimicrobial agents for N. gonorrhoeae (p. 46)
Added:
Antimicrobial agents for S. pneumoniae (pp. 48–49)
Added:
Antimicrobial agents for Streptococcus spp. β-hemolytic group (pp. 50–51)
Added:
Antimicrobial agents for Streptococcus spp. viridans group (p. 52)
Added:
Antimicrobial agents for gram-negative anaerobes (p. 54)
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Table 1P. Gram-Positive Anaerobes Added:
(new table) Antimicrobial agents for gram-positive anaerobes (p. 56)
Overview of Changes (Continued)
Section/Table Changes
Tables 2. Zone Diameter and/or MIC Breakpoints
Table 2A. Zone Diameter and MIC Added:
Breakpoints for Enterobacterales General comment regarding antimicrobial agents that should be considered for testing and
reporting (p. 58)
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Reference for comments regarding cephems and routine ESBL testing and cephems and
third-generation cephalosporin resistance (p. 62)
Comment regarding the accuracy and reproducibility of cefiderocol testing results (p. 64)
Gentamicin, tobramycin, and amikacin combination therapy comment (p. 68)
Gentamicin, tobramycin, and amikacin dosage regimen comments (p. 68)
Plazomicin disk diffusion and MIC breakpoints and associated comments (p. 68)
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Revised:
General comment regarding testing fecal isolates of Salmonella and Shigella spp. (p. 58)
Comment regarding therapy for oral ampicillin (p. 60)
Comment regarding cephems and routine ESBL testing (p. 62)
Comment regarding cephems and third-generation cephalosporin resistance (p. 62)
Comment regarding carbapenems and elevated MICs (p. 66)
Gentamicin, tobramycin, and amikacin disk diffusion and MIC breakpoints (p. 68)
Gemifloxacin reporting comment (p. 69)
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M100-Ed33
xvii
Overview of Changes
Overview of Changes
M100-Ed33
Section/Table Changes
Tables 2. (Continued)
Table 2B-1. Zone Diameter and Added:
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MIC Breakpoints for Pseudomonas General comment regarding antimicrobial agents that should be considered for testing and
aeruginosa reporting (p. 74)
Comment regarding the accuracy and reproducibility of cefiderocol testing results (p. 76)
Comment regarding combination therapy for tobramycin and amikacin (p. 78)
Tobramycin and amikacin dosage regimen comments (p. 78)
Revised:
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Piperacillin disk diffusion and MIC breakpoints and associated dosage regimen comment (p. 76)
Piperacillin-tazobactam disk diffusion and MIC breakpoints and associated dosage regimen
comment (p. 76)
Tobramycin disk diffusion and MIC breakpoints (p. 78)
U designation for amikacin (p. 78)
Deleted:
Gentamicin disk diffusion and MIC breakpoints
Table 2B-2. Zone Diameter and MIC Added:
Breakpoints for Acinetobacter spp. General comment regarding antimicrobial agents that should be considered for testing and
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Revised:
Chloramphenicol reporting comment (p. 85)
Table 2B-4. Zone Diameter and MIC Added:
Breakpoints for Stenotrophomonas General comment regarding antimicrobial agents that should be considered for testing and
maltophilia reporting (p. 86)
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Comment regarding the accuracy and reproducibility of cefiderocol testing results (p. 87)
Levofloxacin Rx monotherapy comment (p. 87)
Revised:
Chloramphenicol reporting comment (p. 87)
Table 2B-5. MIC Breakpoints for Added:
Other Non-Enterobacterales General comment regarding antimicrobial agents that should be considered for testing and
reporting (p. 90)
Revised:
m Comment regarding recommendations for testing and reporting Aeromonas spp. (p. 90)
Chloramphenicol reporting comment (p. 92)
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M100-Ed33
xix
Overview of Changes
Overview of Changes
M100-Ed33
Section/Table Changes
Tables 2. (Continued)
Table 2C. Zone Diameter and Added:
MIC Breakpoints for General comment regarding antimicrobial agents that should be considered for testing and
