Section 5 Fastidious/Miscellaneous Gram Negative Bacilli/Cocci/Coccobacilli

IH Section 5 Fastidious/Miscellaneous Gram
Microbiology
Laboratory Service
Negative Bacilli/Cocci/Coccobacilli
Susceptibility Manual MB 0825.07
Table of Contents
Actinobacillus spp .............................................................................................................................................2
Aggregatibacter spp ..........................................................................................................................................3
Bergeyella spp ..................................................................................................................................................4
Brucella spp ......................................................................................................................................................5
Campylobacter jejuni/coli .................................................................................................................................6
Campylobacter spp ...........................................................................................................................................7
Capnocytophaga spp ....................................................................................................................................... …9
Capnocytophaga spp (canine).......................................................................................................................... 10
Cardiobacterium spp ....................................................................................................................................... 11
Dysgonomonas spp ......................................................................................................................................... 12
Eikenella corrodens......................................................................................................................................... 13
Francisella spp ................................................................................................................................................ 14
Haemophilus influenzae .................................................................................................................................. 15
Haemophilus influenzae Beta-Lactam Chart ..................................................................................................... 17
Haemophilus parainfluenzae ........................................................................................................................... 18
Haemophilus spp (other)................................................................................................................................. 20
Kingella spp .................................................................................................................................................... 21
Mannheimia spp ............................................................................................................................................. 22
Neisseria spp (animal origin) ........................................................................................................................... 23
Neisseria gonorrhoeae .................................................................................................................................... 24
Neisseria meningitidis ..................................................................................................................................... 25
Neisseria spp (other) ....................................................................................................................................... 26
Pasteurella spp ............................................................................................................................................... 27
Suttonella indologenes.................................................................................................................................... 29
Weeksella spp................................................................................................................................................. 30
Appendix 1: Doubling Dilution Chart for ETEST MIC ......................................................................................... 31
References...................................................................................................................................................... 32
May 2019 Page 1 of 36

A printed copy of this document may not be the most current version. The most current version is available in SoftTech.
Fastidious/Miscellaneous Gram Negative Bacilli/Cocci/Coccobacilli MB 0825.07
ORGANISM:
Actinobacillus spp.
- A. equuli - A. suis
- A. hominis - A. ureae
- A. lignieresii
CLINICAL: These organisms are part of the normal flora of the upper respiratory and genitourinary tracts in humans and
animals.
A. equulis, A.suis have caused a variety of illnesses in horses and pigs. Human infections are rare and are
usually associated with horse or pig bites.
A. hominis has been associated with bacteremia in patients with severe liver disease and from the
respiratory tract of patients with chronic lung disease.
A.lignieresii causes actinobacillosis in cattle and sheep which is similar to actinomycosis with formation of
sulfur granules. It may cause soft tissue infections in humans, associated with a bite or other contact with a
cow or sheep.
A. ureae has been associated with bacteremia, endocarditis, meningitis, bone marrow infection, atrophic
rhinitis, pneumonia, conjunctivitis, otitis media and peritonitis. Predisposing factors include
immunosuppression, diabetes, surgery or trauma.
USUAL Actinobacillus spp. are resistant to clindamycin and vancomycin. The activity of penicillin, macrolides and
SUSCEPTIBILITY aminoglycosides is variable. These organisms are usually susceptible to cephalosporins, TMP-SMX,
PATTERN: quinolones, rifampin and tetracycline.
SUSCEPTIBILITY Etest method using Brucella Blood Agar (BBA) or Hemophilus Test Medium (HTM) incubated in 5% CO2 at
METHOD: 35° C for 24-72 hours (depending on growth characteristics).
Use 1.0 McFarland suspension (from 48-72 hour colonies) in BHI broth.
BLOOD
CSF/
SUSCEPTIBILITY STERILE BODY
BRAIN OTHER COMMENTS
REPORTING: SITE
Beta-lactamase * * * *Test but do not report
If beta lactamase positive – report
Ampicillin √ √ √
ampicillin R
Ceftriaxone √ √ √
Ciprofloxacin √ √ Do not report in patients < 18 y
nd
2 line if ampicillin I/R
Doxycycline 2 Use tetracycline breakpoints
Do not report in patients < 8 y
If beta lactamase positive – report
Penicillin √ √ √
penicillin R
TMP-SMX √ Do not report in patients < 3 mo
NOTE: Consult microbiologist regarding the need for susceptibility testing of isolates from nonsterile body sites. For
these sites, or if isolated with other organisms, clinical correlation and correlation with Gram stain is
required.
On isolates where susceptibility results reported, add comment:
“Susceptibility testing for this organism is not standardized.
Results are probable but not definite.” [MSAST]
INTERPRETATION: For Etest, report actual MIC result. For interpretation (S, I, or R) report according to the nearest higher
doubling dilution (Appendix 1).
Use CLSI interpretive document for HACEK group.

ORGANISM:
Aggregatibacter spp.
- A. actinomycetemcomitans
- A. aphrophilus
- A. segnis
CLINICAL: These organisms are part of the normal flora of the upper respiratory tract.
A. actinomycetemcomitans – has been associated with endocarditis, brain abscess, meningitis, parotitis,
septic arthritis, osteomyelitis, disciitis, paraspinal abscess, pneumonia, pericarditis, and soft tissue infections.
In soft tissue infections, this organism is often co-isolated with Actinomyces spp. Patterns of infections may
resemble Actinomyces infection (i.e. cervicofacial, thoracic, abdominal). This organism is also associated
with periodontal disease (along with Porphyromonas gingivalis).
A. aphrophilus – has been associated with endocarditis, meningitis, brain abscesses, pneumonia, sinusitis,
septic arthritis, osteomyelitis and wound infections.
A. segnis – has been associated with endocarditis, brain abscesses, meningitis, pneumonia, sinusitis, septic
arthritis, osteomyelitis and wound infections.
USUAL A. actinomycetemcomitans is resistant to clindamycin and vancomycin. The activity of macrolides and
SUSCEPTIBILITY aminoglycosides is variable. These organisms are usually susceptible to cephalosporins, TMP-SMX,
PATTERN: quinolones, rifampin and tetracycline. Susceptibility to penicillin and ampicillin is variable (altered penicillin
binding protein, permeability mutations, and rarely beta-lactamase production are emerging).
A. aphrophilus and A. segnis are usually susceptible to ampicillin, second/third generation cephalosporins,
TMP-SMX, quinolones, and tetracyclines. One case of third generation cephalosporin resistance has been
reported for A. aphrophilus.
SUSCEPTIBILITY Etest method using Brucella Blood Agar (BBA) or Hemophilus Test Medium (HTM) incubated in 5% CO2 at
METHOD: 35° C for 24-72 hours. Use 1.0 McFarland suspension (from 48-72 hour colonies) in BHI broth.
BLOOD
CSF/
REPORTING: SITE
If beta lactamase positive – report ampicillin R
Ampicillin √* √*
See Interpretation
*Test but do not report
Amox-Clav * * *
See Interpretation
nd
2 line if ampicillin I/R
Doxycycline 2* *Use tetracycline breakpoints
Penicillin √* √* *If beta lactamase positive – report penicillin R
TMP-SMX √ Do not report in patients < 3 mo
NOTE: Consult microbiologist regarding the need for susceptibility testing of isolates from nonsterile body sites. For
these sites, or if isolated with other organisms, clinical correlation and correlation with Gram stain is
required.
Ampicillin For A. actinomycetemcomitans, do not report ampicillin as in vitro susceptibility does

not necessarily predict a favourable outcome.
Amox-Clav If beta-lactamase is negative and amox-clav R, report ampicillin and pencillin as R.

