EUCAST 2012 Disk MIC Breakpoint Table

European Committee on Antimicrobial Susceptibility Testing
Breakpoint tables for interpretation of MICs and zone diameters

Version 2.0, valid from 2012-01-01
Content
Notes Changes Enterobacteriaceae Pseudomonas spp. Stenotrophomonas maltophilia Acinetobacter spp. Staphylococcus spp. Enterococcus spp. Streptococcus groups A, B, C and G Streptococcus pneumoniae Viridans group streptococci Haemophilus influenzae Moraxella catarrhalis Neisseria gonorrhoeae Neisseria meningitidis Gram-positive anaerobes Clostridium difficile Gram-negative anaerobes Helicobacter pylori Listeria monocytogenes Non-species related breakpoints
Page
1 2 3 8 12 13 17 22 27 32 37 41 46 50 54 58 62 63 67 68 69

Notes
1. The EUCAST tables of clinical breakpoints contain clinical MIC breakpoints (determined over the period 2002-2011) and their inhibition zone diameter correlates. The EUCAST breakpoint table version 2.0 includes corrected typographical errors, clarifications, breakpoints for new organisms, revised MIC breakpoints and revised and new zone diameter breakpoints. Changes are best seen on screen or on a colour printout since cells containing a change are yellow. 2. Non-species-related breakpoints (Pk/Pd breakpoints) are listed separately on the last page. 3. Numbered footnotes relate to MIC breakpoints. Lettered footnotes relate to zone diameter breakpoints. 4. Highlighted antimicrobial names link to EUCAST rationale documents. Highlighted MIC breakpoints and zone diameter breakpoints link to EUCAST MIC and zone diameter distributions, respectively. 5. One version of the document is released as an unprotected Excel file to enable users to alter the list of agents to suit the range of agents tested locally and to present breakpoints in the format used locally. The content of single cells cannot be changed. Hide lines by right-clicking on the line number and choosing "hide". Hide columns by right-clicking on the column letter and choosing "hide". If you wish to add the intermediate columns for MICs and/or zone diameters right-click on the column letter and choose "insert". The intermediate values are inferred from the "S" and "R" breakpoints. 6. A zone diameter breakpoint of "S 50 mm" is an arbitrary "off scale" zone diameter breakpoint corresponding to MIC breakpoint situations where wild type isolates are categorised as intermediate (i.e. no fully susceptible isolates exist). 7. In order to simplify the EUCAST tables, the intermediate category is not listed. It is readily interpreted as the values between the S and the R breakpoint. For example, for MIC breakpoints listed as S 1 mg/L and R > 8 mg/L, the intermediate category is 2-8 (technically >1-8) mg/L, and for zone diameter breakpoints listed as S 22 mm and R < 18 mm, the intermediate category is 18-21 mm.
"-" indicates that susceptibility testing is not recommended as the species is a poor target for therapy with the drug. Isolates may be reported as R without prior testing. "IE" indicates that there is insufficient evidence that the species in question is a good target for therapy with the drug. An MIC with a comment but without an accompanying S, I or R categorisation may be reported. NA = Not Applicable IP = In Preparation

Table
All
Changes (cells containing a change, a deletion or an addition) from v 1.3 are marked yellow
Instructions for disk diffusion methodology and quality control included. Typo error on trimethoprim-sulfamethoxazole corrected to 1.25-23.75 g. Telavancin breakpoints added. Revised breakpoints: Ampicillin, ampicillin-sulbactam, amoxicillin, amoxicillin-clavulanate, piperacillin-tazobactam, cefotaxime, ceftibuten, imipenem and tobramycin. Ticarcillin and ticarcillinclavulanate (typo errors). Disk content (30 g) for cefoxitin added. Ceftibuten: "uncomplicated UTI only" is changed to "UTI only". Revised comments: Penicillins, ampicillin, mecillinam comment F and imipenem. Revised breakpoints: Doripenem and fosfomycin. Trimethoprim-sulfamethoxazole breakpoint for Stenotrophomonas maltophilia moved to a separate table. Revised comment: Fosfomycin. New table. Revised comments: Trimethoprim-sulfamethoxazole. Revised breakpoints: Vancomycin (specific breakpoints for S. aureus and coagulase-negative staphylococci). Revised comments: Penicillins, glycopeptides and doxycycline. Revised breakpoints: Mupirocin. Revised comments: Penicillins, amoxicillin-clavulanate and nitrofurantoin. General recommendation for endocarditis added. Revised breakpoints: Mupirocin and trimethoprim. Revised comments: Benzylpenicillin, phenoxymethylpenicillin, doxycycline and trimethoprim. Typo error on benzylpenicillin note corrected. Correct dosages are 1.2 and 2.4 g. Revised breakpoints: Ceftibuten, linezolid (typo error on MIC breakpoint) and mupirocin. Revised comments: Penicillins (several comments merged), benzylpenicillin, ampicillin, ampicillin-sulbactam, phenoxymethylpenicillin and doxycyline. Benzylpenicillin and meropenem (breakpoints for meningitis moved to a separate row). "Other streptococci" changed to "Viridans group streptococci". General recommendation for endocarditis added. Revised breakpoints: Benzylpenicillin (screen) and mupirocin. Revised breakpoints: Benzylpenicillin (screen), amoxicillin, amoxicillin-clavulanate, phenoxymethylpenicillin (screen breakpoint removed), cefepime, cefixime, cefotaxime, cefpodoxime, ceftibuten, ceftriaxone, cefuroxime, cefuroxime-axetil, imipenem, ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin, minocycline, tetracycline, chloramphenicol and rifampicin. Disk content for amoxicillin-clavulanate changed to 2-1 g. Revised comments: Benzylpenicillin, ampicillin, piperacillin, cefaclor, meropenem and doxycycline. Revised breakpoints: Ampicillin, amoxicillin, amoxicillin-clavulanate, piperacillin, cefaclor, cefepime, cefixime, cefpodoxime, ceftibuten, cefuroxime, cefuroxime-axetil, azithromycin, chloramphenicol and rifampicin. Disk content for amoxicillin-clavulanate changed to 2-1 g. Revised comments: Cefaclor and doxycycline. Revised comment: Doxycycline. New comment: Ampicillin-sulbactam, amoxicillin-clavulanate, piperacillin-tazobactam and ticarcillin-clavulanate. New table. All breakpoints and comments new. Revised breakpoints: Teicoplanin. New comment: Ampicillin-sulbactam, amoxicillin-clavulanate, piperacillin-tazobactam and ticarcillin-clavulanate. Table removed. Organisms with breakpoints have new tables. New table. All breakpoints and comments new. New table. All breakpoints new. Revised breakpoints: Nalidixic acid, vancomycin and teicoplanin. Revised comments: Teicoplanin and vancomycin. "Uncomplicated UTI only" removed from antibiotic names.
Enterobacteriaceae
Pseudomonas spp. Stenotrophomonas maltophilia Staphylococcus spp. Enterococcus spp. Streptococcus groups A, B, C and G Stretococcus pneumoniae
Viridans group streptococci (Other streptococci) Haemophilus influenzae
Moraxella catarrhalis
Neisseria gonorrhoeae Gram-positive anaerobes Clostridium difficile Gram-negative anaerobes Miscellaneous Helicobacter pylori Listeria monocytogenes Non-species related
Enterobacteriaceae
EUCAST Clinical Breakpoint Table v. 2.0, valid from 2012-01-01

Disk diffusion (EUCAST standardised disk diffusion method ) Medium: Mueller-Hinton agar Inoculum: McFarland 0.5 Incubation: Air, 351C, 182h Reading: Read zone edges as the point showing no growth viewed from the back of the plate against a black background illuminated with reflected light. Quality control: Escherichia coli ATCC 25922
Penicillins1
MIC breakpoint (mg/L) S R>

8
Disk Zone diameter Notes content breakpoint (mm) Numbers for comments on MIC breakpoints Letters for comments on disk diffusion (g) S R<
10 14A,B 14B 1/A. Wild type Enterobacteriaceae are categorised as susceptible to aminopenicillins. Some countries prefer to categorise wild type isolates of E. coli and P. mirabilis as intermediate. When this is the case, use the MIC breakpoint S 0.5 mg/L and the corresponding zone diameter breakpoint S 50 mm. B. Ignore growth that may appear as a thin inner zone on some batches of Mueller-Hinton agars. 2. For susceptibility testing purposes, the concentration of sulbactam is fixed at 4 mg/L. C. Susceptibility inferred from ampicillin. 3. For susceptibility testing purposes, the concentration of clavulanate is fixed at 2 mg/L. 4. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L.
Benzylpenicillin Ampicillin
81
Ampicillin-sulbactam Amoxicillin Amoxicillin-clavulanate Piperacillin Piperacillin-tazobactam Ticarcillin Ticarcillin-clavulanate Phenoxymethylpenicillin Oxacillin Cloxacillin Dicloxacillin Flucloxacillin Mecillinam (uncomplicated UTI only)
81,2 81 81,3 8 84 8 83 85
82 8 83 16 164 16 163 85
10-10 20-10 30 30-6 75 75-10
14A,B NoteC 17A,B 18 20 23 23 -
14B NoteC 17B 15 17 23 23 15E, F
10
15E,F
5/E. Mecillinam (pivmecillinam) breakpoints relate to E. coli, Klebsiella spp. and P. mirabilis only. F. Ignore isolated colonies within the inhibition zone for E. coli.
Enterobacteriaceae
Cephalosporins1 MIC breakpoint (mg/L) S R>

