CLSI-Pak Apr 2021

1 Staphylococcus S. aureus complex (S. argenteus), S. schweitzeri

Disk R I S Comments
Heaping = Resistant, Beaching = Sensitive See picture on page 18, β-lactamase
Penicillin p 10 U <=28 ---- >= 29 test Same result for Amoxicillin, Ampicillin, Ticarcillin, Piperacillin. If Fox is
resistant, then Penicillin is resistant.
CLSI For MSSA first line include cephalexin, co-amoxiclav /Amc, cephradine, flucloxacin,
Cefoxitin Screen NA Fox 30 <=21 P59 &
Table 3F
>= 22 Cefazolin, For S. pseudintermedius & schleiferi use oxacillin disk. Zone same as epid below. Table 3G

For CoNS except lugdunensis <=24 >= 25 Same for Staph epidermidis Eucast zone for Staph epid is 28 Staph epid with Ox 1 = 17 Sens and 18 Resistant

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 ICR Comment. CLSI Table 3I Not in urine/csf
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 Bacteriostatic = Not for CSF, brain abscess
Ceftaroline NA CPT 30 <=19 20-24 >= 25 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.

Lzd Confirm resistant cases with MIC. Read with transmitted light (plate held up
Linezolid 30
<=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 MIC >=2 1 <= 0.5 Only for Staph. aureus

Cip or Ofx or Lev Cip 5 <=15 16-20 >= 21 Comment: Cipro sensitivity is based on dosage regimen of 750mg every 12h oral or 400 mg TDS I/V

Lev 5 <=15 16-18 >= 19 Eucast 22R – 24S

Ofl 5 <=14 15-17 >= 18

Moxi Mox 5 <=20 21-23 >= 24 Eucast 28S

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 Not for Urine
Disk from Hardy
Telavancin NA TLV 30 >= 15
Tigecycline TGC 15 <=18 - >= 18 Eucast Zone given by BSAC is 26 Note = Tigecycline may cause unexplained death and should be avoided.

Vancomycin MIC MIC >=16 4-8 <= 2 MIC only. Resistance very rare. In VRSA, TLV also Resistant ? Daptomycin MIC Less than 1 is sensitive

CONS MIC >=32 16-8 <= 4 If resistant…. most likely not a Staph ??

Amikacin AK 30 <=13 14-17 >= 18 Do not report routinely.

Teicoplanin MIC 2 2 For CONS = 4 Eucast

Norfloxacin 10 <=12 13-16 >= 17
Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

For Urine - add

Nitrofurantoin f 300 <=14 15-16 >= 17

Sulfonamides Sf 300 <=12 13-16 >= 17 Measure the obvious margin. Ignore tiny growth inside.
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. ICR Comment of D Zone = This isolate is presumed to be resistant to clindamycin based on detection of
inducible clindamycin resistance. Clindamycin may still be effective in some patients. Table 3I

2. If Gent Sensitive….Comment = Gentamicin alone will not be effective in this case. It needs to be combined
with another sensitive drug.
3. If Cipro Sensitive….Comment…..”Avoid ciprofloxacin, as resistance may develop during therapy.”
4. Do not ignore intermediate category. NA = Not available in Pakistan
5. Most important disks are on the top and least important disks are at the bottom. Report upper, suppress lower.
6. Grey shade, has similar results (but not always). To report any error, contact nasar462@gmail.com
7. Vitek is better than E-strip for MIC. So, for blood, CSF and fluid isolates use Vitek MICs.
8. Please don’t miss to apply or report any GREEN antibiotic. They are First Line. Yellow are second line.
2. β-haemolytic Strep (S.pyogenes, group C, G, agalactiae) Apply on MHA with 5% sheep blood 4 disks per plate Apr 21