ORGANISM:
Bergeyella spp.
- B. zoohelcum
CLINICAL: This organism is part of the normal oral and nasal flora of dogs and cats. Human infections (wound
infections, abscesses, septicemia, meningitis, tenosynovitis and pneumonia) have been associated with dog
or cat bites/exposure.
USUAL This organism is susceptible to penicillin/ampicillin and quinolones but is usually resistant to
SUSCEPTIBILITY aminoglycosides. It has a variable susceptibility to TMP-SMX and tetracycline. It is colistin resistant.
PATTERN:
SUSCEPTIBILITY Etest method using Mueller-Hinton agar with 5% sheep blood (MHB) incubated in ambient air at 35°C for 48
METHOD: hours. Use 1.0 McFarland suspension in BHI broth.
BLOOD
CSF/
REPORTING: SITE
Amoxicillin-clavulanate √
Ampicillin √ √ √
nd
Ceftriaxone √ √ 2 2 line if ampicillin I/R
Levofloxacin √ √ Do not report in patients < 18 y
Doxycycline √ Do not report in patients < 8 y
Penicillin √ √ √
TMP-SMX √ √ Do not report in patients < 3 mo
NOTE: For all isolates, add comment:

“This organism is part of the normal oral flora of dogs and cats. Human infection is usually
related to dog or cat bites/exposure. The treatment of choice for bite wounds is amoxicillin/clavulanate”.
[M5NDCF]
For all isolates from sterile body sites, add comment:
“This organism is resistant to aminoglycosides”. [M5AMINO]
Results are probable but not definite”. [MSAST]
Use CLSI interpretive document for Pasteurella spp.

ORGANISM: Brucella spp.

CLINICAL: These organisms primarily cause disease in domestic animals. There are four species which cause
human disease: B. abortus (cattle); B. melitensis (goats and sheep); B. suis (swine); B. canis
(dogs). Clinical manifestations of brucellosis in humans vary from subclinical to serious systemic
disease. Infections include meningoencephalitis, septic arthritis, osteomyelitis, epididymo-orchitis,
prostatitis, endocarditis, hepatitis, and splenic abscess. The organism may be isolated from blood,
body fluids, abscesses, soft tissues, or bone.
NOTE: This organism is a biohazard in the laboratory. If this organism is isolated inadvertently in the
laboratory:
- Consult microbiologist immediately
- Work only in biological safety cabinet
- Refer to Reference Laboratory
SUSCEPTIBILITY Susceptibility testing must be sent to Reference Laboratory for testing. It must be performed in
METHOD: a Level III laboratory. Refer to CLSI Guidelines for Potential Agents of Bioterrorism.

ORGANISM:
Campylobacter jejuni/coli
CLINICAL: These organisms are found in the gastrointestinal tracts of both wild and domesticated animals.
They are often colonizers but may also cause disease in these animals. Most human infections result from
consumption of contaminated food or water, and rarely after direct contact with infected
animals. In humans, these organisms are associated with both diarrheal and systemic illnesses.
C. jejuni: Associated with diarrhea (usually self-limiting in 3-7 days). Bacteremia occurs in < 1% of C. jejuni
infections, usually in individuals at the extreme of ages. C. jejuni has also been rarely associated with septic
abortions, acute cholecystitis, pancreatitis, cystitis, septic arthritis, and meningitis.
C. coli: Causes diarrhea, but tends to produce a milder disease than C. jejuni. One case of urinary tract
infection has been reported.
USUAL These organisms are usually susceptible to erythromycin (except C. coli), gentamicin, tetracycline,
SUSCEPTIBILITY clindamycin, and carbapenems. Resistance to quinolones is rapidly emerging worldwide. Campylobacter
PATTERN: spp. are usually resistant to penicillins and narrow spectrum cephalosporins but may be susceptible to
amoxicillin-clavulanate (not piperacillin/tazobactam). Susceptibility to TMP-SMX and third generation
cephalosporins is variable.
SUSCEPTIBILITY Modified Kirby-Bauer or Etest method, using Mueller-Hinton agar with 5% sheep blood (MHB) incubated
o
METHOD: in microaerophilic conditions at 42 C (depending on growth characteristics) for 24 hours. Use 0.5
McFarland suspension in saline. For Etest use 1.0 McFarland suspension (from 24-48 hourcolonies) in
BHI broth.
Note: Dry MHB plates prior to inoculation at 35°C with the lid removed for 15 minutes.
BLOOD
SUSCEPTIBI CSF/
STERILE BODY
LITY BRAIN STOOL COMMENTS
SITE
REPORTING:
Azithromycin √* * Test erythromycin. See interpretation
Ciprofloxacin √ √ Do not report in patients < 18y
Etest method
Doxycycline 2 nd
2 line if cipro and azithromycin I/R
Erythromycin * *Test but do not report
Gentamicin √
Meropenem √ √ Etest method
NOTE: If reporting from site other than stool , add comment:
“Susceptibility testing performed by unstandardized method.
Results are probable but not definite”. [MSASTM]
CSF/blood isolates:
The Etest method may result in MICs that are one to two dilutions lower than the broth or agar dilution methods.
For all antibiotics reported, if I – report as R.
Stool isolates: Test all Campylobacter isolates for susceptibility pattern, but only report susceptibility results if:
- Patient < 12 months or > 65 years of age
- Patient with immunosuppression
- Patient is a food handler
- Request by physician
For all stool isolates, add comment:
“This organism may cause self-limiting diarrhea. Antibiotic treatment is generally not recommended unless
symptoms are severe or prolonged or patient is immunocompromised”. [MSSLD]
Notify Public Health and/or Infection Control
INTERPRETATION: For Etest, report actual MIC result. For interpretation (S, I, or R) report according to the nearest higher doubling
dilution (Appendix 1).
Use CLSI interpretive document for Campylobacter jejuni/coli.
Exceptions: Gentamicin and meropenem use CLSI interpretive document for Enterobacteriaceae
Azithromycin: Report using erythromycin breakpoints.
ORGANISM: Campylobacter spp

- C. concisus - C. hominis - C. showae
- C. curvis - C. hyointestinalis - C. sputorum
- C. fetus - C. lari - C. upsaliensis
- C. gracilis - C. peloridis
These organisms are mainly found in the gastrointestinal tracts of both wild and domesticated
CLINICAL: animals. They are often colonizers but may also cause disease in these animals. Most human
infections result from consumption of contaminated food or water, and rarely after direct contact with
infected animals. In humans, these organisms may be associated with diarrheal and/or systemic
illnesses.
C. concisus: This organism has been isolated from fecal and blood specimens and has been
associated with gastrointestinal illness.
C. curvis: This organism has been isolated from patients with periodontal infections, liver
abscesses and pneumonia.
C. fetus: This organism causes a systemic illness with/without diarrheal symptoms, often in
debilitated/immunocompromised patients. It has been associated with premature labour, septic
abortion, bacteremia, neonatal sepsis, meningoencephalitis, brain abscess, prosthetic joint
infections, septic arthritis, osteomyelitis, endocarditis, urinary tract infections, and in homosexual
men, proctitis/proctocolitis.
C. gracilis: This organism has been isolated from patients with appendicitis, peritonitis, soft tissue
abscesses, bacteremia and pulmonary infections.
C. lari/C. upsaliensis/C. hyointestinalis: These organisms have been associated with diarrheal
and systemic illnesses, mostly in immunocompromised patients. C. upsaliensis infections may be
acquired from cats and dogs.
C. pelordis: This organism has been isolated from human feces, dialysate fluid and from shellfish.
C. showae: This organism has been isolated from humal gingival crevice and from a blood culture
of a patient with cholangitis.
C. sputorum: This organism has been associated with abscesses in the lung, axilla, groin and
scrotum.
USUAL The susceptibility patterns of Campylobacter spp other than C.jejuni and C.coli, have not been well
SUSCEPTIBILITY studied. C.fetus has been successfully treated with ampicillin, aminoglycosides and imipenem. C.
PATTERN: lari is resistant to nalidixic acid, but may be susceptible to fluoroquinolones. Resistance to
macrolides is not common. C.upsaliensis is generally susceptible to a variety of agents. Resistance
to macrolides and fluoroquinolones is not common.
SUSCEPTIBILITY Modified Kirby-Bauer or Etest method, using Mueller-Hinton agar with 5% sheep blood (MHB)
o
METHOD: incubated in microaerophilic conditions at 35 C for 48 hours.
Use 0.5 McFarland suspension in saline. For Etest use 1.0 McFarland suspension (from 24-48
hour colonies) in BHI broth.
Note: Dry MHB plates prior to inoculation at 35°C with the lid removed for 15 minutes.