1. The cephalosporin breakpoints for Enterobacteriaceae will detect all clinically important resistance mechanisms (including ESBL and plasmid mediated AmpC). Some isolates that produce beta-lactamases are susceptible or intermediate to 3rd or 4th generation cephalosporins with these breakpoints and should be reported as tested, i.e. the presence or absence of an ESBL does not in itself influence the categorisation of susceptibility. In many areas, ESBL detection and characterisation is recommended or mandatory for infection control purposes.
Cefaclor Cefadroxil (uncomplicated UTI only) Cefalexin (uncomplicated UTI only) Cefazolin Cefepime Cefixime (uncomplicated UTI only) Cefotaxime Cefoxitin (screen)2
16 16 1 1 1 NA
16 16 4 1 2 NA 30 5 5 30 30 30
12 12 24 17 20 19
12 12 21 17 17 19 2. The cefoxitin ECOFF (WT 8 mg/L) has a high sensitivity, but poor specificity for identification of AmpC-producing Enterobacteriaceae as this antibiotic is also affected by permeability alterations and some carbapenemases. Classical non-AmpC producers are wild type, whereas plasmid AmpC producers or chromosomal AmpC hyperproducers are non-wild type.
Cefpodoxime (uncomplicated UTI only) Ceftazidime Ceftibuten (UTI only) Ceftriaxone Cefuroxime Cefuroxime axetil (uncomplicated UTI only)
1 1 1 1 83 8
1 4 1 2 8 8
10 10 30 30 30 30
21 22 23 23 18 18
21 19 23 20 18 18 3. The breakpoint relates to a dosage of 1.5 g x 3 and to E. coli, P. mirabilis and Klebsiella spp. only.
Carbapenems1
1. The carbapenem breakpoints for Enterobacteriaceae will detect all clinically important resistance mechanisms (including the majority of carbapenemases). Some isolates that produce carbapenemase are categorised as susceptible with these breakpoints and should be reported as tested, i.e. the presence or absence of a carbapenemase does not in itself influence the categorisation of susceptibility. In many areas, carbapenemase detection and characterisation is recommended or mandatory for infection control purposes.
Doripenem Ertapenem Imipenem2 Meropenem
1 0.5 2 2
4 1 8 8
10 10 10 10
24 25 22 22
18 22 16 16 2. Low-level resistance is common in Morganella spp., Proteus spp. and Providencia spp.
Enterobacteriaceae
Monobactams MIC breakpoint (mg/L) S
Aztreonam1 1

30 27 24 1. The aztreonam breakpoints for Enterobacteriaceae will detect clinically important resistance mechanisms (including ESBL). Some isolates that produce beta-lactamases are susceptible or intermediate to 3rd or 4th generation cephalosporins with these breakpoints and should be reported as tested, i.e. the presence or absence of an ESBL does not in itself influence the categorisation of susceptibility. In many areas, ESBL detection and characterisation is recommended or mandatory for infection control purposes.
R>
4
Fluoroquinolones

1
5 22 19 1. Salmonella spp. - there is clinical evidence for ciprofloxacin to indicate a poor response in systemic infections caused by Salmonella spp. with low-level fluoroquinolone resistance (MIC>0.06 mg/L). The available data relate mainly to S. typhi but there are also case reports of poor response with other Salmonella species.
Ciprofloxacin1
0.5
Levofloxacin Moxifloxacin Nalidixic acid (screen) Norfloxacin Ofloxacin
1 0.5 NA 0.5 0.5
2 1 NA 1 1
5 5 10 5
22 20 NA 22 22
19 17 NA 19 19
Aminoglycosides1

16 4 4 4
1. Aminoglycoside breakpoints are based on once-daily administration of high aminoglycoside dosages. Most often aminoglycosides are given in combination with beta-lactam agents. 30 10 10 10 16 17 15 17 13 14 12 14
Amikacin Gentamicin Netilmicin Tobramycin
8 2 2 2
Enterobacteriaceae
Glycopeptides MIC breakpoint (mg/L) S
Teicoplanin Telavancin Vancomycin -

-
R>
-
Macrolides, lincosamides and streptogramins

-
1. Azithromycin has been used in the treatment of infections with Salmonella typhi (MIC 16 mg/L for wild type isolates) and Shigella spp.
Azithromycin1 Clarithromycin Erythromycin1 Roxithromycin Telithromycin Clindamycin Quinupristin-dalfopristin
Enterobacteriaceae
Tetracyclines MIC breakpoint (mg/L) S
Doxycycline Minocycline Tetracycline Tigecycline1 1

15 18A 15A 1. Tigecycline has decreased activity against Morganella spp., Proteus spp. and Providencia spp. A. Zone diameter breakpoints validated for E. coli only. For other Enterobacteriaceae, use an MIC method.
R>
2
Miscellaneous agents

8 2 32 32 641 4 4
30 17 NoteA 100 11B 5 1.25-23.75 18 16 17 NoteA 11B 15 13 2. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration. 1/B. Breakpoints relate to E. coli only. A. Use an MIC method.
Chloramphenicol Colistin Daptomycin Fosfomycin iv Fosfomycin-trometamol (uncomplicated UTI only) Fusidic acid Linezolid Metronidazole Mupirocin Nitrofurantoin (uncomplicated UTI only) Rifampicin Spectinomycin Trimethoprim (uncomplicated UTI only) Trimethoprim-sulfamethoxazole2
8 2 32 32 641 2 2
Pseudomonas spp.

Disk diffusion (EUCAST standardised disk diffusion method ) Medium: Mueller-Hinton agar Inoculum: McFarland 0.5 Incubation: Air, 351C, 182h Reading: Read zone edges as the point showing no growth viewed from the back of the plate against a black background illuminated with reflected light. Quality control: Pseudomonas aeruginosa ATCC 27853
Penicillins

16 162 16 162 -
Disk Zone diameter Notes content breakpoint (mm) Numbers for comments on MIC breakpoints Letters for comments on disk diffusion (g) R< S
30 30-6 75 75-10 19 19 17 17 19 19 17 17 1. Breakpoints are based on high dose therapy (with or without tazobactam, 4 g x 4). 2. For susceptibility testing purposes, the concentration of beta-lactamase inhibitor is fixed at 4 mg/L. 3. Breakpoints are based on high dose therapy (with or without clavulanate, 3 g x 4).
Benzylpenicillin Ampicillin Ampicillin-sulbactam Amoxicillin Amoxicillin-clavulanate Piperacillin1 Piperacillin-tazobactam1 Ticarcillin3 Ticarcillin-clavulanate3 Phenoxymethylpenicillin Oxacillin Cloxacillin Dicloxacillin Flucloxacillin Mecillinam (uncomplicated UTI only)
16 162 16 162 -
Pseudomonas spp.
Cephalosporins MIC breakpoint (mg/L) S
Cefaclor Cefadroxil Cefalexin Cefazolin Cefepime Cefixime Cefotaxime Cefoxitin Cefpodoxime Ceftazidime Ceftibuten Ceftriaxone Cefuroxime Cefuroxime axetil 81 NA 81 -

30 18 NA 10 16 18 NA 16 1. Breakpoints relate to high dose therapy (2 g x 3).
R>
8 NA 8 -
Carbapenems

4 8 8
10 10 10 25 20 24 19 17 18 1. Breakpoints relate to high dose, frequent therapy (1 g x 4).
Doripenem Ertapenem Imipenem Meropenem
1 41 2
Monobactams

161
30 50 16 1. The resistant breakpoint relates to high dose therapy. The susceptible breakpoint is set to ensure that wild type isolates are reported intermediate.
Aztreonam
Pseudomonas spp.
Fluoroquinolones MIC breakpoint (mg/L) S
Ciprofloxacin Levofloxacin Moxifloxacin Nalidixic acid (screen) Norfloxacin Ofloxacin 0.5 1 NA -

5 5 25 20 NA 22 17 NA -
R>
1 2 NA -
Aminoglycosides1

16 4 4 4
8 4 4 4
Glycopeptides

-
-
Teicoplanin Telavancin Vancomycin
10
Pseudomonas spp.
Macrolides, lincosamides and streptogramins MIC breakpoint (mg/L) S
Azithromycin Clarithromycin Erythromycin Roxithromycin Telithromycin Clindamycin Quinupristin-dalfopristin -

-
R>
-
Tetracyclines

-
-
Doxycycline Minocycline Tetracycline Tigecycline
Miscellaneous

4 -
NoteA NoteA A. Use an MIC method. 1. Anecdotal evidence suggests that infections caused by wild type isolates (ECOFF: WT 128 mg/L) may be treated with combinations of fosfomycin and other agents.
Chloramphenicol Colistin Daptomycin Fosfomycin iv1 Fosfomycin-trometamol (uncomplicated UTI only) Fusidic acid Linezolid Metronidazole Mupirocin Nitrofurantoin (uncomplicated UTI only) Rifampicin Spectinomycin Trimethoprim (uncomplicated UTI only) Trimethoprim-sulfamethoxazole
4 -
11
Stenotrophomonas maltophilia

Disk diffusion (EUCAST standardised disk diffusion method ) Medium: Mueller-Hinton agar Inoculum: McFarland 0.5 Incubation: Air, 351C, 182h Reading: Read zone edges as the point showing no growth viewed from the back of the plate against a black background illuminated with reflected light. Quality control: Escherichia coli ATCC 25922
Antibiotic agent

4
1.25-23.75 16A 16A 1. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration. A. Ignore haze or fine growth within the inhibition zone.
Trimethoprim-sulfamethoxazole1
12
Acinetobacter spp.

Disk diffusion (EUCAST standardised disk diffusion method ) Medium: Mueller-Hinton agar Inoculum: McFarland 0.5 Incubation: Air, 351C, 182h Reading: Read zone edges as the point showing no growth viewed from the back of the plate against a black background illuminated with reflected light. Quality control: Pseudomonas aeruginosa ATCC 27853
Penicillins1

IE IE IE IE IE -
1. Susceptibility testing of Acinetobacter spp. to penicillins is unreliable. In most instances Acinetobacter spp. are resistant to penicillins. IE IE IE IE IE IE IE IE IE IE -
Benzylpenicillin Ampicillin Ampicillin-sulbactam Amoxicillin Amoxicillin-clavulanate Piperacillin Piperacillin-tazobactam Ticarcillin Ticarcillin-clavulanate Phenoxymethylpenicillin Oxacillin Cloxacillin Dicloxacillin Flucloxacillin Mecillinam (uncomplicated UTI only)
IE IE IE IE IE -
13
Acinetobacter spp.
Cefaclor Cefadroxil Cefalexin Cefazolin Cefepime Cefixime Cefotaxime Cefoxitin Cefpodoxime Ceftazidime Ceftibuten Ceftriaxone Cefuroxime Cefuroxime axetil -

-
R>
-
Carbapenems

4 8 8
10 10 10 21 23 21 15 17 15
1 2 2
Monobactams

-
-
Aztreonam
14
Acinetobacter spp.
Ciprofloxacin Levofloxacin Moxifloxacin Nalidixic acid (screen) Norfloxacin Ofloxacin 1 1 NA -

5 5 21 21 NA 21 18 NA -
R>
1 2 NA -
Aminoglycosides1

16 4 4 4
8 4 4 4
Glycopeptides

-
-
15
Acinetobacter spp.
Azithromycin Clarithromycin Erythromycin Roxithromycin Telithromycin Clindamycin Quinupristin-dalfopristin -

-
R>
-
Tetracyclines

IE IE
IE IE IE IE
IE IE
Miscellaneous

2 4
NoteA 1.25-23.75 16 NoteA 13 1. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration. A. Use an MIC method.
2 2
16
Staphylococcus spp.

