Antimicrobial agent interpretative categories and breakpoints

Enterobacterales
Medical Research Institute
Antimicrobial Disk Interpretive categories and Interpretive categories and MIC Comments
agents content Zone Diameter Breakpoints. Breakpoints, µg/ml
Nearest whole mm
S SDD I R S SDD I R
Ampicillin 10µg ≥17 14-16^ ≤13 ≤8 16^ ≥32 Results of ampicillin testing can be used to predict results of
amoxicillin.
Amoxicillin- 20/10µg ≥18 14-17^ ≤13 ≤8/4 16/8^ ≥32/16
clavulanate
Piperacillin- 100/10µg ≥25 21-24 ≤20 ≤8/4 16/4 ≥32/4
tazobactam
Ticarcillin-clavulanate 75/10µg ≥20 15-19^ ≤14 ≤16/2 32/2-64/2^ ≥128/2
Cefepime 30µg ≥25 19-24 ≤18 ≤2 4-8 ≥16 The breakpoint for susceptible is based on a dosage
regimen of 1g administered every 12h. The breakpoint for
SDD is based on dosage regimens that results in higher
cefepime exposure, either higher doses or more frequent
doses or both, up to approved maximum dosage regimens
Cefotaxime 30µg ≥26 23-25^ ≤22 ≤1 2^ ≥4 Breakpoints are based on a dosage regimen of 1g
administered every 24h ceftriaxone and 1g administered
every 8h for cefotaxime
30µg ≥23 20-22^ ≤19 ≤1 2^ ≥4
Ceftriaxone
Cefuroxime 30µg ≥18 15-17^ ≤14 ≤8 16^ ≥32 Breakpoints are based on a dosage regimen of 1.5g
(Parenteral) administered every 8h.
Ceftazidime 30µg ≥21 18-20^ ≤17 ≤4 8^ ≥16 Breakpoints are based on a dosage regimen of 1g
administered every 8h.
Cefuroxime (Oral) 30µg ≥23 15-22^ ≤14 ≤4 8-16^ ≥32
Aztreonam 30µg ≥21 18-20^ ≤17 ≤4 8^ ≥16 Breakpoints are based on a dosage regimen of 1g
administered every 8h.
Ertapenem 10µg ≥22 19-21^ ≤18 ≤0.5 1^ ≥2 Breakpoints are based on a dosage regimen of 1g
administered every 24h.
Imipenem 10µg ≥23 20-22^ ≤19 ≤1 2^ ≥4 Breakpoints are based on a dosage regimen of 500mg
administered every 6h or 1g every 8h.
Meropenem 10µg ≥23 20-22^ ≤19 ≤1 2^ ≥4 Breakpoints are based on a dosage regimen of 1g
administered every 8h.
Gentamicin 10µg ≥18 15-17^ ≤14 ≤2 4^ ≥8 Breakpoints are based on a dosage regimen of 7mg/kg
parenterally administered every 24h.

Page 1 of 12
National External Quality Assessment Scheme in Clinical Microbiology, Department of Bacteriology, Medical Research Institute, Colombo.
 Medical Research Institute
Amikacin 30µg ≥20 17-19^ ≤16 ≤4 8^ ≥16 Breakpoints are based on a dosage regimen of 15mg/kg
parenterally administered every 24h.
Netilmicin 30µg ≥15 13-14^ ≤12 ≤8 16^ ≥32
Ciprofloxacin 5µg ≥26 22-25^ ≤21 ≤0.25 0.5^ ≥1 Breakpoints for ciprofloxacin are based on dosage regimen
of 400mg IV or 500mg orally administered every 12h.
Levofloxacin 5µg ≥21 17-20^ ≤16 ≤0.5 1^ ≥2 Breakpoints for levofloxacin are based on dosage regimen
of 750mg administered every 24h.
Trimethoprim- 1.25/23.75 ≥16 11-15 ≤10 ≤2/38 ≥4/76
sulfamethoxazole µg