Campylobacter spp. (cont’d)

BLOOD
CSF/
BRAIN STOOL COMMENTS
REPORTING: SITE
Azithromycin √* *Test erythromycin. See interpretation
Ciprofloxacin √ √ Do not report in patients < 18y
Etest method
nd
Doxycycline 2 2 line if cipro and azithromycin I/R
Erythromycin * *Test but do not report
Gentamicin √
Meropenem √ √ Etest method
NOTE: If reporting susceptibility results , add comment:
“Susceptibility testing performed by unstandardized method.

Results are probable but not definite”. [MSASTM]
CSF/blood isolates:
The Etest method may result in MICs that are one to two dilutions lower than the broth or agar
dilution methods. For all antibiotics reported, if I – report as R.
Stool isolates: Test all Campylobacter isolates for susceptibility pattern, but only report
susceptibility results if:
- Patient < 12 months or > 65 years of age
- Patient with immunosuppression
- Patient is a food handler
- Request by physician
For all stool isolates, add comment:

“This organism may cause self-limiting diarrhea. Antibiotic treatment
is generally not recommended unless symptoms are severe or prolonged or patient
is immunocompromised”. [MSSLD]
Notify Infection Control and/or Public Health.
INTERPRETATION: For Etest, report actual MIC result. For interpretation (S, I, or R) report according to the nearest
higher doubling dilution (Appendix 1).
Use CLSI interpretive document for Campylobacter jejuni/coli.
Exceptions: Gentamicin and meropenem use CLSI interpretive document for

Enterobacteriaceae.
Azithromycin: Report using erythromycin breakpoints.

ORGANISM: Capnocytophaga spp.

- C. gingivalis - C. leadbetteri
- C. granulosa - C. ochracea
- C. haemolytica - C. sputigena
CLINICAL: Capnocytophaga spp. are part of the normal human oropharyngeal flora and may colonize the
female genital tract. They have been implicated in periodontal disease and have been associated
with intrauterine infections, amnionitis, and neonatal infections in premature infants. They may also
cause septicemia in immunocompromised individuals. Rarely, these organisms have been
associated with endocarditis, peritonitis, deep abscesses, septic arthritis, osteomyelitis, and ocular
infections in both immunocompromised and immunocompetent individuals.
USUAL These organisms are usually susceptible to amoxicillin-clavulanate, clindamycin, erythromycin,
SUSCEPTIBILITY tetracycline, quinolones and carbapenems. Rare resistance has been reported to clindamycin,
PATTERN: erythromycin, ciprofloxacin and tetracycline. Susceptibility to penicillins and cephalosporins is
st nd
variable due to beta-lactamase production. Therapy with 1 and 2 generation cephalosporins may
result in clinical failure despite in vitro susceptible result. Beta lactamase producing strains result in
nd rd
resistance to ampicillin, cephalothin and cefazolin, as well as decreased susceptibility to 2 and 3
generation cephalosporins. Carbapenems and aztreonam retain activity. These organisms are
usually resistant to aminoglycosides, vancomycin, colistin and TMP-SMX.
o
SUSCEPTIBILITY Etest method using Brucella Blood Agar (BBA) incubated in 5% CO2 at 35 C for 48 hours. Use 1.0
METHOD: McFarland suspension in BHI broth.
SUSCEPTIBILITY CSF/
BLOOD STERILE
REPORTING: BRAIN OTHER COMMENTS
BODY SITE
Beta-lactamase * * * * *Test but do not report
Amoxicillin-
√
clavulanate
√* *If beta-lactamase positive report
Ampicillin √* √* √*
ampicillin as R
nd
Ceftriaxone √ √ √ 2 2 line if ampicillin I/R
Clindamycin √ √
Doxycycline √ Do not report on patients < 8 y
Levofloxacin √ √ √ Do not report on patients < 18 y
nd
Meropenem √ 2 2 2 line if ceftriaxone I/R
NOTE: Consult microbiologist regarding the need for susceptibility testing.


Exceptions:
Meropenem: use use CLSI interpretive document for Enterobacteriaceae
Clindamycin: use CLSI interpretive document for Staphylococcus spp.

ORGANISM: Capnocytophaga spp. (Canine)

- C. canimorsus
- C. cynodegmi
CLINICAL: These organisms are part of the normal oral flora of dogs (occasionally cats and rabbits). They
cause infections in association with dog bites or close contact with dogs. Septicemia may range
from mild in healthy individuals to fulminant in immunocompromised/debilitated or high risk
(asplenic, alcoholic, steroid therapy) individuals. Fulminant septicemia resembles meningococcal
disease. Other infections associated with these organisms include meningitis, endocarditis,
pneumonia, cellulitis, septic arthritis, and ocular infections.
USUAL Most strains are susceptible to penicillin; however beta-lactamase production has been described.
SUSCEPTIBILITY If susceptible, penicillin results in clinical efficacy. They are resistant to aminoglycosides and
PATTERN: TMP-SMX. Resistance to clindamycin and macrolides is common. C. canimorsus is usually
susceptible to beta- lactam/beta-lactamase inhibitor combination drugs, erythromycin,
clindamycin, quinolones, third generation cephalosporins, doxycycline, imipenem, vancomycin
and linezolid. It is resistant to aztreonam.
o
SUSCEPTIBILITY Etest method using Brucella Blood Agar (BBA) incubated in 5% CO2 at 35 C for 48 hours. Use 1.0
METHOD: McFarland suspension in BHI broth.
SUSCEPTIBILITY CSF/
BLOOD STERILE
REPORTING: BRAIN OTHER COMMENTS
BODY SITE
Beta-lactamase * * * * *Test but do not report
Amoxicillin-
√
clavulanate
√* √ *If beta-lactamase positive report
Ampicillin √* √*
* ampicillin as R
nd
Ceftriaxone √ √ √ 2 2 line if ampicillin I/R
Clindamycin √ √
Doxycycline √ Do not report on patients < 8 y
Levofloxacin √ √ √ Do not report on patients < 18 y
nd
Meropenem √ 2 2 2 line if ceftriaxone I/R


Exceptions:
Meropenem: Use CLSI interpretive document for Enterobacteriaceae
Clindamycin: Use CLSI interpretive document for Staphylococcus spp.

ORGANISM: Cardiobacterium spp

- C. hominis
- C. valvarum
CLINICAL: These organisms are part of the normal flora of the upper respiratory, gastrointestinal and
genitourinary tracts. They have been associated with endocarditis (especially prosthetic valve
endocarditis), septic embolization, and intra-abdominal abscesses.
USUAL These organisms are usually susceptible to penicillins, cephalosporins, and carbapenems. Beta-
SUSCEPTIBILITY lactamase production has rarely been described and can be overcome by beta-lactamase inhibitors.
PATTERN: They are susceptible to quinolones, aminoglycosides, rifampin and tetracycline, but exhibit variable
susceptibility to macrolides. The therapy of choice is ceftriaxone (one report of third generation
cephalosporin resistance).
SUSCEPTIBILITY Etest method using Brucella Blood Agar (BBA) or Hemophilus Test Medium (HTM) incubated in 5%
METHOD: CO2 at 35°C for 24-72 hours (depending on growth characteristics). Use 1.0 McFarland
suspension in BHI broth.
BLOOD/
SUSCEPTIBILITY
STERILE COMMENTS
REPORTING:
BODY SITE
Beta-lactamase * *Test but do not report
Ampicillin √* *If beta-lactamase positive report ampicillin R
Ceftriaxone √
Ciprofloxacin √ Do not report on patients < 18 y
nd
Meropenem 2 2 line if ceftriaxone I/R
Penicillin √* *If beta-lactamase positive report penicillin R
Susceptibility testing is recommended on all isolates from sterile body sites.

