SELECTION OF ANTIBIOTICS BY ORGANISM AND SPECIMEN TYPE

The following charts may serve as a guideline for antibiotic reporting for common pathogens.

Refer to “Zone Size Interpretive Charts” for interpretation of zone sizes (Document 3.8.2)

1. Staphylococci

BLOOD/
ANTIBIOTIC CSF STERILE WOUND URINE OTHER COMMENTS
SITE
Penicillin* x x x x

Oxacillin × × × × ×

Erythromycin × ×

Clindamycin** × × ×

Trimeth/Sulfa × × ×

Cefazolin × × × × Parenteral

Cephalothin × × × Oral

Chloramphenicol x × 2nd line agent

Nitrofurantoin ×

Tetracycline × × × 2nd line agent

Vancomycin × MIC × MIC 2nd line agent

Medium: Mueller Hinton Agar (MHA)
Inoculum: Growth method or direct colony suspension, equivalent to a 0.5 McFarland standard.
Incubation: 33-35oC; ambient air; 16 – 18 hours; 24 hours for cefoxitin and vancomycin
Testing at temperatures above 35oC may not detect Methicillin resistant staphylococcus (MRS)
Reporting:
1. Use CEFOXITIN disk to test for OXACILLIN resistance. Report OXACILLIN susceptible or
resistant based on the Cefoxitin result
2. For OXACILLIN resistant staphylococci, report PEN as RESISTANT or do not report at all.
3. Report CEFAZOLIN and CEPHALOTHIN susceptible or resistant based on Cefoxitin result
4. Report VANCOMYCIN if the isolate is OXACILLIN resistant
*Penicillin resistant strains of staphylococci produce β-lactamase. Perform penicillin zone edge test
(S. aureus) and/or an induced β-lactamase test on all Staphylococcus isolates for which the zone
diameter is ≥ 29mm before reporting the isolate as penicillin susceptible. Penicillin zone edge test OR
β -lactamase test POSITIVE  report as PENICILLIN RESISTANT. (Refer to latest CLSI M100
document)
** D-zone test should be performed to detect inducible clindamycin resistance. (Refer to latest CLSI
M100 document)
Routine testing of urine isolates of S. saprophyticus is not advised, because infections respond to
concentrations achieved in urine of antimicrobial agents commonly used to treat acute, uncomplicated
urinary tract infections (e.g., nitrofurantoin, trimethoprim ± sulfamethoxazole, or a fluoroquinolone

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SELECTION OF ANTIBIOTICS BY ORGANISM AND SPECIMEN TYPE

2. Enterobacteriaceae

BLOOD/
ANTIBIOTIC CSF STERILE SPUTUM WOUND URINE COMMENTS
SITE
Ampicillin × × x × × CSF - in neonates

Cefazolin × x × × Parenteral

Gentamicin × × x × × CSF – in neonates

Amox/clav x × ×

Cephalothin x × × oral
Note: zone size
Cefuroxime x x x interpretation different
for oral and parenteral
Ceftriaxone/
× × × ×
Cefotaxime
Ciprofloxacin × x × ×

Trimeth/sulfa × x × ×

Nitrofurantoin x

Chloramphenicol x x x x 2nd line agent

Tetracycline × x 2nd line agent

x
Medium: Mueller Hinton Agar (MHA)
Inoculum: Growth method or direct colony suspension, equivalent to a 0.5 McFarland standard.
Incubation: 35 ± 2oC; ambient air; 16 – 18 hours
Reporting:
1. Report AMPICILLIN, CEFAZOLIN, GENTAMICIN, CIPROFLOXACIN, AND TRIMETH/SULFA
2. If AMPICILLIN resistant, report AMOX-CLAV
3. If CEFAZOLIN resistant, report CEFUROXIME; if resistant, report CEFTRIAXONE/
CEFOTAXIME
4. If CIPROFLOXACIN and TRIMETH/SULFA resistant, report TETRACYCLINE
Enterobacter, Citrobacter, and Serratia develop resistance during prolonged therapy with third-
generation cephalosporins as a result of derepression of ampC β-lactamase. Therefore, isolates that
are initially susceptible may become resistant within three to four days after initiation of therapy.
Testing of repeat isolates may be warranted.
Enteric Pathogen: Salmonella spp.
1. Routine susceptibility testing is not indicated for nontyphoidal Salmonella spp. isolated from
intestinal sources.
2. Test and report only AMPICILLIN, CIPROFLOXACIN, AND SULFA/TRIMETH for typhoidal
Salmonella (S. Typhi and Salmonella Paratyphi A – C) isolated from intestinal sources.
3. Test and report only AMPICILLIN, CIPROFLOXACIN, SULFA/TRIMETH,
CEFTRIAXONE/CEFOTAXIME and CHLORAMPHENICOL for ALL Salmonella spp. isolated
from blood and other extra intestinal sites.
Enteric Pathogen: Shigella spp.

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SELECTION OF ANTIBIOTICS BY ORGANISM AND SPECIMEN TYPE

1. Test and report only AMPICILLIN, CIPROFLOXACIN, AND SULFA.TRIMETH

Vibrio cholerae – This organism is not a member of the Enterobacteriaceae but will be included here.
1. Test and report AMPICILLIN, TETRA, TRIMETH/SULFA, AND CHLORAMPHENICOL

3. Pseudomonas aeruginosa

BLOOD/
ANTIBIOTIC CSF STERILE WOUND SPUTUM URINE COMMENTS
SITE
Ceftazidime × × × × ×
Gentamicin × × × × ×
Tobramycin × × × × ×

Piperacillin × × × ×
× CSF if allergic
Ciprofloxacin × × ×
to beta-lactams
Meropenem
x × × × × 2nd line agent
Piperacillin-Tazo
× × × × 2nd line agent
Medium: Mueller Hinton Agar (MHA)
Inoculum: Growth method or direct colony suspension, equivalent to a 0.5 McFarland standard.
Incubation: 35 ± 2oC; ambient air; 16 – 18 hours
Reporting:
1. Report CEFTAZIDIME, GENTAMICIN, TOBRAMYCIN, PIPERACILLIN, and CIPRO
2. If CEFTAZIDIME resistant, report MEROPENEM
3. If PIPERACILLIN resistant, report PIPERACILLIN-TAZOBACTAM

4. Enterococcus spp.

BLOOD/
ANTIBIOTIC CSF STERILE WOUND URINE COMMENT
SITE
Perform beta lactamase
Ampicillin × MIC × MIC × × test on CSF and blood/
sterile site isolates

Gentamicin synergy × ×

Nitrofurantoin ×

Ciprofloxacin x 2nd line agent

Tetracycline × x 2nd line agent

Chloramphenicol × × × 2nd line agent

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SELECTION OF ANTIBIOTICS BY ORGANISM AND SPECIMEN TYPE

Vancomycin × × × × 2nd line agent

Medium: Mueller Hinton Agar (MHA)
Inoculum: Growth method or direct colony suspension, equivalent to a 0.5 McFarland standard.
Incubation: 35 ± 2oC; ambient air; 16 – 18 hours; 24 hours for Vancomycin
Reporting:
1. Combination therapy with Ampicillin, Penicillin, or Vancomycin (for susceptible strains) plus an
aminoglycoside (Gentamicin or Streptomycin) is usually indicated for serious enterococcal
infections such as bacteremia and endocarditis, unless high level resistance for both
Gentamicin and Streptomycin is documented; such combinations are predicted to result in
synergistic killing of Enterococcus.
2. Test for Gentamicin synergy using Gentamicin 120 µg disk
6mm = resistant report GENTAMICIN as NOT synergistic with AMPICILLIN, PENICILLIN,
or VANCOMYCIN
7 - 9mm = inconclusive  confirm with MIC
≥10mm = susceptible  report GENTAMICIN is synergistic with AMPCILLIN or VANCO that
is also susceptible
3. For VANCO, the presence of a haze or any growth within the zone of inhibition indicates
resistance. Organisms with intermediate zones should be tested by an MIC method.