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Staphylococcus spp. reporting (p. 94)
Revised:
Daptomycin reporting comment (p. 101)
Quinupristin-dalfopristin reporting comment (p. 102)
Table 2D. Zone Diameter and MIC Added:
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Breakpoints for Enterococcus spp. General comment regarding antimicrobial agents that should be considered for testing and
reporting (p. 106)
Revised:
Dalbavancin and daptomycin (E. faecium only) reporting comment (p. 109)
Erythromycin and fosfomycin reporting comments (p. 110)
Quinupristin-dalfopristin and tedizolid reporting comments (p. 111)
Table 2E. Zone Diameter and Added:
MIC Breakpoints for Haemophilus MH-F agar as a medium for disk diffusion to the testing conditions box for H. influenzae (p. 112)
influenzae and Haemophilus MH-F broth as a medium for broth dilution to the testing conditions box for H. influenzae
Revised:
Routine QC recommendations box to clarify media for each QC strain (p. 112)
Ceftolozane-tazobactam reporting comment (p. 115)
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Overview of Changes (Continued)
Section/Table Changes
Tables 2. (Continued)
Table 2F. Zone Diameter and Added:
MIC Breakpoints for Neisseria General comment regarding antimicrobial agents that should be considered for testing and
gonorrhoeae reporting (p. 118)
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Table 2G. Zone Diameter and Added:
MIC Breakpoints for Streptococcus General comment regarding antimicrobial agents that should be considered for testing and
pneumoniae reporting (p. 122)
Revised:
Medium information for disk diffusion in testing conditions box (p. 122)
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General comment regarding MIC testing of cefotaxime, ceftriaxone, meropenem, or penicillin
reported with S. pneumoniae isolated from CSF (p. 123)
Comment regarding susceptibility to gemifloxacin, levofloxacin, and moxifloxacin (p. 127)
Table 2H-1. Zone Diameter and MIC Added:
Breakpoints for Streptococcus spp. General comment regarding antimicrobial agents that should be considered for testing and
β-Hemolytic Group reporting (p. 130)
Revised:
Dalbavancin and daptomycin reporting comments (p. 132)
Erythromycin, azithromycin, clarithromycin, and dirithromycin dosage regimen comment
Revised:
Dalbavancin and daptomycin reporting comments (p. 138)
Revised:
Chloramphenicol reporting comment (p. 142)
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meningitidis
M100-Ed33
xxi
Overview of Changes
Overview of Changes
M100-Ed33
Section/Table Changes
Tables 2. (Continued)
Table 2J. MIC Breakpoints for Added:
Anaerobes General comment regarding antimicrobial agents that should be considered for testing and
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reporting (p. 144)
Revised:
Ampicillin and penicillin testing and reporting comment to include test/report tiers (p. 145)
Metronidazole resistance comment to refer users to Appendix D (p. 146)
Tables 3. Specialized Resistance Testing
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Table 3A. Tests for Extended- Added:
Spectrum β-Lactamases in Introductory text regarding reporting of ESBL test results (p. 148)
Klebsiella pneumoniae, Klebsiella
oxytoca, Escherichia coli, and Revised:
Proteus mirabilis NOTE regarding ESBL testing (p. 148)
Introduction to Tables 3B and 3C. Revised:
Tests for Carbapenemases in Introductory text and associated reference (p. 152)
Enterobacterales and Pseudomonas
aeruginosa
Table 3B. CarbaNP Test for Revised:
m Suspected Carbapenemase
Production in Enterobacterales and
Pseudomonas aeruginosa
Deleted:
NOTE regarding the use of former MIC breakpoints for carbapenems
Deleted:
Table 3B-1
Revised:
Indications for when to perform test (p. 162)
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Carbapenemase Production in
Enterobacterales and Pseudomonas Deleted:
aeruginosa NOTE regarding the use of former MIC breakpoints for carbapenems
Table 3C-1. Modifications of Table Deleted:
3C When Using MIC Breakpoints for Table 3C-1
Carbapenems Described in M100-
S20 (January 2010)
