Cefiderocol is a siderophore cephalosporin with activity against aerobic Gram-negative

bacteria. It is approved for the treatment of aerobic Gram-negative infections in adults with
limited therapeutic options. EUCAST has determined clinical breakpoints for
Enterobacterales and Pseudomonas aeruginosa.

For other species against which the agent has activity, such as Acinetobacter baumannii and
Stenotrophomonas maltophilia, there is as yet insufficient evidence to determine a clinical
breakpoint. For these, EUCAST has determined a zone diameter which will exclude isolates
with MIC values clearly above the PK-PD breakpoint.

Cefiderocol shows activity against many isolates with high MIC values for and resistance to
other beta-lactam agents, both cephalosporins and carbapenems. However, resistance to
cefiderocol exists and these organisms can be detected with antimicrobial susceptibility
testing (AST) performed with MIC or disk diffusion AST (see below).

Cefiderocol is administered intravenously and the approved dosage is 2 g x 3 daily, using an

intravenous infusion over 3 hours.

Antimicrobial susceptibility testing methodology

Broth microdilution
Cefiderocol requires low iron levels for optimal activity. Broth microdilution MIC determination
must be performed in iron-depleted Mueller-Hinton broth. The iron concentration of liquid
medium affects reproducibility and therefore should be strictly defined. Chelation is used for
the iron depletion, and this procedure also removes other cations (i.e. calcium, magnesium
and zinc). Following this process, cations are added back to concentrations of calcium 20–25
mg/L, magnesium 10–12.5 mg/L, and zinc 0.5–1.0 mg/L.

The MIC of cefiderocol is read as the first well in which the reduction of growth corresponds
to a button of <1 mm or is replaced by the presence of light haze/faint turbidity. The positive
control should show strong growth in the form of a button of >2 mm or heavy turbidity. See
pictures with reading examples at the end of this document.

Disk diffusion
Disk diffusion of cefiderocol is performed according to EUCAST standard methodology for
non-fastidious organisms on regular un-supplemented Mueller-Hinton agar. It is no more
complicated than disk diffusion for other cephalosporins.
Clinical breakpoints for cefiderocol were set by EUCAST as follows:

Disk Zone diameter

MIC breakpoint (mg/L)
Organisms content breakpoint (mm)
S≤ R> (µg) S≥ R<
Enterobacterales 2 2 30 22 22
Pseudomonas aeruginosa 2 2 30 22 22
Acinetobacter spp.* IE IE – – –
Stenotrophomonas maltophilia* IE IE – – –
PK/PD (non-species related)
2 2 - - -
breakpoints
* Clinical data on efficacy are limited, but in vitro and PK-PD activity support the use in difficult-
to-treat cases

ECOFFs and TECOFFs for cefiderocol were set by EUCAST (SOP 10.1):

ECOFF and (TECOFF) Disk ECOFF and (TECOFF)

Organism content
(MIC; mg/L) (µg) (zone diameter; mm)1

Escherichia coli (0.25) 30 (24)

Klebsiella pneumoniae (0.25) 30 (22)

Pseudomonas aeruginosa (0.5) 30 (23)

Acinetobacter baumannii1 (0.25) 30 (211)

Stenotrophomonas maltophilia2 (0.06) 30 (292)

1
A zone diameter of ≥17 mm is typical for isolates with MIC values of ≤2 mg/L (see below).
2
A zone diameter of ≥20 mm is typical for isolates with MIC values of ≤0.5 mg/L (see below).
MIC-zone diameter correlates for E. coli, K. pneumoniae, P. aeruginosa, A. baumannii
and S. maltophilia.

Cefiderocol 30 µg vs. MIC ≥512

E. coli, 77 isolates (208 correlates) 256
128
40 64
35 32
16
30
No of isolates

8
25 4
20 2
1
15 0.5
10 0.25
0.125
5 0.06
0 0.03
0.016
6
8

18

40
10
12
14
16

20
22
24
26
28
30
32
34
36
38
0.008
Inhibition zone diameter (mm)
0.004

Cefiderocol 30 µg vs. MIC ≥512

K. pneumoniae, 77 isolates (308 correlates) 256
128
45 64
40 32
35 16
No of isolates

8
30
4
25 2
20 1
15 0.5
0.25
10 0.125
5 0.06
0 0.03
0.016
6
8

18

40
10
12
14
16

20
22
24
26
28
30
32
34
36
38

0.008
Inhibition zone diameter (mm)
0.004
 Cefiderocol 30 µg vs. MIC
P. aeruginosa, 101 isolates (404 correlates) 8
60 4
2
50
1
No of isolates

40 0.5
30 0.25
0.125
20
0.06
10 0.03
0.016
0
0.008
6
8

18

40
10
12
14
16

20
22
24
26
28
30
32
34
36
38
Inhibition zone diameter (mm) 0.004

Cefiderocol 30 µg vs. MIC

A. baumannii, 103 isolates (412 correlates) ≥512
256
60 128
64
50 32
No of isolates

16
40
8
30 4
2
20 1
0.5
10 0.25
0.125
0 0.06
6
8

18

40
10
12
14
16

20
22
24
26
28
30
32
34
36
38

0.03
Inhibition zone diameter (mm) 0.016

Cefiderocol 30 µg vs. MIC

S. maltophilia, 75 isolates (300 correlates)
60
0.5
50
0.25
No of isolates

40 0.125
30 0.06
0.03
20
0.016
10 0.008
0.004
0
≤0.002
8
6

14
10
12

16
18
20
22
24
26
28
30
32
34
36
38
40

Inhibition zone diameter (mm)

Quality control ranges for MIC and disk diffusion tests on cefiderocol are as follows:

Disk Inhibition zone

MIC (mg/L)
Organisms content diameter (mm)
Target Range (µg) Target Range
E. coli ATCC 25922 0.125-0.25 0.06-0.5 30 27 24-30
P. aeruginosa ATCC 27853 0.125-0.25 0.06-0.5 30 25 22-28

Examples of reading cefiderocol MIC endpoints

The MIC of cefiderocol is read as the first well in which a reduction of growth corresponding
to a button of <1 mm or the presence of light haze/faint turbidity is observed (red ring). The
positive control should show strong growth (button of >2 mm or heavy turbidity). Cefiderocol
concentrations increase two-fold serially from column 1 (X mg/L) to column 11 (Y mg/L)
wells.

Positive control

Positive control

Positive control