5. Streptococcus pneumoniae

BLOOD/
ANTIBIOTIC CSF STERILE SPUTUM OTHER COMMENTS
SITE
Note: MIC interpretation
Penicillin × MIC × MIC × different for meningitis and
non-meningitis
Note: MIC interpretation
Ceftriaxone × MIC × MIC different for meningitis and
non-meningitis
Note: MIC interpretation
Cefuroxime x MIC × MIC
different for oral and parenteral
Erythromycin × ×

Trimeth/sulfa × ×

Chloramphenicol x 2nd line agent

Tetracycline × × 2nd line agent

Vancomycin × × 2nd line agent

Levofloxacin × ×
Medium: Mueller Hinton Agar (MHA) with 5% sheep blood
Inoculum: Direct colony suspension, equivalent to 0.5 McFarland standard prepared using colonies
from an overnight sheep blood agar plate
Incubation: 35 ± 2oC, 5% CO2, 20 - 24 hours
Reporting:
1. Report VANCOMYCIN if the isolate is PENICILLIN resistant

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SELECTION OF ANTIBIOTICS BY ORGANISM AND SPECIMEN TYPE

2. For isolates from non-sterile sites (sputum/other), set-up OXACILLIN (1 µg) disk screen
Oxacillin disk zone size is ≥ 20 mm  report as PENICILLIN SENSITIVE
Oxacillin disk zone size is ≤ 19 mm  confirm with PENICILLIN MIC

6. Streptococcus spp. Viridans Group

BLOOD/
OTHER
ANTIBIOTIC CSF STERILE COMMENT
SITE
Penicillin × MIC × MIC × MIC

Ceftriaxone × × 2nd line agent

Vancomycin × × 2nd line agent

Chloramphenicol
× 2nd line agent
Clindamycin × × 2nd line agent
Erythromycin
×
Medium: Mueller Hinton Agar (MHA) with 5% sheep blood.
Inoculum: Direct colony suspension, equivalent to 0.5 McFarland standard using colonies from an
overnight sheep blood agar plate.
Incubation: 35 ± 2oC; 5% CO2; 20-24 hours
Reporting:
1. Report Vancomycin if isolate is PENICILLIN resistant
NOTE: The Viridans Group of Streptococci includes the following five groups, with several species
within each group: mutans group, salivarius group, bovis group, anginosis group (previously “S. milleri”
group), and mitis group. The anginosus group include small colony-forming β-hemolytic strains with
Groups A, C, F, and G antigens.

7. Beta-haemolytic Streptococci

ANTIBIOTIC CSF BLOOD/ THROAT OTHER COMMENTS

STERILE
SITE

Resistance have not

Penicillin × MIC × MIC × × been reported – read
below

Erythromycin × ×

Clindamycin × × ×

Ceftriaxone × MIC × MIC

Chloramphenicol x x 2nd line agent

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SELECTION OF ANTIBIOTICS BY ORGANISM AND SPECIMEN TYPE

Vancomycin × × 2nd line agent

Medium: Mueller Hinton Agar (MHA) with 5% sheep blood
Inoculum: Direct colony suspension, equivalent to 0.5 McFarland standard prepared using colonies
from an overnight sheep blood agar plate
Incubation: 35 ± 2oC; 5% CO2; 20 - 24 hours
Reporting:
1. Penicillin and ampicillin are the drugs of choice for treatment of β-hemolytic streptococcal
infections. Susceptibility testing of penicillin and other β-lactams for treatment of β-hemolytic
streptococcal infections need not be performed routinely, because nonsusceptible isolates
are extremely rare in any β-hemolytic streptococcus and have not been reported for S.
pyogenes. If testing is performed, any of β-hemolytic streptococcal isolated found to be
nonsusceptible should be re-identified and retested.
2. Susceptibility testing is not performed on Streptococcus Group A, C, and G isolated from
throat unless there is a history of penicillin allergy.
3. When a Group B Streptococcus is isolated from a pregnant woman with severe penicillin
allergy, ERYTHROMYCIN and CLINDAMYCIN, including inducible clindamycin resistance (D-
zone test) should be tested and only CLINDAMYCIN should be reported. Report isolates with
inducible clindamycin resistance as “CLINDAMYCIN RESISTANT”.
NOTE: The β-hemolytic group includes the large colony-forming pyogenic strains of streptococci with
Group A (S. pyogenes), C or G antigens and strains with Group B (S. agalactiae) antigen, Small
colony-forming β-hemolytic strains Group A,C,F or G antigens (S. anginosus group, previously
termed “S. milleri”) are considered part of the viridans group, and interpretive criteria for the viridans
group should be used.

8. Haemophilus influenzae

ANTIBIOTIC CSF BLOOD/ SPUTUM OTHER COMMENTS

STERILE
SITE

Ampicillin*
x × × ×
Trimeth-Sulfa
× × ×
Ampicillin-sulbactam
× × 2nd line agent
Ceftriaxone/Cefotaxime
x × × ×
Chloramphenicol x ×
Medium: Haemophilus Test Medium (HTM)
Inoculum: Direct colony suspension, equivalent to 0.5 McFarland standard prepared using colonies
from an overnight chocolate agar plate
Incubation: 35 ± 2oC; 5% CO2; 16 - 18 hours
Reporting:
1. Perform β-lactamase test: Negative test  report as AMPICILLIN SENSITIVE.
Positive test  report as AMPICILLIN RESISTANT.

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SELECTION OF ANTIBIOTICS BY ORGANISM AND SPECIMEN TYPE

2. β-lactamase negative, ampicillin resistant (BLNAR) strains of H. influenzae should be

reported resistant to AMPICILLIN-CLAVULANATE regardless of in-vitro susceptibility
result.

9. Neisseria gonorrhoeae

Medium: GC agar base and 1% defined growth supplement

Inoculum: Direct colony suspension, equivalent to 0.5 McFarland standard prepared in MHB or 0.9%
PBS, pH 7.0 using colonies from an overnight chocolate agar plate incubated in CO 2
Incubation: 36 ± 1oC (do not exceed 37oC); 5% CO2; 20 - 24 hours

Reporting:
1. Perform direct β-lactamase test:
Positive test  report as PENICILLIN RESISTANT.
Negative test  set-up PENICILLIN disk diffusion testing to detect strains with
chromosomally-mediated resistance.
2. Test all drugs but report only if PENICILLIN resistant or patient is allergic to penicillin :
CEFIXIME, CEFTRIAXONE, CIPROFLOXACIN, SPECTINOMYCIN and TETRACYCLINE

10. Neisseria meningitidis

BLOOD/
OTHER
ANTIBIOTIC CSF STERILE COMMENT
SITE
Penicillin
x MIC × MIC ×
Ceftriaxone
x MIC × MIC 2nd line agent
Chloramphenicol 2nd line agent
x
Medium: Mueller Hinton Agar (MHA) with 5% sheep blood.
Inoculum: Direct colony suspension from 20 – 24 hours growth from chocolate agar incubated at
35oC; 5% CO2; equivalent to 0.5 McFarland standard
Incubation: 35 ± 2oC; 5% CO2; 20-24 hours
Caution! Perform all AST of N. meningitidis in a biosafety cabinet (BSC). Manipulating suspensions of
N. meningitidis outside a BSC is associated with a high risk for contracting meningococcal disease.
Laboratory acquired meningococcal disease is associated with a case-fatality rate of 50%.
Reporting: Test all drugs; report as listed per body site

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