Overview of Changes (Continued)
Section/Table Changes
Tables 3. (Continued)
Table 3D. Tests for Colistin Revised:
Resistance for Enterobacterales “QC recommendations – routine” row (p. 176)
and Pseudomonas aeruginosa QC strain in Figures 1 and 2 legends (pp. 178-179)
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Table 3E-1. Test for Performing Revised:
Disk Diffusion Directly From Incubation length recommendations to refer users to Tables 3E-2 and 3E-3 (p. 180)
Positive Blood Culture Broth
Table 3E-2. Zone Diameter Added:
Disk Diffusion Breakpoints for General comment regarding organism identification (p. 182)
Enterobacterales Direct From Breakpoints for ampicillin 8-10 h, meropenem 8-10 h and 16-18 h, and ciprofloxacin excluding
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Blood Culture Salmonella 8-10 h and 16-18 h (p. 183)
Deleted:
Test/Report Group column
Table 3E-3. Zone Diameter Added:
Disk Diffusion Breakpoints for General comment regarding organism identification (p. 184)
Pseudomonas aeruginosa Direct Breakpoints for meropenem 8-10 h (p. 184)
From Blood Culture
Deleted:
Test/Report Group column
M100-Ed33
xxiii
Overview of Changes
Overview of Changes
M100-Ed33
Section/Table Changes
Tables 4. Disk Diffusion QC Ranges and Associated Tables
Table 4A-2. Disk Diffusion Added:
QC Ranges for Nonfastidious Organism characteristic OXA-1 for E. coli NCTC 13353 (p. 210)
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Organisms and β-Lactam Footnote e regarding colony morphologies for K. pneumoniae ATCC® 700603 (p. 212)
Combination Agents Ceftibuten QC range for E. coli NCTC 13353
Ceftibuten-ledaborbactam QC range for E. coli NCTC 13353
Table 4B. Disk Diffusion QC Ranges Added:
for Fastidious Organisms Footnote f regarding chloramphenicol QC range for H. influenzae ATCC® 49247 in MH-F agar
(p. 216)
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Gentamicin QC range for N. gonorrhoeae ATCC® 49226 (p. 215)
MH-F agar medium for H. influenzae (p. 216)
Revised:
Footnote e regarding H. influenzae ATCC® 49247 or 49766 to indicate its use with HTM and
to indicate that H. influenzae ATCC® 49247 should be used with MH-F (p. 216)
Footnote g regarding QC ranges for delafloxacin, levonadifloxacin, and nafithromycin
to include clarithromycin with MH-F agar (p. 216)
Incubation temperatures for H. influenzae, N. gonorrhoeae, and streptococci and
N. meningitidis (p. 216)
Revised:
Ceftibuten QC range for E. coli ATCC® 25922
Footnote i regarding additional colistin QC ranges for E. coli NCTC 13846 (p. 228)
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Footnote m regarding exebacase QC ranges, including figures showing determination of
exebacase S. aureus ATCC® 29213 end points (pp. 228-229)
Overview of Changes (Continued)
Section/Table Changes
Tables 5. (Continued)
Table 5A-2. MIC QC Ranges for Added:
Nonfastidious Organisms and Organism characteristic OXA-1 for E. coli NCTC 13353 (p. 232)
β-Lactam Combination Agents
e
Ceftazidime-avibactam QC ranges
E. coli NCTC 13353
Klebsiella pneumoniae ATCC® BAA-1705™
K. pneumoniae ATCC® BAA-2814™
Ceftibuten QC range
pl
K. pneumoniae ATCC® 700603
Ceftibuten-avibactam QC ranges
E. coli ATCC® 25922
K. pneumoniae ATCC® 700603
E. coli NCTC 13353
K. pneumoniae ATCC® BAA-1705™
K. pneumoniae ATCC® BAA-2814™
Ceftibuten-ledaborbactam QC ranges
m
Escherichia coli NCTC 13353
K. pneumoniae ATCC® BAA-1705™
K. pneumoniae ATCC® BAA-2814™
Meropenem-xeruborbactam QC ranges
P. aeruginosa ATCC® 27853
K. pneumoniae ATCC® BAA-2814™
Sa
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xxv
Overview of Changes
Overview of Changes
M100-Ed33
Section/Table Changes
Tables 5. (Continued)
Table 5A-2. MIC QC Ranges for Added (continued):
e
Nonfastidious Organisms and Footnote e regarding colony morphologies for K. pneumoniae ATCC® 700603 (p. 234)
β-Lactam Combination Agents Footnote h regarding ceftazidime-avibactam, ceftibuten, and ceftibuten-avibactam lack of
(continued) equivalency (p. 234)
Footnote i regarding meropenem QC range for P. aeruginosa ATCC® BAA-3197™
(formerly P. aeruginosa PA5257) (p. 234)
Footnote j regarding meropenem-xeruborbactam QC range for P. aeruginosa ATCC® BAA-3197™
(formerly P. aeruginosa PA5257) (p. 234)
pl
NOTE stating that MIC ranges in the table apply to both broth microdilution and agar dilution
unless otherwise specified (p. 234)
Revised:
Ceftibuten QC range for E. coli ATCC® 25922
Piperacillin-tazobactam QC range for E. coli ATCC® 25922
Table 5B. MIC QC Ranges for Added:
Fastidious Organisms (Broth Tebipenem QC ranges
Dilution Methods) H. influenzae ATCC® 49766
S. pneumoniae ATCC® 49619
e
ATCC® 25922, P. aeruginosa ATCC® 27853, E. coli NCTC 13846, and E. coli ATCC® BAA-3170™
Various agents troubleshooting comments for Enterococcus faecalis ATCC® 51299 (p. 250)
Revised:
Carbenicillin troubleshooting comment for P. aeruginosa ATCC® 27853 (p. 248)
Various agents troubleshooting comments for S. pneumoniae ATCC® 49619 (p. 250)
pl
Tables 6. Preparing Antimicrobial Agent Stock Solutions
Table 6A. Solvents and Diluents for Added:
Preparing Stock Solutions of Ledaborbactam (p. 256)
Antimicrobial Agents Footnote i regarding exebacase handling instructions (p. 259)
Footnote j regarding exebacase preparation instructions (p. 259)
Xeruborbactam (p. 258)
Revised:
Ceftibuten solvent and diluent for preparing stock solutions (p. 254)
Exebacase diluent for preparing stock solutions (p. 255)
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xxvii
Overview of Changes
Overview of Changes
M100-Ed33
Section/Table Changes
Appendixes
Appendix A. Suggestions for Added:
Confirming Antimicrobial
e
Enterobacterales (p. 274)
Susceptibility Test Results and Imipenem-relebactam
Organism Identification for Agents Cefiderocol
Approved by the US Food and Drug
Administration for Clinical Use Acinetobacter baumannii complex (p. 275)
Cefiderocol
pl
P. aeruginosa (p. 275)
Ceftazidime-avibactam
Imipenem-relebactam
Cefiderocol
Revised:
NOTE regarding agents not listed because there is no intrinsic resistance (p. 285)
Added:
Organism characteristic OXA-1 for E. coli NCTC 13353 (p. 291)
Comment regarding colony morphologies for K. pneumoniae ATCC® 700603 (p. 291)
Sa
Overview of Changes (Continued)
Section/Table Changes
Appendixes (Continued)
Appendix E. Dosage Regimens Used Added:
to Establish Susceptible or Enterobacterales
Susceptible-Dose Dependent Amikacin (p. 302)
e
Breakpoints Gentamicin (p. 303)
Plazomicin (excluding family Morganellaceae) (p. 304)
Tobramycin (p. 304)
P. aeruginosa
Amikacin (p. 304)
pl
Tobramycin (p. 304)
Revised:
Dosage for piperacillin and piperacillin-tazobactam for P. aeruginosa (p. 304)
Appendix I. Cefiderocol Broth Revised:
Preparation and Reading Broth Step for preparing iron-depleted cation-adjusted Mueller-Hinton broth (p. 335)
Microdilution Minimal Inhibitory
Concentration End Points
Glossaries
Glossary I (Part 1). Β-Lactams: Added:
M100-Ed33
xxix
Overview of Changes
Subcommittee on Antimicrobial Susceptibility Testing Mission Statement
xl
M100-Ed33
The Subcommittee on Antimicrobial Susceptibility Testing is composed of representatives from the professions, government, and
industry, including microbiology laboratories, government agencies, health care providers and educators, and pharmaceutical and
e
diagnostic microbiology industries. Using the CLSI voluntary consensus process, the subcommittee develops standards that
promote accurate antimicrobial susceptibility testing and appropriate reporting. The mission of the Subcommittee on
Antimicrobial Susceptibility Testing is to:
pl
Provide quality control parameters for standard test methods.
Establish breakpoints and interpretive categories for the results of standard antimicrobial susceptibility tests and provide
epidemiological cutoff values when breakpoints are not available.
Provide suggestions for testing and reporting strategies that are clinically relevant and cost-effective.
Continually refine standards and optimize detection of emerging resistance mechanisms through development of new or
revised methods, breakpoints, and quality control parameters.
m
Educate users through multimedia communication of standards and guidelines.
Foster a dialogue with users of these methods and those who apply them.