ORGANISM: Dysgonomonas spp

- D. capnocytophagoides - D. hofstadi
- D. gadei - D. mossii
CLINICAL: These organisms may be a rare cause of gastrointestinal infection, bacteremia, or liver abscesses in
immunocompromised patients.
USUAL These organisms are usually resistant to beta-lactam antibiotics (including 3rd generation
SUSCEPTIBILITY cephalosporins), aminoglycosides, macrolides, vancomycin and quinolones. They are usually
PATTERN: susceptible to tetracyclines, clindamycin, rifampin, TMP-SMX, beta-lactamase inhibitor combinations
and imipenem.
Note: Although imipenem may appear susceptible, documented clinical failure with this antibiotic
has been described.
SUSCEPTIBILITY Etest method, using Mueller-Hinton agar (MHA) with 5% sheep blood incubated in 5% CO2 at 35°C
METHOD: for 24-48 hours (depending on growth characteristics). Use 1.0 McFarland suspension in BHI broth.
STERILE BODY
SUSCEPTIBILITY BLOOD
SITE WOUND COMMENTS
REPORTING:
Ceftriaxone R R R
Ciprofloxacin R R R
Clindamycin √ √
Doxycycline √ √ √ Do not report in patients < 8y
Gentamicin R R R
Meropenem √ √ √
Piperacillin/tazobactam √ √ √
TMP-SMX √ √ √ Do not report in patients < 3 months
Consult microbiologist regarding the need for susceptibility testing.

NOTE:
These organisms exhibit broad spectrum resistance including penicillins,

cephalosporins, aminoglycosides and quinolones.” [M5BSR]
and

Exceptions:
Clindamycin: Use CLSI interpretive document for Staphylococcus spp.
Meropenem and piperacillin/tazobactam: Use CLSI interpretive document for Enterobacteriaceae

ORGANISM: Eikenella corrodens
CLINICAL: This organism is part of the normal flora of the oropharynx and gastrointestinal tract. It is associated
with skin/soft tissue infections (often polymicrobial), especially human bite wounds. Septic arthritis
and osteomyelitis may occasionally complicate these infections. E. corrodens has also been
associated with pneumonia, empyema, ophthalmic infections, post-surgical wound infections,
meningitis, brain abscesses, endocarditis, visceral abscesses, chorioamnionitis and septicaemia.
Intravenous drug users are at higher risk of infection with this organism.
USUAL This organism is usually susceptible to third generation cephalosporins, quinolones, tetracyclines,
SUSCEPTIBILITY carbapenems, azithromycin, and TMP-SMX. Rare resistance to tetracycline and TMP-SMX has been
PATTERN: reported. Although most strains are susceptible to penicillin and ampicillin, there have been several
reports of beta-lactamase mediated resistance (they remain susceptible to amoxicillin/clavulanate).
E. corrodens is resistant to clindamycin, first generation cephalosporins, vancomycin and
metronidazole. Macrolides and aminoglycosides have variable and often weak activity.
SUSCEPTIBILITY Etest method using Brucella Blood Agar (BBA) or Hemophilus Test Medium (HTM) incubated in 5%
METHOD: CO2 at 35° C for 24-72 hours. Use 1.0 McFarland suspension in BHI broth.
Note: If poor growth, inoculum can be made from 48-72 hour growth.
BLOOD/
SUSCEPTIBILITY CSF/ BRAIN STERILE BODY
OTHER COMMENTS
REPORTING: SITE
Amox-Clav √
Ampicillin * √* √* *If beta lactamase positive report ampicillin R
Ceftriaxone nd
√ √ 2 2 line if ampicillin I/R
Doxycycline √
Use tetracycline breakpoints
Penicillin * √* √* *If beta lactamase positive report penicillin R
Consult microbiologist regarding the need for susceptibility testing.

NOTE:
Susceptibility testing is recommended if an organism
isolated from sterile body site. For other sites, or if isolated
with other organisms, clinical correlation and correlation
with Gram stain is required.

ORGANISM: Francisella spp.
CLINICAL: These organisms are zoonotic agents pathogenic for humans and animals. They are the cause of
tularemia, a non-specific febrile illness which manifests in various forms; ulceroglandular, glandular,
oculoglandular, pharyngeal, typhoidal and pneumonic.
USUAL This organism is a biohazard in the laboratory. If this organism is isolated in the laboratory:
SUSCEPTIBILITY - Consult microbiologist immediately
PATTERN:
- Work only in biological safety cabinet
- Refer to Reference Laboratory
SUSCEPTIBILITY Susceptibility testing may be sent to Reference Laboratory for testing.

METHOD: It must be performed in a Level III laboratory.
Refer to CLSI Guidelines for Potential Agents of Bioterrorism.

ORGANISM: Haemophilus influenzae

CLINICAL: H. influenzae may colonize the nasopharynx, conjunctiva, and occasionally the genital tract of
humans.
This organism may also colonize the lower respiratory tract of individuals with chronic obstructive
pulmonary disease (COPD). H. influenzae may cause meningitis, epiglottitis, cellulitis
(includingperiorbital cellulitis), septic arthritis, osteomyelitis, otitis media, sinusitis, acute
exacerbations of chronic bronchitis, pneumonia, empyema, conjunctivitis, bacteremia, neonatal and
maternal sepsis,and rarely urinary tract infections (especially in children
USUAL These organisms have variable susceptibility to ampicillin, TMP-SMX, and tetracyclines and are
SUSCEPTIBILITY resistant to 1st generation cephalospirins. Of the oral cephalosporins, cefuroxime and cefixime
PATTERN: have the best activity, while the activity of cefprozil and cefaclor is less reliable. Imipenem
heteroresistance has been described due to a combination of altered PBP3 and efflux mutations.
These isolates appear to remain susceptibile to meropenem. Ampicillin resistance is either
mediated by beta-lactamase production or by mutation in the penicillin binding protein (PBP3).
Altered PBP3 results in resistance to ampicillin, amoxicillin, amoxicillin-clavulanate, piperacillin-
tazobactam, cefuroxime and cefprozil. Activation of efflux pumps may also result in beta-lactam
resistance. Third generation cephalosporins typically remain susceptible although cefotaxime
rd
resistant, ceftriaxone susceptible strains have been described. High level resistance to 3
generation cephalosporins has been linked to multiple mutations of PBP3 and is common in
isolates from Japan and Korea. Carbapenems tend to remain susceptible as they bind to PBP2.
Although azithromycin has the best activity, the activity of macrolides is not reliable. Resistance to
macrolides is mediated mostly by efflux mechanisms. Fluoroquinolone resistance is increasing in
certain geographic locations.
Note: Low level resistance may not be detected by current CLSI breakpoints.
SUSCEPTIBILITY Modified Kirby-Bauer or Etest method using Haemophilus Test Medium (HTM) incubated in 5% CO2
METHOD: at 35°C for 16-18 hours (20-24 hours for Etest). Use 0.5 McFarland suspension in MH or BHI broth.
For mucoid strains use 1.0 McFarland.
Note: Etest method not recommended for TMP-SMX.
BLOOD/
SUSCEPTIBILITY CSF/ DEEP
STERILE EAR SPUTUM URINE OTHER COMMENTS
REPORTING: BRAIN EYE
BODY SITE
Beta-lactamase * * * * * * * *See H.influenzae Beta Lactam Chart
Ampicillin √* √* √ √ √ √ √ *Etest method
Amoxicillin √ √ √ Report same as ampicillin
2nd line if beta lactamase positive and/or
Amoxicillin/ anaerobes or S.aureus present in smear/
* * * 2* 2* 2* 2*
clavulanate culture.
*Always report if R
Cefixime √
Cefotaxime * * *Test and report only in neonates <1mo
Etest method
Ceftriaxone √ √ √ 2 2
2nd line if cefuroxime I/R
Cefuroxime * * √ √ √ √ √ *Test but do not report
Do not report in patients <18 y
*Report on physician request and/or if
Ciprofloxacin * √ * √ *
co-isolated with P.aeruginosa
See Interpretation
Doxycycline √ √ √ √
Use tetracycline breakpoints to interpret
Levofloxacin 2 2 2nd line if cefuroxime and TMP-SMX I/R
See Interpretation
Moxifloxacin 2 2 2nd line if cefuroxime and TMP-SMX I/R
See Interpretation
Etest method
Meropenem 2 2 3 3
2nd /3rd line if ceftriaxone not susceptible
Do not report in patients <3 months
TMP-SMX √ √ √ √ √ √
See interpretation

Haemophilus
influenzae
(cont’d)
NOTE: EYE SPECIMENS:
Deep: Susceptibility testing performed on deep specimens only:

- vitreous fluid - corneal ulcer - contact lens related infections
- keratitis - ophthalmitis - ophthalmology clinic/ward
- injury/surgery - history of failure of therapy
Superficial:
- Add comment:
“Susceptibility testing of topical antibiotics is not standardized and is not
routinely performed on superficial eye specimens”. [MSASTEYE]
Use CLSI interpretive document for Haemophilus influenzae and Haemophilus parainfluenzae
Exception: Doxycyline – Interpret using tetracycline breakpoints
TMP-SMX – see below
Beta-lactamase For Beta-lactamase testing and reporting of beta-lactam antibiotics:

Refer to H.influenzae Beta Lactam Chart
Cefuroxime: Current CLSI breakpoints may not detect all resistance due to target mutations. Refer to H.
influenzae Beta Lactam Chart for reporting of amoxicillin, amoxicillin- clavulanate and
cefuroxime
Ceftriaxone/ H. influenzae is usually susceptible to ceftriaxone/cefotaxime. If I/R, isolate should be sent

Cefotaxime: to reference laboratory to determine mechanism of resistance (altered penicillin binding
protein or extended spectrum beta-lactamase). Consult microbiologist
Ciprofloxacin/ Resistance to quinolones in H.influenzae is increasing in some

Levofloxacin: locations.
Current CLSI breakpoints may underestimate resistance as the
majority of wild type H.influenzae isolates have MICs of ≤ 0.06 ug/mL.
A higher MIC may indicate acquisition of a resistant mechanism.
Use EUCAST breakpoints
MICs (in ug/mL) KB Zones (in mm)
S R S R
Ciprofloxacin/
≤ 0.06 ≥ 0.12 ≥ 30 ≤29
Levofloxacin
Moxifloxacin ≤ 0.12 ≥ 0.25 ≥28 ≤27
TMP-SMX: Current CLSI and EUCAST zone sizes may undercall resistance for TMP-SMX and
H. influenza (Sierra Y, Clin Microbiol Infect 2019 https://doi.org/10.1016/j.cmi.2019.11.022)
Use proposed zone sizes:

≥ 30mm - S
˂ 30mm -R

Haemophilus influenzae Beta Lactam Chart
Beta lactamase
Negative Positive
Set up KB discs: Set up KB discs:

Ampicillin (10) Cefuroxime (30)
Amox-Clav (20/10) Amox-Clav (20/10)
Cefuroxime (30)
Either or
Any I/R
both I/R
No Yes No Yes
Interpret: Interpret:
No resistance AM R AM R
detected. AMC R Interpret: AMC R
Report as per CXM R AM R CXM R
reporting charts Cefixime as tested AMC S Cefixime as tested
CRO as tested* CXM S CRO as tested*
Add comment: Cefixime as tested Add comment:
M5ATM CRO as tested M5BLATM
Comment M5ATM: This organism likely has an altered target mutation and should be considered resistant to ampicillin,
amoxicillin, amoxicillin- clavulanate, piperacillin-tazobactam, cefuroxime and cefprozil.
Comment M5BLATM: This organism likely has both a beta-lactamase and an altered target mutation and should be
considered resistant to ampicillin, amoxicillin, amoxicillin- clavulanate, piperacillin-tazobactam, cefuroxime and cefprozil.
* Note: Consult microbiologist if sterile body site and/or cefotaxime/ceftriaxone I/R.

ORGANISM: Haemophilus parainfluenzae

CLINICAL: This organism is part of the normal flora of the upper respiratory tract in humans. H.
parainfluenzae may cause infections that are clinically similar to H. influenzae infections, such as
bacteremia, meningitis, epiglottitis, otitis media, and septic arthritis. Other infections include
endocarditis, septicemia, brain abscesses, osteomyelitis, pneumonia, peritonitis, wound and
genitourinary tract infections.
USUAL This organism is usually susceptible to second/third generation cephalosporins and
SUSCEPTIBILITY aminoglycosides. Susceptibility to ampicillin, tetracycline, TMP-SMX, and newer macrolides is
PATTERN: variable. Ampicillin resistance is most often mediated by beta-lactamase production and rarely
by mutation in the penicillin binding protein. Fluoroquinolone resistance is increasing in certain
geographic locations. Low level resistance may not be detected by current CLSI breakpoints.
SUSCEPTIBILITY Modified Kirby-Bauer or Etest method using Haemophilus Test Medium (HTM) incubated in 5% CO 2
o
METHOD: at 35 C for 16-18 hours (20-24 hours for Etest).
Note: For Etest use 0.5 McFarland suspension in MH or BHI broth. For mucoid strains use 1.0
McFarland
BLOOD/
SUSCEPTIBILITY CSF/ URINE/
STERILE SPUTUM OTHER COMMENTS
REPORTING: BRAIN URETHRA
BODY SITE
Beta-lactamase * * * * *
See Interpretation
Amoxicillin √ √ √ Report same as ampicillin
2nd line if beta lactamase positive and/or
Amoxicillin/ anaerobes or S.aureus present in smear/
* * 2* 2* 2*
clavulanate culture.
*Always report if R
*Etest method
Ampicillin √* √* √ √ √
If beta lactamase positive report amp R
Cefixime √
Etest method
Ceftriaxone √ √ 2 2
2nd line if cefuroxime I/R
Cefuroxime √ √ √
*Report on physician request and/or if
Ciprofloxacin * √ * *
co-isolated with P.aeruginosa
See Interpretation
Doxycycline √ √ √
Interpret using tetracycline breakpoints
Levofloxacin 2 2 2nd line if cefuroxime and TMP-SMX I/R
See Interpretation
Moxifloxacin 2 2 2nd line if cefuroxime and TMP-SMX I/R
See Interpretation
Etest method
Meropenem 2 2 3 3
2nd /3rd line if ceftriaxone not susceptible
Do not report in patients <3 months
TMP-SMX √ √ √ √
See interpretation
Susceptibility testing is recommended if organism isolated from sterile body site.

For other body sites, or if isolated with other organisms, clinical correlation and correlation with
Gram stain is required.

Haemophilus
parainfluenzae
(cont’d)
Use CLSI interpretive document for Haemophilus influenzae and Haemophilus parainfluenzae
Exception: Doxycyline – Interpret using tetracycline breakpoints
TMP-SMX – see below
Beta- If beta-lactamase positive – report ampicillin R.

lactamase
testing and If beta-lactamase negative:
reporting of Ampicillin may still be resistant due to alteration of penicillin binding proteins.
beta-lactam Consult microbiologist if beta-lactamase negative and ampicillin R.
antibiotics
If ampicillin R and beta lactamase positive, amoxicillin/clavulanate should be
susceptible - confirm with Kirby Bauer.
If ampicillin I/R and beta lactamase negative, this indicates an altered penicillin binding
protein mechanism of resistance - Ampicillin, cefuroxime and amoxicillin/clavulanate
should be reported as R
Ceftriaxone/ H. parainfluenzae is usually susceptible to ceftriaxone. If I/R, isolate should be sent to
Cefotaxime: reference laboratory to determine mechanism of resistance (altered penicillin binding
protein or extended spectrum beta-lactamase). Consult microbiologist
Ciprofloxacin/ Resistance to quinolones in H.parainfluenzae is increasing in

Levofloxacin: some locations.
Current CLSI breakpoints may underestimate resistance as the
majority of wild type H.influenzae isolates have MICs of ≤ 0.06
ug/mL. A higher MIC may indicate acquisition of a resistant
mechanism.
Use EUCAST breakpoints
MICs (in ug/mL) KB Zones (in mm)
S R S R
Ciprofloxacin/
≤ 0.06 ≥ 0.12 ≥ 30 ≤29
Levofloxacin
Moxifloxacin ≤ 0.12 ≥ 0.25 ≥28 ≤27
TMP-SMX: Current CLSI and EUCAST zone sizes may undercall resistance for TMP-SMX and
H. parainfluenza (Sierra Y et al CMI 2019 https://doi.org/10.1016. J. CMI. 2019.11.022)
Use proposed zone sizes:

≥ 30mm - S
˂ 30mm -R

ORGANISM:
Haemophilus spp. (other)
- H. aegyptius - H. haemolyticus - H. pittmaniae
- H. ducreyi - H. parahaemolyticus - H. sputorum
CLINICAL: These organisms are part of the normal flora of the upper respiratory tract.
H. aegyptius – is associated with acute contagious purulent conjunctivitis.
H. ducreyi – is the cause of chancroid, (soft chancre).
H. haemolyticus – can cause invasive disease such as bacteremia, septic arthritis and peritonitis. It
can be mis-identified as H.influenzae. Hemolysis may be weak or absent.
H. parahaemolyticus – are considered part of normal upper respiratory tract flora, and have rarely
been associated with lower respiratory tract infections.
H. pittmaniae- are considered part of normal upper respiratory flora and may rarely be implicated
in infections such as endocarditis, brain abscesses, sinusitis, arthritis and osteomyelitis
H. sputorum – has been isolated from sputum and the female urethra and have been associated
with bacteremia and pulmonary infections in CF patients.
USUAL These organisms are usually susceptible to ampicillin, second/third generation cephalosporins,
SUSCEPTIBILITY TMP-SMX, quinolones, and tetracyclines. H. ducreyi is usually susceptible to third generation
PATTERN: cephalosporins, quinolones, and macrolides. Plasmid mediated resistance to ampicillin,
tetracyclines, TMP-SMX and aminoglycosides has been reported.
o
SUSCEPTIBILITY Etest method using Haemophilus Test Medium (HTM) incubated in 5% CO 2 at 35 C for 24-72 hours
METHOD: Use 0.5 McFarland suspension in MH or BHI broth. For mucoid strains use 1.0 McFarland standard
BLOOD/
SUSCEPTIBILITY CSF/ BRAIN STERILE BODY OTHER COMMENTS
REPORTING: SITE
Ampicillin √* √* √* *If beta lactamase positive report ampicillin R
Ciprofloxacin Do not report in patients < 18 y
√ √
See Interpretation
Doxycycline √
Interpret using tetracycline breakpoints
TMP-SMX √ √ Do not report in patients < 3 months

Susceptibility testing is recommended if organism isolated from sterile body site. For other sites, or
if isolated with other organisms, clinical correlation and correlation with Gram stain is required.
If susceptibility results reported, add comment:
Consult microbiologist regarding susceptibility testing if Haemophilus ducreyi isolated.
Use CLSI interpretive document for Haemophilus influenzae and H. parainfluenzae
Exception: Doxycycline: use tetracycline breakpoints.
Ciprofloxacin: Resistance to quinolones in Haemophlilus spp is increasing in some locations.
Current CLSI breakpoints may underestimate resistance as the majority of wild type
H.influenzae isolates have MICs of ≤ 0.06 ug/mL. A higher MIC may indicate
acquisition of a resistant mechanism. It is prudent to assume other Haemophilus spp
may demonstrate the same phenomenon. Use EUCAST breakpoints:
Ciprofloxacin MIC: ≤ 0.06 ug/mL = S; ≥ 0.12 ug./mL = R
Ciprofloxacin KB zones ≥ 30 mm = S; ≤ 29 mm = R

ORGANISM:
Kingella spp
- K. kingae - K. oralis
- K. denitrificans - K. potus
CLINICAL: These organisms are part of the normal flora of the upper respiratory (especially children) and
genitourinary tracts.
K. kingae - Although of low pathogenicity, has been associated with endocarditis, bacteremia, and
bone/joint infections. The majority of bone/joint infections occur in children < 4 years of age, and blood
cultures are often negative. Endocarditis tends to occur in patients with underlying heart disease and
affects mostly adults and older children. It has rarely been associated with pneumonia, epiglottitis,
meningitis, and ophthalmic infections.
K. denitrificans - has been associated with granulomatous diseases in patients with AIDS and rarely
with endocarditis.
K. oralis - may be associated with periodontitis.
K. potus – has been associated with wound infections in South and Central America.
USUAL Kingella spp. are usually susceptible to penicillins, cephalosporins,(including cefazolin and
SUSCEPTIBILITY ceftriaxone) TMP-SMX, quinolones, chloramphenicol, aminoglycosides, and tetracycline.
PATTERN: Beta-lactamase production has rarely been reported (remains susceptible to amoxicillin/
clavulanate). MICs to penicillin have occasionally been found to be elevated without a positive
beta-lactamase test. Resistance to TMP-SMX, ciprofloxacin and erythromycin has rarely been
reported. They are often resistant to clindamycin
SUSCEPTIBILITY Etest method using Brucella Blood Agar (BBA) or Haemophilus Test Medium (HTM) incubated in 5%
o
METHOD: CO2 at 35 C for 24-72 hours. Use 1.0 McFarland suspension (from 48-72 hour colonies) in BHI broth.
BLOOD/
REPORTING: SITE
Amoxicillin-clavulanate * √ *Report at physician request only
Ampicillin √* √* √* *If beta lactamase positive report ampicillin R
See Interpretation
Doxycycline √
Use tetracycline breakpoints
Penicillin *If beta lactamase positive report penicillin R
See Interpretation

Susceptibility testing is recommended if organism isolated from sterile body site. For other sites, or if
isolated with other organisms, clinical correlation and correlation with Gram stain is required.
Penicillin/ Consult microbiologist if I/R.

Ampicillin:

ORGANISM: Mannheimia spp.

- M. haemolytica
CLINICAL: Mannheimia haemolytica (previously Pasteurella haemolytica) – This organism causes

mastitis, pneumonia and septicemia in bovine animals, but is a rare human pathogen. One case
of endocarditis has been reported
USUAL These organisms are usually resistant to first generation cephalosporins, erythromycin,
SUSCEPTIBILITY clindamycin, and aminoglycosides. Rare penicillin resistant strains have been reported due to
PATTERN: beta-lactamase production. These organisms are usually susceptible to quinolones, amoxicillin-
clavulanate, tetracyclines, azithromycin and TMP-SMX. Strains from bovine/porcine sources may
be more resistant
SUSCEPTIBILITY Kirby Bauer (KB) or Etest method using Mueller Hinton agar with 5% sheep blood (MHB) incubated
METHOD: in 5% CO2 at 35°C for 16-18 hours (KB) or 48 hours (Etest). Use 0.5 McFarland suspension in BHI
broth for KB. For Etest, use 1.0 McFarland suspension in BHI broth.
BLOOD/
SUSCEPTIBILITY CSF/
STERILE OTHER COMMENTS
REPORTING: BRAIN
BODY SITE
Beta-lactamase * * *
See Interpretation
Amoxicillin-
√
clavulanate
Ampicillin √* √* √* *If beta-lactamase positive report ampicillin as R
Cephalexin R R
If susceptibility results reported, add comment:

Beta-lactamase: If beta-lactamase is positive, report ampicillin R.

ORGANISM: Neisseria spp (animal origin)

- N. animaloris - N. zoodegmatis
- N. animalis - N. weaveri
CLINICAL: These organisms are part of the normal oral flora of dogs and cats. They may be associated with
wound infections in humans following bites from cats and dogs. Systemic infections are rare but
include bacteremia and endophthalmitis and CAPD peritonitis.
USUAL These organisms are usually susceptible to tetracyclines, macrolides, TMP-SMX, and quinolones.
SUSCEPTIBILITY Susceptibility to penicillins and narrow spectrum cephalosporins, aminoglycosides, and
PATTERN: chloramphenicol is variable
SUSCEPTIBILITY Etest method, using Mueller-Hinton agar with 5% sheep blood (MHB) incubated in 5% CO2 at 35°C
METHOD: for 24 hours. Slow growers should be held for 72 hours.
Use 1.0 McFarland suspension in MH or BHI broth
BLOOD/
SUSCEPTIBILITY STERILE BODY WOUND COMMENTS
REPORTING: SITE
*Test but do not report. Consult microbiologist
Beta lactamase * *
if positive
Amoxicillin/ clavulanate √
Ceftriaxone √ √
nd
Meropenem √ 2 2 line if amox/clav I/R
Piperacillin/tazobactam √ √
“Susceptibility testing for this organism is not

standardized. Results are probable but not definite”.
[MSAST]