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National External Quality Assessment Scheme in Clinical Microbiology, Department of Bacteriology, Medical Research Institute, Colombo.
Pseudomonas spp
Medical Research Institute
Antimicrobial Disk Interpretive categories Interpretive categories and MIC Comments
agents content and Zone Diameter Breakpoints, µg/ml
Breakpoints. Nearest
whole mm
S I R S I R
Pipercillin- 100/10µg ≥22 18-21^ ≤17 ≤16/4 32/4 ≥64/4 Breakpoints for susceptible are based on a dosage regimen of 4.5g
tazobactam administered every 6h over 30 minutes or over 3h. Breakpoints for
intermediate are only to provide a buffer zone to prevent small uncontrolled
technical factors from causing major discrepancies in interpretations.
Ticarcillin- 75/10µg ≥24 16-23^ ≤15 ≤16/2 32/2-64/2^ ≥128/2 Breakpoint for ticarcillin (alone or with clavulanate )are based on a ticarcillin
clavulanate dosage regimen of at least 3g administered every 6h.
Ceftazidime 30µg ≥18 15-17^ ≤14 ≤8 16^ ≥32 Breakpoints are based on a dosage regimen of 1g administered every 6h or
2g administered every 8h.
Cefepime 30µg ≥18 15-17^ ≤14 ≤8 16^ ≥32 Breakpoints are based on a dosage regimen of 1g administered every 8h or
2g administered every 12h.
Aztreonam 30µg ≥22 16-21^ ≤15 ≤8 16^ ≥32 Breakpoints are based on a dosage regimen of 1g administered every 6h or
2g administered every 8h.
Imipenem 10µg ≥19 16-18^ ≤15 ≤2 4^ ≥8 Breakpoints for imipenem are based on a dosage regimen of 1g administered
every 8h or 500mg administered every 6h.
Meropenem 10µg ≥19 16-18^ ≤15 ≤2 4^ ≥8 Breakpoints for meropenem are based on a dosage regimen of 1g
administered every 8h
Colistin ≤2 ≥4 Colistin ( methane sulfonate) should be given with a loading dose and
maximum renally adjusted doses.

When colistin or polymyxin B is given systemically, neither is likely to be

effective for pneumoniae.

For colistin, broth microdilution, CBDE and CAT MIC methods are acceptable.
Disk diffusion and gradient diffusion methods should not be performed
Gentamicin 10µg ≥15 13-14^ ≤12 ≤4 8^ ≥16 REMOVED FROM M100 LATEST VERSION
Amikacin (U)b 30µg ≥17 15-16^ ≤14 ≤16 32^ ≥64 Report only on organisms isolated from the urinary tract.
Netilmicin 30µg ≥15 13-14^ ≤12 ≤8 16^ ≥32
Ciprofloxacin 5µg ≥25 19-24^ ≤18 ≤0.5 1^ ≥2 Breakpoints are based on a dosage regimen of 400mg IV administered every
8h.
Levofloxacin 5 µg ≥22 15-21^ ≤14 ≤1 2^ ≥4 Breakpoints are based on a dosage regimen of 750mg administered every
24h.

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National External Quality Assessment Scheme in Clinical Microbiology, Department of Bacteriology, Medical Research Institute, Colombo.
 Staphylococcus spp
Medical Research Institute

Antimicrobi Staphylococcus Disk Interpretive categories and Interpretive categories and MIC Comments
al agents spp. indications content Zone Diameter Breakpoints. Breakpoints, µg/ml
Nearest whole mm
S SDD I R S SDD I R
Penicillin All staphylococci 10 units ≥29 ≤28 ≤0.12 ≥0.25 For methicillin (oxacillin) resistant
staphylococci, report penicillin as resistant or
do not report.
Oxacillin S.aureus 30µg ≥22 ≤21 ≤2 ≥4 Oxacillin disk testing is not reliable for
S.lugdunensis cefoxitin (oxacillin) (oxacill S.aureus and S.lugdunensis.
(surrogate in)
test for ≤4 For isolates of s.aureus that do not grow well
oxacillin) (cefoxitin) ≥8 on CAMHB or un-supplemented MHA (eg,
(cefoxi small-colony variants), testing on other media
tin) (eg,BMHA) does not reliably detect mecA-
mediated resistance. Testing for PBP2a
using induced growth (ie. growth taken from
the zone margin surrounding a cefoxitin disk
on either BMHA or a blood agar plate after 24
hours incubation in 5%CO2) or mecA should
be done.
Oxacillin S.epidermidis 1µg ≥18 ≤17 ≤0.5 ≥1 Cefoxitin MIC testing is not reliable for
oxacillin (ox (oxacilli (oxacillin) (oxacill detecting mecA-mediated resistance in
acill n) in) S.epidermidis.
30µg in)
cefoxitin
(surrogate ≤24
test for ≥25 (cefoxiti
oxacillin) (cef n)
oxit
in)
S.pseudintermedius 1µg ≥18 ≤17 ≤0.5 ≥1 Neither cefoxitin MIC nor cefoxitin disk tests
and S.schleiferi oxacillin are reliable for detecting mecA-mediated
resistance in S.pseudintermedius and
S.schleiferi

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National External Quality Assessment Scheme in Clinical Microbiology, Department of Bacteriology, Medical Research Institute, Colombo.
 Medical Research Institute
Oxacillin Staphylococcus 30µg ≥25 ≤24 ≤0.5 ≥1 Oxacillin MIC breakpoints may overcall
spp.,except: cefoxitin (cef (cefoxiti (oxacillin) (oxacill resistance, and some isolates for which the
S.aureus (surrogate oxit n) in) oxacillin MICs are 1-2µg/ml may be mecA
S.lugdunensis test for in) negative.
S.epidermidis oxacillin) Isolates from serious infections for which
S.pseudintermedius oxacillin MICs are1-2µg/ml may be tested for
S.schleiferi mecA or for PBP2a. Isolates that test mecA
or PBP2a negative should be reported as
methicillin (oxacillin) susceptible.
Vancomycin S.aureus ≤2 4-8 ≥16 For S.aureus, vancomycin-susceptible
isolates may become vancomycin
intermediate during the course of prolonged
therapy.

Staphylococcus sp ≤4 8-16 ≥32

other than S.aureus
Teicoplanin All staphylococci ≤8 16 ≥32 Inv-Investigational agent
(Inv)
Daptomycin All staphylococci ≤1 Not routinely reported on organisms isolated
from the respiratory tract.
Gentamicin All staphylococci 10µg ≥15 13- ≤12 ≤4 8 ≥16
14
Erythromycin All staphylococci 15 µg ≥23 14- ≤13 ≤0.5 1-4 ≥8
22
Tetracycline All staphylococci 30 µg ≥19 15- ≤14 ≤4 8 ≥16
18
Ciprofloxacin All staphylococci 5 µg ≥21 16- ≤15 ≤1 2 ≥4
20
Clindamycin All staphylococci 2 µg ≥21 15- ≤14 ≤0.5 1-2 ≥4 For isolates that test erythromycin resistant
20 and clindamycin susceptible or intermediate,
testing for ICR by disk diffusion using D zone
test or by broth microdilution is required
before reporting clindamycin
Trimethopri All staphylococci 1.25/23.75 ≥16 11- ≤10 ≤2/38 ≥4/76
m- µg 15
sulfamethox
azole

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National External Quality Assessment Scheme in Clinical Microbiology, Department of Bacteriology, Medical Research Institute, Colombo.
 Medical Research Institute

Chloramphe All staphylococci 30 µg ≥18 13- ≤12 ≤8 16 ≥32

nicol 17
Linezolid All staphylococci 30µg ≥21 ≤20 ≤4 ≥8 When testing linezolid, disk diffusion zones
should be examined using transmitted light.
Organisms with resistant results by disk
diffusion should be confirmed using MIC
method.

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National External Quality Assessment Scheme in Clinical Microbiology, Department of Bacteriology, Medical Research Institute, Colombo.
 Streptococcus pneumoniae
Medical Research Institute
Antimicrobial Disk Interpretive categories Interpretive categories Comments
agents content and Zone Diameter and MIC Breakpoints,
Breakpoints. Nearest µg/ml
whole mm
S I R S I R
Penicillin 1µg ≥20 Isolates of pneumococci with oxacillin zone sizes ≥20mm are susceptible
oxacillin (MIC ≤0.06 µg/ml) to penicillin. Penicillin and cefotaxime, ceftriaxone, or
meropenem MICs should be determined for isolates with oxacillin zone
diameters ≤19mm, because zones ≤19mm occur with penicillin resistant,
intermediate, or certain susceptible strains. For isolates with oxacillin zones
≤19mm, do not report penicillin as resistant without performing a penicillin
MIC test.
Penicillin ≤2 4 ≥8 Doses of intravenous penicillin of at least 2 million units every 4 hours in
parenteral (non- adults with normal renal function (12 million units per day ) can be used to
meningitis treat nonmeningeal pneumococcal infections due to strains with penicillin
MICs ≤2 µg/ml. Strains with an intermediate MIC of 4µg/ml may necessitate
penicillin doses of 18-24 million units per day.

For all isolates other than those from CSF, report interpretations for both
meningitis and nonmeningitic.
Penicillin ≤0.06 ≥0.12 Use of penicillin in meningitis requires therapy with maximum doses of
parenteral intravenous penicillin (eg.at least 3 million units every 4 hours in adults with
(meningitidis) normal renal function).

For CSF isolates, report only meningitis interpretations.

Penicillin ≤0.06 0.12-1 ≥2 Interpretation for oral penicillin may be reported for isolates other than those
(Oral penicillin V) from CSF
Cefotaxime ≤0.5 1 ≥2 For CSF isolates, report only meningitis interpretations.
(meningitidis)
Ceftriaxone ≤0.5 1 ≥2 Use of cefotaxime or ceftriaxone in meningitis requires therapy with
(meningitidis) maximum doses
Cefotaxime (non- ≤1 2 ≥4 For all isolates other than those from CSF, report interpretations for both
meningitis) meningitis and non-meningitis
Ceftriaxone
≤1 2 ≥4
(non-meningitis)
Meropenem ≤0.25 0.5 ≥1
Vancomycin 30µg ≥17 ≤1

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National External Quality Assessment Scheme in Clinical Microbiology, Department of Bacteriology, Medical Research Institute, Colombo.
 Medical Research Institute
Erythromycin 15µg ≥21 16-20 ≤15 ≤0.25 0.5 ≥1
Tetracycline 30µg ≥28 25-27 ≤24 ≤1 2 ≥4 Organisms that are susceptible to tetracycline are also considered
susceptible to doxycycline. However, resistance to doxycycline cannot be
inferred from tetracycline resistance.
Levofloxacin 5 µg ≥17 14-16 ≤13 ≤2 4 ≥8 Organisms that are susceptible to levofloxacin are also considered
susceptible to gemifloxacin and moxifloxacin. However, some organisms
that are intermediate or resistant to levofloxacin may be susceptible to
Gemifloxacin, moxifloxacin or both.
Trimethoprim- 1.25/23.75 ≥19 16-18 ≤15 ≤0.5/9. 1/19-2/38 ≥4/76
sulfamethoxazole µg 5
Chloramphenicol 30 µg ≥21 ≤20 ≤4 ≥8
Clindamycin 2 µg ≥19 16-18 ≤15 ≤0.25 0.5 ≥1 For isolates that test erythromycin resistant and clindamycin susceptible or
intermediate, testing for ICR by disk diffusion using the D-zone test or by
broth microdilution is required before reporting clindamycin.
Linezolid 30 µg ≥21 ≤2

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National External Quality Assessment Scheme in Clinical Microbiology, Department of Bacteriology, Medical Research Institute, Colombo.
 Acinetobacter spp
Medical Research Institute
Antimicrobial Disk Interpretive categories Interpretive categories and Comments
agents content and Zone Diameter MIC Breakpoints, µg/ml
Breakpoints. Nearest
whole mm
S I R S I R
Ampicillin- 10/10µg ≥15 12-14 ≤11 ≤8/4 16/8 ≥32/16
sulbactam
Pipercillin- 100/10µg ≥21 18-20 ≤17 ≤16/4 32/4-64/4 ≥128/4
tazobactam
Ticarcillin- 75/10µg ≥20 15-19 ≤14 ≤16/2 32/2-64/2 ≥128/2
clavulanate
Ceftazidime 30µg ≥18 15-17 ≤14 ≤8 16 ≥32
Cefepime 30µg ≥18 15-17 ≤14 ≤8 16 ≥32
Imipenem 10µg ≥22 19-21 ≤18 ≤2 4 ≥8 Breakpoints for imipenem are based on a dosage regimen of 500mg
administered every 6h.
Meropenem 10µg ≥18 15-17 ≤14 ≤2 4 ≥8 Breakpoints for meropenem are based on a dosage regimen of 1g
administered every 8h or 500mg administered every 6h.
Colistin ≤2 ≥4 Colistin (methanesulfonate)should be given with a loading dose and
maximum renally adjusted doses.
The only approved MIC method is broth microdilution. CBDE,CAT, disk
diffusion, and gradient diffusion should not be performed.
Gentamicin 10µg ≥15 13-14 ≤12 ≤4 8 ≥16
Amikacin 30µg ≥17 15-16 ≤14 ≤16 32 ≥64
Netilmicin ≤8 16 ≥32
Tetracycline (U)b 30µg ≥15 12-14 ≤11 ≤4 8 ≥16 Report only on organisms isolated from the urinary tract.
Ciprofloxacin 5µg ≥21 16-20 ≤15 ≤1 2 ≥4
Trimethoprim- 1.25/23.75 ≥16 11-15 ≤10 ≤2/38 ≥4/76
sulfamethoxazole µg

Page 9 of 12
National External Quality Assessment Scheme in Clinical Microbiology, Department of Bacteriology, Medical Research Institute, Colombo.
 Salmonella spp
Medical Research Institute
Antimicrobial Disk Interpretive categories Interpretive categories and Comments
agents content and Zone Diameter MIC Breakpoints, µg/ml
Breakpoints. Nearest
whole mm
S I R S I R
Ciprofloxacin 5µg ≥31 21-30^ ≤20 ≤0.06 0.12-0.5^ ≥1 Isolates of Salmonella spp. not susceptible to ciprofloxacin, levofloxacin,
ofloxacin or pefloxacin may be associated with clinical failure or delayed
response in fluoroquinolone-treated patients with salmonellosis.
Levofloxacin ≤0.12 0.25-1^ ≥2

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National External Quality Assessment Scheme in Clinical Microbiology, Department of Bacteriology, Medical Research Institute, Colombo.
 Moraxella catarrhalis
Medical Research Institute
Antimicrobial Disk Interpretive Interpretive categories and Comments
agents content categories and Zone MIC Breakpoints, µg/ml
Diameter Breakpoints.
Nearest whole mm

S I R S I R
Amoxicillin- 20/10µg ≥24 - ≤23 ≤4/2 - ≥8/4
clavulanate
Cefuroxime - - - - ≤4 8 ≥16
Cefotaxime - - - - ≤2 - -
Ceftazidime - - - - ≤2 - -
Ceftriaxone - - - - ≤2 - -
Azithromycin 15µg ≥26 - - ≤0.25 - -
Clarithromycin 15µg ≥24 - - ≤1 - -
Erythromycin 15µg ≥21 - - ≤2 - -
Ciprofloxacin - - - - ≤1 - - Since CLSI disk diffusion range is not available, use EUCAST range - ≤31
= S, >31 = R (v.12.0, valid from 1.1.2022)
Levofloxacin - - - - ≤2 - -
Tetracyclin 30µg ≥29 25-28 ≤24 ≤2 4 ≥8
Clindamycin - - - - ≤0.5 1-2 ≥4
Trimethoprim- 1.25/23.75 ≥13 11-12 ≤10 ≤0.5/9.5 1/19- ≥4/76
sulfamethoxazole µg 2/38
Chloramphenicol - - - - ≤2 4 ≥8
Rifampin - - - - ≤1 2 ≥4 Rifampin should not be used alone for antimicrobial therapy

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National External Quality Assessment Scheme in Clinical Microbiology, Department of Bacteriology, Medical Research Institute, Colombo.
 Medical Research Institute
REFERENCE

CLSI. Performance Standards for Antimicrobial Susceptibility Testing 33rd ed. 2023

EUCAST Breakpoint table 2022, v.12.0; Moraxella catarrhalis

Methods for Antimicrobial Dilution and Disk Susceptibility Testing of infrequently Isolated or Fastidious Bacteria, M45, 3 rd ed. 2016

Prepared by

Vayishnavi. A, Senior Medical Laboratory Technologist/Quality Control Laboratory, Technical Coordinator/NEQAS

Department of Bacteriology, Medical Research Institute, Colombo 08

Authorized by

Dr. Lilani Karunanayake, Consultant Clinical Microbiologist, PT Coordinator/NEQAS

Department of Bacteriology, Medical Research Institute, Colombo 08

Date 04.05.2023

Page 12 of 12
National External Quality Assessment Scheme in Clinical Microbiology, Department of Bacteriology, Medical Research Institute, Colombo.