The ultimate purpose of the subcommittee’s mission is to provide useful information to enable laboratories to assist the clinician
in the selection of appropriate antimicrobial therapy for patient care. The standards and guidelines are meant to be
comprehensive and to include all antimicrobial agents for which the data meet established CLSI guidelines. The values that guide
this mission are quality, accuracy, fairness, timeliness, teamwork, consensus, and trust.
Sa
Instructions for Use of Tables
©
Tables 1A through 1P: suggested tiers of antimicrobial agents that should be considered for testing and reporting by
e
microbiology laboratories. These suggestions include clinical efficacy, current consensus recommendations for first-
choice and alternative drugs, and US Food and Drug Administration (FDA) clinical indications for use. In other
countries, placement of antimicrobial agents in Tables 1A through 1P should be based on available drugs approved for
clinical use by relevant regulatory organizations.
Tables 2A through 2I: tables for each organism group that contain:
pl
– Recommended testing conditions
– Routine QC recommendations (also see Chapter 4 in M021 and M072)
– General comments for testing the organism group and specific comments for testing particular agent/organism
combinations
– Agents that should be considered for routine testing and reporting by medical microbiology laboratories,
as specified in Tables 1A through 1P (test/report Tiers 1, 2, 3, and 4), including agents reported only on organisms
isolated from the urinary tract (designated by “U”).
– Agents that are appropriate for the respective organism group but are not listed in Tables 1 and would generally not
warrant routine testing by a medical microbiology laboratory in the United States (designated with an asterisk as
m
“other”; designated with “Inv.” for “investigational” [not yet FDA approved]), including agents reported only on
organisms isolated from the urinary tract (designated by “U”).
– Zone diameter and minimal inhibitory concentration (MIC) breakpoints
Tables 1O, 1P, and 2J: tables containing specific recommendations for testing and reporting results on anaerobes and
some of the information listed in the bullets above
Tables 3A through 3K: tables describing tests to detect particular resistance types in specific organisms or organism groups
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M100-Ed33
1
I. Selecting Antimicrobial Agents for Testing and Reporting
2
M100-Ed33
A. Appropriate Agents for Routine Testing
Selecting the most appropriate antimicrobial agents to test and report is a decision best made by each laboratory
e
in consultation with the antimicrobial stewardship team and other relevant institutional stakeholders.
The suggestions for each organism group in Tables 1A-1P include agents of proven efficacy that show acceptable
in vitro test performance. Considerations in the assignment of agents to specific tiers include:
pl
Clinical efficacy
Prevalence of resistance
Minimizing emergence of resistance
FDA clinical indications for use
©
Cost
Tests on selected agents may be useful for infection-prevention purposes (eg, testing ceftazidime for
Enterobacterales to indicate potential extended-spectrum β-lactamase production; see Table 3A).
m B. Equivalent Agents
Antimicrobial agents listed together in a single box are agents for which interpretive categories (susceptible, intermediate,
susceptible-dose dependent, or resistant) and clinical efficacy are similar. A laboratory will often test only one agent
from a box routinely, typically the agent that is on its formulary. In some cases, a laboratory may not test any agents
from a box, depending on institutional needs.
In some boxes, the agents will be listed with an “or” between them. The “or” identifies agents for which cross-
resistance and cross-susceptibility are nearly complete. Results from one agent connected by an “or” can be used to
Sa
resistance to the agents in question must be tested and a result of “resistant” must be obtained with all agents for at least
95% of the strains. “Or” is also used for comparable agents when tested against organisms for which “susceptible-only”
breakpoints are provided (eg, cefotaxime or ceftriaxone with H. influenzae). When no “or” connects agents within a box,
testing of one agent cannot be used to predict results for another, owing either to discrepancies or insufficient data (see
Section VIII, which describes equivalent agent tests).
e
C. Test/Report Tiers and Additional Designations
Antimicrobial Agent Test and Report Tiers and Additional Considerations for Agents Listed in Tables 1
Additional Testing and Reporting
Tier Definition Test Reporta Considerations
pl
1 Antimicrobial agents that are Routine Routine
appropriate for routine, primary testing
and reporting
2 Antimicrobial agents that are Routine Cascadeb Report following cascade reporting rules
appropriate for routine, primary testing due to resistance to agent(s) in Tier 1.
but may be reported following cascade
reporting rules established at each May be reported routinely based on
institution institution-specific guidelines.
3 Antimicrobial agents that are Routine or Cascadeb Test routinely based on institution-
appropriate for routine, primary by request specific guidelines or by clinician request
M100-Ed33
3
Table 1A
Enterobacterales (not including inducible AmpC producers and Salmonella/Shigella)
M02 and M07
Table 1A. Enterobacterales (not including inducible AmpC producers and Salmonella/Shigella)a
26
M100-Ed33
Tier 3: Antimicrobial agents that are
appropriate for routine, primary
Tier 2: Antimicrobial agents that are testing in institutions that serve Tier 4: Antimicrobial agents that
Tier 1: Antimicrobial agents appropriate for routine, primary testing patients at high risk for MDROs but may warrant testing and reporting
e
that are appropriate for but may be reported following cascade should only be reported following by clinician request if antimicrobial
routine, primary testing and reporting rules established at each cascade reporting rules established agents in other tiers are not
reporting institution at each institution optimal because of various factors
Ampicillin
Cefazolin Cefuroxime
Cefotaxime or ceftriaxoneb Cefepimec
Ertapenem Cefiderocol
pl
Imipenem Ceftazidime-avibactam
Meropenem Imipenem-relebactam
Meropenem-vaborbactam
Amoxicillin-clavulanate
Ampicillin-sulbactam
©
Clinical and Laboratory Standards Institute. All rights reserved.
Piperacillin-tazobactam
Gentamicin Tobramycin Plazomicin
Amikacin
Ciprofloxacin
Levofloxacin
Trimethoprim-
m sulfamethoxazole
Urine Only
Cefazolin (surrogate for
uncomplicated UTI)e
Cefotetan
Cefoxitin
Tetracyclined
Aztreonam
Ceftarolineb
Ceftazidimeb
Ceftolozane-tazobactam
Sa
Footnotes
a. See Appendix B for species-specific intrinsic resistance profiles. If an antimicrobial agent–organism combination that is defined as intrinsically
resistant is tested, the result hould be reported as resistant. Consideration may be given to adding comments regarding intrinsic resistance of agents
e
not tested.
b. Citrobacter freundii complex, Enterobacter cloacae complex, Hafnia alvei, Klebsiella (formerly Enterobacter) aerogenes, Morganella morganii,
Providencia spp., Serratia marcescens, and Yersinia enterocolitica may test susceptible to ceftriaxone, cefotaxime, ceftazidime, and
ceftaroline, but these agents may be ineffective against these genera within a few days after initiation of therapy due to derepression of inducible
AmpC β-lactamase. The risk of AmpC derepression during therapy is moderate to high with C. freundii complex, E. cloacae complex, and
K. aerogenes and appears to be less frequent with M. morganii, Providencia spp., and S. marcescens.1 Therefore, isolates that are initially
pl
susceptible may become resistant. Testing subsequent isolates may be warranted if clinically indicated.
c. Cefepime should be considered a Tier 1 agent for testing and/or reporting of C. freundii complex, E. cloacae complex, H. alvei, K. aerogenes,
M. morganii, Providencia spp., S. marcescens, and Y. enterocolitica (see footnote b).1
d. Organisms that are susceptible to tetracycline are also considered susceptible to doxycycline and minocycline. However, some organisms that are
intermediate or resistant to tetracycline may be susceptible to doxycycline or minocycline, or both.
e. See cefazolin comments in Table 2A for using cefazolin as a surrogate test for oral cephalosporins and for reporting cefazolin when used for therapy
in uncomplicated UTIs.
NOTE: Information in black boldface type is new or modified since the previous edition.
M100-Ed33
27
Table 1A
Enterobacterales (not including inducible AmpC producers and Salmonella/Shigella)
M02 and M07
Table 1B
Salmonella and Shigella spp.
M02 and M07
M100-Ed33
Tier 3: Antimicrobial agents that
are appropriate for routine,
Tier 2: Antimicrobial agents that primary testing in institutions that
are appropriate for routine, serve patients at high risk for Tier 4: Antimicrobial agents that may
e
primary testing but may be MDROs but should only be warrant testing and reporting by
Tier 1: Antimicrobial agents that reported following cascade reported following cascade clinician request if antimicrobial
are appropriate for routine, reporting rules established at each reporting rules established at each agents in other tiers are not optimal
primary testing and reporting institution institution because of various factors
Ampicillin
Ciprofloxacin
Levofloxacin
pl
Trimethoprim-sulfamethoxazole
Cefotaxime or ceftriaxone Ertapenemc
Imipenemc
Meropenemc
Azithromycind
©
Tetracyclinee
Clinical and Laboratory Standards Institute. All rights reserved.
Footnotes
a. Table 2A should be used for interpreting antimicrobial susceptibility testing results for Salmonella and Shigella spp.
m b.
c.
d.
WARNING: For Salmonella spp. and Shigella spp., aminoglycosides, first- and second-generation cephalosporins, and cephamycins may appear active
in vitro but are not effective clinically and should not be reported as susceptible. Routine susceptibility testing is not indicated for nontyphoidal
Salmonella spp. isolated from intestinal sources. However, susceptibility testing is indicated for all Shigella isolates. When fecal isolates of
Salmonella and Shigella spp. are tested, only ampicillin, a fluoroquinolone, and trimethoprim-sulfamethoxazole should be reported routinely. In
addition, for extraintestinal isolates of Salmonella spp., a third-generation cephalosporin should be tested and reported. Azithromycin may be
tested and reported per institutional guidelines.
Ertapenem, imipenem, and/or meropenem might be considered for testing and/or reporting for isolates resistant to all agents in Tiers 1 and 2, although
there are limited clinical data suggesting their effectiveness for treating salmonellosis or shigellosis.1
NOTE: Information in black boldface type is new or modified since the previous edition.
M100-Ed33
Testing Conditions Routine QC Recommendations (see Tables 4A-1 and 5A-1 for acceptable
QC ranges)
Medium: Disk diffusion: MHA
e
Broth dilution: CAMHB; iron-depleted CAMHB for cefiderocol Escherichia coli ATCC®a 25922
(see Appendix I)1 Pseudomonas aeruginosa ATCC® 27853 (for carbapenems)
Agar dilution: MHA Staphylococcus aureus ATCC® 25923 (for disk diffusion) or S. aureus ATCC®
29213 (for dilution methods) when testing azithromycin against Salmonella
Inoculum: Broth culture method or colony suspension, equivalent to a enterica ser. Typhi or Shigella spp.
0.5 McFarland standard; positive blood culture broth for Refer to Tables 4A-2 and 5A-2 to select strains for routine QC of β-lactam
select antimicrobial agents with disk diffusion (see general combination agents.
pl
comment [6]).
When a commercial test system is used for susceptibility testing, refer to
Incubation: 35°C 2°C; ambient air the manufacturer’s instructions for QC test recommendations and
Disk diffusion: 16–18 hours QC ranges.
Dilution methods: 16–20 hours
©
Clinical and Laboratory Standards Institute. All rights reserved.
Refer to Tables 3A, 3B, and 3C for additional testing, reporting, and QC for Enterobacterales.
General Comments
(1) Refer to Tables 1A-1B for antimicrobial agents that should be considered for testing and reporting by microbiology laboratories.
m (2) For disk diffusion, test a maximum of 12 disks on a 150-mm plate and no more than 6 disks on a 100-mm plate; disks should be placed no less than 24 mm
apart, center to center (see M02,2 Subchapter 3.6). Each zone diameter should be clearly measurable; overlapping zones prevent accurate measurement.
Measure the diameter of the zones of complete inhibition (as judged by the unaided eye), including the diameter of the disk (see the M02 Disk Diffusion
Reading Guide3). Hold the Petri plate a few inches above a black background illuminated with reflected light. The zone margin should be considered the
area showing no obvious, visible growth that can be detected with the unaided eye. Ignore faint growth of tiny colonies that can be detected only with a
magnifying lens at the edge of the zone of inhibited growth. Strains of Proteus spp. may swarm into areas of inhibited growth around certain antimicrobial
agents. With Proteus spp., ignore the thin veil of swarming growth in an otherwise obvious zone of growth inhibition. With trimethoprim and the
sulfonamides, antagonists in the medium may allow some slight growth; therefore, disregard slight growth (20% or less of the lawn of growth) and measure
the more obvious margin to determine the zone diameter.
(3) When fecal isolates of Salmonella and Shigella spp. are tested, only ampicillin, a fluoroquinolone, and trimethoprim-sulfamethoxazole should be reported
Sa
M100-Ed33