Disk R I S Comments
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, cephradine, ceftriaxone, cefotaxime, ceftizoxime, imipenem,
meropenem
Ampicillin Amp10 >= 24
Erythromycin Ery 15 <=15 16-20 >= 21 Not for urine, pregnant CLSI 2021
Clindamycin Da 2 <=15 16-18 >= 19 If D zone seen. Add ICR comment. CLSI Table 3H Not in urine/CSF

FEP or CTX or CRO 30 >= 24

Vancomycin VAN 30 >= 17

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

Moxifloxacin Mox 5 <=19 - >=19 Eucast Avoid in CSF

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 MIC <=1 Not for respiratory isolates
Tedizolid NA MIC <=0.5 For S. Pyogenes and agalactiae only.
Dalbavancin MIC
Tetracycline Tet 30 <=18 19-22 >= 23
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. See CLSI M45

R I S
Penicillin P1 <=29 >= 29 Eucast

Cefotaxime MIC >=4 2 <= 1

Gentamicin Gen 10 <=23 >= 23 Eucast

Erythromycin MIC >=2 1 <= 0.5

Ceftriaxone MIC >=4 2 <= 1
Cipro / Moxi Cip 5 <=25 >= 25 Eucast

Clinda 2 <=20 >= 20 Eucast Not in urine

Cotrimoxazole MIC >=80 <= 40
Tetracycline Te 30 <=24 >= 24 Eucast

Doxycycline MIC >=16 8 <= 4

Cefepime MIC >=4 2 <= 1
Imipenem MIC >=16 8 <= 4
Meropenem MIC >=16 8 <= 4
Vanvomycin Van 5 <=17 >= 17 Eucast

Linezolid Lz 10 <=25 >= 25 Eucast

Daptomycin NA MIC <= 1

Rifampicin Rif 5 <=25 26-29 >= 30 Eucast
3. Streptococcus species viridans, anginosus (milleri) , mutans, salivarius, bovis, mitis gallolyticus Granulicatella=CLSI M45 Apr 21

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 – Not in urine
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 Not in urine

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.
Tetracycline Tet 30 <=18 19-22 >= 23
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. The response may be
less than the sensitive category.
3. SDD = Higher and/or frequent dosage regimens are recommended. (Appendix E of CLSI)

Not for CSF and Brain abscess = Tetra, Doxy, Imipenem Erta, Mino, Clinda, Azithro, Ery, Cipro, Levo, First and Second
gen cephalosporins (Cephalexin, Cephradine, Cefoxitin,) Co-amox, Cefuroxime, (Avoid/or give as intermediate Cotrimoxazole,
Moxi, Tzp Chloramphenicol, Linezolid)

1. For GNR for CSF = CTX, CRO, MEM, CAZ, Cap?, Ami, (Amp for GPR), Mz, Gen? Aztreonam
2. For GPC for CSF = CTX=MIC, CRO=MIC, P=MIC, Vanco needs high dose in CSF Ox 1 for Pneumo Gent120 for Entero Moxi, Rif Lnz

3B. Micrococcus & Kocuria kristinae See CLSI M45 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. Consult CLSI M45 for Abiotrophia, Aerococcus, Aeromonas, Bacillus, Campylobacter, Corynebacterium, Erysipelothrix, Granulicatella, Gemella,
HACEK (Aggregatibacter = Haemophilus aphrophilus/paraphrophilus/segnis, & Actinobacillus) Cardiobacterium, Eikenella, Kingella, Helicobacter,
Lactobacillus, Lactococcus, Leuconostoc, Listeria, Micrococcus, Moraxella, Pasteurella, Pediococcus, Rothia, Vibrio

Direct sensitivity of GNR in blood = Amp, aztreonam, Caz, Cot, Cro, Tobra
4. Strep pneumoniae on MHA with 5% blood or MH-F agar Apr 21

Disk R I S
Same results for amoxicillin, amoxicillin/clavulanate,
ampicillin/sulbactam, piperacillin, and piperacillin/tazobactam
Penicillin cefaclor, cefdinir, cefotaxime, ceftriaxone, cefuroxime,
Ox 1 >= 20
imipenem, meropenem.(If oxacillin zone ≥ 20 mm, penicillin is sensitive.
If oxacillin zone ≤ 19 mm, penicillin MIC must be done). For CSF only MIC.
See chart last page
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 Cefotaxime. ceftriaxone and Meropenem are also likely to be resistant. Consider
For CSF >=0.12 - <= 0.06 combination therapy like Vancomycin with rifampicin or Vanc with cefotaxime or ceftriaxone.
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 5 <=7 8-13 >= 14 Only for diagnosis – Not to be reported For intermediate = Bile solubility test

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 ICR Comment. CLSI Table 3H. Not in Urine
Resistance
Vancomycin VAN 30 very rare >=17
Cefepime MIC MIC >=4 2 <= 1
Ceftriaxone MIC MIC >=2 1 <= 0.5 Must for CSF If both P & Cro resistant in CSF give Vanc+Rif
Cefotaxime MIC MIC >=2 1 <= 0.5 Report for CSF
Meropenem MIC MIC <= >=
Ceftaroline NA CPT 30 - - >= 26 Not for CSF
Cefuroxime MIC MIC >=4 2 <= 1
Resistance
Linezolid Lnz 30 very rare >=21
Rifampicin Rif 5 <= 16 17-20 >= 19 If Sensitive.... Comment = Rifampicin should not be used alone.
Chloramphenicol Cap
30
<=20 - >= 21
Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

1. Comment if Penicillin is sensitive in sputum or BAL = Amoxicillin, ampicillin, cefepime, cefotaxime, ceftriaxone,
cefuroxime, ertapenem, imipenem, and meropenem may be used to treat pneumococcal infections.

4B. Erysipelothrix See CLSI M45 Always resistant to vancomycin

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 Apr 21

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 almost always
resistant to ampicillin).

Vancomycin VAN 30 <=14 15-16 >= 17 Read with transmitted light (plate held up to light source) See picture on last page
Give in CSF
Linezolid Lnz 30 <=20 21-22 U >= 23
Imipenem ? IPM 10 <=21 22-49 >= 50 Eucast

Teicoplanin TEC 30 >= 16 Eucast

Daptomycin NA MIC >=8 4 <= 2 Not for respiratory specimens. SDD E.faecium <=2 others <=4

Tigecycline TGC 15 <=19 - >= 19 Eucast Note Disk content – from Hardy Resistance very rare

Gentamicin Table 3K CN 120 <=6 7-9 MIC >= 10 Only for blood, CSF and fluid isolates. If sensitive then add note 4…..see below
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.

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. Avoid in urine.

Chloramphenicol Cap 30 <=12 13-17 >= 18 Report only if no other drug sensitive. Otherwise suppress.

Dalbavancin MIC

Rifampicin Rif 5 <=16 17-19 >= 20

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. MHA has no folate = False susceptible cotrimoxazole.

2. Do not report any antibiotic other than these.

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

5B. Moraxella catarrhalis See CLSI M45

R I S
Penicillin Amc 30 <=23 >= 24
Azithro & Moxi Azm 15 >= 26 Resistance is rare.
Clarithro & Ceftriaxone clr 15 >= 24 Resistance is rare.
Erythro Ery 15 <=20 >= 23 Resistance is rare.
Cefotaxime MIC >=1 <=2
Ceftriaxone MIC <=2
Tetra & Levo Te 30 <=24 25-28 >= 29
Clinda MIC >=4 1-2 <= 0.5 Cipro 31 Co-amoxiclav 19 Mino 25 Eucast

Cotrimoxazole Sxt 25 <=10 >= 13 Levo 29, Moxi 26, Cro 24, Mero 33, Imp 29, Eucast
6. Enterobacterales E. coli, Klebsiella, Enterobacter, Citrobacter, Arizona, Proteus, Morganella, Providencia, Hafnia, Serratia, Yersinia, Edwardsiella Apr 21

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 <=21 22-25 >= 26 IV 400 BD, Oral 500 BD

Levofloxacin Lev 5 <=16 17-20 >= 21 Ofloxacin zones in Eucast = 22-24 750 OD

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 (If sensitive……Give Intermediate in brain abscess ) 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

Ceftazidime-Avibactam 30-20 <=20 -- >= 21 Sensitivity is based on dosage regimen of 2.5g/8h

Ceftolozane-Tazobactam
Meropenem-Vaborbactam 20-10 <=14 15-17 >= 18
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 If sensitive to Tet, report Dox and Mino also sensitive.
Ceftazidime CAZ 30 <=17 18-20 >= 21 Comment: Sensitivity is based on dosage regimen of 1g/8h

Cefoperazone Cfp 75 <=15 16-20 >= 21

Chloramphenicol Cap 30 <=12 13-17 >= 18
Aztreonam NA ATM 30 <=17 18-20 >= 21
19-24
Ceftaroline NA CPT 30 <=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 and C.koseri only. Eucast Disk from hardy -- Note disk content 15

Colistin MIC >=4 <=2 ECV CLSI Table 3D Eucast <=2 is Sensitive

Fosfomycin I/V For Ec FOS 200 <=24 -- >= 24 For E. coli only Eucast

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

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. Direct sensitivity of GNR directly from positive blood culture broth = Amp, aztreonam, Caz, Cot, Cro, Tobra Table 3E
3. Enterobacter, Citrob freundii, Serratia may develop resistance to cephalosporins during therapy.

6B . Listeria See CLSI M45

Penicillin P 1 <=13 - >= 13 Eucast

Ampicillin IV Amp 2 <=16 <=16 Eucast See Disk content For CFS ….should be combined with Genta

Cotrimoxazole Sxt 25 <=29 - >= 29 Eucast

Meropenem MEM <=26 - >= 26 Eucast

Erythromycin Ery 15 <=25 - >= 25 Eucast Not in CSF

7. Stool Isolates Salmonella / Shigella panel Apr 21

Disk R I S
Ampicillin Amp 10 <=13 14-16 >= 17
Co-trimoxazole Sxt25 <=10 11-15 >= 16
Cip 5 <=21 22-25 >= 26 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 Azm 15 <=12 >= 13 For Shigella, if zone is hazy perform MIC.
<= - >=
Pefloxacin Pef 5 <=21 - >= 26 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, Cefoxitin, Cefotetan, and
aminoglycosides.
8 Urine GNR except Pseudomonas Apr 21

Disk R I S
Ampicillin Amp10 <=13 14-16 >= 17 Same results for amoxicillin
Cefazolin Kz 30 <=14
P 36
>= 15 Sensitive results same for cefaclor, cefdinir?, cefpodoxime?, cefprozil,
CLSI 20
cefuroxime?, cephalexin, and loracarbef for E.c., K.p, Proteus in uncomplicated UTI
Co-trimoxazole Sxt 25 <=10 11-15 >= 16
Nitrofurantoin f 300 <=14 15-16 >= 17 Not for Proteus
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 U >= 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

Eucast
Tobramycin Tob 10 <=16 - >= 16
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 See picture below

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 don’t miss to apply or report any GREEN antibiotic.
7. Proteus mirabilis is always resistant to ampicillin, tetra, tigecycline and nitrofurantoin. P. vulgaris also to
cefazolin and cefuroxime.
8. Avoid in urine = Erythro, Azithro, Clarithro, Mino, Cap, Clinda, Not in urine Not for urine
9 Pseudomonas aeruginosa Comamonas Apr 21

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

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

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

Tobramycin TOB 10 <=12 13-14U >= 15
Ciprofloxacin Cip 5 <=18 19-24U >= 25 For Eucast 26 is sensitive with dose 750 BD 400 IV tds
Levofloxacin Lev 5 <=14 15-21U >= 22 For Eucast 22 is sensitive 750 OD
Amikacin AK 30 <=14 15-16U >=17
Ceftazidime-Avibactam 30-20 <=20 - >= 21
Ceftolozane-tazobactam
Imipenem IPM 10 <=15 16-18U >= 19 Comment: Imipenem Sensitivity is based on dosage regimen of 1g/8h or 500mg/6h

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

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

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

Ticarcillin 7.5 <=18 >= 18 Eucast

Cefepime FEP 30 <=14 15-17 U >=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 MIC >= 4 <=2 CLSI Table 3D Eucast <=2 is Sensitive

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

Dr. Nasrullah Malik- Shaukat Khanum Hospital Lahore

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

2.
10 Acinetobacter Apr 21

Disk R I S
Doripenem NA DOR10 <=14 15-17 >= 18 Eucast = 21-24 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 Eucast zone = 20R-23S

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 If tet Sensitive then Dox also sensitive, Report tet in urine
Minocycline Mh 30 <=12 13-15 >= 16
Cotrimoxazole Sxt 25 <=10 11-15 >= 16 Eucast 11R – 14S

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 Eucast 17R – 19S

Colistin MIC >= 4 <=2 CLSI Table 3D Eucast <=2 is Sensitive

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 diffusion (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.
11. Pseudomonas spp. /Fastidious non-enterobacterales Apr 21

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 Apr 21

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 resistant to Ampicillin, Amoxicillin, Piperacillin, Ticarcillin, Amp-sulbactam, Co-
amoxiclav, Tazobactam-piperacillin, Cefotaxime, Ceftriaxone, cefpirome, Aztreonam, Imipenem, Ertapenem,
Colistin, Tobramycin, , Gentamicin, Amikacin, Fosfomycin
3. For Burkholderia pseudomallei AMC, CAZ, MEM, IMP, Tet, Cot, Cap = See Eucast
13. Haemophilus Apply on HTM agar (Oxoid CM0898B) 4 Disks per plate Apr 21

Disk R I S
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 Not for CSF ?
Resistance
CTX or CAZ or CRO 30 very rare >= 30 Resistance very rare
Cefuroxime Cxm 30 <=16 17-19 >= 20 Only parenteral may be given in serious cases. Not for CSF.
Resistance
Meropenem MEM very rare >= 20
Resistance
Cip or Lev or Mox Cip 5 very rare
- >= 17
Resistance
Azith or Azm 15 very rare >= 12
Clarith clr 15 <=10 11-12 >= 13
Co-amoxiclav Amc 30 <=19 - >= 20
Cefotaxime CTX 30 <=27 - >= 27 Eucast
Tetracycline Te 30 <=25 24-28 >= 29
Levofloxacin Lev 5 - - >= 20 Resistance very rare
Moxifloxacin Mox 5 - - >= 18
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. Apply Bacitracin 10 units in sputum on chocolate agar plate.

13B. Neisseria gonorrheae on GC agar (Oxoid CM0367B with suppliment) 4 Disks per plate

Disk R I S
Ceftriaxone CRO 30 >= 35
Ciprofloxacin Cip 5 <=27 28-40 >= 41
Azithromycin Azt 15 >= 30 1 g single dose
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. 2 Disks per plate Apr 21

Disk R I S
Ampicillin Amp 10 <= >= For Listeria only
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.
For Neisseria meningitides Cap, Rif, CTX or CRO, MEM, (For contacts Cipro, Mino, Azithro) ….See CLSI

14B . Pasteurella multocida See CLSI M45

Disk R I S
Amoxil MIC <= >=
Ampicillin Amp 10 <= - >= 27
P 10 <= - >= 25 Eucast zone for P1 is 17

Amc 30 <= - >= 27

CTX 30 <= - >= 34
Mox 5 <= - >= 28
Cip/Lev 5 <= - >= 28
Te 30 <= - >=23
Dox 30 <= - >= 23
Ery15 <=24 - >= 27
Azm 15 <= - >= 20
Sxt >= 24

14C Vibrio See CLSI M45

Disk R I S
Tazo-Pip 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 See CLSI M45 Apr 21

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 See CLSI M45 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
16 Anaerobes Bifidobacterium, Propionibacterium, Actinomyces, Staph saccharolyticus. Peptoniphilus, Finegoldia Apr 21

R I S
Ampicillin / Amoxicillin MIC >=2 1 <= 0.5 Same result for Amoxicillin. 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.

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 Apr 21

Disk R I S
Co-trimoxazole Sxt 25 <=10 11-15 >= 16 See picture below Disregard the haze
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; Thirty first Informational Suppliment.
M100-S30. 2021. 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 10.0, http://www.eucast.org. 2021.
3. CLSI. Performance standards for Antimicrobial Susceptibility Testing of infrequently isolated or fastidious
bacteria; Third edition. 2016. 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 Apr 21

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 Gardnerella Amp, Amox, Amc, Cephalospirins, Mz, Clinda

2. For Elizabethkingia meningoseptica (Chryseobacterium meningosepticum) test only Cot, Cipro/Levo and TZP.
Zones are not available. For Ralstonia…Use panels 12 & 17. Add notes “likely to be”.
3. For Achromobacter report only IMP/MEM/TzP/Cot. Zones are not standardized.
4. For Sphingomonas report Tetra/Cap/Cot/Ami/Gen/Cip/Levo/Vanc . Zones not standardized.
5. Rhodotorula mucilaginosa .....Amphotericin B, Fluconazole, Itraconazole
6. Clostridium septicum ….. Van, MZ, IMP, MEM Saccharomyces cerevisiae is a yeast.
7. Ochrobactrum anthropi ………Amika/Genta/Cipro/Levo/Tetra/Imipenem/Cotri
8. Bordetella …….. Co-amoxiclav, Ery, Doxy, Cipro, Levo, Cot,
9. For Prevotella ……Clinda, Amp-sulbacatm, pip-taz, Erta/Imp/Mero, fox, Cap, Dox,
10. Pandoraea ……… amikacin, ciprofloxacin, trimethoprim- sulfumethoxazole, gentamicin, piperacillin tetracycline and imipenem.

For Penicillin in Staph - Beaching/Heaping Zone 29 not 26

Enterococcus Vs Vanco Eucast zone is 12 As per CLSI Use Vanco 30 disk and Zone size 17
Oxacillin in Strep pneumoniae

Aerococcus (MIC of …P, CTX, CRO, MEM, VAN, Cip, Lev, Tet, Cot, Lnz) See CLSI-M45 Apr 21

Disk R I S
P1 <=21 - >= 21 Eucast
Amp 2 <=26 - >= 26 Eucast

MEM10 <=31 - >=31 Eucast

Cip 5 <=21 - >= 21 Eucast For urine only
Van 5 <=16 - >= 16 Eucast

Rif 5 <=25 - >= 25 Eucast

Nit 100 <=16 - >=16 Urine only

Kingella kingae see CLSI M45 Apr 21

Disk R I S
Eucast
Penicillin P1 <=25 - >= 25
Eucast
CTX 5 <=27 - >= 27
Eucast
CRO30 <=30 - >= 30
Eucast
CXM 30 <=29 - >= 29
Eucast
MEM 10 <=30 - >= 30
Eucast
Cip/Lev Cip 5 <=28 - >= 28
Eucast
Ery 15 <=20 - >= 20
Rif 5 <=20 - >= 20 Eucast
Cot 25 <=28 - >= 28 Eucast
Tetracycline Te 30 <=28 - >= 28 Eucast