Disk diffusion (EUCAST standardised disk diffusion method ) Medium: Mueller-Hinton agar Inoculum: McFarland 0.5 Incubation: Air, 351C, 182h Reading: Read zone edges as the point showing no growth viewed from the back of the plate against a black background illuminated with reflected light. Quality control: Staphylococcus aureus ATCC 29213
Penicillins1
1/A. Most staphylococci are penicillinase producers. The benzylpenicillin breakpoint will mostly, but not unequivocally, separate beta-lactamase producers from non-producers. If the MIC is >0.12 mg/L, report resistant. If the MIC is 0.12mg/L, test susceptibility with a disk diffusion test (see note B). Isolates positive for beta-lactamase are resistant to benzylpenicillin, phenoxymethylpenicillin, amino-, carboxy- and ureidopenicillins. Isolates negative for beta-lactamase and susceptible to cefoxitin (cefoxitin is used to screen for methicillin resistance) can be reported susceptible to these drugs. Isolates positive for beta-lactamase and susceptible to cefoxitin are susceptible to penicillin-beta-lactamase inhibitor combinations and penicillinase-resistant penicillins (oxacillin, cloxacillin, dicloxacillin and flucloxacillin). Isolates resistant to cefoxitin are methicillin resistant and resistant to beta-lactam agents, except those with approved anti-MRSA activity and clinical breakpoints.
Benzylpenicillin
0.121
0.121,2
1 unit
26A,B
26A,B
B. Disk diffusion is more reliable than MIC for detection of penicillinase producers, provided the zone diameter is measured AND the zone edge closely inspected. If the zone diameter is <26 mm, report resistant. If the zone diameter is 26 mm and the zone edge is sharp, report resistant. If not sharp, report susceptible and if uncertain, report resistant. Chromogenic cephalosporin-based beta-lactamase tests do not reliably detect staphylococcal penicillinase. C. Breakpoints relate to S. saprophyticus only.
Ampicillin Ampicillin-sulbactam Amoxicillin Amoxicillin-clavulanate Piperacillin Piperacillin-tazobactam Ticarcillin Ticarcillin-clavulanate Phenoxymethylpenicillin Oxacillin2 Cloxacillin Dicloxacillin Flucloxacillin Mecillinam (uncomplicated UTI only)
Note1 Note1 Note1 Note1 Note1 Note1 Note1 Note1 Note1 Note1,2 Note1 Note1 Note1 -
Note1 Note1 Note1 Note1 Note1 Note1 Note1 Note1 Note1 Note1,2 Note1 Note1 Note1 -
15A,C NoteA NoteA NoteA NoteA NoteA NoteA NoteA NoteA NoteA NoteA NoteA NoteA -
15A,C NoteA NoteA NoteA NoteA NoteA NoteA NoteA NoteA NoteA NoteA NoteA NoteA -
2. S. aureus and S. lugdunensis with oxacillin MIC values >2 mg/L are mostly methicillin resistant due to the presence of the mecA gene. The corresponding oxacillin MIC for coagulase-negative staphylococci is >0.25 mg/L.
17
Staphylococcus spp.
Cephalosporins1 MIC breakpoint (mg/L) S
Cefaclor2 Cefadroxil Cefalexin Cefazolin Cefepime Cefixime Cefotaxime Cefoxitin (screen) S. aureus, S. lugdunensis Note1 Note1 Note
1

NoteA NoteA Note
A
R>
Note1 Note1 Note
1
NoteA NoteA NoteA NoteA NoteA NoteA 22A
1. Susceptibility of staphylococci to cephalosporins is inferred from the cefoxitin susceptibility except for ceftazidime, cefixime and ceftibuten, which do not have breakpoints and should not be used for staphylococcal infections. 2. High-dose therapy is required for treatment of staphylococcal infections. A. Susceptibility inferred from cefoxitin.
Note1 Note1 Note1 Note3
Note1 Note1 Note1 Note3 30
NoteA NoteA NoteA 22A
3. S. aureus and S. lugdunensis with cefoxitin MIC values >4 mg/L are mostly methicillin resistant due to the presence of the mecA gene. For coagulase-negative staphylococi other than S. lugdunensis the cefoxitin MIC is a poorer predictor of methicillin resistance than the disk diffusion test.
Cefoxitin (screen) Coagulase-negative staphylococci Cefpodoxime Ceftazidime Ceftibuten Ceftriaxone Cefuroxime Cefuroxime axetil
Note3 Note IE Note1 Note1 Note

1 1
Note3 Note IE Note1 Note1 Note

1 1
30
25A Note IE NoteA NoteA Note

A A
25A NoteA IE NoteA NoteA NoteA
Carbapenems1

1/A. Susceptibility of staphylococci to carbapenems is inferred from the cefoxitin susceptibility. NoteA NoteA NoteA NoteA NoteA NoteA NoteA NoteA
18
Staphylococcus spp.
Aztreonam -

-
R>
-
Fluoroquinolones1

1 2 1 NA NA
5 5 5 10 20 22 24 NA 17A 20 19 21 NA 17A A. The norfloxacin disk diffusion test can be used to screen for fluoroquinolone resistance. Isolates categorised as susceptible can be reported susceptible to ciprofloxacin, levofloxacin, moxifloxacin and ofloxacin. Isolates categorised as resistant should be tested for susceptibility to individual agents. 1. Regarding breakpoints for other fluoroquinolones ( e.g. pefloxacin and enoxacin) - refer to breakpoints determined by national breakpoint committees. 2. Breakpoints relate to high dose therapy.
Ciprofloxacin2 Levofloxacin Moxifloxacin Nalidixic acid (screen) Norfloxacin (screen)
1 1 0.5 NA NA
Ofloxacin2
20
20
Aminoglycosides1

16 16 1 1 1 1 1 1
30 30 10 10 10 10 10 10 18 22 18 22 18 22 18 22 16 19 18 22 18 22 18 22 1. Aminoglycoside breakpoints are based on once-daily administration of high aminoglycoside dosages. Most often aminoglycosides are given in combination with beta-lactam agents. 2. Resistance to amikacin is most reliably determined by testing with kanamycin (zone diameter breakpoints under development).
Amikacin2 S. aureus Amikacin2 Coagulase-negative staphylococci Gentamicin S. aureus Gentamicin Coagulase-negative staphylococci Netilmicin S. aureus Netilmicin Coagulase-negative staphylococci Tobramycin S. aureus Tobramycin Coagulase-negative staphylococci
8 8 1 1 1 1 1 1
19
Staphylococcus spp.
Glycopeptides1 MIC breakpoint (mg/L) S R>

1. Glycopeptide MICs are method dependent and should be determined by broth microdilution (reference ISO 20776). S. aureus with vancomycin MIC values of 2 mg/L are on the border of the wild type MIC distribution and there may be an impaired clinical response. The resistant breakpoint has been reduced to 2 mg/L to avoid reporting "GISA" isolates intermediate as serious infections with "GISA" isolates are not treatable with increased doses of vancomycin or teicoplanin.
Teicoplanin, S. aureus Teicoplanin, Coagulase-negative staphylococci Telavancin, MRSA Vancomycin, S. aureus Vancomycin, Coagulase-negative staphylococci
2 4 1 2 4
2 4 1 2 4
NoteA NoteA NoteA Note NoteA

A
NoteA NoteA NoteA NoteA NoteA
A. Disk diffusion is unreliable and cannot distinguish between wild type isolates and those with non- vanA -mediated resistance.

21 2 2
1
NoteA 15 Note 21
A
Azithromycin Clarithromycin Erythromycin Roxithromycin Telithromycin Clindamycin2 Quinupristin-dalfopristin
11 1 1
1
NoteA NoteA 18 NoteA IE 19B 18C
1/A. Erythromycin can be used to determine susceptibility to azithromycin, clarithromycin and roxithromycin.
11 IE 0.25 1
21 IE 0.5 2 2 15
NoteA IE 22B 21C
2/B. Inducible clindamycin resistance can be detected only in the presence of a macrolide antibiotic. In disk diffusion tests look for apparent antagonism of clindamycin by erythromycin (D-test). C. Isolates non-susceptible by disk diffusion should be confirmed by MIC testing.
Tetracyclines

21
NoteA NoteA 1/A. Isolates susceptible to tetracycline are also susceptible to doxycycline and minocycline, but some resistant to tetracycline may be susceptible to minocycline and/or doxycycline. An MIC method should be used to test doxycycline susceptibility of tetracycline resistant isolates if required.
Doxycycline
11
Minocycline Tetracycline Tigecycline
0.51 11 0.5
2
11 21 0.5
30 30 15
23A 22A 18
20A 19A 18 2. Isolates with MIC values above the susceptible breakpoint are very rare or not yet reported. The identification and antimicrobial susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate sent to a reference laboratory. Until there is evidence regarding clinical response for confirmed isolates with MIC values above the current resistant breakpoint they should be reported resistant.
20
Staphylococcus spp.
Miscellaneous MIC breakpoint (mg/L) S
Chloramphenicol Colistin Daptomycin 8 1

30 18 NoteA 18 NoteA 1. Isolates with MIC values above the susceptible breakpoint are very rare or not yet reported. The identification and antimicrobial susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate sent to a reference laboratory. Until there is evidence regarding clinical response for confirmed isolates with MIC values above the current resistant breakpoint they should be reported resistant. A. Use an MIC method.
R>
8 11
Fosfomycin iv Fosfomycin-trometamol (uncomplicated UTI only) Fusidic acid Linezolid Metronidazole Mupirocin Nitrofurantoin (uncomplicated UTI only) Rifampicin Spectinomycin Trimethoprim (uncomplicated UTI only) Trimethoprim-sulfamethoxazole4
32 1 4 12 643 0.06 2 2
32 1 4 2562 643 0.5 4 4 5 1.25-23.75 200 100 5 10 10
NoteA 24 19 30B 13C 26 17 17
NoteA 24 19 18B 13C 23 14 14 4. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration. 2/B. Breakpoints relate to nasal decolonisation of S. aureus. Intermediate isolates are initially cleared as effectively as susceptible isolates but recolonisation is very common. 3/C. Breakpoints relate to S. saprophyticus only.
21
Enterococcus spp.
In endocarditis, refer to national or international endocarditis guidelines for breakpoints for Enterococcus spp.

Disk diffusion (EUCAST standardised disk diffusion method ) Medium: Mueller-Hinton agar Inoculum: McFarland 0.5 Incubation: Air, 351C, 182h Reading: Read zone edges as the point showing no growth viewed from the back of the plate against a black background illuminated with reflected light. Quality control: Enterococcus faecalis ATCC 29212
Penicillins1

8 8 8 83 Note2 Note2 -
1. E. faecium resistant to penicillins can be considered resistant to all other beta-lactam agents including carbapenems. 2 10 NoteA NoteA NoteA NoteA NoteA 8 NoteA NoteA NoteA NoteA NoteA 2/A. Susceptibility to ampicillin, amoxicillin and pipercillin with and without beta-lactamase inhibitor can be inferred from the ampicillin susceptibility test. 3. For susceptibility testing purposes, the concentration of clavulanate is fixed at 2 mg/L.
Benzylpenicillin Ampicillin Ampicillin-sulbactam2 Amoxicillin2 Amoxicillin-clavulanate2 Piperacillin2 Piperacillin-tazobactam2 Ticarcillin Ticarcillin-clavulanate Phenoxymethylpenicillin Oxacillin Cloxacillin Dicloxacillin Flucloxacillin Mecillinam (uncomplicated UTI only)
4 4 4 43 Note2 Note2 -
22
Enterococcus spp.
Cefaclor Cefadroxil Cefalexin Cefazolin Cefepime Cefixime Cefotaxime Cefoxitin Cefpodoxime Ceftazidime Ceftibuten Ceftriaxone Cefuroxime Cefuroxime axetil -

-
R>
-
Carbapenems

8 -
10 21 18 -
4 -
Monobactams

-
-
Aztreonam
23
Enterococcus spp.
Ciprofloxacin Levofloxacin Moxifloxacin Nalidixic acid (screen) Norfloxacin Ofloxacin NA -

NA NA -
R>
NA -
Aminoglycosides1
1. Aminoglycoside monotherapy is ineffective against enterococci. There is synergism between aminoglycosides and beta-lactam agents against enterococci without acquired aminoglycoside resistance mechanisms.
Amikacin Gentamicin
IE Note2
IE Note2 30
NoteA NoteA
NoteA NoteA 2/A. Isolates with gentamicin MIC >128 mg/L or an inhibition zone diameter <8 mm have acquired resistance mechanisms and can be reported as high-level aminoglycoside resistant (with the exception of streptomycin, which must be tested separately). There is no synergistic effect between aminoglycosides and beta-lactam agents in enterococci with high-level aminoglycoside resistance. 3/B. Isolates with high-level gentamicin resistance may not be high-level resistant to streptomycin. High-level resistance to streptomycin is defined as MIC >512 mg/L and/or an inhibition zone diameter <19 mm. There is no synergistic effect between streptomycin and beta-lactam agents in enterococci with high-level resistance to streptomycin.
Netilmicin Streptomycin
IE Note
3
IE Note
3
NoteA 300 Note

B
NoteA NoteB
Tobramycin
IE
IE
NoteA
NoteA
24
Enterococcus spp.
Teicoplanin 21

30 16A 16A 1. The susceptible breakpoint for vancomycin has been raised to 4 mg/L to avoid dividing the wild type MIC distributions of some species. The resistant breakpoint for teicoplanin has been reduced to 2 mg/L to avoid erroneous reporting of isolates with vanA mediated resistance. A. Glycopeptide susceptible enterococci exhibit sharp zone edges. Suspect resistance when the zone edge is fuzzy or colonies grow within the inhibition zone. Some vanB isolates (vancomycin resistant, teicoplanin susceptible) are particularly difficult to detect with disk diffusion.
R>
2
Telavancin Vancomycin
IE 41
IE 4 5
IE 12A
IE 12A

41
15 22A 20A 1/A. Quinupristin-dalfopristin breakpoints are valid for E. faecium only.
Azithromycin Clarithromycin Erythromycin Roxithromycin Telithromycin Clindamycin Quinupristin-dalfopristin
11
25
Enterococcus spp.
Doxycycline Minocycline Tetracycline Tigecycline 0.251

15 18 15 1. Isolates with MIC values above the susceptible breakpoint are very rare or not yet reported. The identification and antimicrobial susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate sent to a reference laboratory. Until there is evidence regarding clinical response for confirmed isolates with MIC values above the current resistant breakpoint they should be reported resistant.
R>
0.5
Miscellaneous

IE 4 641 1 1
IE 10 19 100 15A 5 1.25-23.75 50 50 IE 19 15A 21 21 2. The activity of trimethoprim is uncertain against enterococci, hence the wild type population is categorised as intermediate. 3. Trimethoprim-sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration. 1/A. Nitrofurantoin breakpoints are valid for E. faecalis only.
Chloramphenicol Colistin Daptomycin Fosfomycin iv Fosfomycin-trometamol (uncomplicated UTI only) Fusidic acid Linezolid Metronidazole Mupirocin Nitrofurantoin (uncomplicated UTI only) Rifampicin Spectinomycin Trimethoprim (uncomplicated UTI only)2 Trimethoprim-sulfamethoxazole3
IE 4 641 0.03 0.03
26
Streptococcus groups A, B, C and G

Disk diffusion (EUCAST standardised disk diffusion method ) Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L -NAD (MH-F) Inoculum: McFarland 0.5 Incubation: 5% CO2, 351C, 182h Reading: Read zone edges as the point showing no growth viewed from the front of the plate with the lid removed and with reflected light. Quality control: Streptococcus pneumoniae ATCC 49619
Penicillins1

0.25
1 unit 18 18 1/A. The beta-lactam susceptibility of beta-haemolytic streptococcus groups A, B, C and G is inferred from the penicillin susceptibility. 2. Isolates with MIC values above the susceptible breakpoint are very rare or not yet reported. The identification and antimicrobial susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate sent to a reference laboratory. Until there is evidence regarding clinical response for confirmed isolates with MIC values above the current resistant breakpoint they should be reported resistant. 3. Streptococcus groups A, B, C and G do not produce beta-lactamase. The addition of a beta-lactamase inhibitor does not add clinical benefit.
Benzylpenicillin2
0.25
Ampicillin Ampicillin-sulbactam3 Amoxicillin Amoxicillin-clavulanate3 Piperacillin Piperacillin-tazobactam Ticarcillin Ticarcillin-clavulanate Phenoxymethylpenicillin Oxacillin Cloxacillin Dicloxacillin Flucloxacillin Mecillinam (uncomplicated UTI only)
3
Note1 Note1 Note1 Note1 Note Note Note1,4 NA Note1 Note1 Note1 1 1
Note1 Note1 Note1 Note1 Note Note Note1,4 NA Note1 Note1 Note1 1 1
NoteA NoteA NoteA NoteA Note Note NoteA,B NA NoteA NoteA NoteA A A
NoteA NoteA NoteA NoteA NoteA NoteA NoteA,B NA NoteA NoteA NoteA 4/B. The phenoxymethylpenicillin breakpoints apply to streptococcus groups A, C and G only.
27

Cefaclor Cefadroxil Cefalexin Cefazolin Cefepime Cefixime Cefotaxime Cefoxitin Cefpodoxime Ceftazidime Ceftibuten Ceftriaxone Cefuroxime Cefuroxime axetil Note1 Note Note Note 1 1

1/A. The beta-lactam susceptibility of beta-haemolytic streptococcus groups A, B, C and G is inferred from the penicillin susceptibility. Note1 Note Note Note 1 1
R>
NoteA Note Note Note A A
NoteA NoteA NoteA NoteA NoteA NoteA NA NoteA NoteA NoteA NoteA NoteA
Note1
1
Note1
1
NoteA
A
Note1 NA Note1 Note1 Note1 Note Note

1 1
Note1 NA Note1 Note1 Note1 Note Note

1 1
NoteA NA NoteA NoteA NoteA Note Note

A A
Carbapenems1

Note1 Note1 Note Note
1 1
1/A. The beta-lactam susceptibility of beta-haemolytic streptococcus groups A, B, C and G is inferred from the penicillin susceptibility. NoteA NoteA Note Note
A A
Note1 Note1 Note Note

1 1
NoteA NoteA NoteA NoteA
Monobactams

-
-
Aztreonam
28

Ciprofloxacin Levofloxacin Moxifloxacin Nalidixic acid (screen) Norfloxacin (screen) 1 0.5 NA NA

5 5 10 18 18 NA 12A 15 15 NA 12A A. The norfloxacin disk diffusion test can be used to screen for fluoroquinolone resistance. Isolates categorised as susceptible can be reported susceptible to levofloxacin and moxifloxacin. Isolates categorised as resistant should be tested for susceptibility to individual agents.
R>
2 1 NA NA
Ofloxacin
Aminoglycosides

-
-
Glycopeptides

2
30 15A 15A 1. Isolates with MIC values above the susceptible breakpoint are very rare or not yet reported. The identification and antimicrobial susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate sent to a reference laboratory. Until there is evidence regarding clinical response for confirmed isolates with MIC values above the current resistant breakpoint they should be reported resistant. A. Zone diameter breakpoints are based on wild type distributions as there are currently no resistant isolates.
Teicoplanin
21
IE 21
IE 2 5
IE 13A
IE 13A
29

Azithromycin Clarithromycin Erythromycin Roxithromycin Telithromycin Clindamycin2 Quinupristin-dalfopristin 0.251 0.25 0.25 0.51 0.25 0.5 1

NoteA 15 15 2 Note 21
A
R>
0.51 0.5 0.5 11 0.5 0.5 1
NoteA NoteA 18 NoteA 19 17B -
1/A. Erythromycin can be used to determine susceptibility to azithromycin, clarithromycin and roxithromycin.
NoteA 22 17B -
2/B. Inducible clindamycin resistance can be detected only in the presence of a macrolide antibiotic. In disk diffusion tests look for apparent antagonism of clindamycin by erythromycin (D-test).
Tetracyclines

21
Doxycycline
11
0.51 11 0.252
11 21 0.5
30 30 15
23A 23A 19
20A 20A 16 2. Isolates with MIC values above the susceptible breakpoint are very rare or not yet reported. The identification and antimicrobial susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate sent to a reference laboratory. Until there is evidence regarding clinical response for confirmed isolates with MIC values above the current resistant breakpoint they should be reported resistant.
30

Miscellaneous agents MIC breakpoint (mg/L) S
Chloramphenicol Colistin Daptomycin 8 11

30 21 NoteA 21 NoteA 1. Isolates with MIC values above the susceptible breakpoint are very rare or not yet reported. The identification and antimicrobial susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate sent to a reference laboratory. Until there is evidence regarding clinical response for confirmed isolates with MIC values above the current resistant breakpoint they should be reported resistant. A. Use an MIC method.
R>
8 1
Fosfomycin iv Fosfomycin-trometamol (uncomplicated UTI only) Fusidic acid Linezolid Metronidazole Mupirocin Nitrofurantoin (uncomplicated UTI only) Rifampicin Spectinomycin Trimethoprim (uncomplicated UTI only) Trimethoprim-sulfamethoxazole4
IE 2 642 0.06 23 1
IE 4 642 0.5 23 2 5 1.25-23.75 100 5 10
IE 19 15B 21 IP 18
IE 16 15B 15 IP 15 3. Trimethoprim breakpoints apply to S. agalactiae (group B streptococci) only. 4. Trimethoprim-sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration. 2/B. Nitrofurantoin breakpoints apply to S. agalactiae (group B streptococci) only.
31
Streptococcus pneumoniae

Disk diffusion (EUCAST standardised disk diffusion method ) Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L -NAD (MH-F) Inoculum: McFarland 0.5 from blood agar or McFarland 1.0 from chocolate agar Incubation: 5% CO2, 351C, 182h Reading: Read zone edges as the point showing no growth viewed from the front of the plate with the lid removed and with reflected light. Quality control: Streptococcus pneumoniae ATCC 49619
Penicillins1
1. Most MIC values for penicillin, ampicillin, amoxicillin and piperacillin (with or without a beta-lactamase inhibitor) differ by no more than one dilution step and isolates fully susceptible to benzylpenicillin (MIC 0.06 mg/L; susceptible by oxacillin disk screen, see note A) can be reported susceptible to beta-lactam agents that have been given breakpoints. A. Screen for beta-lactam resistance with the oxacillin 1 g disk. Isolates categorised as susceptible can be reported susceptible to benzylpenicillin, phenoxymethylpenicillin and aminopenicillins (with or without beta-lactamase inhibitor) irrespective of clinical indication. Isolates categorised as oxacillin resistant can be reported resistant to phenoxymethylpenicillin and to benzylpenicillin in meningitis. For other beta-lactams, determine the MIC of the agent considered for clinical use.
Benzylpenicillin (infections other than meningitis)
0.061,2
21,2
1 unit
NoteA
NoteA
2. In pneumonia, when a dose of 1.2 g x 4 is used, isolates with MIC 0.5 mg/L should be regarded as susceptible to benzylpenicillin. In pneumonia, when a dose of 2.4 g x 4 or 1.2 g x 6 is used, isolates with MIC 1 mg/L should be regarded as susceptible to benzylpenicillin. In pneumonia, when a dose of 2.4 g x 6 is used, isolates with MIC 2 mg/L should be regarded as susceptible.
Benzylpenicillin (meningitis) Ampicillin Ampicillin-sulbactam Amoxicillin Amoxicillin-clavulanate Piperacillin Piperacillin-tazobactam Ticarcillin Ticarcillin-clavulanate Phenoxymethylpenicillin Oxacillin (screen) Cloxacillin Dicloxacillin Flucloxacillin Mecillinam (uncomplicated UTI only)
0.061 0.5 Note1 Note1 Note1 Note1 Note Note1 NA 1 1
0.061 2 Note1 Note1 Note1 Note1 Note Note1 NA 1 1
1 unit 2
NoteA 23
A
NoteA 20A NoteA,B NoteA,B NoteA,B NoteA,B NoteA,B NoteA 20A B. Susceptibility inferred from ampicillin.
NoteA,B NoteA,B NoteA,B NoteA,B Note NoteA 1 20A A,B
32
Cefaclor Cefadroxil Cefalexin Cefazolin Cefepime 0.03 11

30 50 NoteA 28 NoteA 1. Isolates with MIC values above the susceptible breakpoint are very rare or not yet reported. The identification and antimicrobial susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate sent to a reference laboratory. Until there is evidence regarding clinical response for confirmed isolates with MIC values above the current resistant breakpoint they should be reported resistant. A. Screen for beta-lactam resistance with the oxacillin 1 g disk. Isolates categorised as susceptible can be reported susceptible to cefepime, cefotaxime, cefpodoxime, ceftriaxone, cefuroxime and cefuroxime axetil. Isolates categorised as oxacillin resistant should be tested with an MIC method with the agent considered for clinical use.
R>
0.5 2
Cefixime Cefotaxime Cefoxitin Cefpodoxime Ceftazidime Ceftibuten Ceftriaxone Cefuroxime Cefuroxime axetil
0.51 NA 0.25 0.51 0.5 0.25
2 NA 0.5 2 1 0.5
NoteA NA NoteA NoteA NoteA NoteA
NoteA NA NoteA NoteA NoteA NoteA
Carbapenems

1
NoteA NoteA 1. Not for meningitis (meropenem is the only carbapenem used for meningitis). 2. Isolates with MIC values above the susceptible breakpoint are very rare or not yet reported. The identification and antimicrobial susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate sent to a reference laboratory. Until there is evidence regarding clinical response for confirmed isolates with MIC values above the current resistant breakpoint they should be reported resistant. A. Screen for beta-lactam resistance with the oxacillin 1 g disk. Isolates categorised as susceptible can be reported susceptible to doripenem, ertapenem, imipenem and meropenem. Isolates categorised as oxacillin resistant should be tested by an MIC method.
Doripenem1
12
Ertapenem1 Imipenem1 Meropenem (infections other than meningitis) Meropenem (meningitis)

3 3
0.52 22 2 0.25
0.5 2 2 1
NoteA NoteA Note Note

A A,B
NoteA NoteA NoteA NoteA,B 3. Meropenem is the only carbapenem used for meningitis. B. For use in meningitis determine the meropenem MIC.
33
Aztreonam -

-
R>
-
Fluoroquinolones1
1/A. The norfloxacin disk diffusion test can be used to screen for fluoroquinolone resistance. Isolates categorised as susceptible can be reported susceptible to levofloxacin and moxifloxacin and intermediate to ciprofloxacin and ofloxacin. Isolates categorised as resistant should be tested for susceptibility to individual agents.
Ciprofloxacin2 Levofloxacin3 Moxifloxacin Nalidixic acid (screen) Norfloxacin (screen) Ofloxacin

4
0.12 2 0.5 NA NA 0.12
2 2 0.5 NA NA 4
5 5 5 10 5
50A 19A 22A NA 12A 50

A
18A 19A 22A NA 12A 15A
2. Wild type S. pneumoniae are not considered susceptible to ciprofloxacin and are therefore categorised as intermediate. 3. The breakpoints for levofloxacin relate to high dose therapy.
4. Wild type S. pneumoniae are not considered susceptible to ofloxacin and are therefore categorised as intermediate.
Aminoglycosides

-
-
34
Teicoplanin 21

R>
2
IE 21
IE 2 5
IE 16A
IE 16A

0.51 0.51 0.5 11 0.5 0.5 -
NoteA 15 15 2 NoteA 22 NoteA 25 19B NoteA NoteA 19 NoteA 22 19B 2/B. Inducible clindamycin resistance can be detected only in the presence of a macrolide antibiotic. In disk diffusion tests look for apparent antagonism of clindamycin by erythromycin (D-test). 1/A. Erythromycin can be used to determine susceptibility to azithromycin, clarithromycin and roxithromycin.
Azithromycin Clarithromycin Erythromycin Roxithromycin Telithromycin Clindamycin2 Quinupristin-dalfopristin
0.251 0.251 0.25 0.51 0.25 0.5 -
35
Doxycycline 11

R>
21
0.51 11 IE
11 21 IE
30 30
24A 23A IE
21A 20A IE

8 IE IE 4 0.5 2
30 21 IE IE 10 22 5 22 1.25-23.75 18 21 IE IE 19 17 15 1. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.
8 IE IE 2 0.06 1
36
Viridans group streptococci

In endocarditis, refer to national or international endocarditis guidelines for breakpoints for viridans group streptococci.

Disk diffusion (EUCAST standardised disk diffusion method ) Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L -NAD (MH-F) Inoculum: McFarland 0.5 Incubation: 5% CO2, 351C, 182h Reading: Read zone edges as the point showing no growth viewed from the front of the platewith the lid removed and with reflected light. Quality control: Streptococcus pneumoniae ATCC 49619
Penicillins

2 NA
1 unit 1 unit 18 18A 12 18A A. Benzylpenicillin 1 unit can be used to screen for beta-lactam resistance in viridans group streptococci. Isolates categorised as susceptible can be reported susceptible to beta-lactam agents for which clinical breakpoints are listed. Isolates categorised as resistant should be tested for susceptibility to individual agents. 1/B. For isolates susceptible to benzylpenicillin, susceptibility can be inferred from benzylpenicillin or ampicillin. For isolates resistant to benzylpenicillin, susceptibility is inferred from ampicillin.
Benzylpenicillin Benzylpenicillin (screen)
0.25 NA
Ampicillin Ampicillin-sulbactam Amoxicillin Amoxicillin-clavulanate Piperacillin Piperacillin-tazobactam Ticarcillin Ticarcillin-clavulanate Phenoxymethylpenicillin Oxacillin Cloxacillin Dicloxacillin Flucloxacillin Mecillinam (uncomplicated UTI only)
0.5 Note1 0.5 Note Note

1 1
2 Note1 2 Note Note

1 1
21 NoteB NoteB Note Note

B B
15 NoteB NoteB NoteB NoteB NoteB IE IE IE -
Note1 IE IE IE -
Note1 IE IE IE -
NoteB IE IE IE -
37

Cefaclor Cefadroxil Cefalexin Cefazolin Cefepime Cefixime Cefotaxime Cefoxitin Cefpodoxime Ceftazidime Ceftibuten Ceftriaxone Cefuroxime Cefuroxime axetil 0.5 0.5 0.5 NA 0.5 0.5 -

30 30 5 IP 25 23 NA 30 30 27 26 IP 25 23 NA 27 26 -
R>
0.5 0.5 0.5 NA 0.5 0.5 -
Carbapenems

1
Doripenem
11
Ertapenem Imipenem Meropenem
0.51 21 21
0.5 2 2
10 10 10
22 30 25
22 30 25
Monobactams

-
-
Aztreonam
38

Ciprofloxacin Levofloxacin Moxifloxacin Nalidixic acid (screen) Norfloxacin Ofloxacin NA -

NA NA -
R>
NA -
Aminoglycosides

-
-
Glycopeptides

2
Teicoplanin
21
IE 21
IE 2 5
IE 15A
IE 15A
39

Azithromycin Clarithromycin Erythromycin Roxithromycin Telithromycin Clindamycin1 Quinupristin-dalfopristin IE IE IE IE IE 0.5 IE

IE IE IE IE IE 2 19A IE IE IE IE IE IE 19A IE 1/A. Inducible clindamycin resistance can be detected only in the presence of a macrolide antibiotic. In disk diffusion tests look for apparent antagonism of clindamycin by erythromycin (D-test).
R>
IE IE IE IE IE 0.5 IE
Tetracyclines

IE
IE IE
IE

-
-
Chloramphenicol Colistin Daptomycin Fosfomycin iv Fosfomycin-trometamol (uncomplicated UTI only) Fusidic acid Linezolid Metronidazole Mupirocin Nitrofurantoin (uncomplicated UTI only) Rifampicin Spectinomycin Trimethoprim (uncomplicated UTI only) Trimethoprim-sulfamethoxazole
40
Haemophilus influenzae

Disk diffusion (EUCAST standardised disk diffusion method ) Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L -NAD (MH-F) Inoculum: McFarland 0.5 Incubation: 5% CO2, 351C, 182h Reading: Read zone edges as the point showing no growth viewed from the front of the plate with the lid removed and with reflected light. Quality control: Haemophilus influenzae NCTC 8468
Penicillins

IE NA
IE 1 unit 12A IE 12A A. Benzylpenicillin can be used to screen for but not to distinguish between beta-lactamase producing isolates and isolates with PBP changes. Isolates categorised as resistant with the screen breakpoint should be checked for beta-lactamase and non-betalactamase-mediated resistance to aminopenicillins (without and with inhibitors), cephalosporins and/or carbapenems. 1. Breakpoints apply to beta-lactamase negative isolates only. Report beta-lactamase positive isolates resistant to penicillins without beta-lactamase inhibitors. 2. For susceptibility testing purposes, the concentration of sulbactam is fixed at 4 mg/L. 3/B. Susceptibility can be inferred from amoxicillin-clavulanate. C. Susceptibility inferred from ampicillin. 4. For susceptibility testing purposes, the concentration of clavulanate is fixed at 2 mg/L. 5/D. Susceptibility inferred from ampicillin or amoxicillin.
Benzylpenicillin Benzylpenicillin (screen)
IE NA
Ampicillin Ampicillin-sulbactam Amoxicillin Amoxicillin-clavulanate Piperacillin Piperacillin-tazobactam Ticarcillin Ticarcillin-clavulanate Phenoxymethylpenicillin Oxacillin Cloxacillin Dicloxacillin Flucloxacillin Mecillinam (uncomplicated UTI only)
11 12,3 21 24 Note1,5 Note3 IE IE IE -
11 12,3 21 24 Note1,5 Note3 IE IE IE -
2 10-10
16 NoteB NoteC 17 NoteD NoteB IE IE IE -
16 NoteB NoteC 17 NoteD NoteB IE IE IE -
2-1
41
Cefaclor Cefadroxil Cefalexin Cefazolin Cefepime 0.51 0.252

NA 30 27 NA 27 2. Isolates with MIC values above the susceptible breakpoint are very rare or not yet reported. The identification and antimicrobial susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate sent to a reference laboratory. Until there is evidence regarding clinical response for confirmed isolates with MIC values above the current resistant breakpoint they should be reported resistant. 1. MIC breakpoints render all H.influenzae resistant to cefaclor.
R>
0.5 0.25
Cefixime Cefotaxime Cefoxitin Cefpodoxime Ceftazidime Ceftibuten Ceftriaxone Cefuroxime Cefuroxime axetil
0.122 0.122 NA 0.252 12 0.122 1 0.12
0.12 0.12 NA 0.5 1 0.12 2 1
5 5 10 30 30 30 30
25 26 NA 26 25 30 26 50
25 26 NA 23 25 30 25 26
Carbapenems

1
10 20 20 1. Not for meningitis (meropenem is the only carbapenem used for meningitis). 2. Isolates with MIC values above the susceptible breakpoint are very rare or not yet reported. The identification and antimicrobial susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate sent to a reference laboratory. Until there is evidence regarding clinical response for confirmed isolates with MIC values above the current resistant breakpoint they should be reported resistant.
Doripenem1
12
Ertapenem1 Imipenem
1
0.52 22 22 0.25
0.5 2 2 1
10 10 10
20 20 20A NoteA
20 20 20A NoteA 3. Meropenem is the only carbapenem used for meningitis. A. For use in meningitis determine the meropenem MIC value.
Meropenem3 (infections other than meningitis) Meropenem3 (meningitis)
42
Aztreonam IE

IE IE
R>
IE
Fluoroquinolones1,2

0.5
5 26 26 1. Low-level fluoroquinolone resistance (ciprofloxacin MICs of 0.12-0.5 mg/L) may occur but there is no evidence that this resistance is of clinical importance in respiratory tract infections with H. influenzae . 2. Isolates with MIC values above the susceptible breakpoint are very rare or not yet reported. The identification and antimicrobial susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate sent to a reference laboratory. Until there is evidence regarding clinical response for confirmed isolates with MIC values above the current resistant breakpoint they should be reported resistant.
Ciprofloxacin
0.52
Levofloxacin Moxifloxacin Nalidixic acid (screen)
12 0.52 NA
1 0.5 NA
5 5 30
26 25 23A
26 25 23A A. The nalidixic acid disk diffusion test can be used to screen for fluoroquinolone resistance. Isolates with zone diameters 23 mm can be reported susceptible to levofloxacin, ciprofloxacin, moxifloxacin and ofloxacin. Isolates with zone diameters <23 mm may have fluoroquinolone resistance and should be tested against the appropriate agent.
Norfloxacin Ofloxacin
0.52
0.5
23
23
Aminoglycosides

IE IE IE IE
IE IE IE IE IE IE IE IE
IE IE IE IE
43
Glycopeptides MIC breakpoint (mg/L)
S Teicoplanin Telavancin Vancomycin R> Disk content (g)

Zone diameter Notes breakpoint (mm) Numbers for comments on MIC breakpoints Letters for comments on disk diffusion
S R< -
Macrolides1, lincosamides and streptogramins MIC breakpoint (mg/L) S

Azithromycin Clarithromycin Erythromycin Roxithromycin Telithromycin Clindamycin Quinupristin-dalfopristin 0.122 1 0.5 12 0.12 2
R>
42 32 16
2
NoteA 15 15 Note 50
A
NoteA NoteA 10 NoteA 12 -
1. Correlation between macrolide MICs and clinical outcome is weak for H. influenzae . Therefore, breakpoints for macrolides and related antibiotics have been set to categorise wild type H. influenzae as intermediate. 2/A. Erythromycin can be used to determine susceptibility to azithromycin, clarithromycin and roxithromycin.
162 8 -
NoteA 50 -
44
Doxycycline 11

R>
21
11 11 IE
21 21 IE
30 30
24A 25A IE
21A 22A IE

2 IE 1 1 1.25-23.75 5 30
Zone diameter breakpoint (mm) S

28 IE 18 23
R<
28 IE 18 20 1. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.
Chloramphenicol Colistin Daptomycin Fosfomycin iv Fosfomycin-trometamol (uncomplicated UTI only) Fusidic acid Linezolid Metronidazole Mupirocin Nitrofurantoin (uncomplicated UTI only) Rifampicin (for prophylaxis only) Spectinomycin Trimethoprim (uncomplicated UTI only) Trimethoprim-sulfamethoxazole1
2 IE 1 0.5
45

Disk diffusion (EUCAST standardised disk diffusion method ) Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L -NAD (MH-F) Inoculum: McFarland 0.5 Incubation: 5% CO2, 351C, 182h Reading: Read zone edges as the point showing no growth viewed from the front of the plate with the lid removed and with reflected light. Quality control: Haemophilus influenzae NCTC 8468
Penicillins

-1 12,3 -1 14 -1
3
NoteA 2-1 19 NoteA IE IE NoteA 19 NoteA IE IE 4. For susceptibility testing purposes, the concentration of clavulanate is fixed at 2 mg/L.
-1 12,3 -1 1
4
1. Most M. catarrhalis produce beta-lactamase, although beta-lactamase production is slow and may give weak results with in vitro tests. Beta-lactamase producers should be reported resistant to penicillins and aminopenicillins without inhibitors. 2. For susceptibility testing purposes, the concentration of sulbactam is fixed at 4 mg/L. 3/A. Susceptibility can be inferred from amoxicillin-clavulanate.
-1 Note IE IE -
Note3 IE IE -
46
Cefaclor Cefadroxil Cefalexin Cefazolin Cefepime Cefixime Cefotaxime Cefoxitin Cefpodoxime Ceftazidime Ceftibuten Ceftriaxone Cefuroxime Cefuroxime axetil 0.121 4 0.5 1 NA IP IE 1 4 0.12

30 5 5 10 20 21 20 NA IP IE 30 30 30 24 21 50 20 18 17 NA IP IE 21 18 21 1. MIC breakpoints render all M. catarrhalis resistant to cefaclor.
R>
0.121 4 1 2 NA IP IE 2 8 4
Carbapenems

1
Doripenem
11
0.51 21 21
0.5 2 2
10 10 10
29 29 33
29 29 33
Monobactams

IE
IE IE
Aztreonam
IE
47
Ciprofloxacin Levofloxacin Moxifloxacin Nalidixic acid (screen) 0.5 1 0.5 NA

5 5 5 30 23 23 23 23A 23 23 23 23A A. The nalidixic acid disk diffusion test can be used to screen for fluoroquinolone resistance. Isolates with zone diameters 23 mm can be reported susceptible to levofloxacin, ciprofloxacin, moxifloxacin and ofloxacin. Isolates with zone diameters <23 mm may have fluoroquinolone resistance and should be tested against the appropriate agent.
R>
0.5 1 0.5 NA
Norfloxacin Ofloxacin
0.5
0.5 5
25
25
Aminoglycosides

IE IE IE IE
IE IE IE IE
Glycopeptides

-
-
48
Azithromycin Clarithromycin Erythromycin Roxithromycin Telithromycin Clindamycin Quinupristin-dalfopristin 0.251 0.251 0.25 0.51 0.25 -

NoteA 15 15 NoteA 23 NoteA 23 NoteA NoteA 20 NoteA 20 1/A. Erythromycin can be used to determine susceptibility to azithromycin, clarithromycin and roxithromycin.
R>
0.51 0.51 0.5 11 0.5 -
Tetracyclines

21
Doxycycline
11
11 1 IE
21 2 IE
30 30
25A 28 IE
22A 25 IE

21 IE 1
30 30A IE 1.25-23.75 18 30A IE 15 1. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration. 1/A. Breakpoints relate to the topical use of chloramphenicol.
21 IE 0.5
49
Neisseria gonorrhoeae
Penicillins1

MIC breakpoint Notes Numbers for comments on MIC breakpoints (mg/L) Disk diffusion criteria for antimicrobial susceptibility testing of Neisseria gonorrhoeae have R > not yet been determined. S
1. Always test for beta-lactamase. If positive, report resistant to benzylpenicillin, ampicillin and amoxicillin. The susceptibility of beta-lactamase negative isolates to ampicillin and amoxicillin can be inferred from the susceptibility to benzylpenicillin.
Benzylpenicillin Ampicillin1 Ampicillin-sulbactam Amoxicillin1 Amoxicillin-clavulanate Piperacillin Piperacillin-tazobactam Ticarcillin Ticarcillin-clavulanate Phenoxymethylpenicillin Oxacillin Cloxacillin Dicloxacillin Flucloxacillin Mecillinam (uncomplicated UTI only)
0.06 Note1 IE Note1 Note 1
1 Note1 IE Note1 Note1 -
50
Cephalosporins

0.12 0.12 1. Neisseria gonorrhoeae without resistance mechanisms to cefixime have MICs of 0.06 mg/L and can be treated with current standard dosing. The implications of alternative dosing schedules and recent data relating MIC to outcome are under consideration.
Cefaclor Cefadroxil Cefalexin Cefazolin Cefepime Cefixime1
Cefotaxime Cefoxitin Cefpodoxime Ceftazidime Ceftibuten Ceftriaxone Cefuroxime Cefuroxime axetil
0.12 IE IE 0.12 -
0.12 IE IE 0.12 -
Carbapenems
Monobactams
IE IE
Aztreonam
51
Fluoroquinolones1

0.03 IE IE NA IE 0.12 0.06 IE IE NA IE 0.25
Ciprofloxacin Levofloxacin Moxifloxacin Nalidixic acid (screen) Norfloxacin Ofloxacin
Aminoglycosides
-
Glycopeptides
-
52

0.25 0.5 -
Tetracyclines1
1. Isolates susceptible to tetracycline are also susceptible to minocycline, but some isolates resistant to tetracycline may be susceptible to minocycline. IE 0.5 0.5 IE IE 1 1 IE
64 64 -
53
Neisseria meningitidis
Penicillins

MIC breakpoint Notes Numbers for comments on MIC breakpoints (mg/L) Disk diffusion criteria for antimicrobial susceptibility testing of Neisseria meningitidis have R > not yet been determined. S
0.06 0.12 IE 0.12 0.25 1 IE 1 -
54
Cephalosporins

0.121 0.12
Cefaclor Cefadroxil Cefalexin Cefazolin Cefepime Cefixime Cefotaxime
1. Isolates with MIC values above the susceptible breakpoint are very rare or not yet reported. The identification and antimicrobial susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate sent to a reference laboratory. Until there is evidence regarding clinical response for confirmed isolates with MIC values above the current resistant breakpoint they should be reported resistant.
Cefoxitin Cefpodoxime Ceftazidime Ceftibuten Ceftriaxone Cefuroxime Cefuroxime axetil 0.121 0.12 -
Carbapenems
IE 0.252 IE 0.25 1. Isolates with MIC values above the susceptible breakpoint are very rare or not yet reported. The identification and antimicrobial susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate sent to a reference laboratory. Until there is evidence regarding clinical response for confirmed isolates with MIC values above the current resistant breakpoint they should be reported resistant. 2. Breakpoints relate to meningitis only.
Doripenem Ertapenem Imipenem Meropenem1
Monobactams
-
Aztreonam
55
Fluoroquinolones

0.031 IE IE NA IE 0.061 IE IE NA IE 1. Breakpoints apply only to use in the prophylaxis of meningococcal disease.
Aminoglycosides
-
Glycopeptides
-
56

-
Tetracyclines
1 1 IE 2 2 IE 1. Tetracycline can be used to predict susceptibility to minocycline for prophylaxis against N. meningitidis infections.
Doxycycline Minocycline1 Tetracycline Tigecycline
2 0.25 4 0.25 1. For prophylaxis of meningitis only (refer to national guidelines).
Chloramphenicol Colistin Daptomycin Fosfomycin iv Fosfomycin-trometamol (uncomplicated UTI only) Fusidic acid Linezolid Metronidazole Mupirocin Nitrofurantoin (uncomplicated UTI only) Rifampicin1 Spectinomycin Trimethoprim (uncomplicated UTI only) Trimethoprim-sulfamethoxazole
57
Gram-positive anaerobes
except Clostridium difficile Penicillins
MIC breakpoint Notes Numbers for comments on MIC breakpoints (mg/L) Disk diffusion criteria for antimicrobial susceptibility testing of anaerobes have not yet been R > determined. S
0.25 4 42 4 43 8 84 8 83 IE 0.5 8 82 8 83 16 164 16 163 IE 2. For susceptibility testing purposes, the concentration of sulbactam is fixed at 4 mg/L. 3. For susceptibility testing purposes, the concentration of clavulanate is fixed at 2 mg/L. 4. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L. 1. Susceptibility to ampicillin, amoxicillin and piperacillin without beta-lactamase inhibitors can be inferred from susceptibility to benzylpenicillin.
Benzylpenicillin1 Ampicillin Ampicillin-sulbactam Amoxicillin Amoxicillin-clavulanate Piperacillin Piperacillin-tazobactam Ticarcillin Ticarcillin-clavulanate Phenoxymethylpenicillin Oxacillin Cloxacillin Dicloxacillin Flucloxacillin Mecillinam (uncomplicated UTI only)
Cephalosporins
-
Cefaclor Cefadroxil Cefalexin Cefazolin Cefepime Cefixime Cefotaxime Cefoxitin Cefpodoxime Ceftazidime Ceftibuten Ceftriaxone Cefuroxime Cefuroxime axetil
58
except Clostridium difficile Carbapenems
1 1 2 2 1 1 8 8
Monobactams
-
Aztreonam
Fluoroquinolones
IE NA IE NA -
59
except Clostridium difficile Aminoglycosides
-
Glycopeptides
IE IE 2 IE IE 2
IE 4 IE 4 -
Azithromycin Clarithromycin Erythromycin Roxithromycin Telithromycin Clindamycin Quinupristin/dalfopristin
60
except Clostridium difficile Tetracyclines1
1. For anaerobic bacteria there is clinical evidence of activity in mixed intra-abdominal infections, but no correlation between MIC values, Pk/Pd data and clinical outcome. Therefore no breakpoints for susceptibility testing are given.
8 4 8 4 -
61
Clostridium difficile
Antibiotic agent

MIC breakpoint Notes Numbers for comments on MIC breakpoints (mg/L) Disk diffusion criteria for antimicrobial susceptibility testing of Clostridium difficile have not R > yet been determined. S
-1 -2 23 -4 -5 6
Daptomycin Fusidic acid Metronidazole Moxifloxacin Tigecycline Rifampicin Vancomycin
-1 -2 23 -4 -5 -6 23
1. Not used clinically. May be tested for epidemiological purposes only (ECOFF: WT 4 mg/L). 2. Not used clinically. May be tested for epidemiological purposes only (ECOFF: WT 2 mg/L). 3. The breakpoints are based on epidemiological cut-off values (ECOFFs), which distinguish wild-type isolates from those with reduced susceptibility. 4. Not used clinically. May be tested for epidemiological purposes only (ECOFF: WT 4 mg/L). 5. Not used clinically. May be tested for epidemiological purposes only (ECOFF: WT 0.25 mg/L). 6. Not used clinically. May be tested for epidemiological purposes only (ECOFF: WT 0.004 mg/L).
23
62
Gram-negative anaerobes
Penicillins

0.25 0.5 42 0.5 43 16 84 16 83 IE 0.5 2 82 2 83 16 164 16 163 IE 2. For susceptibility testing purposes, the concentration of sulbactam is fixed at 4 mg/L. 3. For susceptibility testing purposes, the concentration of clavulanate is fixed at 2 mg/L. 4. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L. 1. Susceptibility to ampicillin, amoxicillin and piperacillin without beta-lactamase inhibitors can be inferred from susceptibility to benzylpenicillin.
Benzylpenicillin1 Ampicillin1 Ampicillin-sulbactam1 Amoxicillin1 Amoxicillin-clavulanate1 Piperacillin Ticarcillin1 Ticarcillin-clavulanate1 Phenoxymethylpenicillin Oxacillin Cloxacillin Dicloxacillin Flucloxacillin Mecillinam (uncomplicated UTI only)
1
Piperacillin-tazobactam1
Cephalosporins
NA NA -
63
Carbapenems

1 1 2 2 1 1 8 8
Monobactams
-
Aztreonam
Fluoroquinolones
IE NA IE NA -
64
Aminoglycosides

-
Glycopeptides
-
IE IE
4 -
4 -
65
Tetracyclines1

1. For anaerobic bacteria there is clinical evidence of activity in mixed intra-abdominal infections, but no correlation between MIC values, Pk/Pd data and clinical outcome. Therefore no breakpoints for susceptibility testing are given.
Note1 Note Note

1
Note1
1
8 4 8 4 -
66
Helicobacter pylori
Antibiotic agent

MIC breakpoint Notes Numbers for comments on MIC breakpoints (mg/L) R> S
1. The breakpoints are based on epidemiological cut-off values (ECOFFs), which distinguish wild-type isolates from those with reduced susceptibility. 0.121 0.25 11 81 11 11
1
Amoxicillin Clarithromycin Levofloxacin Metronidazole Rifampicin Tetracycline
0.121 0.51 11 81 11 11
67
Listeria monocytogenes

Disk diffusion (EUCAST standardised disk diffusion method ) Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L -NAD (MH-F) Inoculum: McFarland 0.5 Incubation: 5% CO2, 351C, 182h Reading: Read zone edges as the point showing no growth viewed from the front of the plate with the lid removed and with reflected light. Quality control: Streptococcus pneumoniae ATCC 49619
Antibiotic agent
MIC breakpoint (mg/L) R> S

1 1 1 0.25 0.06 1 1 1 0.25 0.06
Disk Zone diameter Notes content breakpoint (mm) Numbers for comments on MIC breakpoints (g) R < Letters for comments on disk diffusion S
2 1 unit 15 10 1.25-23.75 16 13 25 26 29 16 13 25 26 29 1. Trimethoprim-sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.
Ampicillin Benzylpenicillin Erythromycin Meropenem Trimethoprim-sulfamethoxazole1
68
Non-species related breakpoints

Penicillins

MIC breakpoint Non-species related breakpoints are based on the following dosages (mg/L) (See section 8 in Rationale Documents) R> S
0.25 2 2 2 2 4 4 8 8 IE IE IE IE IE IE 2 8 8 8 8 16 16 16 16 IE IE IE IE IE IE The non-species related S/I and I/R breakpoints are based on 600 mg x 4 (2.4 g/day) and 2.4 g x 6 (14.4 g/day) doses respectively. The non-species related breakpoints are based on doses of at least 0.5 g x 3-4 (1.5-2 g/day). Rationale document in preparation. The non-species related breakpoints are based on doses of at least 0.5 g x 3-4 (1.5-2 g/day). Rationale document in preparation. Breakpoints apply to piperacillin-tazobactam dosage of 4 g x 3. Breakpoints apply to piperacillin-tazobactam dosage of 4 g x 3.
Benzylpenicillin Ampicillin Ampicillin-sulbactam Amoxicillin Amoxicillin-clavulanate Piperacillin Piperacillin-tazobactam Ticarcillin Ticarcillin-clavulanate Phenoxymethylpenicillin Oxacillin Cloxacillin Dicloxacillin Flucloxacillin Mecillinam
Cephalosporins
MIC breakpoint Non-species related breakpoints are based on the following dosages (mg/L) (See section 8 in Rationale Documents) S R>
IE IE IE 1 4 IE 1 IE IE 4 IE 1 4 IE IE IE IE 2 8 IE 2 IE IE 8 IE 2 8 IE Breakpoints apply to a daily intravenous dose of 1 g x 1 and a high dose of at least 2 g x 1. Breakpoints apply to a daily intravenous dose of 750 mg x 3 and a high dose of at least 1.5 g x 3. Breakpoints apply to a daily intravenous dose of 1 g x 3 and a high dose of at least 2 g x 3. Breakpoints apply to a daily intravenous dose of 1 g x 3 and a high dose of at least 2 g x 3. Rationale document in preparation. Breakpoints apply to a daily intravenous dose of 2 g x 2 and a high dose of at least 2 g x 3.
69

Carbapenems

1 4 EUCAST breakpoints apply to doripenem 500 mg x 3 daily administered intravenously over 1 hour as the lowest dose. 500 mg x 3 daily administered over 4 hours was taken into consideration for severe infections and in setting the I/R breakpoint. EUCAST breakpoints apply to ertapenem 1000 mg x 1 daily administered intravenously over 30 minutes as the only dose. EUCAST breakpoints apply to imipenem 500 mg x 4 daily administered intravenously over 30 minutes as the lowest dose. 1 g x 4 daily was taken into consideration for severe infections and in setting the I/R breakpoint. EUCAST breakpoints apply to meropenem 1000 mg x 3 daily administered intravenously over 30 minutes as the lowest dose. 2 g x 3 daily was taken into consideration for severe infections and in setting the I/R breakpoint.
Doripenem
0.5 2 2
1 8 8
Monobactams
4 8 Rationale document in preparation.
Aztreonam
Fluoroquinolones
0.5 1 0.5 IE 0.5 0.5 1 2 1 IE 1 1 Breakpoints apply to an oral dose of 400 mg x 2. Breakpoints apply to an oral dose of 200 mg x 2 to 400 mg x 2 and an intravenous dose of 200 mg x 2 to 400 mg x 2. Breakpoints apply to an oral dose of 500 mg x 2 (or as low as 250 mg x 2 for uncomplicated urinary tract infections) to 750 mg x 2 and an intravenous dose of 400 mg x 2 to 400 mg x 3. Breakpoints apply to an oral dose of 500 mg x 1 to 500 mg x 2 and an intravenous dose of 500 mg x 1 to 500 mg x 2. Breakpoints apply to an oral and iv dose of 400 mg x 1.
Ciprofloxacin Levofloxacin Moxifloxacin Nalidixic acid Norfloxacin Ofloxacin
70

Aminoglycosides

8 2 2 2 16 4 4 4 EUCAST breakpoints apply to intravenous amikacin dosage of 15 mg/kg/day. In the absence of Pk/Pd data these have been determined mainly on the basis of Pk data and pre-existing breakpoints. Breakpoints apply to intravenous gentamicin dosage of 3-4.5 mg/kg/day. In the absence of Pk/Pd data these have been determined mainly on the basis of Pk data and pre-existing breakpoints. Breakpoints apply to intravenous netilmicin dosage of 4-6 mg/kg/day. In the absence of Pk/Pd data these have been determined mainly on the basis of Pk data and pre-existing breakpoints. EUCAST breakpoints apply to intravenous tobramycin dosage of 3-4.5 mg/kg/day. In the absence of Pk/Pd data these have been determined mainly on the basis of Pk data and pre-existing breakpoints.
Glycopeptides
IE IE IE IE IE IE
IE IE IE IE IE IE IE IE IE IE IE IE IE IE
71

Tetracyclines

IE IE IE 0.25 IE IE IE 0.5 Breakpoints apply to a tigecycline intravenous dose of 100 mg followed by 50 mg 12 hourly for CSSSI and CIAI.
Miscellaneous
IE IE IE IE IE IE 2 IE IE IE IE IE IE IE IE IE IE IE IE IE 4 IE IE IE IE IE IE IE Breakpoints apply to a linezolid intravenous and oral dosage of 600 mg x 2.
Chloramphenicol Colistin Daptomycin Fosfomycin iv Fosfomycin-trometamol Fusidic acid Linezolid Metronidazole Mupirocin Nitrofurantoin Rifampicin Spectinomycin Trimethoprim Trimethoprim-sulfamethoxazole
72

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European Committee on Antimicrobial Susceptibility Testing

Breakpoint tables for interpretation of MICs and zone diameters

European Committee on Antimicrobial Susceptibility Testing

European Committee on Antimicrobial Susceptibility Testing

Viridans group streptococci (Other streptococci) Haemophilus influenzae

EUCAST Clinical Breakpoint Table v. 2.0, valid from 2012-01-01

MIC breakpoint (mg/L) S R>

10-10 20-10 30 30-6 75 75-10

14A,B NoteC 17A,B 18 20 23 23 -

14B NoteC 17B 15 17 23 23 15E, F

EUCAST Clinical Breakpoint Table v. 2.0, valid from 2012-01-01

MIC breakpoint (mg/L) S R>

Doripenem Ertapenem Imipenem2 Meropenem

EUCAST Clinical Breakpoint Table v. 2.0, valid from 2012-01-01

MIC breakpoint (mg/L) S R>

Levofloxacin Moxifloxacin Nalidixic acid (screen) Norfloxacin Ofloxacin

1 0.5 NA 0.5 0.5

MIC breakpoint (mg/L) S R>

Amikacin Gentamicin Netilmicin Tobramycin

EUCAST Clinical Breakpoint Table v. 2.0, valid from 2012-01-01

Macrolides, lincosamides and streptogramins

MIC breakpoint (mg/L) S R>

Azithromycin1 Clarithromycin Erythromycin1 Roxithromycin Telithromycin Clindamycin Quinupristin-dalfopristin

EUCAST Clinical Breakpoint Table v. 2.0, valid from 2012-01-01

MIC breakpoint (mg/L) S R>

EUCAST Clinical Breakpoint Table v. 2.0, valid from 2012-01-01

MIC breakpoint (mg/L) S R>

EUCAST Clinical Breakpoint Table v. 2.0, valid from 2012-01-01

MIC breakpoint (mg/L) S R>

Doripenem Ertapenem Imipenem Meropenem

MIC breakpoint (mg/L) S R>

EUCAST Clinical Breakpoint Table v. 2.0, valid from 2012-01-01

MIC breakpoint (mg/L) S R>

Amikacin Gentamicin Netilmicin Tobramycin

MIC breakpoint (mg/L) S R>

Teicoplanin Telavancin Vancomycin

EUCAST Clinical Breakpoint Table v. 2.0, valid from 2012-01-01

MIC breakpoint (mg/L) S R>

Doxycycline Minocycline Tetracycline Tigecycline

MIC breakpoint (mg/L) S R>

EUCAST Clinical Breakpoint Table v. 2.0, valid from 2012-01-01

MIC breakpoint (mg/L) S R>

EUCAST Clinical Breakpoint Table v. 2.0, valid from 2012-01-01

MIC breakpoint (mg/L) S R>

EUCAST Clinical Breakpoint Table v. 2.0, valid from 2012-01-01

MIC breakpoint (mg/L) S R>

Doripenem Ertapenem Imipenem Meropenem

MIC breakpoint (mg/L) S R>

EUCAST Clinical Breakpoint Table v. 2.0, valid from 2012-01-01

MIC breakpoint (mg/L) S R>

Amikacin Gentamicin Netilmicin Tobramycin

MIC breakpoint (mg/L) S R>

Teicoplanin Telavancin Vancomycin

EUCAST Clinical Breakpoint Table v. 2.0, valid from 2012-01-01

MIC breakpoint (mg/L) S R>

Doxycycline Minocycline Tetracycline Tigecycline

MIC breakpoint (mg/L) S R>

EUCAST Clinical Breakpoint Table v. 2.0, valid from 2012-01-01