Exceptions:
Meropenem and piperacillin/tazobactam: Use CLSI interpretive document for Enterobacteriaceae

ORGANISM: Neisseria gonorrhoeae

CLINICAL: This organism is a cause of sexually transmitted infections including urethritis, epididymitis, orchitis,
prostatitis, proctitis, cervicitis, salpingitis, pelvic inflammatory disease, Bartholin’s abscess, and
pharyngitis. In rare instances, N. gonorrhoeae may cause bacteremia (disseminated gonococcal
infection – tenosynovitis, dermatitis, polyarthralgia syndrome), septic arthritis, endocarditis, and
peritonitis. Ophthalmic infections of neonates may occur during passage through an infected birth
canal. In prepubertal girls, this organism causes vaginitis rather than cervicitis.
USUAL Penicillin, tetracycline, quinolone and cefixime resistance is widespread and dependent on where
SUSCEPTIBILITY the organism was acquired. Both plasmid-mediated beta-lactamase production and chromosomal
PATTERN: resistance have been described. Ceftriaxone resistance is increasing.
SUSCEPTIBILITY Testing performed at Reference Laboratory.
METHOD:
Send isolate on a regular gel swab – place the swab, after inoculation, into charcoal transport
medium (from a pertussis kit).
NOTE: Notify Public Health and/or Infection Control.

ORGANISM: Neisseria meningitidis

CLINICAL: This organism may colonize the nasopharynx in asymptomatic carriers. Carriage prevalence
increases throughout childhood from 4.5% in infants to about 25% in late teens/early adulthood.
It subsequently decreases to 8% in middle aged adults. It may cause meningococcemia (acute
and chronic bacteremia or fulminant septicemia), meningitis, conjunctivitis, pneumonia, septic
arthritis, osteomyelitis, urethritis, cervicitis, pelvic inflammatory disease, peritonitis, pericarditis,
endocarditis, and endophthalmitis
USUAL Although most strains remain susceptible to penicillin, resistance to penicillin due to an altered
SUSCEPTIBILITY penicillin binding protein and rarely plasmid-mediated beta-lactamase production (Rob-1 from H.
PATTERN: influenzae), have been described. The latter is associated with elevated penicillin MIC values
(0.1-1.0 g/mL). These organisms remain susceptible to ceftriaxone, Non-susceptibility to
ceftriaxone has been described due to altered PBP-1. Most strains are susceptible to ciprofloxacin
and rifampin (agents used for prophylaxis of contacts), but resistance has also been reported to
both agents. Resistance to TMP-SMX, tetracycline and chloramphenicol has been documented.
Minocycline has better activity than tetracycline or doxycycline
SUSCEPTIBILITY Kirby Bauer or Etest method using Mueller-Hinton agar with 5% sheep blood (MHB) incubated in 5%
METHOD: CO2 at 35°C for 20-24 hours. Use 0.5 McFarland suspension in BHI broth.
N.meningitidis poses a biohazard to laboratory staff.
All work on this organism, including susceptibility testing must be performed in a biological
safety cabinet.
SUSCEPTIBILI
CSF/ STERILE
TY BLOOD EYE SPUTUM OTHER COMMENTS
BRAIN BODY SITE
REPORTING:
*Test but do not report. Consult
Beta-lactamase * * * * * *
microbiologist if positive
Etest method
Ceftriaxone √ √ √ √ √ √
Consult microbiologist if I/R
Do not report in patients <18 y unless
I/R
Ciprofloxacin * * * √ √ √
*Test but do not report – consult
microbiologist if I/R
nd
2 line if penicillin and TMP-SMX I/R
Minocycline 2
Etest method
*If beta lactamase pos, report as R
Penicillin √* √* √* √* √* √*
If I, report as R
See Interpretation
*Test but do not report – consult
Rifampin * * *
microbiologist if I/R
TMP-SMX √ Do not report in patients <3 months
NOTE: Report all isolates from sterile body sites to Public Health andr Infection Control.
Isolates from eyes and from clinically significant respiratory specimens are also reported to
Public Health/Infection Control
Use CLSI interpretive document for Neisseria meningitidis
Penicillin: Rare beta-lactamase positive strains have been reported. Test all isolates for beta-
lactamase and report penicillin as resistant if positive. Intermediate resistance (0.12 – 0.25
ug/mL) likely indicates an altered penicillin binding protein. These isolates should be
reported as R. Ceftriaxone resistance has also been described in some of these isolates.

ORGANISM:
Neisseria spp. (other)
- N. bacilliformis - N. lactamica - N. polysaccharea
- N. cinerea - N. mucosa - N. sicca
- N. elongata - N. oris - N. subflava
- N. flavescens
CLINICAL: These organisms are part of the normal oropharyngeal flora of humans and animals. They have been
implicated in infections such as native and prosthetic valve endocarditis, septic arthritis, septicemia,
meningitis, peritonitis, osteomyelitis, and pneumonia..
USUAL Most of the organisms are susceptible to penicillins and cephalosporins. Penicillin resistance
SUSCEPTIBILITY (due to altered penicillin binding proteins) has been reported in N. lactamica, N. flavescens,
PATTERN: and N. polysaccharea
SUSCEPTIBILITY Kirby Bauer or Etest method using Mueller-Hinton agar with 5% sheep blood (MHB) incubated in 5%
METHOD: CO2 at 35° C for 20-24 hours. Use 0.5 McFarland suspension in broth.
BLOOD/
SUSCEPTIBILITY CSF/ BRAIN STERILE BODY
OTHER COMMENTS
REPORTING: SITE
Penicillin √ √ √ If beta lactamase positive report penicillin R
NOTE: Susceptibility testing is recommended if organism isolated from sterile body site. For other sites or if
Consult microbiologist regarding the need for susceptibility testing. On isolates where susceptibility
results are reported, add comment:

ORGANISM: Pasteurella spp.

- P. aerogenes - P. canis - P. multocida
- P. bettyae - P. multocida - P. pneumotropica
- P. caballi
CLINICAL: Pasteurella spp. are found in both healthy and diseased animals (wild and domestic). Animals are the
reservoir for most human infections. The genus Pasteurella is undergoing numerous taxonomic
changes.
P. multocida subsp. multocida, P.multocida subsp. septica, P.multocida subsp. gallicida–
These organisms are commensal in the oral flora of dogs and cats, other mammals, and fowl. They
are associated with bite wound infections and may cause osteomyelitis, bacteremia, endocarditis,
meningitis, brain abscesses, ophthalmic infections, peritonitis, genitourinary infections, pneumonia,
lung abscess and empyema.
P. canis – This organism is found in the oral cavity of dogs. It has been associated with bite wounds.
P. stomatis – This organism is found in the respiratory tract of dogs and cats. It has been associated
with bite wounds.
P. dagmatis – This organism is found in the oral cavity of dogs and cats. It has been associated
withwounds following bites or animal contact. It has also been associated with pneumonia,
endocarditis and septicemia.
P. aerogenes* – This organism is part of the oropharyngeal and gastrointestinal flora of pigs. Rare
human infections, usually following traumatic/occupational exposure include wound infection and
perinatal infection.
P. bettyae* – The reservoir for this organism is not known. It has been recovered from amniotic fluid
urogenital specimens (especially Bartholin’s gland abscesses) and wounds/abscesses. It has also
been associated with bacteremia (especially in newborns).
P. caballi* – This organism has rarely been associated with infections following exposure to horses.
P. pneumotropica* – This organism is part of the upper respiratory tract of dogs, cats, mice and rats.
Humans are usually infected by traumatic exposure. Infections include wound infections, cellulitis,
bacteremia, upper respiratory tract infections, and peritonitis.
* These organisms may soon be reclassified to other genera
USUAL These organisms are usually resistant to first generation cephalosporins, erythromycin,
SUSCEPTIBILITY clindamycin, and aminoglycosides. Rare penicillin resistant strains have been reported due to
PATTERN: plasmid mediated beta-lactamase production (ROB-1). Rare amoxicillin tolerance has been
reported. These organisms are usually susceptible to quinolones, amoxicillin-clavulanate,
tetracyclines, azithromycin and TMP-SMX. Beta lactamase positive isolates are often resistant
multiple classes of antibiotics including tetracycline and TMP-SMX. Strains from bovine/porcine
sources may be more resistant.
SUSCEPTIBILITY Etest method using Mueller Hinton agar with 5% sheep blood (MHB) incubated in 5% CO2 at 35°C
METHOD: for 48 hours (Etest). For Etest, use 1.0 McFarland suspension in BHI broth.

