Mini CLSI CLSI-Pak Feb 2017

1 Staphylococcus

Disk R I S
Heaping = Resistant, Beaching = Sensitive, β-lactamase test
Penicillin p 10 U <=28 ---- >= 29 Same result for Amoxicillin, Ampicillin, Ticarcillin, Piperacillin. If Fox is
resistant, then Penicillin is resistant.
For MSSA Write MSSA Notes. For MRSA, write MRSA Notes. Same results for
Cefoxitin NA Fox 30 <=21 >= 22
Cephradine, Cephalexin, Cefuroxime, Amc, TZP,
For CONS except lugdunensis <=24 >= 25
Azm or Clr or 15 <=13 14-17 >= 18
or Ery15 <=13 14-22 >= 23
Co-trimoxazole Sxt 25 <=10 11-15 >= 16 Ignore slight growth inside zone.
Clindamycin Da 2 <=14 15-20 >= 21 If D zone seen. Add Comments of D zone. 2
Tet / Mh Minocycline TE 30 <=14 15-18 >= 19 If Tet is sensitive, then report Dox and Mino sensitive.
Doxy Dox 30 <=12 13-15 >= 16
Ceftaroline NA CPT 30 <=20 21-23 >= 24 NA = Not available in Pakistan Comment: Dose = 600mg/12h

Rifampicin Rif 5 <=16 17-19 >= 20 If Sensitive.... Comment = Rifampicin should not be used alone.

Confirm resistant cases with MIC. Read with transmitted light (plate held up
Linezolid NA Lzd <=20 >= 21 to light source). Any discernible growth within the zone of inhibition is indicative of resistance
to the respective agent. Resistance is rare.
Tedizolid NA E-strip >=2 1 <= 0.5 Only for Staph. aureus

Cip or Ofx or Lev Cip 5 <=15 16-20 >= 21

Lev 5 <=15 16-18 >= 19
Ofl 5 <=14 15-17 >= 18
Moxi Mox 5 <=20 21-23 >= 24
Gentamicin CN 10 <=12 13-14 >= 15 If Sensitive......Genta Notes.
Chloramphenicol Cap 300 <=12 13-17 >= 18
Fusidic Acid FD 10 <=29 - >= 30 Eucast / BSAC

Disk from Hardy

Telavancin NA TLV 30 >= 15
Vancomycin MIC MIC only. Resistance very rare. In VRSA, TLV also Resistant ? Daptomycin MIC
E-Strip >=16 4-8 <= 2 Less than 1 is sensitive
CONS E-strip >=32 16-8 <= 4
Amikacin Do not report routinely.

Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

For Urine - add

Nitrofurantoin f 300 <=14 15-16

>= 17
Sulfonamides Sf 300 <=12 >= 17 Measure the obvious margin. Ignore tiny growth inside.
13-16
Staph saprophyticus is almost always sensitive to nitrof, Sxt, & FQ (Cip, Lev, Nor, Lom, Mox,
Novobiocin NV 5 >= 16 Ofl, pef). You may report sensitive without testing.
1. Report only first/upper 3 (or 4) sensitive antibiotics. Suppress the rest. Don’t kill a mosquito with a sledgehammer.
2. This isolate is presumed to be resistant to clindamycin based on detection of inducible clinda resistance.
Clinda may still be effective in some patients.
3. Gentamicin alone will not be effective in this case. It needs to be combined with another sensitive drug.
4. Read results in good light with black background.
5. Do not ignore intermediate category.
6. Most important disks are on the top and least important disks are at the bottom. Report upper, suppress lower.
7. Grey shade, has similar results (but not always).
8. Vitek is better than E-strip for MIC. So, for blood, CSF and fluid isolates use Vitek MICs.
9. Please don’t miss to apply or report any GREEN antibiotic. They are First Line. Yellow are secondline.
10. Report only top 4 sensitive. Suppress lower.
2. β-haemolytic Strep (S.pyogenes, group C, G, agalactiae) Apply on MHA with 5% sheep blood Feb 17

Disk R I S
Resistance very rare. You may report sensitive without testing. The
Penicillin P 10 U >=24 isolate is also sensitive / Resistant to Ampicillin, Amoxicillin, co-amoxiclav, ampicillin-
sulbactam, cefazolin, cefepime, ceftaroline, cephradine, ceftriaxone, cefotaxime, ceftizoxime,
imipenem, meropenem
Ampicillin Amp10 >= 24
Erythromycin Ery 15 <=15 16-20 >= 21 Not in urine
Clindamycin Da 2 <=15 16-18 >= 19 If D zone seen. Add comments of D zone. 2 above page
FEP or CTX or CRO 30 >= 24
Vancomycin VAN 30 >= 17

Levofloxacin Lev 5 <=13 14-16 >=17

Linezolid Lnz >= 21
Ceftaroline NA CPT 30 >= 26 Comment: Ceftaroline sensitivity is based on dosage regimen of 600mg every 12h

Telavancin NA TLV 30 >= 15 Disk from Hardy

Daptomycin NA E-strip <=1 Not for respiratory isolates
Tedizolid NA E-strip <=0.5 For S. Pyogenes and agalactiae only.
Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

1. Group B streptococci are susceptible to ampicillin, penicillin, and cefazolin, but may be resistant to
erythromycin and clindamycin. When Group B Streptococcus is isolated from a pregnant woman with severe
penicillin allergy (high risk for anaphylaxis), erythromycin and clindamycin (including inducible clindamycin
resistance) should be tested, and only clindamycin should be reported.
2. From top to bottom, antibiotics/disks are most important to least important for testing and reporting.
3. Vitek is better than E-strip. So, for CSF and blood isolates use Vitek MICs.
4. Apply Bacitracin 0.04 units in throat blood agar plate.

2B. Corynebacterium Required if isolated from sterile sites in immunocompronised patients.

R I S
Penicillin MIC >=4 2 <= 1
Cefotaxime MIC >=4 2 <= 1
Gentamicin MIC >=16 8 <= 4
Erythromycin MIC >=2 1 <= 0.5
Ceftriaxone MIC >=4 2 <= 1
Cipro MIC >=4 2 <= 1
Clinda MIC >=4 1-2 <= 0.5
Cotrimoxazole MIC >=80 <= 40
Tetracycline MIC >=16 8 <= 4
Doxycycline MIC >=16 8 <= 4
Cefepime MIC >=4 2 <= 1
Imipenem MIC >=16 8 <= 4
Meropenem MIC >=16 8 <= 4
Vanvomycin MIC <= 2
Linezolid MIC <= 2
Daptomycin NA MIC <= 1
3. Streptococcus species viridans, anginosus (milleri) , mutans, salivarius, bovis, mitis P107/16 Feb 17

Disk R I S
Penicillin MIC >=4 0.25-2 <=0.12 MIC only Intermediate need to be combined with aminoglycosides.
Ampicillin MIC >=8 0.5-4 <=0.25 MIC only Intermediate need to be combined with AG.
<= >=
Vancomycin Van 30 >= 17
Cefepime FEP 30 <=21 >= 24
Erythromycin Ery 15 <=15 16-20 >= 21 Report same result for Azithro and Clarithro
Cefotaxime CTX <=25 26-27 >= 28
Ceftriaxone CRO <=24 25-26 >=27
Chloramphenicol Cap 30 <=17 18-20 >= 21
Clindamycin Da 2 <=15 16-18 >= 19
Linezolid Lnz 30 >= 21
TLV 30 Disk from Hardy
Telavancin NA >=15
Ceftolozane-tazobacatm MIC >=12 20 <=36 MIC only.
Tedizolid NA MIC <= 0.25For anginosus
Oritavancin NA MIC <=0.25 MIC only.
Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

1. Vitek is better than E-strip for MIC. So, for blood and CSF isolates use Vitek MICs.
2. The intermediate category implies clinical efficacy in body sites where the drugs are physiologically
concentrated or when a higher than normal dosage of the antibiotic is used.

3B. Micrococcus & Kukuria kristanae P66/45/15

R I S
Penicillin MIC >=0.25 <= 0.12
Vanco MIC <= 2
Clinda MIC >=4 1-2 <= 0.5
Erythromycin MIC >=8 1-4 <= 0.5

1. Add CLSI notes.

4. Strep pneumoniae on MHA with blood P97/16 Feb 17

Disk R I S
Same results for amoxicillin, amoxicillin/clavulanate,
Penicillin ampicillin/sulbactam, piperacillin, and piperacillin/tazobactam .(If
Ox 1 >= 20
oxacillin zone ≥ 20 mm, penicillin is sensitive. If oxacillin zone ≤ 19 mm,
penicillin MIC must be done).For CSF only MIC.
Comment: Penicillin sensitivity is based on dosage regimen of 2 million U/4h…… (For Intermediate dose =
MIC >=8 4 <= 2 18-24 million U/24h)
P I/V, I/M
For CSF >=0.12 - <= 0.06
Co-trimoxazole Sxt 25 <=15 16-18 >= 19 Measure the obvious margin. Ignore tiny growth inside.
Erythromycin Ery 5 <=15 16-20 >= 21
Tetracycline Te 30 <=24 25-27 >= 28 If sensitive to Tet, then also report sensitive to Dox and Mino
Optochin <=10 11-14 >= 15 Only for diagnosis – Not to be reported
Doxycycline Dox 30 <=24 25-27 >= 28
Meropenem E-strip >=1 0.5 <= 0.25
Gemifloxacin Gemi 5 <=19 20-22 >= 23
Levofloxacin Lev 5 <=13 14-16 >= 17 Same results for Gemi & moxifloxacin.
Moxifloxacin Moxi 5 <=14 15-17 >= 18
Clindamycin Da 2 <=15 16-22 >= 23 If D zone seen. Add Comments of D zone. 2
Vancomycin VAN 30 >=17
Cefepime MIC MIC >=4 2 <= 1 Avoid in CSF
Ceftriaxone MIC MIC >=2 1 <= 0.5
Cefotaxime MIC MIC >=2 1 <= 0.5
Meropenem MIC MIC <= >=
Ceftaroline NA CPT 30 - - >= 26 Never report in CSF
Cefuroxime MIC MIC <= - >=
Linezolid Lnz 30 >=21
Rifampicin Rif 5 <= - >= If Sensitive.... Comment = Rifampicin should not be used alone.
Chloramphenicol Cap 30 <=20 - >= 21
Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

1. Comment = Amoxicillin, ampicillin, cefepime, cefotaxime, ceftriaxone, cefuroxime, ertapenem, imipenem, and
meropenem may be used to treat pneumococcal infections; however, reliable disk diffusion susceptibility tests with these
agents do not yet exist.
2. Vitek is better than E-strip for MIC. So, for blood and CSF isolates use Vitek MICs.
3. Report only top 4 sensitive. Suppress lower.

4B. Erysipelothrix Always resistant to vancomycin P38/45

R I S
Penicillin MIC <= 0.12
Ampicillin MIC <= 0.25
Ery MIC >=1 0.5 <= 0.25
Clinda MIC >=1 0.5 <= 0.5
Cipro MIC <= 0.5
Levo MIC <= 0.5
Imipenem MIC <= 0.5
Cefepime MIC <= 1
Cefotaxime MIC <= 1
Ceftriaxone MIC <= 1
Meropenem MIC <= 0.5
5. Enterococcus P82/16 Feb 17

Disk R I S
For E. faecalis…The isolate is also sensitive / resistant to
Ampicillin, amoxicillin, amoxicillin/clavulanate,
Penicillin P 10U <=14 >= 15
ampicillin/sulbactam, piperacillin, and
piperacillin/tazobactam . Rare β-lactamase.
Same results for amoxicillin, amoxicillin-clavulanate, ampicillin-sulbactam,
piperacillin, and piperacillin-tazobactam among non–β lactamase-producing
Ampicillin Amp10 <=16 >= 17 enterococci. Same results for imipenem if E. faecalis. (E. faecium is always resistant to
ampicillin).

Vancomycin VAN 30 <=14 15-16 >= 17 Read with transmitted light (plate held up to light source)

Linezolid Lnz 30 <=20 21-22 >= 23

Imipenem ? IPM 10 <=18 19-21 >= 21 Eucast & BSAC criterion

Teicoplanin TEC 30 >= 16 Eucast

Tigecycline TGC 15 <=15 16-17 >= 18 Eucast Note Disk content – from Hardy

Gentamicin CN 120 <=6 7-9 MIC >= 10 Only for blood, CSF and fluid isolates. If sensitive then add note 5…..see below
Daptomycin NA E-strip <=4 Not for respiratory specimens.
Telavancin NA TLV 30 >= 15 Disk from Hardy
? Sxt 25 Eucast Do not report as a routine. Results not reliable on MHA. May not be
Co-trimoxazole ?? <=21 22-49 >= 50 effective. Suppress.
Erythromycin Ery <=13 14-22 >= 23 Report only if no other drug sensitive. Otherwise suppress. Not for Urine.
Report only if no other drug sensitive. Otherwise suppress.
Doxycycline Dox 30 <=12 13-15 >= 16
Report only if no other drug sensitive. Otherwise suppress.
Minocycline MH 30 <=14 15-18 >= 19
Report only if no other drug sensitive. Otherwise suppress.
Chloramphenicol Cap 30 <=12 13-17 >= 18
Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

For Urine- add

Tetracycline Te 30 <=14 15-18 >= 19

Ciprofloxacin Cip 5 <=15 16-20 >= 21
Levofloxacin Lev 5 <=13 14-16 >= 17
Norfloxacin nor 10 <=12 13-16 >= 17
Nitrofurantoin f 300 <=14 15-16 >= 17
Fosfomycin fos 200 <=12 13-15 >= 16

1. Never report Aminoglycosides (except for high-level resistance testing), cephalosporins, clindamycin,
and trimethoprim-sulfamethoxazole.
2. Add CLSI Notes. MHA has no folate = False susceptible cot.

3. Do not report any antibiotic other than these.

4. Enterococcus is always resistant to cephalosporins, aminoglycosides, clindamycin, co-trimoxazole
and fusidic acid.
5. Gentamicin is synergistic with cell wall active agent like ampicillin, penicillin, vancomycin.

5B. Moraxella catarrhalis P48/45

R I S
Penicillin Amc 30 <=23 >= 24
Azithro Azm 15 >= 26 Resistance is rare.
Clarithro clr 15 >= 24 Resistance is rare.
Erythro Ery >= 21 Resistance is rare.
Cefotaxime MIC <=2
Ceftriaxone MIC <=2
Tetra Te 30 <=24 25-28 >= 29
Clinda MIC >=4 1-2 <= 0.5
Cotrimoxazole Sxt 25 <=10 >= 13
6. Enterobacteriaceae E. coli, Klebsiella, Enterobacter, Citrobacter, Arizona, Proteus, Morganella, Providencia, Hafnia, Serratia, Yersinia, Edwardsiella P52/16 Feb 17

Disk R I S
Ampicillin Amp 10 <=13 14-16 >= 17 Same results for Amoxicillin.
Gentamicin CN 10 <=12 13-14 >= 15
Tobramycin TOB10 <=12 13-14 >= 15
Cefazolin Cz 30 <=19 20-22 >= 23 Comment: Cefazolin sensitivity is based on dosage regimen of Dose = 2g/8h

Ciprofloxacin Cip 5 <=15 16-20 >= 21

Levofloxacin Lev 5 <=13 14-16 >= 17
Piperacillin Prl 100 <=17 18-20 >= 21
Amox-clavulanate Amc30 <=13 14-17 >= 18
Amp-sulbactam Sam20 <=11 12-14 >= 15
Pipra-tazobactam Tzp110 <=17 18-20 >= 21
19-24
Cefepime Fep 30 <=18
SDD >= 25 Comment: Cefipime sensitivity is based on dosage regimen of 1g/12h

Cefotaxime or CTX 30 <=22 23-25 >= 26 No need to test or report for ESBL. Comment: sensitivity is based on dosage
regimen of 1g/8h
Ceftriaxone CRO30 <=19 20-22 >= 23 Comment: Ceftriaxone sensitivity is based on dosage regimen of 1g/24h

Cotrimoxazole Sxt 25 <=10 11-15 >= 16

Cefotetan NA CTT 30 <=12 13-16 >= 16
Cefoxitin NA FOX 30 <=14 15-17 >= 18 NA = Not available in Pakistan Comment = Cefoxitin sensitivity is based on dosage regimen of 8g/24h

Cefuroxime oral Cxm 30 <=14 15-22 >= 23

Cefuroxime I/V CXM 30 <=14 15-17 >= 18 Cefuroxime Sensitivity is based on dosage regimen of 1.5g/8h

Amikacin AK 30 <=14 15-16 >= 17

Imipenem IPM 10 <=19 20-22 >= 23 Sensitivity is based on dosage regimen of 1g/8h

Meropenem MEM 10 <=19 20-22 >=23 Sensitivity is based on dosage regimen of 1g/8h

Ertapenem ETP 10 <=18 19-21 >= 22 Sensitivity is based on dosage regimen of 1g/24h

Doripenem NA DOR 10 <=19 20-22 >= 23 Sensitivity is based on dosage regimen of 500mg/8h

Tetracycline Te 30 <=11 12-14 >= 15

Ceftazidime CAZ 30 <=17 18-20 >= 21 Comment: Sensitivity is based on dosage regimen of 1g/8h

Chloramphenicol Cap 30 <=12 13-17 >= 18

Aztreonam NA ATM 30 <=17 18-20 >= 21
Ceftaroline NA CPT 30 19-24
<=18
SDD >= 25 Comment: Sensitivity is based on dosage regimen of 600 mg/12h

Tigecycline For E.coli TGC 15 <=15 16-17 >= 18 For E. coli only. Eucast Disk from hardy -- Note disk content 15

Colistin MIC >=2 - <= 2 Eucast

Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

1. From top to bottom, antibiotics/disks are most important to least important for testing and reporting.
2. Rows with grey shade have similar results, but not always.
3. Do not report colistin by DD (no zones available).
4. Comment = Imipenem sensitivity is based on dosage regimen of 1g every 8h.
5. Please don’t miss to apply and report any GREEN antibiotic.
6. Internationally, colistin sensitivity criterion is still under research and may not be fully reliable.
7. Report only top 4 sensitive. Suppress lower.

6B . Listeria

Penicillin MIC <= <=2

Ampicillin MIC <=2
Cotrimoxazole MIC 80<= <=10
Meropenem MIC <=0.25
7. Stool Isolates Feb 17

Disk R I S
Ampicillin Amp 10 <=13 14-16 >= 17
Co-trimoxazole Sxt25 <=10 11-15 >= 16
Cip 5 <=15 16-20 >= 21 For Salmonella 20 21-30 31 same results for Levo/Oflo
Or Ofx <= - >=
CRO or CTX 30 <= - >= See zones on Page 6 above
Chloramphenicol CAP 30 <=12 13-17 >= 18
Azithromycin Comment –Azithrocin results not fully reliable as it is still
Azm 15 >= 13
<=12 under research. Report for shigella & rarely for S. Typhi only.
<= - >=
Pefloxacin Pef 5 <=23 - >= 24 For Salmonella, If Cipro disk is not available use Pefloxacin
Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

1. For Salmonella and Shigella never report 1st- and 2nd-generation cephalosporins, cephamycins, and
aminoglycosides.
8 Urine GNR except Pseudo Feb 17

Disk R I S
Ampicillin Amp10 <=13 14-16 >= 17 Same results for amoxicillin
Cefazolin Kz 30 <=14 >= 15 Results same for cefaclor, cefdinir, cefpodoxime, cefprozil, cefuroxime, cephalexin, and
loracarbef for E.c., K.p, Proteus Comment: Dose = 1g/12h

Co-trimoxazole Sxt 25 <=10 11-15 >= 16

Nitrofurantoin f 300 <=14 15-16 >= 17
Ciprofloxacin Cip 5 <=15 16-20 >= 21
Levofloxacin Lev 5 <=13 14-16 >=17
Norfloxacin nor 10 <=12 13-16 >= 17
Sulfisoxazole Sf 300 <=12 13-16 >= 17
Co-amoxiclav Amc 30 <=13 14-17 >= 18
Amp-sulbactam Sam 20 <=11 12-14 >= 15
Tet or Dox Te 30 <=11 12-14 >= 15 If sensitive to Tet, report Dox and Mino also sensitive.
Tazobactam-pipracillin TZP 110 <=17 18-20 >= 21
CTX 30 <=22 23-25 >= 26 No need to test or report for ESBL. Comment: D = 1g/8h
CTX or CRO
CRO30 <=19 20-22 >= 23 Comment: Ceftriaxone Sensitivity is based on dosage regimen of 1g/24h

Amikacin AK 30 <=14 15-16 >= 17

Nalidixic Acid na 30 <=13 14-18 >= 19
IPM or MEM or DOR 100 <=19 20-22 >=23 Comment : Sensitivity is based on dosage regimen of 1g/8h

FEP or CPO 30 <=18 19-24 >= 25

GEN or TOB 10 <=12 13-14 >= 15
Fosfomycin for E. coli fos 200 <=12 13-15 >= 16 For E. Coli only
Trimethoprim w5 <=10 11-15 >= 16
Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

1. From top to bottom, antibiotics/disks are most important to least important for testing and reporting.
2. Disk names in CAPITAL letters are injections, in small letters are tablet or capsule.
3. Don’t forget to report intermediate group.
4. Rows with grey shade have similar results, but not always.
5. Comment = Imipenem sensitivity is based on dosage regimen of 1g every 8h.
6. Please add CC (correlate clinically) notes for all candida in urine.
7. Please don’t miss to apply or report any GREEN antibiotic.
8. Proteus mirabilis is always resistant to ampicillin, tetra, tigecycline and nitrofurantoin. P. vulgaris also to
cefazolin and cefuroxime.
9. Report only top 4 sensitive or all green. Suppress lower.
9 Pseudomonas aeruginosa P62/16 Feb 17

Disk R I S
Pipra-tazobactam TZP 110 <=14 15-20 >= 21 Comment: Pip-taz sensitivity is based on dosage regimen of 3g/6h

Ceftazidime CAZ30 <=14 15-17 >= 18 Comment: Ceftazidime sensitivity is based on dosage regimen of 1g/6h or 2g/8h

Gentamicin CN 10 <=12 13-14 >= 15

Tobramycin TOB 10 <=12 13-14 >= 15
Ciprofloxacin Cip 5 <=15 16-20 >= 21
Levofloxacin Lev 5 <=13 14-16 >= 17
Amikacin AK 30 <=14 15-16 >=17
Imipenem IPM 10 <=15 16-18 >= 19 Comment: Imipenem Sensitivity is based on dosage regimen of 1g/8h or 500mg/6h

Meropenem MEM10 <=15 16-18 >= 19 Comment: Meropenem sensitivity is based on dosage regimen of 1g/8h

Doripenem NA DOR10 <=15 16-17 >= 19 Comment: Doripenem sensitivity is based on dosage regimen of 500mg/8h

Aztreonam ATM30 <=15 16-21 >= 22 Comment: Aztreonam sensitivity is based on dosage regimen of 1g/6h or 2g/8h

Cefepime FEP 30 <=14 15-17 >=18 Comment: Cefepime sensitivity is based on dosage regimen of 1g/8h or 2g/12h
40
Ceftolozane-tazobactam NA <=16 17-20 >= 21 Disk available from Hardy Cat # Z9341
Polymixin B PB 300 <=11 - >= 12 Results not reliable. Do not report on Disk diffusion.
Colistin Notes 2 CT 10 <=10 - >= 11 Results not reliable. Do not report on Disk Diffusion

Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

For Urine-add

Norfloxacin nor 10 <=12 13-16 >= 17

1. Please don’t miss to apply and report any GREEN antibiotic.

2. Internationally, colistin sensitivity criterion is still under research and may not be fully reliable.
10 Acinetobacter P66/16 Feb 17

Disk R I S
Doripenem NA DOR10 <=14 15-17 >= 18 Comment: Doripenem sensitivity is based on dosage regimen of 500mg/8h

Imipenem IPM10 <=18 19-21 >= 22 Comment: Imipenem sensitivity is based on dosage regimen of 500mg/6h

Meropenem MEM10 <=14 15-17 >= 18 Comment: Meropenem sensitivity is based on dosage regimen of 1g/8h or 500mg/6h

Ampicillin-sulbactam Sam20 <=11 12-14 >= 15

Ciprofloxacin Cip 5 <=15 16-20 >= 21
Levofloxacin Lev 5 <=13 14-16 >= 17
Ceftazidime CAZ30 <=14 15-17 >= 18
Gentamicin CN 10 <=12 13-14 >= 15
Tobramycin TOB10 <=12 13-14 >=15
Doxycycline Dox 30 <=9 10-12 >= 13
Minocycline Mh 30 <=12 13-15 >= 16
Cotrimoxazole Sxt 25 <=10 11-15 >= 16
Tazo-Pipracillin TZP 110 <=17 18-20 >= 21
Cefepime FEP 30 <=14 15-17 >= 18
Cefotaxime CTX 30 <=14 15-22 >= 23
Ceftriaxone CRO 30 <=13 14-20 >=21
Amikacin AMI30 <=14 15-16 >= 17
Notes 7
Colistin MIC 4<= - 2>=
Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

For Urine

Tetra Te 30 <=11 12-14 >= 15 If sensitive, then report Doxy and mino also sensitive

1. Disks with “CAPITAL letters” are injections. With “small” are oral.
2. Grey shade have mostly similar results, (but not always).
3. Comment = Imipenem sensitivity is based on dosage regimen of 500mg every 6hr.
4. Do not report colistin or Polymixin B by disk (no zones available).
5. Acinetobacter is always resistant to Amp, Amox, AMC, ATM, Erta, Fos, Cap
6. Please don’t miss to apply or report any GREEN antibiotic.
7. Internationally, colistin sensitivity criterion is still under research and may not be fully reliable.
11. Pseudomonas spp. /Fastidious non-enterobacteriaceae Feb 17

R I S
Gentamicin MIC MIC >=16 8 <= 4
Tobramycin MIC MIC >=16 8 <= 4
Ceftazidime MIC >=32 16 <= 4
<= - >=
Cipro MIC >=4 2 <= 1
Levo MIC >=8 4 <= 2
Cotrimoxazole MIC >=80 <= 40
Imipenem MIC >=16 8 <= 4
Meropenem MIC >=16 8 <= 4
Aztreonam NA MIC >=32 16 <= 8
Amikacin MIC >=64 32 <= 16
Cefepime MIC >=8 16 <= 32
Chloramphenicol MIC <=32 16 >= 8
Cefotaxime MIC >=64 16-32 <= 8
Ceftriaxone MIC >=64 16-32 <= 8
Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

For Urine

Norfloxacin E-strip <=16 8 >= 4

Sulphonamides E-strip <=512 - >= 256
Tetracycline E-strip >=16 8 <= 4

1. Vitek is better than E-strip for MIC. So for blood and CSF isolates use Vitek.
12. Burkholderia cepacia Feb 17

Disk R I S
Co-trimoxazole Sxt 25 <=10 11-15 >= 16
Meropenem MEM 10 <=15 16-19 >=20
Levofloxacin MIC >=8 4 <=2
Minocycline Mh 30 <=14 15-18 >= 19
Ceftazidime CAZ 30 <=17 18-20 >= 21
<= >=
Chloramphenicol MIC >=32 16 <=8
Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

1. Add CLSI notes

2. Burkholderia cepacia is always resistant to Amp, Amox, Pip, Tic, Sam, Amc, TZP, CTX, CRO, FEP, ATM, IPM,
Erta, Coli, TOB, GEN, AK, Fos
13. Haemophilus Apply on HTM agar (Oxoid CM0898B) Feb 17

Disk
Ampicillin Amp 10 <=18 19-21 >= 22 Same results for amoxicillin. β-lactamase test.
Co-trimoxazole Sxt 25 <=10 11-15 >= 16
Amp-sulbactam Sam 20 <=19 >= 20 Never report in CSF ?
CTX or CAZ or CRO 30 >= 30
Cefuroxime Cxm 30 <=16 17-19 >= 20 Avoid in CSF
Meropenem MEM >= 20
<= - >=
Azith or Azm 15 >= 12 Never report in CSF
Clarith clr 15 <=10 11-12 >= 13 Never report in CSF
Co-amoxiclav Amc 30 <=19 - >= 20 Never report in CSF
Tetracycline Te 30 <=25 24-28 >= 29 Never report in CSF
Cip or Lev or Mox Cip 5 - - >= 17 Cipro poor in CSF, Levo never report in CSF Moxi can be given in CSF
Levofloxacin Lev 5 - - >= 20 Never report in CSF
Moxifloxacin Mox 5 - - >= 18 Never report in CSF
Chloramphenicol Cap 30 <=25 24-28 >= 29
Ceftaroline NA CPT 30 >= 30 Never report in CSF
Rifampicin Rif 5 <=16 17-19 >= 20 Only for prophylaxis
Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

1. Report Cap, Aztreonam and Mem (IMP, DOR) in CSF. TzP role doubtful
2. Apply Bacitracin 10 units in sputum on chocolate agar plate.
3. For GNR in CSF = CTX, CRO, MEM, CAZ, Cap, Ami, (Ox1 for GPC and Amp for GPR)
4. For GPC in CSF = CTX, CRO, P, Cap, Moxi Vanco needs high dose in CSF

13B. Neisseria gonorrheae on GC agar (Oxoid CM0367B with suppliment)

Disk R I S
Ceftriaxone CRO 30 >= 35
Ciprofloxacin Cip 5 <=27 28-40 >= 41
Tetracycline Te 30 <=30 31-37 >= 38
Cefixime Cfm 5 <= - >= 31
<= - >=
<= - >=
Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore
14. CSF / Niesseria meningitidis Use MHA with 5% sheep blood agar Take all lab safety precautions like use of BSC. Better use N95 mask. Get
vaccination for N. meningitidis. Feb 17

Ampicillin Amp 10 <= >= For Listeria

Cefotaxime CTX >=34 Zones for N. m
Ceftriaxone CRO >=34 Zone for N.m.
Aztreonam NA ATM <= >= See zones on page 6 or 9
Meropenem MEM <= >= 30 Zone for N. m.
Amikacin AMI See zones on page 6 or 9
Chloramphenicol Cap 30 <=19 20-25 >=26 Zones for N.m
Ceftazidime CAZ For Pseudomonas see Page 9
Azithromycin Azm 15 >=20 Comment =For prophylaxis of N.m. contacts only.
Minocycline Da 30 >=20 Comment = For prophylaxis of N.m. contacts only.
Co-trimoxazole Sxt 30 <=25 26-29 >= 30 Comment = For prophylaxis of N.m. contacts only.
Rifampicin Rif 5 <=19 20-24 >= 25 Comment = For prophylaxis of N.m. contacts only.

14B . Pasteurella

Disk
Amoxil MIC <= >=
Ampicillin Amp 10 <= - >= 27
P 10 <= - >= 25
Amc 30 <= - >= 27
CTX 30 <= - >= 34
Mox 5 <= - >= 28
Lev 5 <= - >= 28
Te 30 <= - >=23
Dox 30 <= - >= 23
Ery15 <=24 - >= 27
Azm 15 <= - >= 20
Sxt >= 24

14C Vibrio

Disk R I S
TZP 110 <=17 18-20 >= 21
Ampicillin Amp 10 <=13 14-16 >=17
Sam 20 <=11 12-14 >= 15
Amc 30 <=13 - >= 18
CFP 30 <=14 15-17 >= 18
CTX 30 <=22 23-25 >=26
Fox 30 <=14 15-17 >=18
CAZ 30 <=17 18-20 >=21
IPM 10 <=13 14-15 >= 16
MEM 10 <=13 14-15 >= 16
AK 30 <=14 15-16 >= 17
CN 10 <=12 - >= 15
Te 30 <=11 - >= 15
Cip 5 <=15 - >= 21
Lev 5 <=15 - >=17
Ofl 5 <=12 - >= 16
Sxt 25 <=10 - >=16
15. Aeromonas, Plesiomonas shigelloides CLSI M45 P36 Feb 17

Disk R I S
Co-amoxiclav Amc 30 <=13 14-17 >= 18
Ampicillin-sulbactam Sam 20 <=11 12-14 >= 15
Tazobactam-pipracillin Tzp 110 <=17 18-20 >= 21
Tetracycline Te <= - >=
Ciprofloxacin Cip 5 <=15 16-20 >= 21
Levofloxacin Lev 5 <=13 14-16 >= 17
Co-trimoxazole Sxt 25 <=10 11-15 >= 16
Cefazolin Kz 30 <= >= 30 Comment: Cefazolin sensitivity is based on dosage regimen of 1g/8h

Cefipime FEP 30 <=14 15-17 >= 18

Cefotaxime CTX 30 <=22 23-25 >= 26 Comment: Sensitivity is based on dosage regimen of 1g/8h

Ceftriaxone CRO 30 <=19 20-22 >= 23 Comment: Sensitivity is based on dosage regimen of 1g/24h

Tetracycline Te 30 <=11 12-14 >= 15

Comment: Sensitivity is based on dosage regimen of 1g/8h
Ceftazidime CAZ 30 <=17 18-20 >= 21
Imipenem IPM 10 <=13 14-15 >= 16
Meropenem MEM 10 <=13 14-15 >= 16
Ertapenem ETP 10 <=18 19-21 >= 22
Chloramphenicol Cap 30 <=12 13-17 >= 18
Comment: Sensitivity is based on dosage regimen of 1g/8h
Aztreonam ATM 30 <=17 18-20 >= 21
Amikacin AK 30 <=14 15-16 >= 17
Cefuroxime CXM 30 <=14 15-17 >= 18 Parentral only
Genta CN 10 <=12 13-14 >= 15
<= - >= 1 MIC
Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

1. Aeromonas is always resistant to ampicillin.

15B . Lactobacillus Mostly resistant to vanco

R I S
Penicillin MIC <= 8
Ampicillin MIC <= 8
Ery MIC >=8 1-4 <= 0.5
Clinda MIC >=2 1 <= 0.5
Genta MIC >=16 8 <= 4
Vanco MIC >=16 4-8 <= 2
Imipenem MIC >=2 1 <= 0.5
Dapto NA <= 4
Linezo <= 4

15C Morexella P48/45

Disk R I S
Tetracycline Te 30 <=24 25-28 >= 29
Co-trimoxazole Sxt 25 <=10 11-12 >=13
Co-amoxiclav Amc 30 <=23 - >= 24
Azithro <= - >= 26
Clarithro >=24
Erythro >=21
16 Anaerobes P52/16 115/16 Feb 17

R I S
Ampicillin MIC >=2 1 <= 0.5 Suppress reporting in Bacteroides & GNR
Penicillin MIC >=2 1 <= 0.5 Suppress reporting in Bacteroides & GNR
Amox-Clavulunate MIC >=24 12 <= 6
Amp-sulbactam MIC >=48 24 <= 12
Pipra-tazobactam MIC >=132 68 <= 36
Doripenem NA MIC >=8 4 <= 2
Ertapenem MIC >=16 8 <= 4
Meropenem MIC >=16 8 <= 4
Imipenem MIC >=16 8 <= 4
Clindamycin MIC >=8 4 <= 2
Metronidazole MIC >=32 16 <= 8
Cefotetan NA MIC >=64 32 <= 16
Cefoxitin NA MIC >=64 32 <= 16
Ceftizoxime MIC >=132 64 <= 32
Ceftriaxone MIC >=64 32 <= 16
Moxifloxacin MIC >=8 4 <= 2
Chloramphenicol MIC >=32 16 <= 8 For GNR only
Tetracycline MIC >=16 8 <= 4 For GPC only
Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

16B. Bacillus Required if isolated from sterile sites in immunocompronised patients. P32/45

Ampicillin MIC >=.25 <= .12

Penicillin MIC >=.25 <= .12
Erythromycin MIC >=8 1-4 <= 0.5
Tetracycline MIC >=16 8 <= 4
Cipro MIC >=4 2 <= 1
Levo MIC >=8 4 <= 2
Clinda MIC >=4 1-2 <= .5
Co-trimoxazole MIC >=80 <= 40
Cefazolin MIC >=32 16 <= 8
Cefotaxime MIC
Gentamicin MIC
Pipra-tazobactam MIC
Doripenem NA MIC
Ceftriaxone MIC
Amikacin MIC
Imipenem MIC
Clindamycin MIC
Vancomycin MIC
Ceftazidime
17. Stenotrophomonas maltophilia Feb 17

Disk R I S
Co-trimoxazole Sxt 25 <=10 11-15 >= 16
Minocycline Mh 30 <=14 15-18 >= 19
Levofloxacin Lev 5 <=13 14-16 >= 17
Ceftazidime MIC >=32 16 <=8 Vitek - if E-strip not available.
Chloramphenicol MIC >=32 16 <=8
Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

1. Add CLSI notes.

2. Disk name = Capital letters are injections, small letters are tablet or capsule.
3. Stenotrophomonas is always resistant to Amp, Amox, Pip, Ticar, Una, AMC, Sam, TZP, CTX, CRO, ATM, IPM,
MEM, AK, TOB, GEN, FOS

1. To report any error, contact nasar462@gmail.com

References

1. CLSI. Performance standards for Antimicrobial Susceptibility Testing; Twenty-Sixth Informational Suppliment.
M100-S27. 2017. Wayne, PA, Clinical and Laboratory Standards Institute.
2. The European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of
MICs and zone diameters.Version 6.0, http://www.eucast.org. 2016.
3. CLSI. Performance standards for Antimicrobial Susceptibility Testing of infrequently isolated or fastidious
bacteria; Second edition. 2014. M45 Wayne, PA, Clinical and Laboratory Standards Institute.
4. Ellen Jo Baron Richard B Thomson Jr. editor. Manual of Clinical Microbiology. 11th ed. Washington DC: ASM
Press; 2015.
5. British society for antimicrobial chemotherapy BSAC Version 14.0 , 2015
Rare Isolates

For nocardia = Cot, IMP, MEM, Lnz, Amika, Mino, CRO Zones not standardized.

For Streptomyces Ami,LNZ,Mino,IMP, Clar, Amc

For Comamonas testosteroni = CTX, CRO, IMP, MEM, Cot

Streptomyces usually responds to amikacin, linezolid or minocycline.

1. For Aerococcus MIC of …P, CTX, CRO, MEM, VAN, Cip, Lev, Tet, Cot, Lnz CLSI-M45
2. For Leuconostoc apply P, Amp, Clinda, Tobra Notes = Zones not standardized
3. For Elizabethkingia meningoseptica (Chryseobacterium meningosepticum) test only Cot, Cipro/Levo and TZP.
Zones are not available.
4. For Achromobacter report only IMP/MEM/TzP/Cot. Zones are not standardized.
5. For Sphingomonas report Tetra/Cap/Cot/Ami/Gen/Cip/Levo/Vanc . Zones not standardized.
6. Rhodotorula mucilaginosa .....Amphotericin B, Fluconazole, Itraconazole
7. Kocuria -lactams(AMC, Una, IMP, CRO), macrolides, tetracycline, linezolid, rifampin, and Vanco/Teico
8. Clostridium septicum ….. Van, MZ, IMP, MEM