Pasteurella spp. (cont.)

BLOOD/
SUSCEPTIBILITY CSF/
STERILE OTHER+ COMMENTS
REPORTING: BRAIN
BODY SITE
Beta-lactamase * * * See Interpretation
Amoxicillin-clavulanate √
Ampicillin * * * *Report as R If beta-lactamase positive

Cephalexin R
Ceftriaxone √ √
Levofloxacin 2 2 nd
2 line if TMP-SMX I/R
Do not report in patients < 3 months
TMP-SMX √ *
*Test, report at physician request
+NOTE: Wounds
When isolated from a wound, add the following comment:
The treatment choice for bite wounds should include an agent with both aerobic and anaerobic
coverage such as amoxicillin/clavulanate [M5AMCAC]
Perform susceptibility testing as per ‘other’ category.
Beta-lactamase: If beta-lactamase is positive, report Ampicillin as R.

ORGANISM:
Suttonella indologenes
CLINICAL: This organism may be part of the flora of the upper respiratory tract. It is rarely isolated in clinical
specimens but has been implicated in ophthalmic infections and endocarditis
USUAL This organism is susceptible to penicillins, cephalosporins, aminoglycosides, chloramphenicol,

SUSCEPTIBILITY and tetracyclines. Susceptibility pattern for other classes of antibiotics has not been well
PATTERN: documented.
SUSCEPTIBILITY Etest method using Brucella Blood agar (BBA) or Haemophilus Test Medium (HTM) incubated in 5%
METHOD: CO2 at 35°C for 24-72 hours (depending on growth characteristics). Use 1.0 McFarland suspension
(from 48-72 hour colonies) in BHI broth.
BLOOD/
REPORTING: SITE
Ampicillin √ √ √ If beta lactamase positive, report as R
Doxycycline √ Use tetracycline breakpoints
NOTE: Consult with microbiologist regarding the need for susceptibility testing.
Susceptibility testing is recommended if organism isolated from sterile body site. For other sites, or if
“Susceptibility testing for this organism is not standardized. Results are probable
but not definite”. [MSAST]

ORGANISM:
Weeksella spp
- W. virosa
CLINICAL: W. virosa – This organism has been recovered from the urogenital tract of women. It has been
implicated in septicemia, pneumonia, peritonitis, and urogenital infections (including labial abscess
and amnionitis).
USUAL These organisms are usually susceptible to cephalosporins, piperacillin/tazobactam and

SUSCEPTIBILITY carbapenems. Susceptibility to quinolones, TMP-SMX and aminoglycosides is variable and
PATTERN: these agents should not be used empirically.
SUSCEPTIBILITY Etest method using Mueller-Hinton agar incubated in ambient air at 35°C for 24 hours.
METHOD:
Use 1.0 McFarland suspension in MH or BHI broth.
BLOOD/
OTHER COMMENTS
REPORTING: SITE
Ceftriaxone √ √
Piperacillin/tazobactam √ √
NOTE: Consult with microbiologist regarding the need for susceptibility testing.
“Susceptibility testing for this organism is not standardized. Results are probable
but not definite”. [MSAST]
Use CLSI interpretive document for Pasteurella spp

Exception: Piperacillin/tazobactam use CLSI interpretive document for Enterobacteriaceae

Appendix 1: Doubling Dilution Chart for ETEST MIC
Strip MIC Doubling dilution Strip MIC Doubling dilution

value Value to report value Value to report
g/ml g/ml g/ml g/ml
256 256
192 .5 .5
128 .38
128
96 .25 .25
64 .19
64
48 .125 .125
32 .094
32
24 .064 0.06
16 .047
16
12 .032
8 8 .023 0.03
6 .016
4 .012
4
3 .008
2 .006
2
1.5 .004
1.0 1 .003
.75 .002
Note:
Due to the continuous antibiotic concentration gradient of the Etest method, obtained
MIC values can be more precise than conventional MIC values obtained from two-
fold serial broth dilutions. CLSI breakpoints are based on the latter. To interpret Etest
MIC values, this chart provides a guide to report MIC values according to CLSI
breakpoints. Recommend reporting actual MIC result. For interpretation use S,I, or
R according to the nearest higher doubling dilution and the corresponding CLSI
breakpoint interpretations. For organisms for which there are no published CLSI
breakpoints, refer to the Interpretation Section for recommended breakpoint
interpretations. All susceptibility results for these organisms must be accompanied by
the following comment:
"Susceptibility testing for this organism is not standardized.

Results are probable but not definite".

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https://doi.org/10.1016/j.cmi.2019.11.022


Section 5 Fastidious/Miscellaneous Gram Negative Bacilli/Cocci/Coccobacilli

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May 2019 Page 1 of 36

Use CLSI interpretive document for HACEK group.

May 2019 Page 2 of 36

Ampicillin For A. actinomycetemcomitans, do not report ampicillin as in vitro susceptibility does

Amox-Clav If beta-lactamase is negative and amox-clav R, report ampicillin and pencillin as R.

May 2019 Page 3 of 36

NOTE: For all isolates, add comment:

Use CLSI interpretive document for Pasteurella spp.

May 2019 Page 4 of 36

ORGANISM: Brucella spp.

- Consult microbiologist immediately

- Work only in biological safety cabinet

- Refer to Reference Laboratory

May 2019 Page 5 of 36

ORGANISM: Campylobacter spp

May 2019 Page 7 of 36

Campylobacter spp. (cont’d)

NOTE: If reporting susceptibility results , add comment:

“Susceptibility testing performed by unstandardized method.

For all stool isolates, add comment:

Notify Infection Control and/or Public Health.

Use CLSI interpretive document for Campylobacter jejuni/coli.

Exceptions: Gentamicin and meropenem use CLSI interpretive document for

Azithromycin: Report using erythromycin breakpoints.

May 2019 Page 8 of 36

ORGANISM: Capnocytophaga spp.

NOTE: Consult microbiologist regarding the need for susceptibility testing.

On isolates where susceptibility results reported, add comment:

“Susceptibility testing for this organism is not standardized.

Use CLSI interpretive document for Pasteurella spp.

May 2019 Page 9 of 36

ORGANISM: Capnocytophaga spp. (Canine)

NOTE: Consult microbiologist regarding the need for susceptibility testing.

On isolates where susceptibility results reported, add comment:

“Susceptibility testing for this organism is not standardized.

Use CLSI interpretive document for Pasteurella spp.

May 2019 Page 10 of 36

ORGANISM: Cardiobacterium spp

Ampicillin √* *If beta-lactamase positive report ampicillin R

NOTE: Consult microbiologist regarding the need for susceptibility testing.

Susceptibility testing is recommended on all isolates from sterile body sites.

Use CLSI interpretive document for HACEK group.

May 2019 Page 11 of 36

ORGANISM: Dysgonomonas spp

Consult microbiologist regarding the need for susceptibility testing.

These organisms exhibit broad spectrum resistance including penicillins,

Use CLSI interpretive document for Pasteurella spp.

May 2019 Page 12 of 36

ORGANISM: Eikenella corrodens

Consult microbiologist regarding the need for susceptibility testing.

Use CLSI interpretive document for HACEK group.

May 2019 Page 13 of 36

ORGANISM: Francisella spp.

SUSCEPTIBILITY Susceptibility testing may be sent to Reference Laboratory for testing.

May 2019 Page 14 of 36

ORGANISM: Haemophilus influenzae

May 2019 Page 15 of 36

Deep: Susceptibility testing performed on deep specimens only:

Beta-lactamase For Beta-lactamase testing and reporting of beta-lactam antibiotics:

Ceftriaxone/ H. influenzae is usually susceptible to ceftriaxone/cefotaxime. If I/R, isolate should be sent

Ciprofloxacin/ Resistance to quinolones in H.influenzae is increasing in some

Use proposed zone sizes: