Clinical Microbiology and Infection 27 (2021) 55e60

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Clinical Microbiology and Infection

journal homepage: www.clinicalmicrobiologyandinfection.com

Narrative review

How to: perform antifungal susceptibility testing of microconidia-

forming dermatophytes following the new reference EUCAST method
E.Def 11.0, exemplified by Trichophyton*
Maiken C. Arendrup 1, 2, 3, *, Gunnar Kahlmeter 4, Jesus Guinea 5, 6, 7, y,
Joseph Meletiadis 8, 9, y, the Subcommittee on Antifungal Susceptibility Testing (AFST) of
the ESCMID European Committee for Antimicrobial Susceptibility Testing (EUCAST)
1
Unit of Mycology, Department of Microbiological Surveillance and Research, Statens Serum Institut, Copenhagen, Denmark
2
Department of Clinical Microbiology, University Hospital Rigshospitalet, Copenhagen, Denmark
3
Department of Clinical Medicine, University of Copenhagen, Denmark
4
The EUCAST Development Laboratory, Clinical Microbiology, Va €xjo
€, Sweden
5
Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Maran ~o
n, Madrid, Spain
6
CIBER de Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
7 n Sanitaria Gregorio Maran
Instituto de Investigacio ~o
n, Madrid, Spain
8
Clinical Microbiology Laboratory, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
9
Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands

a r t i c l e i n f o a b s t r a c t

Article history:
Background: Antifungal drug resistance in dermatophytes was first reported shortly after the turn of the
Received 11 June 2020
millennium and has today been reported in Trichophyton and occasionally in Microsporum, but not in
Received in revised form
26 August 2020 Epidermophyton species. Although drug resistance in dermatophytes is not routinely investigated,
Accepted 31 August 2020 resistance in Trichophyton spp. is increasingly reported worldwide. The highest rates are observed in
Available online 8 September 2020 India (36% and 68% for terbinafine (MIC 4 mg/L) and fluconazole (MICs 16 mg/L), respectively), and
apparently involve the spread of a unique clade related to the Trichophyton mentagrophytes/Trichophyton
Editor: Emmanuel Roilides interdigitale complex.
Objectives: The European Committee on Antimicrobial Susceptibility Testing Subcommittee on Anti-
Keywords: fungal Susceptibility Testing (EUCAST-AFST) has released a new method (E.Def 11.0) for antifungal sus-
Amorolfine ceptibility testing against microconidia-forming dermatophytes including tentative MIC ranges for
Itraconazole
quality control strains and tentative breakpoints against Trichophyton rubrum and T. interdigitale. Here,
MIC
the details of the new procedure E.Def 11.0 are described.
Microdilution
Terbinafine Sources: This technical note is based on the multicentre validation of the EUCAST dermatophyte anti-
Trichophyton fungal susceptibility testing method, the mould testing method (E.Def 9.3.2) and the updated quality
Voriconazole control tables for antifungal susceptibility testing document, v 5.0 (available on the EUCAST website).
Contents: The method is based on the EUCAST microdilution method for moulds but significant differ-
ences include: (a) an altered test medium selective for dermatophytes; (b) an altered incubation time and
temperature; and (c) a different end-point criterion (spectrophotometric determination) of fungal
growth. It can easily be implemented in laboratories already performing EUCAST microdilution methods
and has been validated for terbinafine, voriconazole, itraconazole and amorolfine against T. rubrum and
T. interdigitale.
Implications: This standardized procedure with automated end-point reading will allow broader
implementation of susceptibility testing of dermatophytes and so facilitate earlier appropriate therapy.

*
Affiliations for collaborative authors are listed in the Supplementary material (Appendix S1).
* Corresponding author: Maiken C. Arendrup, Unit for Mycology building 43/317, Statens Serum Institut, Artillerivej 5, DK-2300, Copenhagen S, Denmark.
E-mail address: maca@ssi.dk (M.C. Arendrup).
y
Jesus Guinea and Joseph Meletiadis contributed equally and share the last author position.

https://doi.org/10.1016/j.cmi.2020.08.042
1198-743X/© 2020 Published by Elsevier Ltd on behalf of European Society of Clinical Microbiology and Infectious Diseases.
56 M.C. Arendrup et al. / Clinical Microbiology and Infection 27 (2021) 55e60

This is important, as resistance is rapidly emerging and largely underdiagnosed. Maiken C. Arendrup,
Clin Microbiol Infect 2021;27:55
© 2020 Published by Elsevier Ltd on behalf of European Society of Clinical Microbiology and Infectious
Diseases.

Introduction Trichophyton species is rapidly rising [5e16]. Hence, mycological

Antifungal susceptibility tests are performed for fungi causing
disease, especially when infections are invasive, relapsing or failing
therapy, when inherent or acquired resistance is a possibility, or
when susceptibility cannot reliably be predicted from the species
identification alone. Antifungal susceptibility testing (AFST) is also
important in resistance surveillance, in epidemiological studies and
for comparison of the in vitro activity of new and existing agents.
Dilution methods are used to establish the MICs of antimicrobial
agents. These are the reference methods for antimicrobial suscep-
tibility testing and are mainly used: to (a) establish the activity of
new antimicrobial agents; (b) confirm the susceptibility of organ-
isms that give equivocal results in other test formats (such as
commercial susceptibility tests); and (c) determine the suscepti-
bility of organisms where other test formats may be unreliable or
not yet validated (which is still a common scenario for suscepti-
bility testing of fungi and dermatophytes in particular). In dilution
tests, fungi are tested for their ability to produce sufficient growth
in microplate wells of broth culture medium containing serial di-
lutions of the antimicrobial agents (broth microdilution).
The antifungal MIC is defined as the lowest concentration, in
mg/L, of an agent that inhibits the growth of a fungus. The MIC
informs about the susceptibility or resistance of the organism to the
antifungal agent, which can help in treatment decisions.
Dermatophyte infections are rarely invasive but when they
involve the scalp or nails, systemic therapy for weeks to months is
required [1,2]. Systemic antifungal therapy is indicated also in
cutaneous dermatophytosis presenting with extensive lesions or in
patients with lack of response to topical therapy [3,4]. Presumptive
diagnosis often relies on clinical findings and direct microscopic
examination only, but differential diagnoses are many, systemic
therapy is associated with risk of side effects, and resistance in
diagnosis and standardized AFST methods for determining the
in vitro susceptibilities of clinical isolates of dermatophytes are
needed to limit inappropriate therapy, unnecessary toxicity and
selection of resistance [17].
Dermatophytes grow slowly and often require 4e7 days of
culture or more. Skin scrapings and nail samples are not sterile and
although cultured on selective agars, MIC determination in non-
selective broth medium is often challenged by contamination
(Fig. 1). Such contamination interferes with end-point reading and
often necessitates repetition of the test after isolation, which adds
days or even weeks to the turnover time before a result can be
provided. For these reasons, European Committee on Antimicrobial
Susceptibility Testing (EUCAST) initially investigated if addition of
cycloheximide and chloramphenicol to the standard EUCAST AFST
growth medium, to render it selective for dermatophytes, inter-
fered with microdilution MIC determination of selected wild-type
and mutant Trichophyton isolates. Subsequently, EUCAST investi-
gated the optimal test conditions for a dermatophyte EUCAST
microdilution method, including various end-point definitions for
the correct separation of susceptible wild-type and resistant non-
wild-type clinical isolates of Trichophyton rubrum and Trichophy-
ton interdigitale in a multicentre study [18].
This first version of the standard is based on the general EUCAST
principles for microtitre plate production described in the yeast and
mould microdilution method documents (E.Def 7.3.2 and E.Def
9.3.2) with subsequent addition of cycloheximide and chloram-
phenicol during the inoculation step. This will allow the use of
plates already prepared for mould testing (and thus prepared
without cycloheximide and chloramphenicol in the plates) rather
than requiring production of special plates for dermatophyte
testing. Details on plate production are given in the Supplementary
material (Appendix S1).

Fig. 1. Terbinafine growth inhibition curves for (a) a resistant Trichophyton rubrum isolate (SSI-7885) harbouring a F397L target gene alteration and (b) a susceptible wild-type
T. rubrum isolate (SSI-6714) tested following the E.Def 9.3.2 mould testing method (black curve) and the new E.Def 11.0 dermatophyte testing method with cycloheximide and
chloramphenicol-supplemented medium (green curve). Solid lines indicate the inhibition curves, dashed lines the mean of four positive growth controls. Contaminated wells
interfering with the susceptibility testing of the resistant isolate with the E.Def 9.3.2 method are indicated with grey arrows. The background is not subtracted (~OD 0.100).
 M.C. Arendrup et al. / Clinical Microbiology and Infection 27 (2021) 55e60
Scope
This EUCAST standard describes a suitable method for testing
the susceptibility of microconidia-producing dermatophytes to
antifungal agents by determination of the MIC. MICs show the
in vitro activity of a given antifungal drug under the test conditions
described, and can be used for patient management in conjunction
with other factors, such as pharmacokinetics, pharmacodynamics
and resistance mechanisms. The MIC permits microorganisms to be
categorized as Susceptible (S), susceptible, Increased exposure (I),
or Resistant (R) to an antifungal drug when appropriate break-
points are applied [19]. In addition, MIC distributions can be used to
define wild-type or non-wild-type fungal populations when
species-specific epidemiological cut-off values (ECOFFs) are
applied.
The method described herein is intended to provide a suitable,
easy and economic method for testing the susceptibility to anti-
fungal agents against Trichophyton spp. and to facilitate an
acceptable degree of conformity, e.g. agreement within specified
ranges, between laboratories. Many factors influence the MIC of
filamentous fungi against antifungal agents as shown by Rambali
et al. [20]. For example the MIC of itraconazole against Aspergillus
was profoundly influenced by shape of the microdilution well,
inoculum concentration, temperature and length of incubation
time. As technical laboratory factors are of utmost importance, this
standard focuses on testing conditions including inoculum prep-
aration and inoculum size, incubation time and temperature, and
end-point definition. The terms and definitions used as basis for
this procedure are found in the Supplementary material
(Appendix S1).
Test procedures
The general test procedures concerning type of microtitre
plates, choice of medium, preparation of stock and working solu-
tions of antimicrobial agents, and preparation and storage of pre-
pared plates with antifungals are identical to the recommendations
in the mould (E.Def 9.3.2) reference method document, available at
https://www.eucast.org/astoffungi/. The details are found in the
Supplementary material (Appendix S1) and Tables 1 and 2.
General
The test is performed in flat-bottom well microdilution plates.
Different plastics are likely to impact on drug binding, which may
affect MIC values. The validation of this method has been per-
formed using tissue-treated microdilution plates, and the use of
such plates is therefore more likely to yield similar MIC values.
The method is based on the preparation of antifungal agent
working solutions in 100-mL volumes per well to which 100 mL of
inoculum supplemented with cycloheximide and chloramphen-
icol is added.
Cycloheximide and chloramphenicol working solutions are
prepared in the following concentrations: cycloheximide: 100 mg/
mL (¼ 100 000 mg/L) in dimethylsulphoxide, followed by filtration
(0.2 mm) (available ready to use from Sigma-Aldrich, St Louis, MO,
Table 1
The amount of powder or diluent required to prepare a standard solution of anti-
fungal powder, cycloheximide or chloramphenicol may be calculated as follows
VolumeðLÞ  Concentrationðmg=LÞ
WeightðgÞ ¼
Potencyðmg=gÞ
WeightðgÞ  Potencyðmg=gÞ
VolumeðLÞ ¼
Concentrationðmg=LÞ
57
USA; Cat. No. C4859). Chloramphenicol: 50 mg/mL (¼ 50 000 mg/L)
in ethanol.
Solutions must be prepared taking into account the potency of
the lot of antifungal drug powder that is being used. The amount of
powder or diluent required to prepare a standard solution may be
calculated as described in Table 1.
Preparation of inoculum supplemented with cycloheximide and
chloramphenicol
Standardization of the inoculum is essential for accurate and
reproducible antifungal susceptibility tests. The final inoculum
must be between 1  105 CFU/mL and 2.5  105 CFU/mL.
Microconidia suspension method
The isolates are subcultured on Sabouraud dextrose, potato
dextrose agar or malt agar supplemented with cycloheximide (300
mg/L) and chloramphenicol (50 mg/L) and incubated at 25 Ce28 C
for 4e7 days. It may be advisable to inoculate two or three agar
plates per isolate to ensure that a sufficient amount of microconidia
can be harvested. Other culture media selective for dermatophyte
growth, and where the fungus is able to sporulate sufficiently, can
be used. Inoculum suspensions are prepared from fresh, mature
cultures. In some cases, an extended incubation is required for
proper sporulation of the isolate.
Colonies are covered with approximately 5 mL of sterile water
supplemented with 0.1% Tween-20. Then, the microconidia are
carefully rubbed with a sterile cotton swab and transferred with a
pipette to a sterile tube. Alternatively, a damp sterile cotton swab
could be used to gently touch the culture, and the microconidia
transferred to a sterile tube containing 5 mL water supplemented
with 0.1% Tween-20. The suspension is vortexed for 15 seconds
with a gyratory vortex mixer at approximately 2000 rpm and
transferred to a sterile syringe attached to a sterile filter with a pore
diameter of 11 mm, filtered and collected in a sterile tube. This step
removes hyphae and yields a suspension composed of
microconidia.
The suspension is adjusted with sterile distilled water to 2  106
to 5  106 microconidia/mL by counting the microconidia in a
haemocytometer chamber. Alternatively, a spectrophotometer can
be used to adjust the filtered suspension to a concentration
equivalent to McFarland 0.5 [21,22]. The suspension is then diluted
1:10 with sterile distilled water to obtain a final working inoculum
of 2  105 to 5  105 CFU/mL [21e24].
Inoculum supplementation with cycloheximide and
chloramphenicol
Each inoculum suspension is supplemented with cyclohexi-
mide and chloramphenicol in an amount that results in a double-
strength final concentration (100 mg/L chloramphenicol and 600
mg/L cycloheximide, respectively). This allows further dilution
when the inoculum is added to the test plate, resulting in a final
concentration of 50 mg/L chloramphenicol and 300 mg/L cyclo-
heximide in the inoculated plate. In Table 3, examples of a final
inoculum of 8 mL are prepared for microdilution plates with four
antifungals in a horizontal format, and of 12 mL for a full plate with
eight compounds. The volumes can be adjusted to the preferred
use in the individual laboratory. The total volume of chloram-
phenicol and cycloheximide corresponds to 0.8% of the total vol-
ume of the inoculum. This will result in a small dilution of the
inoculum suspension; but this is below the limit of precision for
AFST.
58 M.C. Arendrup et al. / Clinical Microbiology and Infection 27 (2021) 55e60

Table 2 sufficient growth and validated in a multicentre study [18]. A, in-

Solvents for preparation of stock solutions, characteristics and appropriate test cubation longer than 7 days is not recommended.
concentration ranges for antifungal agents

Antifungal agent Solvent Characteristics Test range (mg/L) Reading results

Amorolfine DMSO Hydrophobic 0.008e4
Itraconazole DMSO Hydrophobic 0.008e4 During the validation process, spectrophotometric readings
Posaconazole DMSO Hydrophobic 0.008e4 (most experience with 490 nm but 405e540 nm applied) using 50%
Terbinafine DMSO Hydrophobic 0.004e2
Voriconazole DMSO Hydrophobic 0.008e4
and 90% reduction of the optical density of the growth control
when the background was subtracted were compared with visual
DMSO, dimethyl sulfoxide.
reading of the plates [18]. However, for itraconazole, trailing
growth complicated visual and 90% spectrophotometric inhibition
end-point readings. The performance for correct separation of
Inoculation of microdilution plates terbinafine wild-type and non-wild-type isolates harbouring target
gene mutations was comparable across these end-point methods
The microdilution plates should be inoculated within 30 min of provided the end-point specific wild-type upper limits were
the preparation of the inoculum suspension to maintain viable adopted. Hence, the spec-50% end-point was regarded as preferable
microconidia concentration. because it allows an objective end-point determination applicable
The cycloheximide and chloramphenicol supplemented inoc- to the four drugs evaluated. This will avoid subjectivity and lower
ulum suspension is vortexed and each well of the microdilution interlaboratory variation and hopefully facilitate a broader imple-
plate is inoculated with 100 mL of the 2  105 to 5  105 CFU/mL mentation of susceptibility testing of dermatophytes also in labo-
microconidial suspension, without touching the contents of the ratories that are less experienced with visual end-point reading.
well. This will give the required final drug concentration and
inoculum density (final inoculum 1  105 to 2.5  105 CFU/mL). The
Interpretation of results
growth control wells (column 11), which contained 100 mL of sterile
drug-free medium, are also inoculated with 100 mL of the same
Clinical breakpoints for antifungal agents and dermatophyte
inoculum suspension. Column 12 of the microdilution plate is filled
species have not yet been established because sufficient MIC and
with 100 mL of sterile distilled water from the lot used to prepare
clinical outcome data are not yet available. Interpretation of MICs in
the inoculum as a sterility control for medium and distilled water
the absence of breakpoints is challenging and should be done very
(drug-free medium only). Quality control organisms are tested
carefully taking into account any available data including clinical
using the same method each time an isolate is tested.
experience and drug exposure during therapy. However, the MIC
Viability counts should be performed for quality control pur-
may still provide some information regarding susceptibility and,
poses to ensure that test wells contain between 1  105 and
importantly, generation of MICs for dermatophytes is a vital pre-
2.5  105 CFU/mL, as follows. Ten microlitres of the inoculum
requisite for future ECOFF and breakpoint selection. EUCAST
suspension should be diluted in 2 mL of sterile distilled water
established tentative ECOFFs for terbinafine, itraconazole, vor-
supplemented with 0.1% Tween-20. The suspension is then vor-
iconazole and amorolfine against T. interdigitale and T. rubrum at the
texed with a gyratory vortex mixer at 2000 rpm. Then 100 mL of this
time of establishing this method and they are available at https://
suspension is spread over the surface of a suitable agar plate (such
www.eucast.org/astoffungi/. These may serve to categorize the
as Sabouraud dextrose agar with cycloheximide and chloram-
organism as presumably wild-type or non-wild-type until final
phenicol), which is then incubated at 25 Ce28 C until colonies can
ECOFFs and breakpoints are set. Non-wild-type isolates harbour
be counted. One hundred to 250 colonies are expected from an
resistance mechanisms and may respond less well to standard
acceptable test suspension. A further dilution of 100 mL suspension
therapy.
in 900 mL sterile distilled water supplemented with 0.1% Tween-20,
vortexing, and 100 mL plated out would provide an optional/addi-
Quality control
tional count e 10 to 50 colonies would be expected. It is recom-
mended that this is completed for every isolate when the
Control procedures are the means by which the quality of results
laboratory is setting up this test or conducts the test rarely, when
is assured and are described in detail by the CLSI. The routine
unexplained results are suspected, or periodically (to be locally
quality of test results is monitored by the use of control strains.
defined dependent on need).
Control strains
Incubation of microdilution plates
The two Aspergillus flavus EUCAST QC strains ATCC 204304 and
Microdilution plates are incubated without agitation at CLM-CM1813 can be used as quality control of the plates with a 2-
25 Ce28 C in ambient air [18]. Most Trichophyton isolates should day incubation provided the inoculum is prepared without cyclo-
be read at day 5, whichwas previously found appropriate for heximide and chloramphenicol supplementation. Of note, the MICs

Table 3
Instructions on calculating the volume needed of chloramphenicol and cycloheximide for addition to the inoculum preparation depending on the final
inoculum volume prepared

Inoculum volume Volume needed of chloramphenicol Volume needed of cycloheximide Total volume added
stock solution (50 000 mg/L) stock solution (100 000 mg/L) to the inoculum

8 mL 100mg=L  8000 mL 600mg=L  8000mL 64 mL

¼ 16 mL ¼ 48 mL
50000mg=L 1 00 000mg=L
12 mL 100mg=L  12 000 mL 600mg=L  12 000 mL 96 mL
¼ 24 mL ¼ 72 mL
50 000mg=L 1 00 000mg=L
 M.C. Arendrup et al. / Clinical Microbiology and Infection 27 (2021) 55e60
for the Aspergillus strains should be read adopting the visual no
growth end-point criterion used for mould testing, as outlined in
the E.Def 9.3.2 standard. This will allow a quick quality control of
prepared plates, without the need for 5 days of incubation. For
quality control of dermatophyte testing, two new quality control
strains may be used: Trichophyton interdigitale SSI-9396 and Tri-
chophyton rubrum SSI-7583. Both strains are wild-type and have
tentative MIC targets and ranges established in parallel with the
multicentre validation of the method [18]. The recommended MIC
target and ranges as well as information on availability of the rec-
ommended control strains are available at https://www.eucast.org/
astoffungi/.
Storage of control strains
Fungal isolates may be stored lyophilized or frozen at e70 C or
below [25]. Cultures can be stored short term (<2 weeks) on Sab-
ouraud dextrose agar or potato dextrose agar slopes (Aspergillus) at
2 Ce8 C, or Sabouraud dextrose agar supplemented with cyclo-
heximide and chloramphenicol (Trichophyton spp.), with new cul-
tures prepared from frozen stocks every 2 weeks.
Routine use of control strains
For routine use of control strains, fresh cultures must be pre-
pared from agar slopes, frozen or lyophilized cultures by inocula-
tion on nutritive agar medium (e.g. Sabouraud dextrose agar or
potato dextrose agar for Aspergillus spp. or Sabouraud dextrose agar
supplemented with cycloheximide and chloramphenicol for Tri-
chophyton spp.)
1. At least one control strain must be included per test run and the
MICs should be within the control ranges (available at https://
www.eucast.org/astoffungi/). Two or more strains are needed
if the MIC for the quality control strain falls outside the con-
centration range tested for one or several compounds. If control
strain MIC results are out of range, the test should be repeated. If
more than one in 20 tests is out of range the source of error must
be investigated.
2. Each test must include a well of medium without antifungal
drug to demonstrate growth of the test organism and to provide
a turbidity control for reading end-points.
3. Subculture inoculum on a suitable agar medium to ensure purity
and to provide fresh colonies if re-testing is required.
4. Test each new batch/lot of medium, microdilution plate, and
RPMI-1640 2% glucose broth with at least two of the quality
control strains (available on the EUCAST website http://www.
EUCAST.org) to ensure that MICs fall within the expected range.
EUCAST-AFST
EUCAST-AFST: M.C. Arendrup (Chairman, Denmark), J. Meletia-
dis (Scientific Data Coordinator, Greece), J. Guinea (Scientific Sec-
retary, Spain), G. Kahlmeter (EUCAST steering committee
representative), S. Arikan-Akdagli (Steering Committee, Turkey), N.
Friberg (Steering Committee, Finland), F. Barchiesi (Italy), M. Cas-
€rv (Estonia), I. Hil-
tanheira (USA), P. Hamal (Czech Republic), H. Ja
marsdottir (Iceland), N. Klimko (Russia), O. Kurzai (Germany), K.
Lagrou (Belgium), C. Lass-Flo€rl (Austria), T. Matos (Slovenia), C.B.
Moore (UK), K. Muehlethaler (Switzerland), T.R. Rogers (Ireland), A.
Velegraki (Greece).
Funding
None.
59
Transparency declarations
The authors have no conflicts with respect to the current study.
Outside the current work MCA has, over the past 5 years, received
research grants/contract work (paid to the SSI) from Amplyx,
Basilea, Cidara, F2G, Gilead, Novabiotics, Scynexis and T2Bio-
systems and speaker honoraria (personal fee) from Astellas, Gilead,
MSD, SEGES and Pfizer. She is the current chairman of the EUCAST-
AFST. GK has nothing to declare. JM has, over the past 5 years,
received research grants/contract work (paid to the NKUA) from
F2G, Gilead, Astellas, MSD and Pfizer. He is the current clinical data
coordinator of the EUCAST-AFST. JG has received funds for partici-
pating in educational activities organized on behalf of Astellas,
Gilead, MSD, Scynexis and Biotoscana-United Medical; he has also
received research funds from FIS, Gilead, Scynexis and Cidara,
outside the submitted work.
Author contributions
MCA contributed to the conceptualization and wrote the orig-
inal draft. GK, JM and JG contributed to the conceptualization and to
review and editing of the article. All other authors contributed to
the review and editing of the article.
Acknowledgements
None.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.cmi.2020.08.042.
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[16] Taghipour S, Shamsizadeh F, Pchelin IM, Rezaei-Matehhkolaei A,
Mahmoudabadi AZ, Valadan R, et al. Emergence of terbinafine resistant Tri-
chophyton mentagrophytes in Iran, harboring mutations in the squalene
epoxidase (Sqle) gene. Infect Drug Resist 2020;13:845e50.
[17] Danielsen AG, Thomsen JS, Svejgaard EL. Severe skin rash in patients treated
with terbinafine. Ugeskr Laeger 2006;168:3825e6.
[18] Arendrup MC, Jørgensen KM, Guinea J, Lagrou K, Chryssanthou E,
Hayette M, et al. Multicentre validation of a EUCAST method for the
antifungal susceptibility testing of microconidia-forming dermatophytes.
J Antimicrob Chemother 2020:1e13. https://doi.org/10.1093/jac/
dkaa111.
[19] Arendrup MC, Friberg N, Mares M, Kahlmeter G, Meletiadis J, Guinea J, Sub-
committee on Antifungal Susceptibility Testing (AFST) of the ESCMID Euro-
pean Committee for Antimicrobial Susceptibility Testing (EUCAST). How to:
Interpret MICs of antifungal compounds according to the revised clinical
breakpoints v. 10.0 European Committee on Antimicrobial Susceptibility
Testing (EUCAST). Clin Microbiol Infect 2020;26:1464e72.
[20] Rambali B, Fernandez JA, Van Nuffel L, Woestenborghs F, Baert L, Massart DL,
et al. Susceptibility testing of pathogenic fungi with itraconazole: a process
analysis of test variables. J Antimicrob Chemother 2001;48:163e77.
[21] Rodriguez-Tudela JL, Chryssanthou E, Petrikkou E, Mosquera J, Denning DW,
Cuenca-Estrella M. Interlaboratory evaluation of hematocytometer method of
inoculum preparation for testing antifungal susceptibilities of filamentous
fungi. J Clin Microbiol 2003;41:5236e7.
[22] Arendrup MC, Howard S, Lass-Flo €rl C, Mouton JW, Meletiadis J, Cuenca-
Estrella M. EUCAST Testing of isavuconazole susceptibility in Aspergillus:
comparison of results for inoculum standardization using conidium counting
versus optical density. Antimicrob Agents Chemother 2014;58:6432e6.
[23] Aberkane A, Cuenca-Estrella M, Gomez-Lopez A, Petrikkou E, Mellado E,
Monzo  n A, et al. Comparative evaluation of two different methods of inoc-
ulum preparation for antifungal susceptibility testing of filamentous fungi.
J Antimicrob Chemother 2002;50:719e22.
[24] Petrikkou E, Rodríguez-Tudela JL, Cuenca-Estrella M, Go mez a, Molleja a,
Mellado E. Inoculum standardization for antifungal susceptibility testing of
filamentous fungi pathogenic for humans. J Clin Microbiol 2001;39:1345e7.
[25] Pasarell L, McGinnis MR. Viability of fungal cultures maintained at -70 degrees
C. J Clin Microbiol 1992;30:1000e4.
 EUCAST disk diffusion
method for antimicrobial
susceptibility testing
Version 11.0
January 2023
Changes from previous version (v 10.0)
Slide Change
39 Subculturing scheme for QC strains added.

EUCAST 2023 Version 11.0 2

Susceptibility testing media

EUCAST 2023 Version 11.0 3

 Susceptibility testing media
• Un-supplemented Mueller-Hinton (MH) agar is used for
non-fastidious organisms.

• MH with 5% mechanically defibrinated horse blood and

20 mg/L β-NAD (MH-F, Mueller-Hinton Fastidious) is used
for fastidious organisms.

• Use β-NAD with a purity of ≥ 98%.

EUCAST 2023 Version 11.0 4

Media for non-fastidious organisms
Organisms Medium
Enterobacterales
Pseudomonas spp.
Stenotrophomonas maltophilia
Acinetobacter spp.
Staphylococcus spp.
Enterococcus spp. Mueller-Hinton agar
Aeromonas spp.
Achromobacter xylosoxidans
Vibrio spp.
Bacillus spp.
Burkholderia pseudomallei

EUCAST 2023 Version 11.0 5

 Media for fastidious organisms
Organisms Medium
Streptococcus pneumoniae
Streptococcus groups A, B, C and G
Viridans group streptococci
Haemophilus influenzae
Moraxella catarrhalis Mueller-Hinton agar + 5%
mechanically defibrinated horse
Listeria monocytogenes blood + 20 mg/L β-NAD
Pasteurella multocida (MH-F)
Campylobacter jejuni and coli
Corynebacterium spp.
Aerococcus sanguinicola and urinae
Kingella kingae

EUCAST 2023 Version 11.0 6

 In-house preparation of media
• Prepare media according to the manufacturer’s instructions.

• For MH-F, do not add blood or β-NAD until the medium has
cooled to 42-45°C and mix well after the supplements have
been added to the cooled medium.

• Pour plates on a level surface to give a uniform depth of

4.0 ± 0.5 mm. Adjust the volume if the agar depth is within
the acceptable range but repeatedly above or below 4 mm.
Approximate volume for 90 mm circular plate: 25 mL, 100 mm circular
plate: 31 mL, 150 mm circular plate: 71 mL, 100 mm square plate: 40 mL.
Plate dimensions may differ between manufacturers. Ascertain that a
correct volume, based on the true dimensions of the Petri dish in use, is
calculated.

EUCAST 2023 Version 11.0 7

Quality control of Mueller-Hinton agar
Test each new batch of MH agar to ensure that
all zones are within EUCAST QC ranges.

Particular problems:
– High or low concentrations of divalent cations (Ca2+, Mg2+) may
be indicated by inhibition zones for aminoglycosides with P.
aeruginosa ATCC 27853 below/above quality control limits,
respectively.

– Excess thymine and thymidine may be indicated by inhibition

zones for trimethoprim-sulfamethoxazole and E. faecalis ATCC
29212 below quality control limits.
EUCAST 2023 Version 11.0 8
Drying and storage of agar plates
• In-house prepared plates:
– Store at 4-8°C.
– Plate drying, storage conditions and shelf life should
be determined locally.

• Commercially prepared plates:

– Store as recommended by the manufacturer.
– Use within the labelled expiry date.

EUCAST 2023 Version 11.0 9

Drying and storage of agar plates
• Make sure that agar plates are at room temperature prior
to inoculation.
• The surface of the agar should be dry before use.
Excess moisture may cause fuzzy zone edges and/or
haze within zones.
– No drops of water should be visible on the surface of the agar or
inside the lid. This is often seen with plates stored in plastic bags
or sealed containers.
• If necessary, dry plates either at 20-25°C overnight, or at
35°C, with the lid removed, for 15 min.
• Do not over-dry plates.
EUCAST 2023 Version 11.0 10
 Inoculum

• The method requires an

inoculum suspension with
a turbidity equivalent to a
0.5 McFarland standard*.

* Approximately corresponding
to 1-2 x108 CFU/mL for E. coli.

EUCAST 2023 Version 11.0 11

Select well-isolated colonies from overnight
growth on non-selective medium

EUCAST 2023 Version 11.0 12

 Inoculum preparation
• Use a sterile loop or cotton swab to pick colonies from
an overnight culture on non-selective media. If possible,
use several morphologically similar colonies to avoid
selecting an atypical variant.
• Suspend in saline and mix to an even turbidity.
• Adjust the density of the suspension to 0.5 McFarland by
adding saline or more bacteria. Preferably use a
photometric device to measure the turbidity.
– Exception: Streptococcus pneumoniae is suspended to 0.5
McFarland from a blood agar plate, but to 1.0 McFarland from a
chocolate agar plate.
EUCAST 2023 Version 11.0 13
 Inoculation of plates
• Optimally, use the inoculum suspension within 15
minutes of preparation and always within 60 minutes.
• Make sure that agar plates are at room temperature prior
to inoculation.
• Dip a sterile cotton swab into the suspension.
• For Gram-negative bacteria, remove excess fluid by
pressing and turning the swab against the inside of the
tube to avoid over-inoculation.
• For Gram-positive bacteria, do not press or turn the
swab against the inside of the tube.

EUCAST 2023 Version 11.0 14

 Inoculation of plates
• Spread the inoculum evenly over the entire surface by
swabbing in three directions or by using a plate rotator.
• For Gram-positive bacteria, take particular care to ensure that
there are no gaps between streaks.
• When inoculating several agar plates with the same inoculum,
dip the cotton swab into the suspension for each agar plate.

EUCAST 2023 Version 11.0 15

 Storage of antimicrobial disks
• Store stocks and working supplies of disks according to
the manufacturers’ instructions.
– Some agents are more labile than others and may have specific
recommendations.

• Store disks in current use in sealed containers with a

moisture-indicating desiccant and protected from light.
• To prevent condensation, allow disks to reach room
temperature before opening containers.
– Rather keep disks at room temperature during the day than
transfer repeatedly to and from cold storage.

• Do not use disks beyond the manufacturer’s expiry date.

EUCAST 2023 Version 11.0 16

 Application of antimicrobial disks
• Apply disks within 15 min of
inoculation.
• Disks must be in close and even
contact with the agar surface.
• The number of disks on a plate
should be limited to avoid
overlapping of zones and
interference between agents. It is
important that zone diameters can
be reliably measured.

EUCAST 2023 Version 11.0 17

 Incubation of plates
• Invert agar plates and make sure disks do not fall off the
agar surface.

• Incubate plates within 15 min of disk application.

• Stacking plates in the incubator may affect results due to

uneven heating. The efficiency of incubators varies, but for
most incubators, a maximum of five plates per stack is
appropriate.

• Incubate MH plates at 35±1°C in air.

• Incubate MH-F plates at 35±1°C in air with 4-6% CO2

(except for Campylobacter).
EUCAST 2023 Version 11.0 18
 Incubation of plates
Organism Incubation conditions
Enterobacterales 35±1ºC in air for 18±2 h
Pseudomonas spp. 35±1ºC in air for 18±2 h
Stenotrophomonas maltophilia 35±1ºC in air for 18±2 h
Acinetobacter spp. 35±1ºC in air for 18±2 h
Staphylococcus spp. 35±1ºC in air for 18±2 h
Enterococcus spp. 35±1ºC in air for 18±2 h
(24 h for glycopeptides)
Aeromonas spp. 35±1ºC in air for 18±2 h
Achromobacter xylosoxidans 35±1ºC in air for 18±2 h
Vibrio spp. 35±1ºC in air for 18±2 h
Bacillus spp. 35±1ºC in air for 18±2 h
Burkholderia pseudomallei 35±1ºC in air for 18±2 h

EUCAST 2023 Version 11.0 19

 Incubation of plates
Organism
Streptococcus groups A, B, C
and G
Viridans group streptococci
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Listeria monocytogenes
Pasteurella multocida
Campylobacter jejuni and coli
Corynebacterium spp.
Aerococcus sanguinicola and
urinae
Kingella kingae
Incubation conditions
35±1ºC in air with 4-6% CO2 for 18±2 h
35±1ºC in air with 4-6% CO2 for 18±2 h
35±1ºC in air with 4-6% CO2 for 18±2 h
35±1ºC in air with 4-6% CO2 for 18±2 h
35±1ºC in air with 4-6% CO2 for 18±2 h
35±1ºC in air with 4-6% CO2 for 18±2 h
35±1ºC in air with 4-6% CO2 for 18±2 h
41±1ºC in microaerobic environment for 24 h (40-48 h)
35±1ºC in air with 4-6% CO2 for 18±2 h (40-44 h)
35±1ºC in air with 4-6% CO2 for 18±2 h (40-44 h)
35±1ºC in air with 4-6% CO2 for 18±2 h (40-44 h)

EUCAST 2023 Version 11.0 20

 The 15-15-15 minute rule
Follow these instructions for disk diffusion:

• Use the inoculum suspension optimally within 15 minutes

of preparation, and always within 60 minutes.

• Apply disks within 15 minutes of inoculation.

• Incubate plates within 15 minutes of disk application.

EUCAST 2023 Version 11.0 21

Examination of plates after incubation
• A correct inoculum and satisfactorily streaked plates
should result in a confluent lawn of growth.

• The growth should be evenly distributed over the agar

surface to achieve uniformly circular (non-jagged)
inhibition zones (see next slide).

• If individual colonies can be seen, the inoculum is too

light and the test must be repeated.

EUCAST 2023 Version 11.0 22

 The growth should be confluent and
evenly spread over the plate

Plates should look like this.. ..and NOT like this!

EUCAST 2023 Version 11.0 23
 Reading zones
• Zone edges should be read at the point of complete
inhibition as judged by the naked eye with the plate held
about 30 cm from the eye.
Examples:

E. coli S. aureus CoNS S. pneumoniae

Ciprofloxacin Erythromycin Trimethoprim Rifampicin

EUCAST 2023 Version 11.0 24

 Reading zones
• Read MH plates from the back
against a dark background
illuminated with reflected light.

• Read MH-F plates from the front

with the lid removed illuminated
with reflected light.

EUCAST 2023 Version 11.0 25

 Reading zones
• Do not use transmitted light (plate held up to light) or a magnifying
glass, unless otherwise stated.

• Holding the plate at a 45-degree angle to the work bench may

facilitate reading when zone edges are difficult to define.

• Measure zone diameters to the nearest millimetre with a ruler or a

calliper. If an automated zone reader is used, it must be calibrated to
manual reading.

• In case of double zones, or distinct colonies within zones, check for

purity and repeat the test if necessary. If cultures are pure, colonies
within zones should be taken into account when measuring the
diameter.
EUCAST 2023 Version 11.0 26
 Reading zones – exceptions (1)
Organism Antimicrobial agent Reading inhibition zones
Enterobacterales Ampicillin Ignore fine growth that may appear as an inner
Ampicillin-sulbactam zone on some batches of MH agar.
Amoxicillin-clavulanic
acid
Enterobacterales Temocillin Ignore isolated colonies within the inhibition zone.

Enterobacterales Mecillinam Ignore isolated colonies within the inhibition zone.

E. coli Fosfomycin Ignore isolated colonies within the inhibition zone

and read the outer zone edge.
Proteus spp. Any Ignore swarming.
S. maltophilia, Trimethoprim- Ignore growth within the zone if any zone edge
A. xylosoxidans and B. sulfamethoxazole can be seen, even when growth within the zone is
pseudomallei substantial.
S. aureus Benzylpenicillin Examine zone edge from the front of the plate
with transmitted light (plate held up to light).

EUCAST 2023 Version 11.0 27

 Reading zones – exceptions (2)
Organism Antimicrobial agent Reading inhibition zones
Staphylococci Cefoxitin Examine zones carefully to detect colonies within
the inhibition zone.
Enterococcus spp. Vancomycin Examine zone edge from the front of the plate
with transmitted light (plate held up to light).
Streptococcus spp. Any Read inhibition of growth and not the inhibition of
haemolysis.
H. influenzae Beta-lactam agents Read the outer edge of zones where an otherwise
clear inhibition zone contains an area of growth
around the disk.
Aeromonas spp. Trimethoprim- Read the obvious zone edge and disregard haze
sulfamethoxazole or growth within the inhibition zone
Any Trimethoprim Ignore faint growth up to the disk and measure at
Trimethoprim- the more obvious zone edge.
sulfamethoxazole

EUCAST 2023 Version 11.0 28

 Interpreting zones
• Check that zone diameters for quality control strains are
within acceptable ranges before interpreting tests.

• Interpret zone diameters into susceptibility categories (S,

I and R) according to the current EUCAST Breakpoint
Tables (www.eucast.org). Alternatively, a template with
EUCAST breakpoints may be used.

EUCAST 2023 Version 11.0 29

 Control of susceptibility testing
• Use the recommended routine quality control strains to monitor test
performance (see EUCAST QC Tables).

• For β-lactam-inhibitor combination disks, specific β-lactamase-

producing strains are recommended to control the inhibitor
component. This should be part of the routine QC. The active
component is checked with a susceptible QC strains.

• Quality control strains with defined resistance mechanisms may be

used to confirm the ability to detect resistance (Extended QC, see
EUCAST QC Tables).

• Quality control strains may be purchased from culture collections or

from commercial sources.

EUCAST 2023 Version 11.0 30

EUCAST routine quality control strains
Organism Culture collection numbers Characteristics
E. coli ATCC 25922; NCTC 12241; CIP 76.24 Susceptible, wild-type
DSM 1103; CCUG 17620; CECT 434
ATCC 35218; NCTC 11954; CIP 102181 TEM-1 β-lactamase
E. coli
DSM 5923; CCUG 30600; CECT 943 producer
K. pneumoniae ATCC 700603; NCTC 13368 ESBL producer
CCUG 45421; CECT 7787 (SHV-18)
K. pneumoniae ATCC BAA-2814 KPC-3, SHV-11 and
TEM-1
P. aeruginosa ATCC 27853; NCTC 12903; CIP 76.110 Susceptible, wild-type
DSM 1117; CCUG 17619; CECT 108
S. aureus ATCC 29213; NCTC 12973; CIP 103429 Weak β-lactamase
DSM 2569; CCUG 15915; CECT 794 producer
E. faecalis ATCC 29212; NCTC 12697; CIP 103214 Susceptible, wild-type
DSM 2570; CCUG 9997; CECT 795

EUCAST 2023 Version 11.0 31

EUCAST routine quality control strains
Organism Culture collection numbers Characteristics
S. pneumoniae ATCC 49619; NCTC 12977 Reduced susceptibility to
CIP 104340; DSM 11967 benzylpenicillin
CCUG 33638
H. influenzae ATCC 49766; NCTC 12975 Susceptible, wild-type
CIP 103570; DSM 11970
CCUG 29539
Campylobacter ATCC 33560; NCTC 11351 Susceptible, wild-type
jejuni CIP 70.2T; DSM 4688
CCUG 11284

EUCAST 2023 Version 11.0 32

 EUCAST strains for detection of specific
resistance mechanisms (extended QC)
Organism Culture collection numbers Characteristics
ATCC 700603; NCTC 13368 ESBL producer (SHV-18)
K. pneumoniae
CCUG 45421; CECT 7787
mecA positive, methicillin
S. aureus NCTC 12493; CCUG 67181
resistant (MRSA)
High-level aminoglycoside
ATCC 51299; NCTC 13379
resistant (HLAR) and
E. faecalis CIP 104676; DSM 12956
vancomycin resistant (vanB
CCUG 34289
positive)
ATCC 49247; NCTC 12699 Reduced susceptibility to β-
H. influenzae CIP 104604; DSM 9999 lactam agents due to PBP
CCUG 26214 mutations

EUCAST 2023 Version 11.0 33

 Culture Collections
ATCC American Type Culture Collection, USA
http://www.atcc.org
NCTC National Collection of Type Cultures, Public Health England, UK
https://www.phe-culturecollections.org.uk/collections/nctc
CIP Collection de l`Institut Pasteur, France
https://www.pasteur.fr/en/public-health/biobanks-and-collections/collection-
institut-pasteur-cip
DSM Deutsche Sammlung von Mikroorganismen und Zellkulturen (DSMZ)
https://www.dsmz.de
CCUG Culture Collection University of Gothenburg, Sweden
http://www.ccug.se
CECT Colección Española de Cultivos Tipo, Spain
http://www.cect.org

EUCAST 2023 Version 11.0 34

 Use routine quality control strains to
assess general performance
• Control tests should be set up and checked daily, or at least four
times per week, for antibiotics which are part of routine panels.

• Control tests should always be read and evaluated before reporting

results for clinical isolates.

• Each day that tests are set up, examine the results of the last 20
consecutive tests.

• Examine results for trends and for zones falling consistently above
or below the target.

• If two or more of 20 tests are out of range investigation is required.

EUCAST 2023 Version 11.0 35

Monitoring test performance
Single results
out of range

Upper limit

Target

Lower limit

All results within Consecutive results

range but on one out of range on same
side of the target side of the target

EUCAST 2023 Version 11.0 36

 Response to QC results out of range
• If two non-consecutive control zone diameters of 20 tests are
outside the acceptable range – then report susceptibility test results
and investigate.
• If two consecutive control zone diameters of 20 tests are outside the
acceptable range – then investigate before reporting susceptibility
test results. The tests may have to be repeated.
• If multiple disks (>2) are out of range on one day – then investigate
before reporting susceptibility test results. The tests may have to be
repeated.
• If resistance in a resistant control strain is not recognised – then
suppress susceptibility test results, investigate and retest.

EUCAST 2023 Version 11.0 37

Storage and subculture of control strains
• Store control strains on beads at -70°C in glycerol broth (or
commercial equivalent). Store two vials of each strain, one for in-use
and one as an archive.
• Each week, subculture from the in-use vial onto appropriate non-
selective media and check for purity.
• Each day of the week, prepare a subculture from the purity plate.
Use several colonies to avoid selecting a mutant. Fastidious
organisms only may be subcultured serially from day to day.
• QC strains may be subcultured for a maximum of 6 days. Then,
discard plates and prepare a new purity plate form the frozen in-use
vial.
• When the in-use vial is depleted, subculture from the archive vial
and prepare another in-use vial from the subculture.
EUCAST 2023 Version 11.0 38
Subculturing of QC strains

EUCAST 2023 Version 11.0 39

 Potential sources of error (1)
Storage of plates
Not prepared according to instructions
Batch to batch variation or change of supplier of agar
Medium Supplements (batch to batch variations, incorrect amount or
expired)
pH
Agar depth/Agar volume
Expiry date
“15-15-15 minute”-rule not adhered to (suspension used within
15 min, disks applied within15 min, incubation within 15 min)
Test Incubation (temperature, atmosphere and time)
conditions
Incorrect inoculation (too light, too heavy or uneven)
Reading conditions (background, light)
Reading zone edges
EUCAST 2023 Version 11.0 40
 Potential sources of error (2)
Incorrect disk (wrong agent or wrong disk strength)
Disks Disk potency (incorrect storage, labile agent, expiry date)
Disks not at room temperature when containers opened
Too many disks on plate (interference between agents)
Incorrect QC strain
Control
Mutation
organisms
Contamination
Age of culture

EUCAST 2023 Version 11.0 41

 EUCAST website
• Check the EUCAST website regularly for
updates on methodology, QC ranges and
breakpoints.
www.eucast.org

• Please send any comments and suggestions to

erika.matuschek@escmid.org or to the
EUCAST secretariat (see website).

EUCAST 2023 Version 11.0 42

 Reading guide
EUCAST disk diffusion
method for antimicrobial
susceptibility testing
Version 10.0
January 2023
Changes from previous version (v 9.0)

Slide Change
25 Clarification on that zone edges for enterococci and vancomycin
only have to be examined for zones ≥12 mm.
26 Clarification on that zone edges for S. aureus and benzylpenicillin
only have to be examined for zones ≥26 mm.

2
 Reading zones
• The following instructions for reading inhibition zone
diameters are part of the EUCAST disk diffusion method.

• Zone edges should be read at the point of complete inhibition

as judged by the naked eye with the plate held about 30 cm
from the eye (for exceptions and specific reading instructions,
see slides 15-29).

• Holding the plate at a 45-degree angle to the work bench may

facilitate reading when zone edges are difficult to define.

• Measure zone diameters to the nearest millimetre with a ruler

or a calliper. If an automated zone reader is used, it must be
calibrated to manual reading.
3
 Reading zones
• Read MH plates from the back
against a dark background
illuminated with reflected light.

• Read MH-F plates from the front

with the lid removed illuminated
with reflected light.

4
 Colonies within zone
• In case of distinct colonies within zones, check for purity
and repeat the test if necessary.

• If cultures are pure, colonies within zones should be taken

into account when measuring the diameter.

No zone

Reading of zones with colonies within the zone. 5

 Colonies within zone
• In case of distinct colonies within zones, check for purity
and repeat the test if necessary.

• If cultures are pure, colonies within zones should be taken

into account when measuring the diameter.
E. coli with H. influenzae with
ESBL PBP mutations

No zone No zone
6
Reading of zones with colonies within the zone.
 Swarming
• For Proteus spp., ignore swarming and read
inhibition of growth.

7
 Double zones
• In case of double zones, check for purity and repeat the
test if necessary.

• If cultures are pure, read the inner zone.

Reading of double zones.

8
 Fuzzy zone edges
Enterobacterales
• Hold the plate against a dark background about 30 cm
from the naked eye and estimate where the zone edge is.
Do not hold the plate up to light (transmitted light) or use
a magnifying glass.

Reading of zones with fuzzy zone edges for Enterobacterales.

9
 Fuzzy zone edges
Staphylococci
• Hold the plate against a dark background about 30 cm
from the naked eye and estimate where the zone edge is.
Do not hold the plate up to light (transmitted light) or use
a magnifying glass.

Reading of zones with fuzzy zone edges for staphylococci.

10
 Fuzzy zone edges
S. pneumoniae
• Small colonies that are visible when the plate is held about
30 cm from the naked eye at a 45-degree angle to the work
bench should be taken into account when reading zones.
• The presence of small colonies close to the zone edge may
be related to excess humidity in the MH-F media, and may be
reduced by drying the plates prior to use.

11
Reading of zones with fuzzy zone edges for S. pneumoniae.
 Growth or haemolysis?
• Read inhibition of growth and not inhibition of
haemolysis.

• It is sometimes difficult to distinguish between

haemolysis and growth.
– β-Haemolysins diffuse in agar. β-haemolysis is therefore usually
free from growth.
– α-Haemolysins do not diffuse. There is often growth within areas
of α-haemolysis.
– Zone edges accompanied with α-haemolysis is most common
with S. pneumoniae and β-lactam antibiotics.

12
 β-haemolysis
• Tilt the plate back and forth to better differentiate
between haemolysis and growth.
• β-haemolysis is usually free from growth.

13
S. pyogenes Streptococcus group C
 α-haemolysis
• Tilt the plate back and forth to better differentiate
between haemolysis and growth.

There is usually growth in the For some organisms, there is additional

whole area of α-haemolysis. α-haemolysis without growth. Tilt the
plate to differentiate between
haemolysis and growth. 14
 Specific reading instructions
• Enterobacterales with ampicillin, ampicillin-sulbactam and
amoxicillin-clavulanic acid
• Enterobacterales and temocillin
• Enterobacterales and mecillinam
• E. coli and fosfomycin
• Trimethoprim and trimethoprim-sulfamethoxazole in general
• Stenotrophomonas maltophilia, Achromobacter xylosoxidans and
Burkholderia pseudomallei with trimethoprim-sulfamethoxazole
• Aeromonas spp. and trimethoprim-sulfamethoxazole
• Enterococci and vancomycin
• S. aureus and benzylpenicillin
• Detection of inducible clindamycin resistance in staphylococci and
streptococci
• H. influenzae and beta-lactam agents
15
Enterobacterales with ampicillin, ampicillin-
sulbactam and amoxicillin-clavulanic acid
• Ignore growth that may appear as a thin inner zone on
some batches of Mueller-Hinton agars. The inner zone is
not seen with some batches of agar and when the outer
zone is read there is no difference between batches.

16
 Enterobacterales and temocillin
• Ignore isolated colonies within the inhibition zone and
read the outer zone edge.

17
 Enterobacterales and mecillinam
• Ignore isolated colonies within the inhibition zone and
read the outer zone edge.

No zone

18
 E. coli and fosfomycin
• Ignore isolated colonies within the inhibition zone and
read the outer zone edge.

No zone

19
 Trimethoprim and
trimethoprim-sulfamethoxazole
• Follow the instructions for reading and read the inner zone
when double zones appear (see examples below).

• Ignore haze or faint growth up to the disk within a zone

with otherwise clear zone edge.

E. coli CoNS Moraxella Haemophilus

20
 S. maltophilia with
trimethoprim-sulfamethoxazole
• Ignore growth within the zone if any zone edge can be
seen, even when growth within the zone is substantial.
– Read the outer zone edge and interpret according to the
breakpoints.
• If there is growth up to the disk and no sign of inhibition
zone, report resistant.

No zone

An outer zone can be seen Growth up to the disk

21
 A. xylosoxidans with
trimethoprim-sulfamethoxazole
• Ignore growth within the zone if any zone edge can be
seen, even when growth within the zone is substantial.
– Read the outer zone edge and interpret according to the
breakpoints.
• If there is growth up to the disk and no sign of inhibition
zone, report resistant.

An outer zone can be seen Growth up to the disk

22
 B. pseudomallei with
trimethoprim-sulfamethoxazole
• Ignore growth within the zone if any zone edge can be
seen, even when growth within the zone is substantial.
– Read the outer zone edge and interpret according to the
breakpoints.
• If there is growth up to the disk and no sign of inhibition
zone, report resistant.

An outer zone can be seen Growth up to the disk

23
 Aeromonas spp. and
trimethoprim-sulfamethoxazole
• Read the obvious zone edge and disregard haze or
growth within the inhibition zone.
• If there is an obvious inner zone edge, read the inhibition
zone as the inner zone.

24
 Enterococci and vancomycin
• For isolates with zone diameters ≥12 mm: Examine the
zone edge from the front of the plate with transmitted light
(plate held up to light).
– If the zone edge is sharp, report susceptible.
– If the zone edge is fuzzy, colonies grow within the zone or if you
are uncertain, suspect VRE and perform confirmatory testing, even
if the zone diameter is ≥ 12 mm.
– Isolates must not be reported susceptible before 24 h incubation.

25
non-VRE VRE
 S. aureus and benzylpenicillin
• For isolates with zone diameters ≥26 mm: Examine the
zone edge from the front of the plate with transmitted light
(plate held up to light).
– If the zone is ≥ 26 mm and the zone edge is sharp (no reduction of growth
towards zone edge, like a “cliff”), the isolate is a pencillinase producer,
report resistant.
– If the zone is ≥ 26 mm and the zone edge is fuzzy (reduction of growth
towards zone edge, like a “beach”), report susceptible.

Zone ≥ 26 mm and Zone ≥ 26 mm and

sharp zone edge= Resistant fuzzy zone edge = Susceptible 26
Detection of inducible clindamycin
resistance in staphylococci
• Inducible clindamycin resistance can be detected by
antagonism of clindamycin activity and a macrolide
agent.
• Place the erythromycin and clindamycin disks 12-20 mm
apart (edge to edge) and look for antagonism (the D
phenomenon).

Examples of D phenomenon for staphylococci. 27

Detection of inducible clindamycin
resistance in streptococci
• Inducible clindamycin resistance can be detected by
antagonism of clindamycin activity and a macrolide
agent.
• Place the erythromycin and clindamycin disks 12-16 mm
apart (edge to edge) and look for antagonism (the D
phenomenon).

Examples of D phenomenon for streptococci. 28

 H. influenzae and
beta-lactam agents
• Read the outer edge of zones where an otherwise clear
inhibition zone contains an area of growth around the
disk.

29
 ORIGINAL ARTICLE BACTERIOLOGY

Development of the EUCAST disk diffusion antimicrobial susceptibility

testing method and its implementation in routine microbiology
laboratories

E. Matuschek1, D. F. J. Brown2 and G. Kahlmeter1

1) EUCAST Laboratory for Antimicrobial Susceptibility Testing, V€axj€o, Sweden and 2) EUCAST Scientific Secretary, Peterborough, UK

Abstract

With the support of ESCMID and European countries, EUCAST has developed a disk diffusion test with zone diameter breakpoints
correlated with the EUCAST clinical MIC breakpoints. The development of the EUCAST disk diffusion method and quality control criteria
are described, together with guidance on quality control and implementation of the method in clinical microbiology laboratories. The
method includes the use of Mueller–Hinton agar without supplements for non-fastidious organisms and with 5% mechanically defibrinated
horse blood and 20 mg/L b-NAD for fastidious organisms, a standardized inoculum resulting in confluent growth, an incubation time of 16–
20 h, a reading guide on how to read zone diameters on individual species-agent combinations and zone diameter breakpoints calibrated to
the EUCAST clinical MIC breakpoints. EUCAST recommendations are described in detail and updated regularly on the EUCAST website
(http://www.eucast.org).

Keywords: Antimicrobial susceptibility testing, disk diffusion, European Committee on Antimicrobial Susceptibility Testing, MIC, Mueller–
Hinton agar, zone diameter breakpoints
Original Submission: 30 May 2013; Revised Submission: 19 August 2013; Accepted: 19 August 2013
Editor: R. Cant
on
Article published online: 28 August 2013
Clin Microbiol Infect 2014; 20: O255–O266
10.1111/1469-0691.12373

Corresponding author: E. Matuschek, EUCAST Laboratory for
Antimicrobial Susceptibility Testing, c/o Clinical Microbiology, Central
Hospital, SE-351 85 V€axj€o, Sweden
E-mail: erika.matuschek@ltkronoberg.se
Introduction
Disk diffusion is one of the oldest approaches to antimicrobial
susceptibility testing (AST) and remains one of the most widely
used AST methods in routine clinical microbiology laborato-
ries. The method is versatile in that it is suitable for testing the
majority of bacterial pathogens, including the more common
fastidious bacteria, almost all antimicrobial agents can be tested
and it requires no special equipment. When performed
according to recommendations, disk diffusion is a reproducible
and accurate method for AST [1,2]. Several of the European
national antimicrobial breakpoint committees, including BSAC
in the UK [3], CA-SFM in France [4], DIN in Germany [5] and
SRGA in Sweden [6], developed their own disk diffusion
methods for AST, but there was no common method
calibrated to European breakpoints. Following the harmoniza-
tion of European MIC breakpoints [7] by the European
Committee on Antimicrobial Susceptibility Testing (EUCAST),
the committee initiated the development of a standardized
disk diffusion method calibrated to the harmonized MIC
breakpoints. In common with most other disk diffusion
techniques, the EUCAST method is based on the principles
defined in the report of the International Collaborative Study
of Antimicrobial Susceptibility Testing [8] and on the experi-
ence of expert groups worldwide.
The need for a standardized disk diffusion method cali-
brated to EUCAST clinical MIC breakpoints became obvious
from responses to a questionnaire sent by EUCAST to
EUCAST European national representatives in 2007. The
questionnaire responses indicated that the disk diffusion
methods used most widely included Mueller–Hinton (MH)

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Clinical Microbiology and Infection ª2013 European Society of Clinical Microbiology and Infectious Diseases
O256 Clinical Microbiology and Infection, Volume 20 Number 4, April 2014
agar with an inoculum corresponding to a McFarland 0.5
turbidity standard, as described by Bauer et al. [9]. Many
laboratories followed the performance standards published by
the United States Clinical and Laboratory Standards Institute
(CLSI) [10,11] or local modifications of the CLSI method. The
opinions expressed in the questionnaire strongly supported
the development of a European disk diffusion method, based
on the widely used Kirby–Bauer method [9] and calibrated to
EUCAST clinical MIC breakpoints. It was also evident that a
common medium for fastidious organisms instead of separate
media for Streptococcus spp. and Haemophilus influenzae would
facilitate laboratory work. In response to these demands,
EUCAST, in collaboration with and financed by The European
Society for Clinical Microbiology and Infectious Diseases
(ESCMID), developed a standardized disk diffusion method
based on MH agar with an inoculum density equivalent to a
McFarland 0.5 standard and with the specific aim to develop a
common medium for fastidious organisms. These objectives
have been achieved and zone diameter breakpoints calibrated
to the EUCAST clinical MIC breakpoints have been established
by analysis of MIC-zone diameter correlations, inhibition zone
diameter distributions and MIC distributions. This paper
describes the development and calibration of the disk diffusion
method, how quality control targets and ranges were devel-
oped and validated, and presents guidance on how to
implement the EUCAST disk diffusion method in the routine
laboratory.
Basic Materials and Methodology
The following description of the EUCAST disk diffusion
methodology is a summary of the methodology detailed in a
manual on the EUCAST website [12]. The first version of the
manual was released in December 2009 and it is updated
annually. The described technique must be adhered to without
modification in order to obtain reliable results. Tables
including organisms covered by the EUCAST disk diffusion
method, and corresponding methodology recommendations
for each of these, are available in the EUCAST disk diffusion
test manual and, from 2014, will also be in a table on the first
page of the EUCAST breakpoint tables.
Preparation of media
Unsupplemented MH agar is used for non-fastidious organisms
and MH agar supplemented with 5% (v/v) mechanically
defibrinated horse blood and 20 mg/L b-NAD (‘Mueller–
Hinton fastidious’, MH-F) for fastidious organisms. MH agar is
prepared according to the manufacturer’s instructions and
supplements are added after cooling to 42–45°C. Agar is
ª2013 The Authors
Clinical Microbiology and Infection ª2013 European Society of Clinical Microbiology and Infectious Diseases, CMI, 20, O255–O266
CMI
dispensed in Petri dishes to achieve an even depth of 4.0 mm
with a maximum variation of 0.5 mm.
Preparation of inoculum
The inoculum suspension is prepared by selecting several
morphologically similar colonies (when possible) from over-
night growth (16–24 h of incubation) on a non-selective
medium with a sterile loop or a cotton swab and suspending
the colonies in sterile saline (0.85% NaCl w/v in water) to the
density of a McFarland 0.5 standard, approximately corre-
sponding to 1–2 9 108 CFU/mL for Escherichia coli. The
density of the suspension is preferably measured with a
photometric device that has been calibrated with a McFarland
standard according to the manufacturer’s instructions. Alter-
natively, the density of the suspension can be compared
visually to a 0.5 McFarland turbidity standard. The density of
the suspension is adjusted to McFarland 0.5 by addition of
saline or more organisms. Streptococcus pneumoniae is prefer-
ably suspended from colonies on a blood agar plate to the
density of a McFarland 0.5 standard. When S. pneumoniae is
suspended from colonies on a chocolate agar plate, the
inoculum must be equivalent to a McFarland 1.0 standard in
order to contain a sufficient number of viable cells. All
inoculum suspensions should optimally be used within 15 min
and always within 60 min of preparation.
Inoculation of agar plates
A sterile cotton swab is dipped into the inoculum suspension
and the excess fluid removed by turning the swab against the
inside of the tube to avoid over-inoculation of plates,
particularly for Gram-negative organisms. The inoculum is
spread evenly over the entire surface of the agar plate by
swabbing in three directions or by using an automatic plate
rotator.
Application of antimicrobial disks
Antimicrobial disks should be handled and stored according to
the manufacturer’s instructions. Disks are applied firmly on the
agar surface within 15 min of inoculation of the plates. It is
important that zone diameters can be reliably measured and
the maximum number of disks on a plate depends on the size
of the plate, the organism and the antimicrobial agents tested.
The number of disks on a plate should be limited so that
unacceptable overlapping of zones is avoided. A maximum of
six disks can be accommodated on a 90-mm circular plate and
12 on a 150-mm circular plate.
Incubation of plates
Within 15 min of application of antimicrobial disks, the plates
are inverted and incubated at 35  1°C for 16–20 h, unless
CMI Matuschek et al. The EUCAST disk diffusion testing method O257

otherwise stated in the disk diffusion test manual on the TABLE 1. Strains recommended by EUCAST for routine
EUCAST website [12]. Unsupplemented MH agar plates are quality control
incubated in air and MH-F agar plates in 5  1% CO2 in air. Organism Strain collection number Characteristics
The efficiency of incubators varies so appropriate numbers of
Escherichia coli ATCC 25922 Susceptible, wild type
plates in stacks should be determined as part of the NCTC 12241
CIP 76.24
laboratory’s quality assurance programme. Small stacks of DSM 1103
CCUG 17620
plates with a space between stacks are more likely to ensure CECT 434
uniform and rapid heating of all plates. Pseudomonas ATCC 27853 Susceptible, wild type
aeruginosa NCTC 12903
CIP 76.110
DSM 1117
Examination of plates after incubation CCUG 17619
CECT 108
A correct inoculum and satisfactorily streaked plates should Staphylococcus ATCC 29213 Weak b-lactamase
aureus NCTC 12973 producer
result in an even confluent lawn of growth. If individual CIP 103429
DSM 2569
colonies can be seen, the inoculum is too light and the test CCUG 15915
CECT 794
should be repeated. The age of the culture, the nutritional Enterococcus ATCC 29212 Susceptible, wild type
requirements of the strains or failure to comply with faecalis NCTC 12697
CIP 103214
recommendations should be considered before retesting. If DSM 2570
CCUG 9997
zone edges are jagged, the evenness of streaking of the plate CECT 795
Streptococcus ATCC 49619 Low-level, chromosomally
should be improved. pneumoniae NCTC 12977 mediated penicillin resistant
CIP 104340
DSM 11967
CCUG 33638
Measurement of inhibition zone diameters and interpretation Haemophilus NCTC 8468 Susceptible, wild type
influenzae CIP 54.94
of results CCUG 23946
After incubation, inhibition zones are read at the point where ATCC, American Type Culture Collection, USA; NCTC, National Collection of
no obvious growth is detected by the unaided eye when the Type Cultures, UK; CIP, Collection de Institut Pasteur, France; DSM, Deutsche
Stammsammlung f€ur Mikroorganismen und Zellkulturen, Germany; CCUG, The
plate is held about 30 cm from the eye. The inhibition zone Culture Collection University of Gothenburg, Sweden; CECT, Coleccion Espa~nola
de Cultivos Tipo, Spain.
diameters are measured to the nearest millimetre with a ruler,
calliper or an automated zone reader. Unsupplemented MH
agar plates are read from the back of the plate with reflected
Development of Methodology
light against a dark background whereas MH-F agar plates are
read from the front with the lid removed and with reflected
light. For haemolytic streptococci on MH-F agar plates, Medium
inhibition of growth and not inhibition of haemolysis should Mueller–Hinton medium is the only generic, commercially
be read. If double zones are visible, the inner zone should be available medium for AST and it has been recommended by the
read, unless otherwise specifically stated. Specific reading CLSI and CA-SFM for more than 25 years. Many laboratories
instructions are given in the EUCAST disk diffusion test manual and manufacturers of pre-poured plates have long traditions
[12] and in the EUCAST reading guide [13]. Zone diameters and extensive knowledge of production and use of MH media.
are interpreted and categorized as susceptible, intermediate or MH was therefore the obvious choice for EUCAST when
resistant according to the EUCAST clinical breakpoint tables deciding on the medium. However, there is some variation in
[14]. MH from different manufacturers and between batches from
the same manufacturer. Some of this variation (e.g. cation
Quality control content) affects antimicrobial activity and some affects the
Defined control strains (Table 1) are used to monitor test growth of the bacteria, which in turn may affect the size of
performance. For antimicrobial agents that are part of routine inhibition zones, and each new batch of MH agar must be
panels, control tests should optimally be set up daily. In quality controlled to ensure that inhibition zones are within
addition to the daily routine quality control tests, each new EUCAST ranges.
batch of MH agar (i.e. a different batch (new lot) of agar
powder or a switch in the manufacturer of agar for Development of MH-F medium
in-house-produced plates or each new shipment of commer- For fastidious organisms EUCAST did not want to recom-
cial pre-poured plates) should be tested to ensure that all mend different media for different organisms. We aimed to
zones are within the acceptable ranges defined in the EUCAST develop a common medium for H. influenzae, S. pneumoniae,
routine quality control tables [15]. streptococcus groups A, B, C and G, viridans group strepto-

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Clinical Microbiology and Infection ª2013 European Society of Clinical Microbiology and Infectious Diseases, CMI, 20, O255–O266
O258 Clinical Microbiology and Infection, Volume 20 Number 4, April 2014
cocci, Campylobacter spp., Pasteurella multocida, Listeria mono-
cytogenes, Corynebacterium spp., Neisseria spp. and rapidly
growing anaerobes. National antimicrobial breakpoint com-
mittees have previously developed or adopted different media
for fastidious organisms. The CLSI [10] and CA-SFM [4]
recommend MH agar supplemented with 5% sheep blood for
streptococci and Haemophilus Test Medium (HTM) for
H. influenzae. The BSAC [3] and SRGA [6] have both
recommended Iso-Sensitest agar (Thermo Fisher Ltd, Basing-
stoke, UK) supplemented with 5% mechanically defibrinated
horse blood and 20 mg/L b-NAD. We exchanged the
Iso-Sensitest agar for MH agar and found that this medium,
named ‘Mueller–Hinton fastidious’ (Mueller–Hinton agar with
5% defibrinated horse blood and 20 mg/L b-NAD, MH-F),
supports good growth of most of the fastidious organisms
listed above, including H. influenzae (21st European Congress
of Clinical Microbiology and Infectious Diseases (ECCMID),
poster 749; 22nd ECCMID, posters 671, 676 and 682).
However, MH-F has been shown to be inadequate for growth
of Neisseria gonorrhoeae and anaerobes.
MH-F agar was compared with a similar medium where
sheep blood was used instead of horse blood. However, with
sheep blood the growth of H. influenzae was inadequate unless
the concentration of b-NAD was increased at least five-fold (to
100 mg/L), which would significantly increase the cost of the
medium. At a concentration of 20 mg/L in MH-F agar, b-NAD
from seven different manufacturers [Acros (Fair Lawn, NJ,
USA), BDH (VWR International, Radnor, PA, USA), Biomol
(Hamburg, Germany), Fluka (Sigma-Aldrich, Steinheim, Ger-
many), ICN Biomedicals (Irvine, CA, USA), Merck (Whitehouse
station, CA, USA) and Sigma-Aldrich resulted in good and very
similar growth of H. influenzae NCTC 8468 and inhibition zone
diameters were within 1 mm for all investigated antimicrobial
agents, including b-lactam agents, tetracyclines and trimetho-
prim-sulphamethoxazole. Concentrations of b-NAD as low as
10 mg/L supported good growth and resulted in reliable
inhibition zone diameters for H. influenzae and S. pneumoniae,
but 20 mg/L b-NAD was selected for MH-F medium to allow
for some variation in purity, quality and concentration between
manufacturers.
MH-F plates prepared at the EUCAST Laboratory for
Antimicrobial Susceptibility Testing (V€axj€o, Sweden) between
2009 and 2012 using a total of 11 different batches of MH agar
from four manufacturers (Oxoid, Bio-Rad, BBL and bioMerie-
ux) and more than 150 batches of defibrinated horse blood
have shown reproducible inhibition zones for S. pneumoniae
ATCC 49619 and H. influenzae NCTC 8468 over time, with
random variation within the quality control ranges similar to
that for other organisms and agents on unsupplemented MH
agar (Fig. 1).
ª2013 The Authors
Clinical Microbiology and Infection ª2013 European Society of Clinical Microbiology and Infectious Diseases, CMI, 20, O255–O266
CMI
Inoculum preparation, inoculation of plates and application of
disks
The preparation and handling of inoculum suspensions, inocu-
lated plates and antimicrobial disks affect the size of inhibition
zone diameters in disk diffusion tests and therefore require
careful standardization. EUCAST recommends that the inocu-
lum suspension should optimally be used within 15 and always
within 60 min of preparation to ensure the correct number of
viable cells. Numbers of colony forming units in suspensions of
overnight cultures of E. coli ATCC 25922, S. pneumoniae ATCC
49619 and H. influenzae NCTC 8468 adjusted to the density of a
McFarland 0.5 turbidity standard were shown to be within the
recommended range (1–2 9 108 CFU/mL) when left at ambi-
ent temperature (20–22°C) for 15 and 60 min. However, the
effect of leaving the inoculum suspension at ambient tempera-
ture for more than 15 min has not been investigated for all
organisms and we strongly recommend that the inoculum
suspension is used within 15 min. Disks should be placed on
inoculated plates within 15 min and then placed in the correct
incubation atmosphere within another 15 min. If inoculated
plates are left at room temperature for longer periods of time
before the disks are applied, the organisms may begin to grow
prior to disk application, resulting in erroneous reduction in
sizes of inhibition zones. When inoculated plates were left at
room temperature for 2 h before application of disks, inhibition
zone diameters for E. coli ATCC 25922 and Staphylococcus
aureus ATCC 29213 (with 9 and 11 antimicrobial agents,
respectively, representing different classes of antimicrobial
agents) were 1–3 mm smaller compared with when disks were
applied immediately. Systematic accumulation of such deviations
will significantly affect the results and can contribute to
misinterpretation of susceptibility testing results. Furthermore,
if the plates are left at room temperature for longer than 15 min
after disks have been applied, pre-diffusion may result in
erroneously large zones of inhibition.
Incubation of plates
Unless otherwise stated in the EUCAST disk diffusion test
manual [12], plates are incubated at 35  1°C for 16–20 h.
MH plates are incubated in air and MH-F plates in 5% CO2.
Repeated reading of inhibition zones of quality control strains
after 16, 18 and 20 h incubation, respectively, yielded inhibi-
tion zone diameters that varied randomly within 1 mm for
each antimicrobial agent tested (with 6–11 antimicrobial
agents, depending on the strain, representing different classes
of agents). However, prolonging incubation beyond 20 h
resulted in growth of colonies within the inhibition zones for
some organism-agent combinations. Incubation beyond 20 h is
permitted only for species and/or antimicrobial agents for
which a longer incubation has been validated (e.g. for
CMI Matuschek et al. The EUCAST disk diffusion testing method O259

(a) (b)

Inhibition zone diameter (mm)

Inhibition zone diameter (mm)

40 40

30 30

20 20

10 10

0 0
2009/04/30
2009/07/31
2009/10/31
2010/01/31
2010/04/30
2010/07/31
2010/10/31
2011/01/31
2011/04/30
2011/07/31
2011/10/31
2012/01/31
2012/04/30
2012/07/31
2012/10/31

2009/04/30
2009/07/31
2009/10/31
2010/01/31
2010/04/30
2010/07/31
2010/10/31
2011/01/31
2011/04/30
2011/07/31
2011/10/31
2012/01/31
2012/04/30
2012/07/31
2012/10/31
Date Date

(c) (d)
Inhibition zone diameter (mm)

Inhibition zone diameter (mm)

40 40

30 30

20 20

10 10

0 0
2009/04/30
2009/07/31
2009/10/31
2010/01/31
2010/04/30
2010/07/31
2010/10/31
2011/01/31
2011/04/30
2011/07/31
2011/10/31
2012/01/31
2012/04/30
2012/07/31
2012/10/31

2009/04/30
2009/07/31
2009/10/31
2010/01/31
2010/04/30
2010/07/31
2010/10/31
2011/01/31
2011/04/30
2011/07/31
2011/10/31
2012/01/31
2012/04/30
2012/07/31
2012/10/31
Date Date

(e) (f)
Inhibition zone diameter (mm)

Inhibition zone diameter (mm)

40 40

30 30

20 20

10 10

0 0
2009/04/30
2009/07/31
2009/10/31
2010/01/31
2010/04/30
2010/07/31
2010/10/31
2011/01/31
2011/04/30
2011/07/31
2011/10/31
2012/01/31
2012/04/30
2012/07/31
2012/10/31

2009/04/30
2009/07/31
2009/10/31
2010/01/31
2010/04/30
2010/07/31
2010/10/31
2011/01/31
2011/04/30
2011/07/31
2011/10/31
2012/01/31
2012/04/30
2012/07/31
2012/10/31

Date Date

FIG. 1. Examples of reproducibility of inhibition zones over time for quality control strains. Strains were routinely tested on in-house prepared MH
and MH-F plates (212 and 125 batches, respectively, including 11 different batches of MH agar from four manufacturers). For each strain-agent
combination, the inhibition zone was read once daily. Altogether, 15 laboratory technicians were involved in setting up and reading tests. Thick black
lines show EUCAST QC limits. (a) S. aureus ATCC 29213 with erythromycin 15 lg disk on MH agar (n = 697 with eight zone diameters (1.1%) out
of range). (b) S. pneumoniae ATCC 49619 with erythromycin 15 lg disk on MH-F agar (n = 707 with 16 zone diameters (2.3%) out of range). (c)
S. aureus ATCC 29213 with rifampicin 5 lg disk on MH agar (n = 695 with 12 zone diameters (1.7%) out of range). (d) S. pneumoniae ATCC 49619
with rifampicin 5 lg disk on MH-F agar (n = 704 with 29 zone diameters (4.1%) out of range). (e) S. aureus ATCC 29213 with
trimethoprim-sulphamethoxazole 25 lg disk on MH agar (n = 674 with 37 zone diameters (5.5%) out of range). (f) S. pneumoniae ATCC 49619
with trimethoprim-sulphamethoxazole 25 lg disk on MH-F agar (n = 705 with seven zone diameters (1.0%) out of range).

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Clinical Microbiology and Infection ª2013 European Society of Clinical Microbiology and Infectious Diseases, CMI, 20, O255–O266
O260 Clinical Microbiology and Infection, Volume 20 Number 4, April 2014 CMI

Campylobacter jejuni and coli with all agents and for enterococci 25922, Pseudomonas aeruginosa ATCC 27853 and S. aureus
with glycopeptides). ATCC 25923, were generated using CLSI disk contents.
Repeated testing was performed with a total of five different
Reading of zones batches of MH agar from three manufacturers (two batches
In any disk diffusion test, the reading of zones is the most from Oxoid, two from BBL and one from bioMerieux) and disks
difficult variable to standardize. Reading of zones includes from Oxoid. For each recommended CLSI zone diameter range,
measuring the zone diameter, inspecting the zone edge and the a median value was calculated (the ‘CLSI target’). The measured
detection of colonies within the inhibition zone. For some mean inhibition zone diameters were compared with the ‘CLSI
organism-agent combinations (e.g. S. aureus and benzylpenicil- targets’. All mean values were within 2 mm of the ‘CLSI
lin) a sharp zone edge indicates the presence, and for others targets’, with the majority being within 1 mm (Table 3).
(e.g. enterococci and vancomycin) the absence, of a resistance As part of the validation of materials and testing conditions
mechanism. Excluding contamination, the presence of growth (as described above), tests to establish control ranges were
within a zone may be due to resistance, but for some performed for (i) S. aureus ATCC 29213 and E. faecalis ATCC
organism-agent combinations is typical for susceptible strains 29212 on MH, (ii) S. pneumoniae ATCC 49619 and H. influen-
(e.g. Stenotrophomonas maltophilia with trimethoprim-sulpha- zae NCTC 8468 on MH-F, (iii) additional antimicrobial agents
methoxazole). In order to improve standardization of reading, and (iv) agents with a different disk content to CLSI (EUCAST
EUCAST has published reading guidelines in the EUCAST disk disk content). All other test characteristics were identical to
diffusion test manual [12] and illustrative pictures in the those used for the CLSI control strains. From these tests,
EUCAST reading guide [13]. EUCAST quality control ranges were calculated as described in
the section on establishment of EUCAST quality control
ranges (see below). Batches of MH agar from additional
Accuracy and Reproducibility
manufacturers (Bio-Rad, MAST and Liofilchem) were subse-
quently tested when available. Disks from one or more
Validation of accuracy using available quality control criteria additional manufacturer (BD, Bio-Rad, I2a, Liofilchem, MAST,
The technical aspects of the EUCAST [12] and the CLSI [10] disk Oxoid and Rosco) were tested if there was a difference of
diffusion methodologies are almost identical for non-fastidious >1 mm between CLSI and EUCAST results.
organisms and EUCAST has checked and then adopted several
of the quality control strains and the criteria recommended by Reproducibility
CLSI. There is a small difference in the standard incubation time, The reproducibility of the EUCAST disk diffusion test was
16–18 h in the CLSI method and 16–20 h in the EUCAST investigated by analysis of data for quality control strains and
method, and for a few agents EUCAST recommends lower disk data for clinical isolates tested between 2009 and 2012 at the
contents than CLSI (Table 2). In order to validate materials and Department of Clinical Microbiology, V€axj€ o Central Hospital,
testing conditions used for the EUCAST disk diffusion test, Sweden, which was the first laboratory where the EUCAST
inhibition zones for CLSI quality control strains, E. coli ATCC methodology was implemented. A total of 212 and 125 in-house
prepared batches of MH and MH-F agar plates, respectively,
TABLE 2. Differences in disk content between EUCAST and (including a total of 11 different batches of MH agar from four
CLSI disk diffusion methods manufacturers) were used in routine antimicrobial susceptibility
Antimicrobial agenta EUCAST disk content CLSI disk content TABLE 3. Comparison of EUCAST mean zone diametersa
Benzylpenicillin 1 unit 10 units and ‘target values’b for CLSI recommended quality control
Ampicillin 2 and 10 lgb 10 lg
Amoxicillin-clavulanate 2–1 and 20–10 lgc 20–10 lg strains
Piperacillin 30 lg 100 lg
Piperacillin-tazobactam 30–6 lg 100–10 lg Number of antimicrobial agents/total
Cefotaxime 5 lg 30 lg number of agents tested
Ceftaroline 5 lg 30 lg
Ceftazidime 10 lg 30 lg
E. coli P. aeruginosa S. aureus
Gentamicin (test for HLAR) 30 lg 120 lg
Vancomycin 5 lg 30 lg ATCC 25922 ATCC 27853 ATCC 25923
Linezolid 10 lg 30 lg
Nitrofurantoin 100 lg 300 lg ≤2 mm from ‘CLSI target’ 29/29 15/15 31/31
≤1 mm from ‘CLSI target’ 24/29 10/15 30/31
HLAR, high-level aminoglycoside resistance. =CLSI target 8/29 3/15 9/31
a
Ceftriaxone 30 lg and cefepime 30 lg are also under consideration for lower
disk contents in the EUCAST disk diffusion test. a
EUCAST mean values were each calculated from a total of ≥20 separate tests on
b
2 lg for Haemophilus influenzae, Pasteurella multocida, Listeria monocytogenes, MH agar from Oxoid (two batches), BBL (two batches) and bioMerieux (one
Staphylococcus saprophyticus and streptococci. batch).
c
2–1 lg for Haemophilus influenzae, Moraxella catarrhalis and Pasteurella multocida. b
Median values of published CLSI control zone diameter ranges.

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Clinical Microbiology and Infection ª2013 European Society of Clinical Microbiology and Infectious Diseases, CMI, 20, O255–O266
CMI Matuschek et al. The EUCAST disk diffusion testing method O261

tests during this time period, and inhibition zones were read by (a) 25
a total of 15 different technicians. Several lots of antimicrobial 2009
20 2010
disks (≥5 per agent) were used during this time period. Of the No. of isolates
2009: 4449 2011
investigated 48 combinations of quality control strains and

% isolates
2010: 5313 2012
15
antimicrobial agents, most showed excellent reproducibility 2011: 5470
2012: 4703
with random variation within the control range and very few 10
zone diameters out of range (e. g. Fig. 1). For control ranges
established by EUCAST, only four combinations had >5% 5
readings out of range, S. aureus ATCC 29213 with trimetho-
prim-sulphamethoxazole (5.5%), S. pneumoniae ATCC 49619 0
6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40
with tetracycline (5.2%) and H. influenzae NCTC 8468 with
Inhibition zone diameter (mm)
cefotaxime (6.7%) and trimethoprim-sulphamethoxazole
(8.8%). Of these, H. influenzae with trimethoprim-sulphameth- (b) 25
2009
oxazole has been shown to be particularly sensitive to variation
20 2010
in media (manufacturer and batch), presumably due to varying No. of isolates 2011
2009: 2539
content of thymidine. However, testing of clinical isolates

% isolates
2010: 2952 2012
15
(n = 147) on MH-F agar prepared with MH from Oxoid and 2011: 2707
2012: 2448
BBL resulted in similar susceptibility categorization with only a 10
few minor errors for both media. For clinical isolates, annual
zone diameter distributions for 2009–2012 were very similar 5
for all organism-antimicrobial agent combinations tested, with
medians within 1 mm (e. g. Fig. 2). 0
6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40
Inhibition zone diameter (mm)
Quality Control Criteria (c) 25
2009
2010
20 No. of isolates
Following testing of control strains as described above, EUCAST 2009: 280 2011
% isolates

has, when possible, adopted the CLSI criteria for quality control
strains for disk diffusion tests [11]. In cases where EUCAST
recommendations for strains, medium or disk contents are
different from those of CLSI, EUCAST has developed separate
criteria. EUCAST quality control tables list both acceptable
ranges and target values (Table 4). The targets are based on the
median value of the CLSI range and have been checked for
accuracy during the development of the EUCAST methodology
as described above. A few discrepancies between the ‘CLSI
targets’ and the EUCAST results have been identified (e.g. E. coli
ATCC 25922 with meropenem 10 lg disks and P. aeruginosa
ATCC 27853 with gentamicin 10 lg and tobramycin 10 lg
disks). When discrepancies have been confirmed in tests in
multiple laboratories, some of these have been revised in
collaboration with the CLSI (e. g. P. aeruginosa with gentamicin
10 lg and tobramycin 10 lg disks) [11].
Establishment of EUCAST quality control ranges
When there were no CLSI quality control criteria, targets and
ranges were developed by EUCAST. The targets were initially
based on the mean values of 20 separate tests for each
strain-agent combination, using a total of five different batches
of MH agar from three manufacturers (two batches from
15
2010: 341 2012
2011: 301
2012: 313
10
5
0
6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40
Inhibition zone diameter (mm)
FIG. 2. Reproducibility of the EUCAST disk diffusion method as
illustrated by three comparisons of annual zone diameter distributions.
For each organism-antimicrobial agent combination, the distributions
are highly reproducible with similar medians and ranges. (a) E. coli vs.
cefotaxime 5 lg. (b) S. aureus vs. cefoxitin 30 lg. (c) S. pneumoniae vs.
tetracycline 30 lg.
Oxoid, two from BBL and one from bioMerieux) and disks
from Oxoid. All testing was performed in parallel with testing
of the CLSI control strains as described above. EUCAST
control ranges were based on mean values 2 SD, with a
minimum range of 3 mm. All targets and ranges were
re-evaluated with additional media and disk batches from a
range of manufacturers. Control criteria were revised when
there were data to support a change, and since version 1.0 of

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Clinical Microbiology and Infection ª2013 European Society of Clinical Microbiology and Infectious Diseases, CMI, 20, O255–O266
O262 Clinical Microbiology and Infection, Volume 20 Number 4, April 2014 CMI

the EUCAST QC tables, 11 zone diameter ranges have been
slightly modified.
Establishment of Zone Diameter
Breakpoints Calibrated to the EUCAST
Clinical MIC Breakpoints
For most antimicrobial agents, there is good correlation
between MIC values and inhibition zone diameters [8,16].
This is especially true when species-specific correlations are
calculated. The establishment of EUCAST clinical MIC
breakpoints is described elsewhere [17–19] and techniques
for establishing zone diameter breakpoint correlates have
recently been reviewed by Kronvall et al. [20]. We utilize
several of these techniques when establishing species-specific
(e.g. for S. pneumoniae and H. influenzae) or group-specific
(e.g. for Enterobacteriaceae and staphylococci) zone diame-
ter breakpoints calibrated to the EUCAST clinical MIC
breakpoints. MIC-zone diameter correlates and MIC and
zone diameter distributions were analysed. Large series of
MIC determinations and parallel disk diffusion tests (100–
1000 per organism-antimicrobial agent combination) were
performed at the EUCAST Laboratory of Antimicrobial
Susceptibility Testing in collaboration with several other
laboratories. In addition, we have had access to MIC-zone
diameter distributions produced with CLSI methodology
(courtesy of Dr R.N. Jones at JMI Laboratories, North
Liberty, Iowa, USA).
Determination of epidemiological cut-off (ECOFF) values
from wild-type MIC and zone diameter distributions
The use of wild-type MIC distributions to distinguish wild-type
isolates from those with acquired resistance mechanisms and
to establish ECOFFs has been described by Kahlmeter et al.
[7]. The MIC distributions in the EUCAST database are based
on more than 50 000 isolates for some antimicrobial
agent-organism combinations. These MIC distributions are
composed of collated data from a large number of investiga-
tors and laboratories. The zone diameter distributions, all
from tests performed with the EUCAST disk method as
described in this paper, were originally all from the EUCAST
Laboratory for Antimicrobial Susceptibility Testing, but data
from other laboratories using the EUCAST disk diffusion test
have been added subsequently. By analysis of MIC and zone
diameter distributions, we have defined wild-type distributions
from which MIC and zone diameter epidemiological cut-off
values (ECOFFs) were established (e.g. Fig. 3b) [21].
Calibrating inhibition zone diameters to MIC values and/or
resistance mechanisms
The zone diameter breakpoints were established by performing
simultaneous MIC determination and disk diffusion tests on 10–
1000 isolates per species, particularly isolates with MIC values
close to EUCAST breakpoints or inhibition zone diameters close
to the low end of the wild-type population. When establishing
EUCAST zone diameter breakpoints, MIC determination was
performed by both reference methodology (i.e. broth microdi-
lution according to the International Standards Organisation

TABLE 4. Excerpt from the EUCAST routine quality control tables version 3.0
Escherichia coli ATCC 25922
(NCTC 12241, CIP 76.24, DSM 1103, CCUG 17620, CECT 434)

Mueller-Hinton agar, McFarland 0.5, air, 35±1ºC, 18±2h. Read zone edges as the point showing no
growth viewed from the back of the plate against a dark background illuminated with reflected light.
Inhibition zone diameter
MIC (mg/L) (mm)

Antimicrobial agent Targeta Rangeb Disk content (lg) Targeta Rangec

Amikacin 1–2 0.5–4 30 23 19–26

Cefadroxil – – 30 17 14–20
Cefotaxime 0.06 0.03–0.12 5 28 25–31
Cefoxitin 4 2–8 30 26 23–29
Ceftriaxone 0.06 0.03–0.12 30 32 29–35
Cefuroxime 4 2–8 30 23 20–26
Ciprofloxacin 0.008 0.004–0.015 5 35 30–40
Gentamicin 0.5 0.25–1 10 23 19–26
Meropenem 0.015–0.03 0.008–0.06 10 31 28–34
Piperacillin-tazobactam 2/4 1/4–4/4 30–6 24 21–27
Tobramycin 0.5 0.25–1 10 22 18–26
Trimethoprim 1 0.5–2 5 25 21–28
Trimethoprim-sulphamethoxazole ≤0.5/9.5b – 1.25–23.75 26 23–29
a
Calculated by EUCAST.
b
From the International Standards Organisation, ISO 20776-1: 2006, except ranges in bold/italics established by EUCAST.
c
From the Clinical and Laboratory Standards Institute, M100-S22: 32:3, 2012, except ranges in bold/italics established by EUCAST. All ranges have been validated
by EUCAST.

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Clinical Microbiology and Infection ª2013 European Society of Clinical Microbiology and Infectious Diseases, CMI, 20, O255–O266
CMI Matuschek et al. The EUCAST disk diffusion testing method O263

Tobramycin 10 μg vs. MIC

S. aureus, 100 clinical isolates
(a)
18
16
14
MIC
(mg/L)

No of isolates
12
≥8
10 4
8 2
1
6 0.5
4 0.25

2
0
10
12
14
16
18
20
22
24
26
28
30
32
34
36
38
40
6
8

Inhibition zone diameter (mm)

(b)

FIG. 3. Examples of MIC-zone diameter correlations for S. aureus vs. tobramycin 10 lg as used by EUCAST to determine and validate zone
diameter breakpoints. (a) Inhibition zone diameter distribution with corresponding MIC values represented as different coloured bars, as presented
on the EUCAST website http://www.eucast.org/eucast_disk_diffusion_test/calibration_and_validation/. (b) Inhibition zone diameter distribution
(aggregated clinical data from several test sites) and MIC correlates from Figure 3(a) and additional data from multiple sources, as presented in the
EUCAST MIC and zone diameter distribution database http://mic.eucast.org/Eucast2/.

(ISO) standard [22]) and other methodologies calibrated to the
ISO method (e.g. broth microdilution with media supplemented
for fastidious organisms [23,24] and gradient MIC tests). When
possible, isolates with known resistance mechanisms (e.g.
ESBL-producing Enterobacteriaceae, Staphylococcus spp. positive
for mecA and Enterococcus spp. positive for vanA and vanB) have
been used to test the breakpoints. Correlations of MICs and
zone diameters for a wide range of organisms and antimicrobial
agents are presented on the EUCAST website in two formats.
Firstly, as zone diameter bar charts in which bars are subdivided
with each MIC value plotted in a colour representing a specific
MIC value [16] (e.g. Fig. 3a) and, secondly, as MIC-zone diameter
distributions on the zone diameter distribution website [25] (e.g.
Fig. 3b). Several MIC-zone diameter distributions are the result
of collaborations with other laboratories, both within and
outside Europe. An important principle in the setting of clinical
breakpoints by EUCAST is, when possible, to avoid setting
breakpoints that divide wild-type distributions of target species
[7]. The same principle was applied to the zone diameter
breakpoints by checking breakpoints indicated by the MIC-zone
diameter correlations against zone diameter distributions for
clinical isolates [25].
EUCAST Breakpoint Tables
The EUCAST clinical breakpoint tables v 1.0, with tentative zone
diameter breakpoints, were published on the EUCAST website

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Clinical Microbiology and Infection ª2013 European Society of Clinical Microbiology and Infectious Diseases, CMI, 20, O255–O266
O264 Clinical Microbiology and Infection, Volume 20 Number 4, April 2014
in December 2009. The breakpoint tables are revised yearly and
are published for consultation on the website early in December
each year. The finalized revised version is published on 1 January
each year and contains revisions of existing breakpoints,
breakpoints for added species or new antimicrobial agents.
Should there be an urgent need for changing or adding
breakpoints during a year, these are published in an addendum.
EUCAST clinical breakpoint tables present clinical MIC break-
points expressed as S ≤ X mg/L, R > X mg/L and zone diam-
eter breakpoints expressed as S ≥ X mm, R < X mm. The
intermediate category is not spelled out and is inferred from the
susceptible and resistant breakpoints. Relevant background data
on antimicrobial agents and breakpoints, as well as relevant MIC
and zone diameter distributions, can be accessed via links in the
table on the EUCAST website, where antimicrobial agent names
are linked to EUCAST rationale documents, and MIC and zone
diameter breakpoints are linked to MIC and zone diameter
distributions, respectively.
Implementation of the EUCAST Disk
Diffusion Test in Routine Clinical
Microbiology Laboratories
Changing from another method to the EUCAST standardized
disk diffusion test is not difficult, but needs planning. In order
to facilitate this process, EUCAST has published an implemen-
tation guide on the EUCAST website [26]. A few important
aspects are highlighted and discussed below.
How to select and prepare Mueller–Hinton medium
MH agar may vary between manufacturers and between
batches from the same manufacturer and each batch of MH
agar used for disk diffusion testing should be tested to ensure
that inhibition zone diameters for antimicrobial agents are
within EUCAST quality control limits for agents that are used
routinely in the laboratory. Laboratories making their own
media are encouraged to obtain test samples and to ensure
that the new batch meets the quality control criteria prior to
buying a large quantity of a batch. By extensively testing a new
batch and then purchasing large quantities, the laboratory can
ensure long periods of consistent quality. Each new batch of
MH agar, disks or supplements should be tested to ensure that
inhibition zones for all antimicrobial agents that are part of
routine panels are within the acceptable ranges defined in the
EUCAST quality control tables.
Agar depth and supplements for fastidious organisms must
be consistently as defined for the method. The agar depth
should be 4.0  0.5 mm and systematic use of plates that are
close to the limits, particularly the lower limit, is more likely to
ª2013 The Authors
Clinical Microbiology and Infection ª2013 European Society of Clinical Microbiology and Infectious Diseases, CMI, 20, O255–O266
CMI
result in errors due to variation in medium depth. It is crucial
that the horse blood is mechanically, not chemically, defibrin-
ated and it must not be lysed. Chemical defibrination will result
in inhibition zone diameters out of range for some organ-
ism-antimicrobial agent combinations. For b-NAD, a purity of
≥98% should be used to ensure adequate growth of H. influ-
enzae and to minimize batch-to-batch variation. Several
manufacturers provide b-NAD of required purity.
Preparation and incubation of plates
Inoculation of agar plates with the standardized organism
suspension can be performed either by hand or by using a plate
rotator. Safety regulations prohibit the use of flooding, which
may result in splashing and/or production of aerosols of
concentrated bacteria. Regardless of whether plates are
inoculated by hand or by use of a rotating device, it is
important to achieve an even confluent growth for all
organisms tested. For Gram-negative organisms, it is particu-
larly important to avoid over-inoculation. This is best achieved
by removing excess fluid from the swab before streaking the
plates. The growth should be even over the agar surface and
jagged zone edges indicate uneven inoculation. Furthermore, it
is important not to exceed the incubation period of 16–20 h
because prolonged incubation often results in indistinct zone
edges or colonies within the inhibition zones, which might
result in reporting isolates as falsely resistant. When testing
H. influenzae, it is also important to remove excess moisture
before inoculation of plates. If condensation can be seen on the
inside of the lid, fuzzy zone edges and/or hazes within zones
are more likely to be seen with some isolates.
Reading of inhibition zones
When implementing the EUCAST disk diffusion test, training in
the reading of zones is essential to ensure consistent reading
between technologists. This is best achieved by introducing
regular exercises where all laboratory staff read inhibition zones
from the same plate with EUCAST quality control strains. The
mean and variation of all readings can be compared with the
target values and the ranges published in the quality control
tables [15]. From experiments performed with staff in routine
laboratories we know that standardized reading to within
1 mm can be achieved among 15–20 technologists. The
quality of reading can furthermore be assessed by comparing
the ranges and medians of in-house zone diameter distributions
(n ≥ 50) for routine clinical isolates with those published by
EUCAST [25]. For wild-type isolates, the median and width of
the in-house distribution should match that of the EUCAST
distribution. Wild-type distributions with a median that deviates
more than 2 mm from the EUCAST target clearly indicate a
systematic difference between the in-house and the recom-
CMI Matuschek et al.
mended method. Wild-type distributions that are wider than
the reference distribution are normally the result of variation in
reading of zones among staff. This is also likely to be the reason
for irregular wild-type distributions. The EUCAST reading guide
[13] contains specific instructions and illustrative pictures and is
recommended for use during implementation of the EUCAST
disk diffusion test and also for continued education of staff.
Routine quality control
Several factors affect inhibition zone sizes, including the medium,
preparation of agar plates, inoculum density, age of colonies,
quality of disks, incubation temperature, incubation time and
reading of zone diameters [1,8,9]. Variations in zone diameters
can be due to either in-house factors, such as inadequate
training, inconsistency in reading results or inadequate control
of equipment or reagents, or to external factors such as variation
between batches of media or disks. Variation caused by a change
in medium or other reagents should have been detected by
testing before these were accepted for routine use. Strictly
controlling the in-house variation provides confidence when
diagnosing and dealing with external reasons for variation. The
EUCAST Laboratory for Antimicrobial Susceptibility Testing in
V€axj€
o may be contacted for assistance in investigation of the
cause of unexplained variation.
Repeat testing of EUCAST control strains as part of
consecutive daily or weekly quality control can be expected to
yield individual values randomly distributed within the recom-
mended range and with a mean within 1 mm of the EUCAST
target if the number of tests is ≥10. A systematic deviation of
the mean value, above or below the target for several agents,
should be investigated. Guidelines for investigation of quality
control results out of range or changes in trends over time are
available in the EUCAST disk diffusion test manual [12].
The ranges for the quality control strains are set to
accommodate some variation between media and disks and
repeated testing of quality control strains is sometimes not
sufficient to detect specific problems [27], which may be
detected by comparison of results with reference distribu-
tions. Comparison of the median and range of zone diameter
distributions from a laboratory with the reference distribu-
tions available on the EUCAST website [25] can be more
effective than testing of quality control strains for detection of
systematic errors, or problems with disks or media, as well as
problems with specific organism-antimicrobial agent combina-
tions. Examples are shown in Fig. 4, where zone diameter
distributions from 17 Swedish laboratories are compared with
the EUCAST reference distribution. The highlighted distribu-
tion is from a laboratory with excellent reproducibility but
with a systematic deviation from the reference distribution.
Systematic differences in median values compared with the
Clinical Microbiology and Infection ª2013 European Society of Clinical Microbiology and Infectious Diseases, CMI, 20, O255–O266
The EUCAST disk diffusion testing method O265
35
30
25
% isolates
20
15
10
5
0
6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40
Inhibition zone diameter (mm)
FIG. 4. Inhibition zone diameter distributions for E. coli with cefo-
taxime 5 lg based on consecutive clinical isolates from 17 Swedish
laboratories using the EUCAST disk diffusion method. The EUCAST
reference zone diameter distribution is shown as a thick black line.
Systematic deviations can be detected by comparing the median and
range of each graph with the reference distribution. One deviating
laboratory is highlighted in blue.
reference distributions will result in erroneous susceptibility
categorization, especially for organism-antimicrobial agent
combinations where there are resistant isolates with zone
diameters close to the susceptible zone diameter breakpoint.
The Future of the EUCAST Disk Diffusion
Test
Since 2011, more and more countries, mainly in Europe, have
adopted the EUCAST clinical breakpoints and the EUCAST disk
diffusion test. EUCAST encourages laboratories with expertise
in susceptibility testing to participate in a network of collabo-
rating laboratories interested in contributing to the develop-
ment and maintenance of the disk diffusion test. With this
network, the financial support of the European Society of
Clinical Microbiology and Infectious Diseases (ESCMID) and the
support and interest of National Antimicrobial Susceptibility
Testing Committees (NACs), the future of the EUCAST disk
diffusion method is secured. Automated susceptibility testing
may relieve laboratories of some AST work, but their lack of
versatility, the unavailability of some agents and tests for some
species, and their long development times, still favour the use of
disk diffusion testing for many years to come. All documents and
data on the EUCAST website are freely available.
Acknowledgements
The authors would like to thank Jenny 
Ahman, Stina Bengtsson
and Anna Petersson, Department of Clinical Microbiology,
ª2013 The Authors
O266 Clinical Microbiology and Infection, Volume 20 Number 4, April 2014
V€axj€
o Central Hospital, Sweden, for technical assistance. This
work was funded by The European Society for Clinical
Microbiology and Infectious Diseases (ESCMID).
Transparency Declaration
EM is clinical scientist at the EUCAST Antimicrobial Suscept-
ibility Testing Laboratory. GK and DB are, respectively, Clinical
Data Coordinator and Scientific Secretary of EUCAST. DB is a
consultant for UKNEQAS. DB and GK are members of the
UKNEQAS Microbiology Steering Committee and the Specialist
Advisory Group for Antimicrobial Susceptibility Testing.
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 European Committee on Antimicrobial Susceptibility Testing
Breakpoint tables for interpretation of MICs and zone diameters
Version 13.0, valid from 2023-01-01
This document should be cited as "The European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs and zone diameters.
Version 13.0, 2023. http://www.eucast.org."

Content Page Additional information

Changes 1
Notes 6
Guidance on reading EUCAST Breakpoint Tables 8
Dosages used to define breakpoints 9
Information on technical uncertainty 13
Enterobacterales 15
Pseudomonas spp. 22
Stenotrophomonas maltophilia 27 Link to Guidance Document on Stenotrophomonas maltophilia
Acinetobacter spp. 29
Staphylococcus spp. 34
Enterococcus spp. 41
Streptococcus groups A, B, C and G 46
Streptococcus pneumoniae 51
Viridans group streptococci 57
Haemophilus influenzae 62
Moraxella catarrhalis 68
Neisseria gonorrhoeae 72
Neisseria meningitidis 76
Anaerobic bacteria 80
Helicobacter pylori 83
Listeria monocytogenes 84
Pasteurella spp. 86
Campylobacter jejuni and C. coli 88
Corynebacterium spp. other than C. diphtheriae and C. ulcerans 89
Corynebacterium diphtheriae and C. ulcerans 91
Aerococcus sanguinicola and A. urinae 93
Kingella kingae 95
Aeromonas spp. 97
Achromobacter xylosoxidans 99
Vibrio spp. 100
Bacillus spp. 102
Content Page Additional information
Burkholderia pseudomallei 104
Burkholderia cepacia complex 106 Link to Guidance Document on Burkholderia cepacia complex
Legionella pneumophila 107 Link to Guidance Document on Legionella pneumophila
Mycobacterium tuberculosis 108
Topical agents 109 Link to Guidance Document on Topical Agents
PK-PD (Non-species related) breakpoints 110
Expert Rules - Link to EUCAST Expert Rules and Expected Phenotypes
Detection of Resistance Mechanisms - Link to EUCAST Guidelines on Detection of Resistance Mechanisms
Antimicrobial susceptibility tests on groups of organisms or agents Link to Guidance Document on how to test and interpret results when there
-
for which there are no EUCAST breakpoints are no breakpoints
Guidance on breakpoints in brackets - Link to Guidance Document on breakpoints in brackets
Guidance on screening tests - Link to Guidance Document on screening tests
EUCAST Reading Guide for broth microdilution - Link to EUCAST Reading Guide for broth microdilution
EUCAST Reading Guide for disk diffusion - Link to EUCAST Reading Guide for disk diffusion
 European Committee on Antimicrobial Susceptibility Testing
Breakpoint tables for interpretation of MICs and zone diameters
Version 13.0, valid from 2023-01-01
Changes (cells containing a change, a deletion or an addition) from v. 12.0 are marked yellow.
Version 13.0, 2023-01-01
Changed comments are underlined. Removed comments are shown in strikethrough font style.
General • The explanation of "off scale" breakpoints used to categorise wild-type organisms as "Susceptible, increased exposure" (I) has been removed and a link to the
Notes sheets for "Abbreviations and explanations of breakpoints" has been added in all sheets.
• Ticarcillin removed from all tabs.
Notes • Note 7: Explanation of dash ("-") updated.
Dosages General
• Name of sheet updated for clarification
• Explanation of dosages sheet updated
New dosages
• Ampicillin-sulbactam oral
• Netilmicin
Revised dosages
• Oxacillin
• Cloxacillin
• Dicloxacillin
• Flucloxacillin
• Teicoplanin
• Clarithromycin
• Erythromycin
• Clindamycin
• Quinupristin-dalfopristin
• Doxycycline
• Tetracycline
• Fosfomycin iv
• Fusidic acid
• Metronidazole
New comments
• Cefepime
• Aztreonam
• Ciprofloxacin
• Moxifloxacin
• Linezolid
• Trimethoprim-sulfamethoxazole
Revised comments
• Cloxacillin
• Flucloxacillin
• Chloramphenicol
Removed comments
• Oxacillin
• Dicloxacillin

1
 Changes (cells containing a change, a deletion or an addition) from v. 12.0 are marked yellow.
Version 13.0, 2023-01-01
Changed comments are underlined. Removed comments are shown in strikethrough font style.
Enterobacterales General
• Indications added to ampicillin, ampicillin-sulbactam, amoxicillin and amoxicillin-clavulanic acid
• Indication added to cefaclor
• New indications related to meningitis for ciprofloxacin
• Species information added for pefloxacin (screen only)
New breakpoints
• Ampicillin iv and oral (MIC and zone diameter)
• Ampicillin-sulbactam iv and oral (MIC and zone diameter)
• Amoxicillin iv and oral (MIC)
• Amoxicillin-clavulanic acid iv and oral (MIC and zone diameter)
• Ciprofloxacin (meningitis) [MIC]
Revised breakpoints
• Cefaclor (changed to IE)
• Norfloxacin (zone diameter)
• Chloramphenicol (MIC and zone diameter, changed to Note)
New ATUs
• Imipenem-relebactam (zone diameter)
New comments
• Penicillins comment 3/D
• Penicillins comment C
• Penicillins comment E
• Fluoroquinolones comment 2/B
• Miscellaneous agents comment 4
Revised comments
• Penicillins comment 1
• Penicillins comment B
• Macrolides comment 1
• Tetracyclines comment 3/A
• Miscellaneous agents comment 1/A
Pseudomonas spp. Revised breakpoints
• Fosfomycin iv (changed to Note)
Revised comments
• Miscellaneous agents comment 3

2

Version 13.0, 2023-01-01
Staphylococcus spp.
Enterococcus spp.
Streptococcus groups A, B, C and G
Changes (cells containing a change, a deletion or an addition) from v. 12.0 are marked yellow.
Changed comments are underlined. Removed comments are shown in strikethrough font style.
Revised breakpoints
• Clarithromycin (MIC)
• Erythromycin (MIC and zone diameter)
• Roxithromycin (MIC)
• Quinupristin-dalfopristin (MIC and zone diameter)
• Doxycycline (MIC)
• Tetracycline (MIC and zone diameter)
• Chloramphenicol (changed to IE)
• Rifampicin (zone diameter breakpoints specific for S. aureus and coagulase-negative staphylococci)
Removed breakpoints
• Erythromycin (screen only) [no longer needed with the new revision of macrolide breakpoints]
• Tetracycline (screen only) [no longer needed with the new revision of tetracycline breakpoints]
New comments
• Miscellaneous agents comment 3
Revised comments
• Penicillins comment B
• Cephalosporins comment B
• Miscellaneous agents comment 4
Removed comments
• Miscellaneous agents comment 1
General
• Text on species included updated
Revised breakpoints
• Quinupristin-dalfopristin (MIC and zone diameter)
Revised comments
• Penicillins comment 2/A
Revised breakpoints
• Azithromycin (MIC)
• Clarithromycin (MIC)
• Erythromycin (MIC and zone diameter)
• Roxithromycin (MIC)
• Telithromycin (MIC and zone diameter)
• Doxycycline (MIC)
• Tetracycline (MIC and zone diameter)
• Chloramphenicol (changed to IE)
Removed breakpoints
• Tetracycline (screen only) [no longer needed with the new revision of tetracycline breakpoints]
New comments
• Miscellaneous agents comment 3
Revised comments
• Penicillins comment 1/A
• Macrolides comment 1/A
Removed comments
• Miscellaneous agents comment 1
3

Version 13.0, 2023-01-01
Streptococcus pneumoniae
Viridans group streptococci
Haemophilus influenzae
Changes (cells containing a change, a deletion or an addition) from v. 12.0 are marked yellow.
Changed comments are underlined. Removed comments are shown in strikethrough font style.
Revised breakpoints
• Cefpodoxime (MIC)
• Cefuroxime oral (MIC)
• Azithromycin (MIC)
• Clarithromycin (MIC)
• Erythromycin (MIC and zone diameter)
• Roxithromycin (MIC)
• Telithromycin (MIC and zone diameter)
• Doxycycline (MIC)
• Tetracycline (MIC and zone diameter)
• Chloramphenicol (MIC and zone diameter, changed to Note)
Removed breakpoints
• Tetracycline (screen only) [no longer needed with the new revision of tetracycline breakpoints]
Revised comments
• Macrolides comment 1/A
• Miscellaneous agents comment 1/A
Removed comments
• Penicillins comment B, cephalosporins comment B and carbapenems comment C (removed since the recommendation is not specific for meningitis and the
information is available in the flow chart)
General
• Information on species included updated
Revised breakpoints
• Benzylpenicillin (zone diameter)
• Benzylpenicillin (screen only) [zone diameter]
Revised comments
• Fluoroquinolones comment 1/B
• Miscellaneous agents comment 1/A
General
• New indications related to meningitis for ciprofloxacin
New breakpoints
• Ciprofloxacin (meningitis) [MIC and zone diameter]
Revised breakpoints
• Doxycycline (MIC)
Revised ATUs
• Piperacillin-tazobactam (zone diameter)
New comments
• Fluoroquinolones comment B
Removed comments
• Cephalosporins comment D and carbapenems comment D (removed since the recommendation is not specific for meningitis and the information is available in the
flow chart)
4
 Changes (cells containing a change, a deletion or an addition) from v. 12.0 are marked yellow.
Version 13.0, 2023-01-01
Changed comments are underlined. Removed comments are shown in strikethrough font style.
Moraxella catarrhalis Revised breakpoints
• Cefixime (MIC and zone diameter)
• Azithromycin (MIC)
• Clarithromycin (MIC)
• Erythromycin (MIC and zone diameter)
• Roxithromycin (MIC)
• Telithromycin (MIC and zone diameter)
• Doxycycline (MIC)
Revised comments
• Macrolides comment 1/A
Neisseria gonorrhoeae Revised breakpoints
• Tetracycline (MIC)
Neisseria meningitidis General
• New indications for ciprofloxacin
Revised breakpoints
• Ciprofloxacin (MIC)
Anaerobic bacteria General
• Clarification on the media used for anaerobic bacteria to the methodology section at the top of the table.
• Information added on species included for Bacteroides spp.
Helicobacter pylori Revised breakpoints
• Clarithromycin (MIC)
Listeria monocytogenes New breakpoints
• Moxifloxacin (meningitis) [IE]
• Linezolid (meningitis) [IE]
Pasteurella spp. General
• Other species of Pasteurella included and name of table changed from "Pasteurella multocida" to "Pasteurella spp."
• Text on species included added
Corynebacterium spp. General
• Name of table changed to "Corynebacterium spp. other than C. diphtheriae and C. ulcerans "
Revised breakpoints
• Rifampicin (MIC and zone diameter)
Removed breakpoints
• Erythromycin
Corynebacterium diphtheriae and C. ulcerans • New table
Vibrio spp. Revised breakpoints
• Pefloxacin (screen only) [zone diameter]
• Trimethoprim-sulfamethoxazole (MIC and zone diameter)
Revised comments
• Macrolides comment 1/A
• Tetracyclines comment 1/A
Mycobacterium tuberculosis Revised breakpoints
• Pretomanid (changed to Note)
Revised comments
• Comment 2
PK-PD breakpoints General
• Indication added to fosfomycin oral

5
 European Committee on Antimicrobial Susceptibility Testing
Breakpoint tables for interpretation of MICs and zone diameters
Version 13.0, valid from 2023-01-01
Notes
1. The EUCAST clinical breakpoint tables contain clinical MIC breakpoints (determined or revised during 2002-2022) and their inhibition zone diameter correlates. The EUCAST breakpoint
table version 13.0 includes corrected typographical errors, clarifications, breakpoints for new agents and/or organisms, revised MIC breakpoints and revised and new zone diameter
breakpoints. Changes are best seen on screen or on a colour printout since cells containing a change are yellow. New or revised comments are underlined. Removed comments are shown in
strikethrough font style.

2. PK-PD (Non-species related) breakpoints are listed separately.

3. Numbered notes relate to general comments and/or MIC breakpoints. Lettered notes relate to the disk diffusion method.

4. Antimicrobial agent names in blue are linked to EUCAST rationale documents. MIC and zone diameter breakpoints in blue are linked to the search page of the EUCAST MIC and zone
diameter distribution database.

5. The document is released as an Excel file suitable for viewing on screen and as an Acrobat pdf file suitable for printing. To utilize all functions in the Excel file, use Microsoft original
programs only. The Excel file enables users to alter the list of agents to suit the local range of agents tested. The content of single cells cannot be changed. Hide lines by right-clicking on the
line number and choose "hide". Hide columns by right-clicking on the column letter and choose "hide".

6. EUCAST breakpoints are used to categorise results into three susceptibility categories:
S - Susceptible, standard dosing regimen: A microorganism is categorised as Susceptible, standard dosing regimen, when there is a high likelihood of therapeutic success using a
standard dosing regimen of the agent.
I - Susceptible, increased exposure: A microorganism is categorised as Susceptible, increased exposure * when there is a high likelihood of therapeutic success because exposure to the
agent is increased by adjusting the dosing regimen or by its concentration at the site of infection.
R - Resistant: A microorganism is categorised as Resistant when there is a high likelihood of therapeutic failure even when there is increased exposure.
*Exposure is a function of how the mode of administration, dose, dosing interval, infusion time, as well as distribution and excretion of the antimicrobial agent will influence the infecting
organism at the site of infection.

7. Dash (“-“) in breakpoint tables indicates that the agent is unsuitable for treatment of systemic infections caused by the organism or group. For this reason EUCAST refrained from
determining breakpoints and recommend that the agent is not included in susceptibility test reports. If included, report resistant without prior testing.

8. "IE" indicates that there is insufficient evidence that the organism or group is a good target for therapy with the agent. An MIC with a comment but without an accompanying S, I or R
categorisation may be reported.

9. A screening test uses one agent to predict resistance or susceptibility to one or more antimicrobial agents in the same class. The screening test is often more sensitive and/or robust than
testing individual agents. Using a screening test will often reduce the number of tests needed in primary susceptibility testing since it will predict susceptibility and/or resistance to several
agents. Guidance on how to act on the screening test result is described in the Note related to each specific screening test.
Negative screening test: MIC below or equal to or zone diameter above or equal to the susceptible breakpoint for the screening agent. No resistance mechanisms to the antimicrobial class
detected.
Positive screening test: MIC above or zone diameter below the resistant breakpoint for the screening agent. Resistance mechanisms to the antimicrobial class detected.

6
Notes
10. For an agent and a species, the ECOFF (epidemiological cut-off) value is the highest MIC (or the smallest inhibition zone diameter) for organisms devoid of phenotypically detectable
acquired resistance mechanisms. Breakpoints in brackets are based on ECOFF values for relevant species. They are used to distinguish between organisms with and without acquired
resistance mechanisms. ECOFFs do not predict clinical susceptibility but in some situations and/or when the agent is combined with another active agent, therapy may be considered.

11. Breakpoints in brackets distinguish between isolates without and with phenotypically detectable resistance mechanisms. They are based on ECOFFs but since they may serve more than
one species, the value may represent a best fit. For these agents, clinical evidence as monotherapy is usually lacking but for a specific indication or in combination with another active agent or
measure they may still be used. Isolates with resistance can be reported R (resistant). Reporting S or I should be avoided and if considered necessary, there should be a comment to explain
the need for adjunctive measures as mentioned above.

12. An MIC breakpoint of S ≤ 0.001 mg/L is an arbitrary, "off scale" breakpoint (corresponding to a zone diameter breakpoint of "S ≥ 50 mm") which categorises wild-type organisms
(organisms without phenotypically detectable resistance mechanisms to the agent) as "Susceptible, increased exposure" (I). For these organism-agent combinations, never report
“Susceptible, standard dosing regimen” (S).

13. For some organism-agent combinations, results may be in an area where the interpretation is uncertain. EUCAST has designated this an Area of Technical Uncertainty (ATU). It
corresponds to an MIC value and/or zone diameter interval where the categorisation is doubtful. See separate page for more information on ATU and how to deal with results in the ATU.

14. In order to simplify the EUCAST tables, the "Susceptible, increased exposure" (I category) is not listed. It is interpreted as values between the S and the R breakpoints. For example, for
MIC breakpoints listed as S ≤ 1 mg/L and R > 8 mg/L, the I category is 2-8 (technically >1-8) mg/L, and for zone diameter breakpoints listed as S ≥ 22 mm and R < 18 mm, the I category is 18-
21 mm.

15. For Escherichia coli with fosfomycin, Staphylococcus aureus with benzylpenicillin, enterococci with vancomycin, Haemophilus influenzae with beta-lactam agents, Stenotrophomonas
maltophilia , Aeromonas spp., Achromobacter xylosoxidans and Burkholderia pseudomallei with trimethoprim-sulfamethoxazole, and for anaerobic bacteria in general, it is crucial to follow
specific reading instructions for correct interpretation of the disk diffusion test. For these, pictures with reading examples are included at the end of the corresponding breakpoint table. For
general and other specific reading instructions, please refer to the EUCAST Reading Guide.

16. With a few exceptions, EUCAST recommends the use of the broth microdilution reference method as described by the International Standards Organisation for MIC determination of non-
fastidious organisms. For fastidious organisms, EUCAST recommends the use of the same methodology but with the use of MH-F broth (Mueller-Hinton broth with lysed horse blood and beta-
NAD), see EUCAST media preparation file at www.eucast.org. There are a number of commercially available surrogate methods, for which it is the responsibility of the manufacturer to
guarantee the accuracy of the system and the responsibility of the user to quality control the results.

17. By international convention, MIC dilution series are based on twofold dilutions up and down from 1 mg/L. At dilutions below 0.25 mg/L, this leads to concentrations with multiple decimal
places. To avoid having to use these in tables and documents, EUCAST has decided to use the following format (in bold): 0.125→ 0.125, 0.0625→0.06, 0.03125→0.03, 0.015625→0.016,
0.0078125→0.008, 0.00390625→0.004 and 0.001953125→0.002 mg/L.

18. Definitions of "uncomplicated UTI" and “Infections originating from the urinary tract” used with EUCAST breakpoints:
Uncomplicated UTI: acute, sporadic or recurrent lower urinary tract infections (uncomplicated cystitis) in patients with no known relevant anatomical or functional abnormalities within the
urinary tract or comorbidities.
Infections originating from the urinary tract: Infections originating from, but not confined to, the urinary tract, including acute pyelonephritis and bloodstream infections.

Abbeviations
NA = Not Applicable
IP = In Preparation

7
Guidance on reading EUCAST Breakpoint Tables EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01

MIC determination (broth microdilution according to ISO standard 20776-1) Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Medium:
Inoculum: Inoculum:
EUCAST methodology and quality EUCAST methodology and
Incubation: Incubation:
Reading:
control for MIC determination Reading:
quality control for disk diffusion
Quality control: Quality control:

Breakpoints with a The I category is not listed but is interpreted as the values between the
An arbitrary "off scale"
species name apply S and the R breakpoints. If the S and R breakpoints are the same value
breakpoint which
only to that particular there is no I category.
categorises wild-type
species (in this Area of Technical Uncertainty
organisms as
example S. aureus) Agent A: No I category See specific information on how to
"Susceptible, increased
Agent B: I category: 4 mg/L, 23-25 mm handle technical uncertainty in
exposure (I)".
Agent H: I category: 1-2 mg/L, 24-29 mm antimicrobial susceptibility testing.

Antimicrobial agent MIC breakpoint Disk Zone diameter breakpoint Notes

(mg/L) content (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Antimicrobial agent A 11 11 X 20A 20A 1. Notes that are general comments and/or relating to MIC breakpoints.
Antimicrobial agent B 2
2 4 Y 26 23 2. New comment
Removed comment
Antimicrobial agent C 0.001 8 X 50 18
Antimicrobial agent D, S. aureus IE IE IE IE A. Comment on disk diffusion
Antimicrobial agent E - - - -
Antimicrobial agent F IP IP IP IP
Antimicrobial agent G (screen only) NA NA Y 25 25
Antimicrobial agent H 0.5 2 Z 30 24
Antimicrobial agent I (8)1 (8)1 30 (18)A (18)A

Changes from previous

A screening test that uses version highlighted in yellow
one agent to predict Not Applicable
resistance or susceptibility No breakpoints.
to one or more antimicrobial Susceptibility testing
agents in the same class is not recommended
In Preparation
MIC breakpoints in blue
are linked to MIC Zone diameter breakpoints
distributions in blue are linked to zone
diameter distributions
Breakpoints in brackets are used to
Antimicrobial agents in blue distinguish between organisms with and Insufficient evidence that the
are linked to EUCAST without acquired resistance mechanisms organism or group is a good
rationale documents (see Notes) target for therapy with the agent
8
Dosages used to define breakpoints EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01

EUCAST breakpoints are based on the following dosages (see section 8 in Rationale Documents). Alternative dosing regimens may result in equivalent exposure. The table should not be used
as a guidance for dosing in clinical practice as dosages can vary widely by indication. It does not replace specific national, regional or local dosing guidelines. However, if national practices
significantly differ from those listed below, EUCAST breakpoints may not be valid. Situations where less antibiotic is given as standard or high dose should be discussed locally or regionally.

Uncomplicated UTI: acute, sporadic or recurrent lower urinary tract infections (uncomplicated cystitis) in patients with no known relevant anatomical or functional abnormalities within the
urinary tract or comorbidities.

Penicillins Standard dosage High dosage Uncomplicated UTI Special situations

Benzylpenicillin 0.6 g (1 MU) x 4 iv 1.2 g (2 MU) x 4-6 iv Meningitis caused by S. pneumoniae:
For a dose of 2.4 g (4 MU) x 6 iv, isolates with MIC ≤0.06 mg/L are susceptible.

Pneumonia caused by S. pneumoniae: breakpoints are related to dosage:

For a dose of 1.2 g (2 MU) x 4 iv, isolates with MIC ≤ 0.5 mg/L are susceptible.
For a dose of 2.4 (4 MU) g x 4 iv or 1.2 g (2 MU) x 6 iv, isolates with MIC ≤1 mg/L are
susceptible.
For a dose of 2.4 g (4 MU) x 6 iv, isolates with MIC ≤2 mg/L are susceptible.

Ampicillin 2 g x 3 iv 2 g x 4 iv Meningitis: 2 g x 6 iv
Ampicillin-sulbactam iv (2 g ampicillin + 1 g sulbactam) x 3 iv (2 g ampicillin + 1 g sulbactam) x 4 iv

Ampicillin-sulbactam oral None None 0.75 g x 2 oral

Amoxicillin iv 1 g x 3-4 iv 2 g x 6 iv Meningitis: 2 g x 6 iv
Amoxicillin oral 0.5 g x 3 oral 0.75-1 g x 3 oral 0.5 g x 3 oral
Amoxicillin-clavulanic acid iv (1 g amoxicillin + 0.2 g clavulanic (2 g amoxicillin + 0.2 g clavulanic
acid) x 3-4 iv acid) x 3 iv
Amoxicillin-clavulanic acid oral (0.5 g amoxicillin + 0.125 g (0.875 g amoxicillin + 0.125 g (0.5 g amoxicillin + 0.125 g Amoxicillin-clavulanic acid has separate breakpoints for systemic infections and
clavulanic acid) x 3 oral clavulanic acid) x 3 oral clavulanic acid) x 3 oral uncomplicated UTI. When amoxicillin-clavulanic acid is reported for uncomplicated UTI,
the report must make clear that the susceptibility category is only valid for uncomplicated
UTI.
Piperacillin 4 g x 4 iv 4 g x 4 iv High dosage for more serious infections.
by extended 3-hour infusion
Piperacillin-tazobactam (4 g piperacillin + 0.5 g tazobactam) (4 g piperacillin + 0.5 g tazobactam) A lower dosage of (4 g piperacillin + 0.5 g tazobactam) x 3 iv, 30-minute infusion, is
x 4 iv 30-minute infusion or x 4 iv by extended 3-hour infusion adequate for some infections such as complicated UTI, intraabdominal infections and
x 3 iv by extended 4-hour infusion diabetic foot infections, but not for infections caused by isolates resistant to third-
generation cephalosporins.
Ticarcillin
Ticarcillin-clavulanic acid (3 g ticarcillin + 0.1-0.2 g clavulanic (3 g ticarcillin + 0.1 g clavulanic acid)
acid) x 4 iv x 6 iv
Temocillin 2 g x 2 iv 2 g x 3 iv The 2 g x 2 iv dose has been used in the treatment of uncomplicated UTI caused by
bacteria with beta-lactam resistance mechanisms.
Phenoxymethylpenicillin 0.5-2 g x 3-4 oral None
depending on species and/or infection
type
Oxacillin 1 g x 4 iv Dosages vary by indication
Cloxacillin 0.5 g x 4 oral or 1 g x 4 iv Dosages vary by indication Meningitis: 2 g x 6 iv
Dicloxacillin 0.5-1 g x 4 oral or 1 g x 4 iv Dosages vary by indication
Flucloxacillin 1 g x 3 oral or 2 g x 4 iv Dosages vary by indication Meningitis: 2 g x 6 iv
(or 1 g x 6 iv)
Mecillinam oral (pivmecillinam) None None 0.2-0.4 g x 3 oral

9
Dosages used to define breakpoints EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01

Cephalosporins Standard dosage High dosage Uncomplicated UTI Special situations

Cefaclor 0.25-0.5 g x 3 oral 1 g x 3​ oral Staphylococcus spp.: Minimum dose 0.5 g x 3 oral
depending on species and/or infection
type
Cefadroxil 0.5-1 g x 2 oral None 0.5-1 g x 2 oral
Cefalexin 0.25-1 g x 2-3 oral None 0.25-1 g x 2-3 oral
Cefazolin 1 g x 3 iv 2 g x 3 iv
Cefepime 1 g x 3 iv or 2 g x 2 iv 2 g x 3 iv Severe P. aeruginosa infections: 2 g x 3 with extended 4-hour infusion
Cefiderocol 2 g x 3 iv over 3 hours None
Cefixime 0.2-0.4 g x 2 oral None 0.2-0.4 g x 2 oral Uncomplicated gonorrhoea: 0.4 g oral as a single dose
Cefotaxime 1 g x 3 iv 2 g x 3 iv Meningitis: 2 g x 4 iv
S. aureus: High dose only
Cefpodoxime 0.1-0.2 g x 2 oral None 0.1-0.2 g x 2 oral

Ceftaroline
Ceftazidime
Ceftazidime-avibactam
Ceftibuten
Ceftobiprole
Ceftolozane-tazobactam (intra-
abdominal infections and UTI)
Ceftolozane-tazobactam (hospital
acquired pneumonia, including
ventilator associated pneumonia)
Ceftriaxone
0.6 g x 2 iv over 1 hour
1 g x 3 iv
(2 g ceftazidime + 0.5 g avibactam) x 3 iv over 2 hours
0.4 g x 1 oral
0.5 g x 3 iv over 2 hours
(1 g ceftolozane + 0.5 g tazobactam) x
3 iv over 1 hour
(2 g ceftolozane + 1 g tazobactam)
x 3 iv over 1 hour
2 g x 1 iv
0.6 g x 3 iv over 2 hours S. aureus in complicated skin and skin structure infections: There is some PK-PD
evidence to suggest that isolates with MICs of 4 mg/L could be treated with high dose.
2 g x 3 iv or 1 g x 6 iv
None
None
None
None
2 g x 2 iv or 4 g x 1 iv Meningitis: 2 g x 2 iv or 4 g x 1 iv
S. aureus: High dose only
Uncomplicated gonorrhoea: 0.5-1 g im as a single dose

Cefuroxime iv 0.75 g x 3 iv 1.5 g x 3 iv

Cefuroxime oral 0.25 g x 2 oral 0.5 g x 2 oral 0.25 g x 2 oral

Carbapenems Standard dosage High dosage Uncomplicated UTI Special situations

Doripenem 0.5 g x 3 iv over 1 hour 1 g x 3 iv over 1 hour HAP/VAP* due to non-fermenting Gram-negative pathogens (such as Pseudomonas spp.
and Acinetobacter spp.) should be treated with 1 g x 3 iv over 4 hours.
Ertapenem 1 g x 1 iv over 30 minutes None
Imipenem 0.5 g x 4 iv over 30 minutes 1 g x 4 iv over 30 minutes
Imipenem-relebactam (0.5 g imipenem + 0.25 g relebactam) None
x 4 iv over 30 minutes
Meropenem 1 g x 3 iv over 30 minutes 2 g x 3 iv over 3 hours Meningitis: 2 g x 3 iv over 30 minutes (or 3 hours)
Meropenem-vaborbactam (2 g meropenem + 2 g vaborbactam) x 3 iv over 3 hours
* HAP/VAP = hospital-acquired pneumonia/ventilator-associated pneumonia

10
Dosages used to define breakpoints EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01

Monobactams Standard dosage High dosage Uncomplicated UTI Special situations

Aztreonam 1 g x 3 iv 2 g x 4 iv Severe P. aeruginosa infections: 2 g x 4 with extended 3-hour infusion

Fluoroquinolones Standard dosage High dosage Uncomplicated UTI Special situations

Ciprofloxacin 0.5 g x 2 oral or 0.4 g x 2 iv 0.75 g x 2 oral or 0.4 g x 3 iv Meningitis: 0.4 g x 3 iv
Delafloxacin 0.45 g x 2 oral or 0.3 g x 2 iv None
Levofloxacin 0.5 g x 1 oral or 0.5 g x 1 iv 0.5 g x 2 oral or 0.5 g x 2 iv
Moxifloxacin 0.4 g x 1 oral or 0.4 g x 1 iv None Meningitis: 0.4 g x 1 iv
Norfloxacin None None 0.4 g x 2 oral
Ofloxacin 0.2 g x 2 oral or 0.2 g x 2 iv 0.4 g x 2 oral or 0.4 g x 2 iv

Aminoglycosides Standard dosage High dosage Uncomplicated UTI Special situations

Amikacin 25-30 mg/kg x 1 iv None
Gentamicin 6-7 mg/kg x 1 iv None
Netilmicin 6-7 mg/kg x 1 iv None
Tobramycin 6-7 mg/kg x 1 iv None

Glycopeptides and Standard dosage High dosage Uncomplicated UTI Special situations
lipoglycopeptides
Dalbavancin 1 g x 1 iv over 30 minutes on day 1 None
If needed, 0.5 g x 1 iv over 30 minutes
on day 8
Oritavancin 1.2 g x 1 (single dose) iv None
over 3 hours
Teicoplanin 0.4 g x 1 iv Dosages vary by indication
Telavancin 10 mg/kg x 1 iv over 1 hour None
Vancomycin 0.5 g x 4 iv or 1 g x 2 iv None Based on body weight. Therapeutic drug monitoring should guide dosing.
or 2 g x 1 by continuous infusion

Macrolides, lincosamides and Standard dosage High dosage Uncomplicated UTI Special situations
streptogramins
Azithromycin 0.5 g x 1 oral or 0.5 g x 1 iv None Uncomplicated gonorrhoea: 2 g oral as a single dose
Clarithromycin 0.25 g x 2 oral Dosages vary by indication In some countries clarithromycin is available for intravenous administration at a dose of 0.5
g x 2, principally for treating pneumonia.
Erythromycin 0.5 g x 2-4 oral or 0.5 g x 2-4 iv Dosages vary by indication
Roxithromycin 0.15 g x 2 oral None
Telithromycin 0.8 g x 1 oral None
Clindamycin 0.3 g x 2 oral or 0.6 g x 3 iv Dosages vary by indication The high exposure dosing regimen pertains to the severity of the infection or drug
exposure at the site of infection.
Quinupristin-dalfopristin 7.5 mg/kg x 2 iv Dosages vary by indication

11
Dosages used to define breakpoints EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01

Tetracyclines Standard dosage High dosage Uncomplicated UTI Special situations

Doxycycline 0.1 g x 1 oral Dosages vary by indication
Eravacycline 1 mg/kg x 2 iv None
Minocycline 0.1 g x 2 oral None
Tetracycline 0.25 g x 4 oral Dosages vary by indication
Tigecycline 0.1 g loading dose None
followed by 50 mg x 2 iv

Oxazolidinones Standard dosage High dosage Uncomplicated UTI Special situations

Linezolid 0.6 g x 2 oral or 0.6 g x 2 iv None Meningitis: 0.6 g x 2 iv
Tedizolid 0.2 g x 1 oral or 0.2 g x 1 iv None

Miscellaneous agents Standard dosage High dosage Uncomplicated UTI Special situations
Chloramphenicol 1 g x 4 oral or 1 g x 4 iv 2 g x 4 oral or 2 g x 4 iv Meningitis: 2 g x 4 iv
Colistin 4.5 MU x 2 iv None
with a loading dose of 9 MU
Daptomycin (cSSTI** without concurrent 4 mg/kg x 1 iv None . .
S. aureus bacteraemia)
Daptomycin (cSSTI** with concurrent S. 6 mg/kg x 1 iv None Enterococcal bloodstream infection and endocarditis, see
aureus bacteraemia; right-sided https://www.eucast.org/eucastguidancedocuments.
infective endocarditis due to S. aureus )
Fidaxomicin 0.2 g x 2 oral None
Fosfomycin iv 16-18 g/day divided in 3-4 doses Dosages vary by indication
Fosfomycin oral None None 3 g x 1 oral as a single dose
Fusidic acid 0.5 g x 2 oral or 0.5 g x 2 iv Dosages vary by indication
Lefamulin 0.15 g x 2 iv or 0.6 g x 2 oral None
Metronidazole 0.4 g x 3 oral or 0.4 g x 3 iv Dosages vary by indication
Nitrofurantoin None None 50-100 mg x 3-4 oral Dosing is dependent on drug formulation.
Nitroxoline None None 0.25 g x 3 oral
Rifampicin 0.6 g x 1 oral or 0.6 g x 1 iv None
Spectinomycin 2 g x 1 im None
Trimethoprim None None 0.16 g x 2 oral
Trimethoprim-sulfamethoxazole (0.16 g trimethoprim + 0.8 g (0.24 g trimethoprim + 1.2 g (0.16 g trimethoprim + 0.8 g Meningitis: (5 mg/kg up to 0.48 g trimethoprim + 25 mg/kg up to 2.4 g sulfamethoxazole)
sulfamethoxazole) x 2 oral sulfamethoxazole) x 2 oral sulfamethoxazole) x 2 oral x 3 iv
or (0.16 g trimethoprim + 0.8 g or (0.24 g trimethoprim + 1.2 g
sulfamethoxazole) x 2 iv sulfamethoxazole) x 2 iv
** cSSTI = complicated skin and skin structure infection

12
 European Committee on Antimicrobial Susceptibility Testing
Breakpoint tables for interpretation of MICs and zone diameters
Version 13.0, valid from 2023-01-01
How to handle technical uncertainty in antimicrobial susceptibility testing

All measurements are affected by random variation and some by systematic variation. Systematic variation can normally be avoided and random variation should be reduced
as much as possible. Antimicrobial susceptibility testing (AST), irrespective of method, is no exception.

EUCAST strives to minimise variation by providing standardised methods for MIC determination and disk diffusion and by avoiding setting breakpoints which seriously affect
the reproducibility of AST. Variation in AST can be further reduced by setting more stringent standards for manufacturers of AST material (broth, agar, antimicrobial disks)
and criteria for quality control of manufacturing processes and laboratory practices.

It is tempting to think that generating an MIC value will solve all problems. However, MIC measurements also have variation and a single value is not automatically accurate.
Even when using the reference method, MICs might vary between days and technicians. Under the best of circumstances, an MIC of 1.0 mg/L should be considered as a
value between 0.5 and 2.0 mg/L, although the probability of getting any one of these three values is not equal and will vary among strains and antimicrobial agents. Not
infrequently, EUCAST discovers problems with commercial testing systems including quality of disks and media for disk diffusion, commercial panels for broth microdilution
tests, gradient tests and semi-automated AST devices. Some of these affect accuracy (poorly calibrated concentration series) and others precision (poor general quality,

Although AST is straightforward for most agents and species, there are problematic situations even when testing is performed to a high standard. It is important to warn
laboratories about these and the uncertainty of susceptibility categorisation. Analysis of EUCAST data (readily available at
http://www.eucast.org/ast_of_bacteria/calibration_and_validation/) that have been generated over the years has identified such situations, named by EUCAST “Area of
Technical Uncertainty (ATU)”. The ATUs are warnings to laboratory staff that there is an uncertainty that needs to be addressed before reporting AST results to clinical
colleagues. The ATU is not a susceptibility category and does not prevent the laboratory from interpreting the susceptibility test result.

Below are alternatives for how the ATUs can be dealt with by the laboratory. Which of these actions are chosen will depend on the situation. The type of sample (blood
culture vs. urine culture), the number of alternative agents available, the severity of the disease, whether or not a consultation with clinical colleagues is feasible, will
• Repeat the test
To ONLY repeat the test is relevant if there is reason to suspect a technical problem in the primary AST. To repeat the test while confirming the result with another test is
good laboratory practice. If an MIC test is performed, the chances are that this result may also end up in the ATU. If so, a primary test and an alternative test may both
point to a result and an interpretation in the ATU. In this case, interpret the result according to the breakpoints and report.
• Use an alternative test (perform an MIC or a genotypic test)
This may be relevant if the susceptibility report otherwise leaves only few therapeutic alternatives. If the organism is multi-resistant, perform an MIC determination for
several antibiotics, possibly extending the AST to include new beta-lactam inhibitor combinations, cefiderocol and colistin for Gram-negative bacteria. Sometimes it may be
necessary to perform genotypic or phenotypic characterisation of the resistance mechanism to obtain more information, some of which may be of importance for
epidemiological decisions. When performing an MIC, this result may end up in the ATU. In this case, interpret the result according to the breakpoints and report.
• Downgrade the susceptibility category
If there are other therapeutic alternatives in the AST report, it is permissible to downgrade the result (from S to I, or from I to R or from S to R). However, a comment should
be included and the isolate saved for further testing.
13
How to handle technical uncertainty in antimicrobial susceptibility testing

• Include the uncertainty as part of the report

It is common practice in many other laboratory settings to include information on the uncertainty of the reported result. This can be dealt with in several alternative ways:
• Report results in the ATU as "uncertain". This can be achieved by leaving the interpretation "blank + a comment".
• Develop the LIS system to deliver an asterix or Note (instead of an S, I or R) which refers to a comment explaining the uncertainty.
• Categorise the result according to the breakpoints but include information about the technical difficulties and/or the uncertainty of the interpretation. In many instances, an
“R” is less ambiguous than other alternatives, especially when there are alternative agents. Do not report "S" unless you have confirmed the result.
For serious situations, take the opportunity to contact the clinical colleague to explain and discuss the results.
• Omit an uncertain result
When there are several therapeutic options, or when an ambiguous interpretation cannot be readily resolved in a timely manner, an ATU result is best left either unreported
or downgraded (see above).

The Area of Technical Uncertainty is typically listed as a defined MIC value or in disk diffusion a range of zone diameters. ATUs are only listed when obviously needed. The
absence of an ATU (MIC and/or zone diameter) means that there is no immediate need for a warning. The ATUs introduced in 2019 (v. 9.0) will be evaluated and ATUs may
be added as more information develops.
Link to the guidance material available on the EUCAST website.

14
Enterobacterales * EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1 except for mecillinam and Disk diffusion (EUCAST standardised disk diffusion method)
fosfomycin where agar dilution is used) Medium: Mueller-Hinton agar
Medium: Mueller-Hinton broth (for cefiderocol, see https://www.eucast.org/eucastguidancedocuments/) Inoculum: McFarland 0.5
Inoculum: 5x105 CFU/mL Incubation: Air, 35±1ºC, 18±2h
Incubation: Sealed panels, air, 35±1ºC, 18±2h Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the back of the plate
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely against a dark background illuminated with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information. information.
Quality control: Escherichia coli ATCC 25922. For agents not covered by this strain and for control of the Quality control: Escherichia coli ATCC 25922. For agents not covered by this strain and for control of the inhibitor
inhibitor component of beta-lactam inhibitor combinations, see EUCAST QC Tables. component of beta-lactam inhibitor-combination disks, see EUCAST QC Tables.

* Recent taxonomic studies have narrowed the definition of the family Enterobacteriaceae. Some previous members of this family are now included in other families within the order Enterobacterales . Breakpoints in this table apply to all
members of the Enterobacterales .

15
Enterobacterales * EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Penicillins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin - - - - 1. For information on how to implement the new aminopenicillin breakpoints, see
Ampicillin iv1 8 8 10 14A 14A https://www.eucast.org/eucastguidancedocuments/.
2. For susceptibility testing purposes, the concentration of sulbactam is fixed at 4 mg/L.
Ampicillin oral (uncomplicated UTI only) 1 8 8 10 14A 14A
3/D. For information on how to use breakpoints in brackets, see https://www.eucast.org/eucastguidancedocuments/.
Ampicillin-sulbactam iv 1
82 82 10-10 14A 14A 4. For susceptibility testing purposes, the concentration of clavulanic acid is fixed at 2 mg/L.
Ampicillin-sulbactam oral (uncomplicated 82 82 10-10 14A 14A 5. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L.
UTI only)1 6. Agar dilution is the reference method for mecillinam MIC determination.
Amoxicillin iv1 8 8 - NoteB NoteB
Amoxicillin oral (infections originating from 0.001 8 - NoteC NoteC A. Ignore growth that may appear as a thin inner zone on some batches of Mueller-Hinton agars.
the urinary tract)1 B. Susceptibility inferred from ampicillin (iv or oral).
Amoxicillin oral (uncomplicated UTI only)1 8 8 - NoteB NoteB C. Isolates susceptible to ampicillin (iv or oral) can be reported "susceptible, increased exposure” (I) to "amoxicillin oral
1
(8) 3
(8) 3
- Note D,E
NoteD,E (infections originating from the urinary tract)". Isolates resistant to ampicillin (iv or oral) can be reported resistant to
Amoxicillin oral (other indications)
"amoxicillin oral (infections originating from the urinary tract)".
Amoxicillin-clavulanic acid iv1 84 84 20-10 19A 19A 19-20
4 4 A
E. Infer from ampicillin oral, but the report should explain the meaning of breakpoints in brackets.
Amoxicillin-clavulanic acid oral (infections 0.001 8 20-10 50 19A 19-20
F. Ignore isolated colonies within the inhibition zone.
originating from the urinary tract)1
Amoxicillin-clavulanic acid oral 324 324 20-10 16A 16A
(uncomplicated UTI only)1
Amoxicillin-clavulanic acid oral (other (8)3,4 (8)3,4 20-10 (19)A,D (19)A,D 19-20
indications)1
Piperacillin 8 8 30 20 20
Piperacillin-tazobactam 85 85 16 30-6 20 20 19
Ticarcillin
Ticarcillin-clavulanic acid 84 164 75-10 23 20
Temocillin (infections originating from the 0.001 16 30 50F 17F
urinary tract), E. coli, Klebsiella spp. (except
K. aerogenes ) and P. mirabilis
Phenoxymethylpenicillin - - - -
Oxacillin - - - -
Cloxacillin - - - -
Dicloxacillin - - - -
Flucloxacillin - - - -
Mecillinam oral (pivmecillinam) 86 86 10 15F 15F
(uncomplicated UTI only), E. coli, Citrobacter
spp., Klebsiella spp., Raoultella spp.,
Enterobacter spp. and P. mirabilis

16
Enterobacterales * EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Cephalosporins1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Cefaclor (uncomplicated UTI only) IE IE IE IE 1. The cephalosporin breakpoints for Enterobacterales will detect all clinically important resistance mechanisms
Cefadroxil (uncomplicated UTI only) 16 16 30 12 12 (including ESBL and plasmid mediated AmpC). Some isolates that produce beta-lactamases are susceptible to 3rd or 4th
generation cephalosporins with these breakpoints and should be reported as tested, i.e. the presence or absence of an
Cefalexin (uncomplicated UTI only) 16 16 30 14 14
ESBL does not in itself influence the categorisation of susceptibility. ESBL detection and characterisation are
Cefazolin (infections originating from the 0.0012 42 30 50A 20A recommended for public health and infection control purposes.
urinary tract), E. coli and Klebsiella spp. 2/A. Isolates susceptible to cefadroxil and/or cefalexin can be reported "susceptible, increased exposure” (I) to cefazolin.
(except K. aerogenes ) 3. Broth microdilution MIC determination must be performed in iron-depleted Mueller-Hinton broth and specific reading
Cefepime 1 4 30 27 24 instructions must be followed. For testing conditions and reading instructions, see
Cefiderocol 23 23 30 22 22 18-22 https://www.eucast.org/eucastguidancedocuments/.
Cefixime (uncomplicated UTI only) 1 1 5 17 17 4. The cefoxitin cut-off value (8 mg/L) has a high sensitivity but poor specificity for identification of AmpC-producing
1 2 20 17 Enterobacterales as this agent is also affected by permeability alterations and some carbapenemases. Classical non-
Cefotaxime (indications other than 5
AmpC producers are wild type, whereas plasmid AmpC producers or chromosomal AmpC hyperproducers are non-wild
meningitis)
type.
Cefotaxime (meningitis) 1 1 5 20 20
5. For susceptibility testing purposes, the concentration of avibactam is fixed at 4 mg/L.
Cefoxitin (screen only)4 Note4 Note4 30 19 19 6. See table of dosages for dosing for different indications.
Cefpodoxime 1 1 10 21 21 7. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L.
(uncomplicated UTI only)
Ceftaroline 0.5 0.5 5 23 23 22-23
Ceftazidime 1 4 10 22 19
Ceftazidime-avibactam 85 85 10-4 13 13
Ceftibuten (infections originating from the 1 1 30 23 23
urinary tract)
Ceftobiprole 0.25 0.25 5 23 23
Ceftolozane-tazobactam6 27 27 30-10 22 22 19-21
Ceftriaxone (indications other than 1 2 30 25 22
meningitis)
Ceftriaxone (meningitis) 1 1 30 25 25
Cefuroxime iv, E. coli , Klebsiella spp. (except 0.001 8 30 50 19
K. aerogenes ), Raoultella spp. and P. mirabilis
Cefuroxime oral (uncomplicated UTI only), 8 8 30 19 19
E. coli, Klebsiella spp. (except K. aerogenes ),
Raoultella spp. and P. mirabilis

17
Enterobacterales * EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Carbapenems1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doripenem 1 2 10 24 21 1. Some isolates that produce carbapenemase are categorised as susceptible with the current breakpoints and should be
Ertapenem 0.5 0.5 10 25 25 reported as tested, i.e. the presence or absence of a carbapenemase does not in itself influence the categorisation of
susceptibility. Carbapenemase detection and characterisation are recommended for public health and infection control
Imipenem, Enterobacterales except 2 4 10 22 19
purposes. For carbapenemase screening, a meropenem screening cut-off of >0.125 mg/L (zone diameter <28 mm) is
Morganellaceae
recommended.
Imipenem2, Morganellaceae 0.001 4 10 50 19
2. The intrinsically low activity of imipenem against Morganella morganii , Proteus spp. and Providencia spp. requires the
Imipenem-relebactam, Enterobacterales 23 23 10-25 22 22 20-22 high exposure of imipenem.
except Morganellaceae 3. For susceptibility testing purposes, the concentration of relebactam is fixed at 4 mg/L.
Meropenem (indications other than 2 8 10 22 16 4. For susceptibility testing purposes, the concentration of vaborbactam is fixed at 8 mg/L.
meningitis)
Meropenem (meningitis) 2 2 10 22 22 A. For isolates in the ATU, if resistant to meropenem report resistant to meropenem-vaborbactam. If not resistant to
Meropenem-vaborbactam 84 84 20-10 20 20 15-19A meropenem, investigate further.

Monobactams MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Aztreonam1 1 4 30 26 21 1. The aztreonam breakpoints for Enterobacterales will detect clinically important resistance mechanisms (including
ESBL). Some isolates that produce beta-lactamases are susceptible to aztreonam with these breakpoints and should be
reported as tested, i.e. the presence or absence of an ESBL does not in itself influence the categorisation of
susceptibility. ESBL detection and characterisation are recommended for public health and infection control purposes.

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin, Salmonella spp.1 0.06 0.06 NoteA NoteA 1. There is clinical evidence for ciprofloxacin to indicate a poor response in systemic infections caused by Salmonella
Ciprofloxacin (indications other than 0.25 0.5 0.5 5 25 22 22-24 spp. with low-level ciprofloxacin resistance (MIC >0.06 mg/L). The available data relate mainly to Salmonella Typhi but
meningitis) there are also case reports of poor response with other Salmonella species.
2/B. In meningitis, where low-level ciprofloxacin resistance must be excluded, either perform an MIC test, or infer
Ciprofloxacin (meningitis)2 0.125 0.125 NoteB NoteB
susceptibility from the pefloxacin 5 µg screening test.
Pefloxacin (screen only) NA NA 5 24A,B,C 24A,B,C
Delafloxacin, E. coli 0.125 0.125 NoteD NoteD A. Tests with a ciprofloxacin 5 µg disk will not reliably detect low-level resistance in Salmonella spp. Perform an MIC test,
Levofloxacin 0.5 1 5 23 19 or infer susceptibility from the pefloxacin 5 µg screening test.
Moxifloxacin 0.25 0.25 5 22 22 C. The pefloxacin screening test can also be used to detect fluoroquinolone resistance mechanisms in other
Nalidixic acid (screen only) NA NA NA NA Enterobacterales such as E. coli, K. pneumoniae and Shigella spp.
D. A disk diffusion test awaits action from the responsible pharmaceutical company.
Norfloxacin (uncomplicated UTI only) 0.5 0.5 10 24 24
Ofloxacin 0.25 0.5 5 24 22

18
Enterobacterales * EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Aminoglycosides1,2 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Amikacin (systemic infections) (8)1 (8)1 30 (18)A (18)A 1/A. For information on how to use breakpoints in brackets, see https://www.eucast.org/eucastguidancedocuments/.
Amikacin (infections originating from the 8 8 30 18 18 2. Breakpoints do not apply to Plesiomonas shigelloides since aminoglycosides have low intrinsic activity against this
urinary tract) species.
Gentamicin (systemic infections) (2)1 (2)1 10 (17)A (17)A
Gentamicin (infections originating from the 2 2 10 17 17
urinary tract)
Netilmicin IE IE IE IE
Tobramycin (systemic infections) (2)1 (2)1 10 (16)A (16)A
Tobramycin (infections originating from the 2 2 10 16 16
urinary tract)

Glycopeptides and MIC breakpoints Disk Zone diameter Notes

lipoglycopeptides (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Dalbavancin - - - -
Oritavancin - - - -
Teicoplanin - - - -
Telavancin - - - -
Vancomycin - - - -

Macrolides, lincosamides and MIC breakpoints Disk Zone diameter Notes

streptogramins (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Azithromycin1 - - - - 1. Azithromycin has been used in the treatment of enteric infections, primarily with Salmonella Typhi and Shigella
Clarithromycin - - - - species and although wild type distributions vary somewhat, isolates with MICs above 16 mg/L (azithromycin 15 µg disk
zone diameters <12 mm) are likely to have azithromycin resistance mechanisms.
Erythromycin - - - -
Roxithromycin - - - -
Telithromycin - - - -
Clindamycin - - - -
Quinupristin-dalfopristin - - - -

19
Enterobacterales * EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doxycycline - - - - 1. Tetracycline can be used to predict doxycycline susceptibility for the treatment of Yersinia enterocolitica infections
Eravacycline, E. coli 0.5 0.5 20 17 17 (tetracycline MIC ≤4 mg/L for wild-type isolates). The corresponding zone diameter for the tetracycline 30 µg disk is ≥19
mm.
Minocycline - - - -
2. For tigecycline broth microdilution MIC determination, the medium must be prepared fresh on the day of use.
Tetracycline1 - - - -
3/A. For other Enterobacterales , the activity of tigecycline varies from insufficient in Serratia spp., Proteus spp.,
Tigecycline, E. coli and C. koseri 0.52,3 0.52,3 15 18A,B 18A,B Morganella morganii and Providencia spp. to variable in other species. For more information, see
https://www.eucast.org/eucastguidancedocuments/.

B. Zone diameter breakpoints validated for E. coli only. For C. koseri, use an MIC method.

Oxazolidinones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Linezolid - - - -
Tedizolid - - - -

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Chloramphenicol Note1 Note1 NoteA NoteA 1/A. Efficacy for this order is uncertain. Screening cut-off values can be used to distinguish wild-type isolates from
Colistin2
(2) 3
(2) 3
Note B
NoteB isolates with acquired resistance (MIC >16 mg/L; zone diameter <17 mm for the chloramphenicol 30 µg disk ). For
chloramphenicol treatment in meningitis, see table of dosages.
Daptomycin - - - -
2. Colistin MIC determination should be performed with broth microdilution. Quality control must be performed with both a
Fosfomycin iv4 325 325 200C 21D,E 21D,E susceptible QC strain (E. coli ATCC 25922 or P. aeruginos a ATCC 27853) and the colistin resistant E. coli NCTC 13846
5 5 E
Fosfomycin oral 8 8 200 C
24 24E (mcr-1 positive).
(uncomplicated UTI only), E. coli 3. For information on how to use breakpoints in brackets, see https://www.eucast.org/eucastguidancedocuments/.
Fusidic acid - - - -
Lefamulin - - - - 4. Breakpoints for fosfomycin iv are currently under review.
Metronidazole - - - - 5. Agar dilution is the reference method for fosfomycin. MICs must be determined in the presence of glucose-6-
phosphate (25 mg/L in the medium). Follow the manufacturers' instructions for commercial systems.
Nitrofurantoin (uncomplicated UTI only), 64 64 100 11 11
E. coli 6. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.

Nitroxoline (uncomplicated UTI only), 16 16 30 15 15 B. Use an MIC method (broth microdilution only).
E. coli C. Fosfomycin 200 µg disks must contain 50 µg glucose-6-phosphate.
Rifampicin - - - - D. Zone diameter breakpoints apply to E. coli only. For other Enterobacterales , use an MIC method.
Spectinomycin - - - - E. Ignore isolated colonies within the inhibition zone (see pictures below).
Trimethoprim 4 4 5 15 15
(uncomplicated UTI only)
Trimethoprim-sulfamethoxazole 6 2 4 1.25-23.75 14 11

20
Enterobacterales * EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Examples of inhibition zones for Escherichia coli with fosfomycin.

a-c) Ignore all colonies and read the outer zone edge.
d) Record as no inhibition zone.

21
Pseudomonas spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1 except for fosfomycin Disk diffusion (EUCAST standardised disk diffusion method)
where agar dilution is used) Medium: Mueller-Hinton agar
Medium: Mueller-Hinton broth (for cefiderocol, see https://www.eucast.org/eucastguidancedocuments/ Inoculum: McFarland 0.5
Inoculum: 5x105 CFU/mL Incubation: Air, 35±1ºC, 18±2h
Incubation: Sealed panels, air, 35±1ºC, 18±2h Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the back of the plate
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely against a dark background illuminated with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information. information.
Quality control: Pseudomonas aeruginosa ATCC 27853. For agents not covered by this strain and for Quality control: Pseudomonas aeruginosa ATCC 27853. For agents not covered by this strain and for control of the
control of the inhibitor component of beta-lactam inhibitor combinations, see EUCAST QC Tables. inhibitor component of beta-lactam inhibitor-combination disks, see EUCAST QC Tables.

Pseudomonas aeruginosa is the most frequent species of this genus. Other less frequent Pseudomonas species recovered in clinical samples are: P. fluorescens group, P. putida group and P. stutzeri group.

Penicillins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin - - - - 1. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L.
Ampicillin - - - - 2. For susceptibility testing purposes, the concentration of clavulanic acid is fixed at 2 mg/L.
Ampicillin-sulbactam - - - -
Amoxicillin - - - -
Amoxicillin-clavulanic acid - - - -
Piperacillin 0.001 16 30 50 18 18-19
Piperacillin-tazobactam 0.0011 161 30-6 50 18 18-19
Ticarcillin
Ticarcillin-clavulanic acid 0.0012 162 75-10 50 18
Temocillin - - - -
Phenoxymethylpenicillin - - - -
Oxacillin - - - -
Cloxacillin - - - -
Dicloxacillin - - - -
Flucloxacillin - - - -
Mecillinam oral (pivmecillinam) - - - -
(uncomplicated UTI only)

22
Pseudomonas spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Cephalosporins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Cefaclor - - - - 1. Broth microdilution MIC determination must be performed in iron-depleted Mueller-Hinton broth and specific reading
Cefadroxil - - - - instructions must be followed. For testing conditions and reading instructions, see
- - https://www.eucast.org/eucastguidancedocuments/.
Cefalexin - -
2. For susceptibility testing purposes, the concentration of avibactam is fixed at 4 mg/L.
Cefazolin - - - -
3. See table of dosages for dosing for different indications.
Cefepime 0.001 8 30 50 21 4. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L.
Cefiderocol, P. aeruginosa 21 21 30 22 22 14-22
Cefixime - - - -
Cefotaxime - - - -
Cefoxitin - - - -
Cefpodoxime - - - -
Ceftaroline - - - -
Ceftazidime 0.001 8 10 50 17
Ceftazidime-avibactam, P. aeruginosa 82 82 10-4 17 17 16-17
Ceftibuten - - - -
Ceftobiprole IE IE IE IE
Ceftolozane-tazobactam3, P. aeruginosa 44 44 30-10 23 23
Ceftriaxone - - - -
Cefuroxime iv - - - -
Cefuroxime oral - - - -

Carbapenems MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doripenem 0.001 2 10 50 22 1. For susceptibility testing purposes, the concentration of relebactam is fixed at 4 mg/L.
Ertapenem - - - - 2. For susceptibility testing purposes, the concentration of vaborbactam is fixed at 8 mg/L.
Imipenem 0.001 4 10 50 20
Imipenem-relebactam, P. aeruginosa 21 21 10-25 22 22
Meropenem (indications other than 2 8 10 20 14
meningitis), P. aeruginosa
Meropenem (indications other than 2 8 10 24 18
meningitis), Pseudomonas other than P.
aeruginosa
Meropenem (meningitis), P. aeruginosa 2 2 10 20 20
Meropenem-vaborbactam, 82 82 20-10 14 14
P. aeruginosa

23
Pseudomonas spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Monobactams MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Aztreonam 0.001 16 30 50 18

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin 0.001 0.5 5 50 26
Delafloxacin IE IE IE IE
Levofloxacin 0.001 2 5 50 18
Moxifloxacin - - - -
Nalidixic acid (screen only) NA NA NA NA
Norfloxacin (uncomplicated UTI only) - - - -
Ofloxacin - - - -

Aminoglycosides1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Amikacin (systemic infections) (16)1 (16)1 30 (15)A (15)A 1/A. For information on how to use breakpoints in brackets, see https://www.eucast.org/eucastguidancedocuments/.
Amikacin (infections originating from the 16 16 30 15 15
urinary tract)
Gentamicin (systemic infections) IE IE IE IE
Gentamicin (infections originating from the IE IE IE IE
urinary tract)
Netilmicin IE IE IE IE
Tobramycin (systemic infections) (2)1 (2)1 10 (18)A (18)A
Tobramycin (infections originating from the 2 2 10 18 18
urinary tract)

Glycopeptides and MIC breakpoints Disk Zone diameter Notes

lipoglycopeptides (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Dalbavancin - - - -
Oritavancin - - - -
Teicoplanin - - - -
Telavancin - - - -
Vancomycin - - - -

24
Pseudomonas spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Macrolides, lincosamides and MIC breakpoints Disk Zone diameter Notes

streptogramins (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Azithromycin - - - -
Clarithromycin - - - -
Erythromycin - - - -
Roxithromycin - - - -
Telithromycin - - - -
Clindamycin - - - -
Quinupristin-dalfopristin - - - -

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doxycycline - - - -
Eravacycline - - - -
Minocycline - - - -
Tetracycline - - - -
Tigecycline - - - -

Oxazolidinones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Linezolid - - - -
Tedizolid - - - -

25
Pseudomonas spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Chloramphenicol - - - - 1. Colistin MIC determination should be performed with broth microdilution. Quality control must be performed with both a
Colistin1 (4)2 (4)2 NoteA NoteA susceptible QC strain (E. coli ATCC 25922 or P. aeruginosa ATCC 27853) and the colistin resistant E. coli NCTC 13846
(mcr-1 positive).
Daptomycin - - - -
2. For information on how to use breakpoints in brackets, see https://www.eucast.org/eucastguidancedocuments/.
Fosfomycin iv3 Note3 Note3 - -
3. Agar dilution is the reference method for fosfomycin. MICs must be determined in the presence of glucose-6-
Fosfomycin oral3 - - - - phosphate (25 mg/L in the medium). Follow the manufacturers' instructions for commercial systems. Infections caused by
Fusidic acid - - - - wild-type isolates (ECOFF: MIC 128 mg/L; corresponding zone diameter 12 mm using the disk potency and reading
Lefamulin - - - - instructions for E. coli) have been treated with fosfomycin in combination with other agents. The ECOFF is 256 mg/L.
Metronidazole - - - -
A. Use an MIC method (broth microdilution only).
Nitrofurantoin (uncomplicated UTI only) - - - -
Nitroxoline (uncomplicated UTI only) - - - -
Rifampicin - - - -
Spectinomycin - - - -
Trimethoprim (uncomplicated UTI only) - - - -
Trimethoprim-sulfamethoxazole - - - -

26
Stenotrophomonas maltophilia EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Trimethoprim-sulfamethoxazole is the only agent for which EUCAST breakpoints are currently available. For further information, see EUCAST Guidance Document for S. maltophilia.

MIC determination (broth microdilution according to ISO standard 20776-1) Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton broth (for cefiderocol, see https://www.eucast.org/eucastguidancedocuments/) Medium: Mueller-Hinton agar
Inoculum: 5x105 CFU/mL Inoculum: McFarland 0.5
Incubation: Sealed panels, air, 35±1ºC, 18±2h Incubation: Air, 35±1ºC, 18±2h
Reading: For trimethoprim-sulfamethoxazole, the MIC should be read at the lowest concentration that Reading: Read zone edges from the back of the plate against a dark background illuminated with reflected light (see
inhibits approximately 80% of growth as compared with the growth control well. See ”EUCAST Reading below for specific instructions). See ”EUCAST Reading Guide for disk diffusion” for further information.
Guide for broth microdilution” for further information. Quality control: Escherichia coli ATCC 25922
Quality control: Escherichia coli ATCC 25922

Cephalosporins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Cefiderocol IE1 IE1 NoteA NoteA 1. Broth microdilution MIC determination must be performed in iron-depleted Mueller-Hinton broth and specific reading
instructions must be followed. For testing conditions and reading instructions, see
https://www.eucast.org/eucastguidancedocuments/.

A. Zone diameters of ≥20 mm for the cefiderocol 30 µg disk correspond to MIC values below the PK-PD breakpoint of S ≤
2 mg/L.

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Trimethoprim-sulfamethoxazole 1 0.001 4 1.25-23.75 50A 16A,B 1. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.

A. There may be growth within the inhibition zone. The density of growth may vary from a fine haze to substantial growth
(see pictures below). If any zone edge can be seen, ignore growth within the inhibition zone and read the zone diameter.
B. Trimetoprim-sulfamethoxazole resistance in S. maltophilia is rare and should be confirmed with an MIC test.

27
Stenotrophomonas maltophilia EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Examples of inhibition zones for Stenotrophomonas maltophilia with trimethoprim-sulfamethoxazole.

a-c) An outer zone can be seen. Read the outer zone edge and interpret according to the breakpoints.
d) Growth up to the disk and no sign of inhibition zone. Report resistant.

28
Acinetobacter spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1) Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton broth (for cefiderocol, see https://www.eucast.org/eucastguidancedocuments/) Medium: Mueller-Hinton agar
Inoculum: 5x105 CFU/mL Inoculum: McFarland 0.5
Incubation: Sealed panels, air, 35±1ºC, 18±2h Incubation: Air, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the back of the plate
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information. against a dark background illuminated with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further
Quality control: Pseudomonas aeruginosa ATCC 27853. For agents not covered by this strain, see information.
EUCAST QC Tables. Quality control: Pseudomonas aeruginosa ATCC 27853. For agents not covered by this strain, see EUCAST QC
Tables.

This genus includes several species. The most frequent Acinetobacter species recovered in clinical samples are those included in the A. baumannii group, which includes A. baumannii, A. nosocomialis, A. pittii, A. dijkshoorniae and A.
seifertii . Other species are A. haemolyticus, A. junii, A. lwoffii, A. ursingii and A. variabilis.

Penicillins1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin - - - - 1. Susceptibility testing of Acinetobacter spp. to penicillins is unreliable. In most instances, Acinetobacter spp. are
Ampicillin - - - - resistant to penicillins.
Ampicillin-sulbactam IE IE IE IE
Amoxicillin - - - -
Amoxicillin-clavulanic acid - - - -
Piperacillin IE IE IE IE
Piperacillin-tazobactam IE IE IE IE
Ticarcillin
Ticarcillin-clavulanic acid IE IE IE IE
Temocillin - - - -
Phenoxymethylpenicillin - - - -
Oxacillin - - - -
Cloxacillin - - - -
Dicloxacillin - - - -
Flucloxacillin - - - -
Mecillinam oral (pivmecillinam) - - - -
(uncomplicated UTI only)

29
Acinetobacter spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Cephalosporins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Cefaclor - - - - 1. Broth microdilution MIC determination must be performed in iron-depleted Mueller-Hinton broth and specific reading
Cefadroxil - - - - instructions must be followed. For testing conditions and reading instructions, see
https://www.eucast.org/eucastguidancedocuments/.
Cefalexin - - - -
Cefazolin - - - - A. Zone diameters of ≥17 mm for the cefiderocol 30 µg disk correspond to MIC values below the PK-PD breakpoint of S ≤
Cefepime - - - - 2 mg/L.
Cefiderocol IE1 IE1 NoteA NoteA
Cefixime - - - -
Cefotaxime - - - -
Cefoxitin - - - -
Cefpodoxime - - - -
Ceftaroline - - - -
Ceftazidime - - - -
Ceftazidime-avibactam - - - -
Ceftibuten - - - -
Ceftobiprole - - - -
Ceftolozane-tazobactam - - - -
Ceftriaxone - - - -
Cefuroxime iv - - - -
Cefuroxime oral - - - -

Carbapenems MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doripenem 0.001 2 10 50 22 1. For susceptibility testing purposes, the concentration of relebactam is fixed at 4 mg/L.
Ertapenem - - - - 2/A. The beta-lactamases produced by the organisms either do not modify the parent carbapenem or are not affected by
2 4 24 21 the inhibitor. Therefore the addition of the beta-lactamase inhibitor does not add clinical benefit.
Imipenem 10
Imipenem-relebactam2 21 21 10-25 24 24
Meropenem (indications other than 2 8 10 21 15
meningitis)
Meropenem (meningitis) 2 2 10 21 21
Meropenem-vaborbactam2 Note2 Note2 NoteA NoteA

Monobactams MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Aztreonam - - - -

30
Acinetobacter spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin 0.001 1 5 50 21
Delafloxacin IE IE IE IE
Levofloxacin 0.5 1 5 23 20
Moxifloxacin - - - -
Nalidixic acid (screen only) NA NA NA NA
Norfloxacin (uncomplicated UTI only) - - - -
Ofloxacin - - - -

Aminoglycosides1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Amikacin (systemic infections) (8)1 (8)1 30 (19)A (19)A 1/A. For information on how to use breakpoints in brackets, see https://www.eucast.org/eucastguidancedocuments/.
Amikacin (infections originating from the 8 8 30 19 19
urinary tract)
Gentamicin (systemic infections) (4)1 (4)1 10 (17)A (17)A
Gentamicin (infections originating from the 4 4 10 17 17
urinary tract)
Netilmicin IE IE IE IE
Tobramycin (systemic infections) (4)1 (4)1 10 (17)A (17)A
Tobramycin (infections originating from the 4 4 10 17 17
urinary tract)

Glycopeptides and MIC breakpoints Disk Zone diameter Notes

lipoglycopeptides (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Dalbavancin - - - -
Oritavancin - - - -
Teicoplanin - - - -
Telavancin - - - -
Vancomycin - - - -

31
Acinetobacter spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Macrolides, lincosamides and MIC breakpoints Disk Zone diameter Notes

streptogramins (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Azithromycin - - - -
Clarithromycin - - - -
Erythromycin - - - -
Roxithromycin - - - -
Telithromycin - - - -
Clindamycin - - - -
Quinupristin-dalfopristin - - - -

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doxycycline - - - -
Eravacycline IE IE IE IE
Minocycline IE IE IE IE
Tetracycline - - - -
Tigecycline IE IE IE IE

Oxazolidinones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Linezolid - - - -
Tedizolid - - - -

32
Acinetobacter spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Chloramphenicol - - - - 1. Colistin MIC determination should be performed with broth microdilution. Quality control must be performed with both a
Colistin1 (2)2 (2)2 NoteA NoteA susceptible QC strain (E. coli ATCC 25922 or P. aeruginosa ATCC 27853) and the colistin resistant E. coli NCTC 13846
(mcr-1 positive).
Daptomycin - - - -
2. For information on how to use breakpoints in brackets, see hhttps://www.eucast.org/eucastguidancedocuments/.
Fosfomycin iv - - - -
3. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.
Fosfomycin oral - - - -
Fusidic acid - - - - A. Use an MIC method (broth microdilution only).
Lefamulin - - - -
Metronidazole - - - -
Nitrofurantoin (uncomplicated UTI only) - - - -
Nitroxoline (uncomplicated UTI only) - - - -
Rifampicin - - - -
Spectinomycin - - - -
Trimethoprim (uncomplicated UTI only) - - - -
Trimethoprim-sulfamethoxazole 3 2 4 1.25-23.75 14 11

33
Staphylococcus spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1 except for fosfomycin Disk diffusion (EUCAST standardised disk diffusion method)
where agar dilution is used) Medium: Mueller-Hinton agar
Medium: Mueller-Hinton broth Inoculum: McFarland 0.5
Inoculum: 5x105 CFU/mL Incubation: Air, 35±1ºC, 18±2h
Incubation: Sealed panels, air, 35±1ºC, 18±2h Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the back of the plate
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely against a dark background illuminated with reflected light (except for benzylpenicillin, see below). See ”EUCAST Reading
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information. Guide for disk diffusion” for further information.
Quality control: Staphylococcus aureus ATCC 29213. For agents not covered by this strain, see EUCAST Quality control: Staphylococcus aureus ATCC 29213. For agents not covered by this strain, see EUCAST QC Tables.
QC Tables.

Unless otherwise indicated, breakpoints apply to all members of the Staphylococcus genus. Where such information exists, specific breakpoints are provided.
• For coagulase-positive species other than S. aureus (S. argenteus, S. schweitzeri, S. intermedius, S. pseudintermedius and S. coagulans ) there is limited information on the performance of breakpoints for most agents. For S.
argenteus , breakpoints for S. aureus can be used without caveats.
• Coagulase-negative staphylococci include S. capitis, S. cohnii, S. epidermidis, S. haemolyticus, S. hominis, S. hyicus, S. lugdunensis, S. pettenkoferi, S. saprophyticus, S. schleiferi, S. sciuri, S. simulans, S. warneri and S. xylosus .
• For S. saccharolyticus, use methodology for anaerobic bacteria and consult EUCAST Guidance Document on how to interpret results when there are no breakpoints, https://www.eucast.org/eucastguidancedocuments/.

34
Staphylococcus spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Penicillins1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin, S. aureus 0.1251 0.1251 1 unit 26A,B 26A,B 1/A. Most S. aureus are penicillinase producers and some are methicillin resistant. Either mechanism renders them
Benzylpenicillin, S. lugdunensis 0.125 0.125 1 unit 26 26 resistant to benzylpenicillin, phenoxymethylpenicillin, ampicillin, amoxicillin, piperacillin and ticarcillin. Isolates that test
susceptible to benzylpenicillin and cefoxitin can be reported susceptible to all penicillins. Isolates that test resistant to
Benzylpenicillin, other staphylococci Note2 Note2 NoteC NoteC
benzylpenicillin but susceptible to cefoxitin are susceptible to β-lactam β-lactamase inhibitor combinations, the
Ampicillin, S. saprophyticus Note2,3 Note2,3 2 18C,D 18C,D isoxazolylpenicillins (oxacillin, cloxacillin, dicloxacillin and flucloxacillin) and nafcillin. For agents given orally, care to
Ampicillin-sulbactam Note1,2,3 Note1,2,3 NoteA,C,D NoteA,C,D achieve sufficient exposure at the site of the infection should be exercised. Isolates that test resistant to cefoxitin are
Amoxicillin Note1,2,3 Note1,2,3 NoteA,C,D NoteA,C,D resistant to all penicillins.
Amoxicillin-clavulanic acid Note1,2,3 Note1,2,3 NoteA,C,D NoteA,C,D 2/C. Most staphylococci are penicillinase producers and some are methicillin resistant. Either mechanism renders them
1,2,3 1,2,3 A,C,D resistant to benzylpenicillin, phenoxymethylpenicillin, ampicillin, amoxicillin, piperacillin and ticarcillin. No currently
Piperacillin Note Note Note NoteA,C,D
available method can reliably detect penicillinase production in all species of staphylococci but methicillin resistance can
Piperacillin-tazobactam Note1,2,3 Note1,2,3 NoteA,C,D NoteA,C,D be detected with cefoxitin as described.
Ticarcillin 3/D. Ampicillin susceptible S. saprophyticus are mecA -negative and susceptible to ampicillin, amoxicillin and piperacillin
Ticarcillin-clavulanic acid Note1,2 Note1,2 NoteA,C NoteA,C (without or with a beta-lactamase inhibitor).
Temocillin - - - - 4. S. aureus, S. lugdunensis and S. saprophyticus with oxacillin MIC values >2 mg/L are mostly methicillin resistant due
to the presence of the mecA or mecC gene. Occasionally oxacillin MIC values are high in S. aureus in absence of mec -
Phenoxymethylpenicillin, S. aureus Note1 Note1 NoteA NoteA
2 2 C
gene mediated resistance. These isolates have been called BORSA (borderline oxacillin resistant S. aureus ). EUCAST
Phenoxymethylpenicillin, - - Note NoteC does not recommend systematic screening for BORSA. For coagulase-negative staphylococci other than S.
Coagulase-negative staphylococci
saprophyticus and S. lugdunensis , the oxacillin MIC in methicillin resistant isolates is >0.25 mg/L.
Oxacillin (screen only), S. pseudintermedius, NA NA 1 20E 20E
S. schleiferi and S. coagulans B. For S. aureus , disk diffusion is more reliable than MIC determination for detection of penicillinase producers, provided
the zone diameter is measured AND the zone edge for isolates with zone diameters ≥26 mm is closely inspected (see
Oxacillin4, other staphylococci Note1,4 Note1,4 NoteA NoteA pictures below). Examine the zone edge with transmitted light (plate held up to light). If the zone diameter is <26 mm,
Cloxacillin Note1,2 Note1,2 NoteA,C NoteA,C then report resistant. If the zone diameter is ≥26 mm AND the zone edge is sharp (no reduction of growth towards zone
edge, like a "cliff"), then report resistant. If not sharp (reduction of growth towards zone edge, like a "beach"), then report
Dicloxacillin Note1,2 Note1,2 NoteA,C NoteA,C
susceptible and if uncertain, then report resistant. Chromogenic cephalosporin-based beta-lactamase tests do not
Flucloxacillin Note1,2 Note1,2 NoteA,C NoteA,C reliably detect staphylococcal penicillinase.
Mecillinam oral (pivmecillinam) - - - - E. For screening for methicillin resistance in S. pseudintermedius, S. schleiferi and S. coagulans.
(uncomplicated UTI only)

35
Staphylococcus spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Cephalosporins1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Cefaclor2 Note1 Note1 NoteA NoteA 1/A. Susceptibility of staphylococci to cephalosporins is inferred from the cefoxitin susceptibility except for cefixime,
Cefadroxil Note1 Note1 NoteA NoteA ceftazidime, ceftazidime-avibactam, ceftibuten and ceftolozane-tazobactam, which do not have breakpoints and should
not be used for staphylococcal infections. For agents given orally, care to achieve sufficient exposure at the site of the
Cefalexin Note1 Note1 NoteA NoteA
1 1 A
infection should be exercised. If cefotaxime and ceftriaxone are reported for methicillin-susceptible staphylococci, these
Cefazolin Note Note Note NoteA should be reported “Susceptible, increased exposure” (I). Some methicillin-resistant S. aureus are susceptible to
Cefepime Note1 Note1 NoteA NoteA ceftaroline and ceftobiprole, see Notes 5/D and 7/F.
Cefiderocol - - - - 2. See table of dosages.
Cefixime - - - - 3. S. aureus and S. lugdunensis with cefoxitin MIC values >4 mg/L and S. saprophyticus with cefoxitin MIC values >8
mg/L are methicillin resistant, mostly due to the presence of the mecA or mecC gene. Disk diffusion reliably predicts
Cefotaxime2 Note1 Note1 NoteA NoteA
methicillin resistance.
Cefoxitin (screen only), S. aureus and Note3,4 Note3,4 30 22A,B 22A,B 4. For staphylococci other than S. aureus, S. lugdunensis and S. saprophyticus , the cefoxitin MIC is a poorer predictor of
coagulase-negative staphylococci except S.
methicillin resistance than the disk diffusion test.
epidermidis and S. lugdunensis
5/C. In S. pseudintermedius,S. schleiferi and S. coagulans the cefoxitin disk is less predictive for the detection of
Cefoxitin (screen only), S. epidermidis and S. Note4 Note4 30 27A,B 27A,B 27 methicillin resistance than in other staphylococci. Use the oxacillin 1 µg disk with zone diameter breakpoints S≥20, R<20
lugdunensis mm.
Cefoxitin (screen only), Note5 Note5 NoteC NoteC 6/D. Methicillin-susceptible isolates can be reported susceptible to ceftaroline without further testing.
S. pseudintermedius, S. schleiferi and 7/E. Resistant isolates are rare.
S. coagulans 8/F. Methicillin-susceptible isolates can be reported susceptible to ceftobiprole without further testing.
Cefpodoxime Note1 Note1 NoteA NoteA
Ceftaroline (indications other than 1 6
2 6,7
1 5 20 D
17D,E 19-20 B. If coagulase-negative staphylococci are not identified to species level, use zone diameter breakpoints S≥25, R<25
pneumonia), S. aureus mm, with an ATU of 22-24 mm. For isolates with results inside the ATU: identify species, perform PCR for mecA/mecC or
Ceftaroline (pneumonia), S. aureus 16 16 1 5 20D 20D 19-20 report resistant.
Ceftazidime - - - -
Ceftazidime-avibactam - - - -
Ceftibuten - - - -
Ceftobiprole, S. aureus 28 28 2 5 17F 17F 16-17
Ceftolozane-tazobactam - - - -
Ceftriaxone2 Note1 Note1 NoteA NoteA
1 1 A
Cefuroxime iv Note Note Note NoteA
1 1 A
Cefuroxime oral Note Note Note NoteA

36
Staphylococcus spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Carbapenems1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doripenem Note1 Note1 NoteA NoteA 1/A. Susceptibility of staphylococci to carbapenems is inferred from the cefoxitin susceptibility.
Ertapenem Note1 Note1 NoteA NoteA
Imipenem Note1 Note1 NoteA NoteA
1 1 A
Imipenem-relebactam Note Note Note NoteA
Meropenem Note1 Note1 NoteA NoteA
1 1 A
Meropenem-vaborbactam Note Note Note NoteA

Monobactams MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Aztreonam - - - -

Fluoroquinolones1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin, S. aureus 0.001 1 5 50A 21A 1. For breakpoints for other fluoroquinolones (e.g. pefloxacin and enoxacin), refer to breakpoints set by national
Ciprofloxacin, 0.001 1 5 50 A
24A breakpoint committees.
Coagulase-negative staphylococci 2/D. Ofloxacin breakpoints for Staphylococcus spp. have been removed since in systemic infections with staphylococci
the agent is inferior to other fluoroquinolones. For topical use of ofloxacin, see tables of topical agents.
Delafloxacin (community-acquired 0.016 0.016 NoteB NoteB
pneumonia), S. aureus
A. The norfloxacin disk diffusion test can be used to screen for fluoroquinolone resistance. See Note C.
Delafloxacin (skin and skin structure 0.25 0.25 NoteB NoteB
B. A disk diffusion test awaits action from the responsible pharmaceutical company.
infections), S. aureus
C. Isolates categorised as screen negative can be reported susceptible to moxifloxacin and "susceptible increased
Levofloxacin, S. aureus 0.001 1 5 50A 22A
exposure" (I) to ciprofloxacin and levofloxacin. Isolates categorised as screen positive should be tested for susceptibility
Levofloxacin, 0.001 1 5 50A 24A to individual agents or reported resistant.
Coagulase-negative staphylococci
Moxifloxacin, S. aureus 0.25 0.25 5 25A 25A
Moxifloxacin, 0.25 0.25 5 28A 28A
Coagulase-negative staphylococci
Nalidixic acid (screen only) NA NA NA NA
Norfloxacin (screen only) NA NA 10 17C 17C
Ofloxacin Note2 Note2 NoteD NoteD

37
Staphylococcus spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Aminoglycosides1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Amikacin2, S. aureus (16)1 (16)1 30 (15)A (15)A 1/A. For information on how to use breakpoints in brackets, see https://www.eucast.org/eucastguidancedocuments/.
Amikacin2, (16)1 (16)1 30 (15)A (15)A 2. Resistance to amikacin is most reliably determined by testing with kanamycin (MIC >8 mg/L). The corresponding zone
Coagulase-negative staphylococci diameter for the kanamycin 30 µg disk is R<18 mm for S. aureus and R<22 mm for coagulase-negative staphylococci.
Gentamicin, S. aureus (2)1 (2)1 10 (18)A (18)A
Gentamicin, (2)1 (2)1 10 (22)A (22)A
Coagulase-negative staphylococci
Netilmicin IE IE IE IE
Tobramycin, S. aureus (2)1 (2)1 10 (18)A (18)A
Tobramycin, (2)1 (2)1 10 (20)A (20)A
Coagulase-negative staphylococci

Glycopeptides and MIC breakpoints Disk Zone diameter Notes

lipoglycopeptides1 (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Dalbavancin2 0.1253,4 0.1253 NoteA NoteA 1. Glycopeptide MICs are method dependent and should be determined by broth microdilution (ISO standard 20776-1).
Oritavancin2, S. aureus 0.1253,4 0.1253 NoteA NoteA S. aureus with vancomycin MIC values of 2 mg/L are on the border of the wild-type distribution and there may be an
impaired clinical response.
Teicoplanin2, S. aureus 2 2 NoteA NoteA
2. Resistant isolates are rare or not yet reported. The identification and antimicrobial susceptibility test result on any such
Teicoplanin, 4 4 NoteA NoteA isolate must be confirmed and the isolate sent to a reference laboratory.
Coagulase-negative staphylococci
3. MICs must be determined in the presence of polysorbate-80 (0.002% in the medium for broth dilution methods; agar
Telavancin2, MRSA 0.1253,5 0.1253 NoteA NoteA dilution methods have not been validated). Follow the manufacturers' instructions for commercial systems.
A
2
Vancomycin , S. aureus 2 2 Note NoteA 4. S. aureus isolates susceptible to vancomycin can be reported susceptible to dalbavancin and oritavancin.
Vancomycin2, 4 4 NoteA NoteA 5. MRSA isolates susceptible to vancomycin can be reported susceptible to telavancin.
Coagulase-negative staphylococci
A. Disk diffusion is unreliable and cannot distinguish between wild-type isolates and those with non-vanA -mediated
glycopeptide resistance.

38
Staphylococcus spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Macrolides, lincosamides and MIC breakpoints Disk Zone diameter Notes

streptogramins (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Azithromycin 21 21 NoteA NoteA 1/A. Erythromycin can be used to screen for macrolide resistance in staphylococci. Isolates categorised as susceptible
Clarithromycin 11 11 NoteA NoteA can be reported susceptible to azithromycin, clarithromycin and roxithromycin. Isolates categorised as resistant should be
tested for susceptibility to individual agents or reported resistant.
Erythromycin 11 11 15 21A 21A
2. Inducible clindamycin resistance can be detected by antagonism of clindamycin activity by a macrolide agent. If not
Erythromycin (screen only) detected, then report as tested according to the clinical breakpoints. If detected, then report as resistant and consider
Roxithromycin 11 11 NoteA NoteA adding this comment to the report: "Clindamycin may still be used for short-term therapy of less serious skin and soft
Telithromycin IE IE IE IE tissue infections as constitutive resistance is unlikely to develop during such therapy".
Clindamycin2 0.25 0.25 2 22B 22B
B. Place the erythromycin and clindamycin disks 12-20 mm apart (edge to edge) and look for antagonism (the D
Quinupristin-dalfopristin 1 1 15 21 21C
phenomenon) to detect inducible clindamycin resistance.
C. Isolates resistant by disk diffusion should be confirmed by MIC testing.

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doxycycline 11 11 NoteA NoteA 1/A. Tetracycline can be used to screen for resistance in tetracycline agents. Isolates categorised as susceptible can be
Eravacycline, S. aureus 0.25 0.25 20 20B 20B reported susceptible to doxycycline and minocycline. Isolates categorised as resistant should be tested for susceptibility
to individual agents or reported resistant.
Minocycline 0.51 0.51 30 23A 23A
1 1 A
2. Resistant isolates are rare or not yet reported. The identification and antimicrobial susceptibility test result on any such
Tetracycline 1 1 30 22 22A isolate must be confirmed and the isolate sent to a reference laboratory.
Tetracycline (screen only) 3. For tigecycline broth microdilution MIC determination, the medium must be prepared fresh on the day of use.
Tigecycline2 0.53 0.53 15 19 19
B. For MRSA that test susceptible with disk diffusion, the results should be confirmed with an MIC test.

Oxazolidinones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.

Linezolid 4 4 10 21 21 1/A. Isolates susceptible to linezolid can be reported susceptible to tedizolid.

Tedizolid 0.51 0.5 2 20A 20 19

39
Staphylococcus spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Chloramphenicol IE IE IE IE 1. The clinical efficacy of chloramphenicol in meningitis has been questioned and breakpoints are currently under review.
Colistin - - - - For chloramphenicol treatment in meningitis, see table of dosages.
1. Resistant isolates are rare or not yet reported. The identification and antimicrobial susceptibility test result on any such
Daptomycin1 12 12 NoteA NoteA
4 4 A isolate must be confirmed and the isolate sent to a reference laboratory.
Fosfomycin iv 3
32 32 Note NoteA
2. Daptomycin MICs must be determined in the presence of Ca 2+ (50 mg/L in the medium for broth dilution methods; agar
Fosfomycin oral - - - -
dilution methods have not been validated). Follow the manufacturers' instructions for commercial systems.
Fusidic acid 1 1 10 24 24 3. Breakpoints for fosfomycin iv are currently under review.
Lefamulin, S. aureus 0.25 0.25 5 23 23 4. Agar dilution is the reference method for fosfomycin. MICs must be determined in the presence of glucose-6-
Metronidazole - - - - phosphate (25 mg/L in the medium). Follow the manufacturers' instructions for commercial systems.
Nitrofurantoin (uncomplicated UTI only), S. 64 64 100 13 13 5. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.
saprophyticus
A. Use an MIC method.
Nitroxoline (uncomplicated UTI only), IE IE IE IE
S. saprophyticus
Rifampicin, S. aureus 0.06 0.06 5 26 26
Rifampicin, Coagulase-negative staphylococci 0.06 0.06 5 30 30
Spectinomycin - - - -
Trimethoprim (uncomplicated UTI only) 4 4 5 14 14
Trimethoprim-sulfamethoxazole 5 2 4 1.25-23.75 17 14

Examples of inhibition zones for Staphylococcus aureus with benzylpenicillin.

a) Fuzzy zone edge (reduction of growth towards zone edge, like a "beach") and zone diameter ≥ 26 mm. Report susceptible.
b) Sharp zone edge (no reduction of growth towards zone edge, like a "cliff") and zone diameter ≥ 26 mm. Report resistant.

40
Enterococcus spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

In endocarditis, refer to national or international endocarditis guidelines for breakpoints for Enterococcus spp.

MIC determination (broth microdilution according to ISO standard 20776-1) Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton broth Medium: Mueller-Hinton agar
Inoculum: 5x105 CFU/mL Inoculum: McFarland 0.5
Incubation: Sealed panels, air, 35±1ºC, 18±2h Incubation: Air, 35±1ºC, 18±2h (for glycopeptides 24h)
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the back of the plate
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information. against a dark background illuminated with reflected light (except for vancomycin, see below). See ”EUCAST Reading
Quality control: Enterococcus faecalis ATCC 29212. For agents not covered by this strain and for control of Guide for disk diffusion” for further information.
the inhibitor component of beta-lactam inhibitor combinations, see EUCAST QC Tables. Quality control: Enterococcus faecalis ATCC 29212. For agents not covered by this strain see EUCAST QC Tables.

The Enterococcus genus includes several species. The most frequent enterococci recovered in clinical samples are E. faecalis and E. faecium but also E. avium, E. casseliflavus, E. durans, E. gallinarum, E. hirae, E. mundtii and E.
raffinosus are occasionally encountered. Listed breakpoints have been largely developed using pre-clinical and clinical data on E. faecalis and E. faecium . The applicability of these breakpoints to other Enterococcus species is less
certain as both clinical and pre-clinical data for these are mostly lacking. During 2023, in collaboration between EUCAST and experts in enterococci, data and breakpoints for other enterococci will be developed. Until then, use breakpoints
below or the EUCAST Guidance Document on how to test and interpret results when there are no breakpoints.

Penicillins1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin - - - - 1. Aminopenicillin breakpoints in enterococci are based on intravenous administration. For oral administration the
Ampicillin1 42 82 2 10A 8A breakpoints are relevant for urinary tract infections only.
2/A. In E. faecalis , susceptibility to ampicillin, amoxicillin and piperacillin (with and without beta-lactamase inhibitor) is the
Ampicillin-sulbactam1 42,3 82,3 NoteA NoteA
expected phenotype, while in E. faecium , resistance is common. Isolates resistant to ampicillin can be reported resistant
Amoxicillin 1
42 82 NoteA NoteA to ampicillin, amoxicillin and piperacillin (with or without inhibitor). For E. faecalis that test resistant to ampicillin with disk
Amoxicillin-clavulanic acid1 42,4 82,4 NoteA NoteA diffusion, confirm with an MIC test.
2 2 A
Piperacillin Note Note Note NoteA 3. For susceptibility testing purposes, the concentration of sulbactam is fixed at 4 mg/L.
Piperacillin-tazobactam Note2 Note2 NoteA NoteA 4. For susceptibility testing purposes, the concentration of clavulanic acid is fixed at 2 mg/L.
Ticarcillin
Ticarcillin-clavulanic acid - - - -
Temocillin - - - -
Phenoxymethylpenicillin - - - -
Oxacillin - - - -
Cloxacillin - - - -
Dicloxacillin - - - -
Flucloxacillin - - - -
Mecillinam oral (pivmecillinam) - - - -
(uncomplicated UTI only)

41
Enterococcus spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Cephalosporins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Cefaclor - - - -
Cefadroxil - - - -
Cefalexin - - - -
Cefazolin - - - -
Cefepime - - - -
Cefiderocol - - - -
Cefixime - - - -
Cefotaxime - - - -
Cefoxitin - - - -
Cefpodoxime - - - -
Ceftaroline - - - -
Ceftazidime - - - -
Ceftazidime-avibactam - - - -
Ceftibuten - - - -
Ceftobiprole - - - -
Ceftolozane-tazobactam - - - -
Ceftriaxone - - - -
Cefuroxime iv - - - -
Cefuroxime oral - - - -

Carbapenems MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doripenem - - - - 1/A. The addition of a beta-lactamase inhibitor does not add clinical benefit.
Ertapenem - - - -
Imipenem 0.001 4 10 50 21
Imipenem-relebactam1 Note1 Note1 NoteA NoteA
Meropenem - - - -
Meropenem-vaborbactam - - - -

Monobactams MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Aztreonam - - - -

42
Enterococcus spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin (uncomplicated UTI only) 4 4 5 15A 15A 1/B. Moxifloxacin has been used in oral follow-up treatment of endocarditis caused by Enterococcus spp. There are no
Delafloxacin IE IE IE IE clinical breakpoints but acquired resistance should be excluded (isolates with MIC >1 mg/L). The norfloxacin disk
diffusion screen test can be used to exclude resistance mechanisms. When excluded, the isolate should be reported
Levofloxacin (uncomplicated UTI only) 4 4 5 15A 15A
1 1 B
“devoid of fluoroquinolone resistance mechanisms”, but not as susceptible to moxifloxacin.
Moxifloxacin Note Note Note NoteB
Nalidixic acid (screen only) NA NA NA NA A. The norfloxacin disk diffusion test can be used to screen for fluoroquinolone resistance. See Note C.
Norfloxacin (screen only) NA NA 10 12C 12C C. Susceptibility to ciprofloxacin and levofloxacin can be inferred from the norfloxacin disk diffusion screening test. For
Ofloxacin - - - - moxifloxacin, see comment 1/B.

Aminoglycosides1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Amikacin Note2 Note2 NoteA NoteA 1. Enterococci are intrinsically resistant to aminoglycosides and aminoglycoside monotherapy is ineffective. There is likely
Gentamicin (test for high-level Note 2
Note 2
30 Note A
NoteA to be synergy between aminoglycosides and penicillins or glycopeptides against enterococci without acquired high-level
aminoglycoside resistance) aminoglycoside resistance. All testing is therefore to distinguish between intrinsic and high-level acquired resistance.
2/A. Gentamicin can be used to screen for high-level aminoglycoside resistance (HLAR).
Netilmicin Note2 Note2 NoteA NoteA
3 3 B Negative test: Isolates with gentamicin MIC ≤128 mg/L or a zone diameter ≥8 mm. The isolate is wild type for gentamicin
Streptomycin (test for high-level Note Note 300 Note NoteB and low-level intrinsic resistant. For other aminoglycosides, this may not be the case. Synergy with penicillins or
streptomycin resistance)
glycopeptides can be expected if the isolate is susceptible to the penicillin or glycopeptide.
Tobramycin Note2 Note2 NoteA NoteA Positive test: Isolates with gentamicin MIC >128 mg/L or a zone diameter <8 mm. The isolate is high-level resistant to
gentamicin and other aminoglycosides, except streptomycin which must be tested separately if required (see note 3/B).
There will be no synergy with penicillins or glycopeptides.
3/B. Isolates with high-level gentamicin resistance may not be high-level resistant to streptomycin.
Negative test: Isolates with streptomycin MIC ≤512 mg/L or a zone diameter ≥14 mm. The isolate is wild type for
streptomycin and low-level intrinsic resistant. Synergy with penicillins or glycopeptides can be expected if the isolate is
susceptible to the penicillin or glycopeptide.
Positive test: Isolates with streptomycin MIC >512 mg/L or a zone diameter <14 mm. The isolate is high-level resistant
to streptomycin. There will be no synergy with penicillins or glycopeptides.

Glycopeptides and MIC breakpoints Disk Zone diameter Notes

lipoglycopeptides (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Dalbavancin IE IE IE IE A. Vancomycin susceptible enterococci exhibit sharp zone edges and do not exhibit colonies in the inhibition zone.
Oritavancin IE IE IE IE Examine zone edges with transmitted light (plate held up to light). If the zone edge is fuzzy, colonies grow within the zone
2 2 16 16 or if you are uncertain, then perform confirmatory testing with PCR or report resistant (see pictures below) even if the
Teicoplanin 30
zone diameter is ≥ 12 mm. Isolates must not be reported susceptible before 24 h incubation.
Telavancin IE IE IE IE
Vancomycin 4 4 5 12A 12A

43
Enterococcus spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Macrolides, lincosamides and MIC breakpoints Disk Zone diameter Notes

streptogramins (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Azithromycin - - - -
Clarithromycin - - - -
Erythromycin - - - -
Roxithromycin - - - -
Telithromycin - - - -
Clindamycin - - - -
Quinupristin-dalfopristin, E. faecium 1 1 15 22 22

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doxycycline - - - - 1. Resistant isolates are rare or not yet reported. The identification and antimicrobial susceptibility test result on any such
Eravacycline, E. faecalis 0.125 0.125 20 22 22 isolate must be confirmed and the isolate sent to a reference laboratory.
Eravacycline, E. faecium 0.125 0.125 20 24 24 2. For tigecycline broth microdilution MIC determination, the medium must be prepared fresh on the day of use.

Minocycline - - - -
Tetracycline - - - -
Tigecycline1, E. faecalis 0.252 0.252 15 20 20
Tigecycline1, E. faecium 0.252 0.252 15 22 22

Oxazolidinones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Linezolid 4 4 10 20 20
Tedizolid IE IE IE IE

44
Enterococcus spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Chloramphenicol - - - - 1. For more information, see https://www.eucast.org/eucastguidancedocuments/.
Colistin - - - - 2/A. Lefamulin has insufficient activity against E. faecalis. For E. faecium, the ECOFF of 0.5 mg/L can be used to
distinguish wild type from non-wild type isolates.
Daptomycin1 IE IE IE IE
3/B. The activity of trimethoprim and trimethopr im-sulfamethoxazole is uncertain against enterococci, and it is not
Fosfomycin iv - - - -
possible to predict clinical outcome. The ECOFF to categorise isolates as wild type or non-wild type for both E. faecalis
Fosfomycin oral - - - - and E. faecium is 1 mg/L, with a corresponding zone diameter ECOFF of 21 mm for trimethoprim and 23 mm for
Fusidic acid - - - - trimethoprim-sulfamethoxazole.
Lefamulin Note2 Note2 NoteA NoteA 4. Trimethoprim-sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.
Metronidazole - - - -
Nitrofurantoin (uncomplicated UTI only), E. 64 64 100 15 15
faecalis
Nitroxoline (uncomplicated UTI only) IE IE IE IE
Rifampicin - - - -
Spectinomycin - - - -
Trimethoprim (uncomplicated UTI only) Note3 Note3 5 NoteB NoteB
Trimethoprim-sulfamethoxazole 4 Note3 Note3 1.25-23.75 NoteB NoteB

Examples of inhibition zones for Enterococcus spp. with vancomycin.

a) Sharp zone edge and zone diameter ≥ 12 mm. Report susceptible.
b-d) Fuzzy zone edge or colonies within zone. Perform confirmatory testing with PCR or report resistant even if the zone diameter ≥ 12 mm.

45
Streptococcus groups A, B, C and G EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1)
Medium: Mueller-Hinton broth + 5% lysed horse blood and 20 mg/L β-NAD (MH-F broth)
Inoculum: 5x105 CFU/mL
Incubation: Sealed panels, air, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information.
Quality control: Streptococcus pneumoniae ATCC 49619. For agents not covered by this strain, see
EUCAST QC Tables.
Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L β-NAD (MH-F)
Inoculum: McFarland 0.5
Incubation: 5% CO2, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the front of the plate
with the lid removed and with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further information.
Quality control: Streptococcus pneumoniae ATCC 49619. For agents not covered by this strain, see EUCAST QC
Tables.

This group of bacteria includes many species, which can be grouped as follows:
Group A: S. pyogenes
Group B: S. agalactiae
Group C: S. dysgalactiae (plus the more rarely isolated S. equi )
Group G: S. dysgalactiae and S. canis
S. dysgalactiae includes the subspecies equisimilis and dysgalactiae, S. equi includes the subspecies equi and zooepidemicus.

Penicillins1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin (indications other than 0.25 0.25 1 unit 18 18 1/A. The susceptibility of streptococcus groups A, B, C and G to penicillins is inferred from the benzylpenicillin
meningitis)2 susceptibility (indications other than meningitis) with the exception of phenoxymethylpenicillin and isoxazolylpenicillins for
Benzylpenicillin (meningitis)2, 0.125 0.125 1 unit 19 19 streptococcus group B, for which therapy with either of these agents is considered inadequate.
S. agalactiae (group B streptococci) 2. Resistant isolates are rare or not yet reported. The identification and antimicrobial susceptibility test result on any such
Ampicillin Note1 Note1 NoteA NoteA isolate must be confirmed and the isolate sent to a reference laboratory.
3. The addition of a beta-lactamase inhibitor does not add clinical benefit.
Ampicillin-sulbactam3 Note1 Note1 NoteA NoteA
1 1 A
Amoxicillin Note Note Note NoteA
Amoxicillin-clavulanic acid3 Note1 Note1 NoteA NoteA
Piperacillin Note1 Note1 NoteA NoteA
1 1 A
Piperacillin-tazobactam 3
Note Note Note NoteA
Ticarcillin
Ticarcillin-clavulanic acid - - - -
Temocillin - - - -
Phenoxymethylpenicillin Note1 Note1 NoteA NoteA
Streptococcus groups A, C and G
Oxacillin Note1 Note1 NoteA NoteA
Streptococcus groups A, C and G
Cloxacillin Note1 Note1 NoteA NoteA
Streptococcus groups A, C and G
Dicloxacillin Note1 Note1 NoteA NoteA
Streptococcus groups A, C and G
Flucloxacillin Note1 Note1 NoteA NoteA
Streptococcus groups A, C and G
Mecillinam oral (pivmecillinam) - - - -
(uncomplicated UTI only)

46
Streptococcus groups A, B, C and G EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Cephalosporins1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Cefaclor Note1 Note1 NoteA NoteA 1/A. The susceptibility of streptococcus groups A, B, C and G to cephalosporins is inferred from the benzylpenicillin
Cefadroxil Note1 Note1 NoteA NoteA susceptibility.
2. The addition of a beta-lactamase inhibitor does not add clinical benefit.
Cefalexin Note1 Note1 NoteA NoteA
1 1 A
Cefazolin Note Note Note NoteA
Cefepime Note1 Note1 NoteA NoteA
Cefiderocol IE IE IE IE
Cefixime - - - -
Cefotaxime Note1 Note1 NoteA NoteA
Cefoxitin IE IE IE IE
Cefpodoxime Note1 Note1 NoteA NoteA
Ceftaroline Note1 Note1 NoteA NoteA
Ceftazidime - - - -
Ceftazidime-avibactam - - - -
Ceftibuten Note1 Note1 NoteA NoteA
Ceftobiprole IE IE IE IE
Ceftolozane-tazobactam2 IE IE IE IE
Ceftriaxone Note1 Note1 NoteA NoteA
Cefuroxime iv Note1 Note1 NoteA NoteA
Cefuroxime oral Note1 Note1 NoteA NoteA

Carbapenems1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doripenem Note1 Note1 NoteA NoteA 1/A. The susceptibility of streptococcus groups A, B, C and G to carbapenems is inferred from the benzylpenicillin
Ertapenem Note 1
Note 1
Note A
NoteA susceptibility.
2/B. The addition of a beta-lactamase inhibitor does not add clinical benefit.
Imipenem Note1 Note1 NoteA NoteA
Imipenem-relebactam2 Note2 Note2 NoteB NoteB
1 1 A
Meropenem Note Note Note NoteA
Meropenem-vaborbactam 2
Note2 Note2 NoteB NoteB

Monobactams MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Aztreonam - - - -

47
Streptococcus groups A, B, C and G EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin - - - - A. A disk diffusion test awaits action from the responsible pharmaceutical company.
Delafloxacin 0.03 0.03 NoteA NoteA B. The norfloxacin disk diffusion test can be used to screen for fluoroquinolone resistance. See Note C.
C. Isolates categorised as screen negative can be reported susceptible to moxifloxacin and as "susceptible increased
Levofloxacin 0.001 2 5 50B 17B
B
exposure" (I) to levofloxacin. Isolates categorised as screen positive should be tested for susceptibility to individual
Moxifloxacin 0.5 0.5 5 19 19B agents or reported resistant.
Nalidixic acid (screen only) NA NA NA NA
Norfloxacin (screen only) NA NA 10 12C 12C
Ofloxacin - - - -

Aminoglycosides MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Amikacin - - - -
Gentamicin - - - -
Netilmicin - - - -
Tobramycin - - - -

Glycopeptides and MIC breakpoints Disk Zone diameter Notes

lipoglycopeptides (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Dalbavancin1 0.1252,3 0.1252 NoteA NoteA 1. Resistant isolates are rare or not yet reported. The identification and antimicrobial susceptibility test result on any such
Oritavancin1 0.252,3 0.252 NoteA NoteA isolate must be confirmed and the isolate sent to a reference laboratory.
2. MICs must be determined in the presence of polysorbate-80 (0.002% in the medium for broth dilution methods; agar
Teicoplanin1 2 2 30 15B 15B
dilution methods have not been validated). Follow the manufacturer's instructions for commercial systems.
Telavancin IE IE IE IE
3. Isolates susceptible to vancomycin can be reported susceptible to dalbavancin and oritavancin.
Vancomycin1 2 2 5 13B 13B
A. Disk diffusion criteria have not been defined and an MIC method should be used.
B. Non-wild type isolates were not available when developing the disk diffusion method.

48
Streptococcus groups A, B, C and G EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Macrolides, lincosamides and MIC breakpoints Disk Zone diameter Notes

streptogramins (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Azithromycin 0.251 0.251 NoteA NoteA 1/A. Erythromycin can be used to screen for macrolide resistance in Streptococcus groups A, B, C and G. Isolates
Clarithromycin 0.251 0.251 NoteA NoteA categorised as susceptible can be reported susceptible to azithromycin, clarithromycin and roxithromycin. Isolates
categorised as resistant should be tested for susceptibility to individual agents or reported resistant.
Erythromycin 0.251 0.251 15 21A 21A
1 1 A
2. Inducible clindamycin resistance can be detected by antagonism of clindamycin activity by a macrolide agent. If not
Roxithromycin 0.5 0.5 Note NoteA detected, then report as tested according to the clinical breakpoints. If detected, then report as resistant and consider
Telithromycin 0.25 0.25 15 20 20 adding this comment to the report: "Clindamycin may still be used for short-term therapy of less serious skin and soft
Clindamycin2 0.5 0.5 2 17B 17B tissue infections as constitutive resistance is unlikely to develop during such therapy". The clinical importance of inducible
Quinupristin-dalfopristin - - - - clindamycin resistance in combination treatment of severe S. pyogenes infections is not known.

B. Place the erythromycin and clindamycin disks 12-16 mm apart (edge to edge) and look for antagonism (the D
phenomenon) to detect inducible clindamycin resistance.

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doxycycline 11 11 NoteA NoteA 1/A. Tetracycline can be used to screen for resistance in tetracycline agents. Isolates categorised as susceptible can be
Eravacycline IE IE IE IE reported susceptible to doxycycline and minocycline. Isolates categorised as resistant should be tested for susceptibility
to individual agents or reported resistant.
Minocycline 0.51 0.51 30 23A 23A
2. Resistant isolates are rare or not yet reported. The identification and antimicrobial susceptibility test result on any such
Tetracycline 11 11 30 23A 23A isolate must be confirmed and the isolate sent to a reference laboratory.
Tetracycline (screen only) 3. For tigecycline broth microdilution MIC determination, the medium must be prepared fresh on the day of use.
Tigecycline2 0.1253 0.1253 15 19 19

Oxazolidinones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Linezolid1 2 2 10 19 19 1. Resistant isolates are rare or not yet reported. The identification and antimicrobial susceptibility test result on any such
Tedizolid1 0.52 0.5 2 18A 18A isolate must be confirmed and the isolate sent to a reference laboratory.
2/A. Isolates susceptible to linezolid can be reported susceptible to tedizolid.

49
Streptococcus groups A, B, C and G EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Chloramphenicol IE IE IE IE 1. The clinical efficacy of chloramphenicol in meningitis has been questioned and breakpoints are currently under review.
Colistin - - - - For chloramphenicol treatment in meningitis, see table of dosages.
1. Resistant isolates are rare or not yet reported. The identification and antimicrobial susceptibility test result on any such
Daptomycin1 12 12 NoteA NoteA
isolate must be confirmed and the isolate sent to a reference laboratory.
Fosfomycin iv - - - -
2. Daptomycin MICs must be determined in the presence of Ca 2+ (50 mg/L in the medium for broth dilution methods; agar
Fosfomycin oral - - - -
dilution methods have not been validated). Follow the manufacturer's instructions for commercial systems.
Fusidic acid IE IE IE IE 3. Breakpoints for trimethoprim are currently under review.
Lefamulin IE IE IE IE 4. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.
Metronidazole - - - -
Nitrofurantoin (uncomplicated UTI only), 64 64 100 15 15 A. Use an MIC method.
S. agalactiae (group B streptococci)
Nitroxoline (uncomplicated UTI only) - - - -
Rifampicin 0.06 0.06 5 21 21
Spectinomycin - - - -
Trimethoprim (uncomplicated UTI only), S. 2 2 5 IP IP
agalactiae (group B streptococci)3
Trimethoprim-sulfamethoxazole 4 1 2 1.25-23.75 18 15

50
Streptococcus pneumoniae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1)
Medium: Mueller-Hinton broth + 5% lysed horse blood and 20 mg/L β-NAD (MH-F broth)
Inoculum: 5x105 CFU/mL
Incubation: Sealed panels, air, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information.
Quality control: Streptococcus pneumoniae ATCC 49619. For agents not covered by this strain, see
EUCAST QC Tables.
Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L β-NAD (MH-F)
Inoculum: McFarland 0.5 from blood agar or McFarland 1.0 from chocolate agar
Incubation: 5% CO2, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the front of the plate
with the lid removed and with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further information.
Quality control: Streptococcus pneumoniae ATCC 49619. For agents not covered by this strain, see EUCAST QC
Tables.

Penicillins1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin (indications other than 0.06 2 NoteA NoteA 1/A. The oxacillin 1 µg disk diffusion screening test or a benzylpenicillin MIC test shall be used to exclude beta-lactam
meningitis)2 resistance mechanisms. When the screen is negative (oxacillin zone diameter ≥20 mm, or benzylpenicillin MIC ≤0.06
Benzylpenicillin (meningitis) 0.06 0.06 NoteA NoteA mg/L) all beta-lactam agents for which clinical breakpoints are available, including those with “Note” can be reported
Ampicillin (indications other than 0.5 1 2 22 19 susceptible without further testing, except for cefaclor, which if reported, should be reported as “susceptible, increased
meningitis) exposure” (I). When the screen is positive (zone diameter <20 mm, or benzylpenicillin MIC >0.06 mg/L), see flow chart
below.
Ampicillin (meningitis) 0.5 0.5 NoteA NoteA
1,4 1,4 A,B
2. For breakpoints and dosing in pneumonia, see table of dosages.
Ampicillin-sulbactam 3
Note Note Note NoteA,B 3. The addition of a beta-lactamase inhibitor does not add clinical benefit.
1,4 1,4 A,B
Amoxicillin iv (indications other than Note Note Note NoteA,B 4/B. Susceptibility inferred from ampicillin (indications other than meningitis).
meningitis) 5. For susceptibility testing purposes, the concentration of clavulanic acid is fixed at 2 mg/L.
Amoxicillin iv (meningitis) 0.5 0.5 NoteA NoteA
Amoxicillin oral 0.5 1 Note A,B
NoteA,B B. For isolates with an oxacillin 1 µg zone <9 mm, determine the MIC. For isolates with an oxacillin zone ≥9 mm, report
Amoxicillin-clavulanic acid iv 3
Note1,4 Note1,4 NoteA,B NoteA,B susceptible without further testing.
C. For interpretation of the oxacillin disk screen, see flow chart below.
Amoxicillin-clavulanic acid oral3 0.55 15 NoteA,B NoteA,B
1,4 1,4 A,B
Piperacillin Note Note Note NoteA,B
Piperacillin-tazobactam3 Note1,4 Note1,4 NoteA,B NoteA,B
Ticarcillin
Ticarcillin-clavulanic acid - - - -
Temocillin - - - -
Phenoxymethylpenicillin Note1 Note1 NoteA NoteA
Oxacillin (screen only)1 NA NA 1 20C 20C
Cloxacillin - - - -
Dicloxacillin - - - -
Flucloxacillin - - - -
Mecillinam oral (pivmecillinam) - - - -
(uncomplicated UTI only)

51
Streptococcus pneumoniae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Cephalosporins1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Cefaclor 0.001 0.5 30 50 28 1/A. The oxacillin 1 µg disk diffusion screening test or a benzylpenicillin MIC test shall be used to exclude beta-lactam
Cefadroxil - - - - resistance mechanisms. When the screen is negative (oxacillin zone diameter ≥20 mm, or benzylpenicillin MIC ≤0.06
mg/L) all beta-lactam agents for which clinical breakpoints are available, including those with “Note” can be reported
Cefalexin - - - -
susceptible without further testing, except for cefaclor, which if reported, should be reported as “susceptible, increased
Cefazolin - - - - exposure” (I). When the screen is positive (oxacillin zone diameter <20 mm, or benzylpenicillin MIC >0.06 mg/L), see
Cefepime 1 2 NoteA NoteA flow chart below.
Cefiderocol IE IE IE IE
Cefixime - - - - B. For isolates with an oxacillin 1 µg zone <9 mm, determine the MIC. For isolates with an oxacillin zone ≥9 mm, report
susceptible without further testing.
Cefotaxime (indications other than 0.5 2 NoteA NoteA
meningitis)
Cefotaxime (meningitis) 0.5 0.5 NoteA NoteA
Cefoxitin IE IE IE IE
Cefpodoxime 0.25 0.25 NoteA NoteA
A
Ceftaroline 0.25 0.25 Note NoteA
Ceftazidime - - - -
Ceftazidime-avibactam - - - -
Ceftibuten - - - -
Ceftobiprole 0.5 0.5 NoteA NoteA
Ceftolozane-tazobactam - - - -
Ceftriaxone (indications other than 0.5 2 NoteA NoteA
meningitis)
Ceftriaxone (meningitis) 0.5 0.5 NoteA NoteA
A
Cefuroxime iv 0.5 1 Note NoteA
A
Cefuroxime oral 0.25 0.25 Note NoteA

Carbapenems1,2 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doripenem 1 1 NoteA NoteA 1/A. The oxacillin 1 µg disk diffusion screening test or a benzylpenicillin MIC test shall be used to exclude beta-lactam
Ertapenem 0.5 0.5 NoteA NoteA resistance mechanisms. When the screen is negative (oxacillin zone diameter ≥20 mm, or benzylpenicillin MIC ≤0.06
mg/L) all beta-lactam agents for which clinical breakpoints are available, including those with “Note” can be reported
Imipenem 2 2 NoteA NoteA
3 3 B
susceptible without further testing, except for cefaclor, which if reported, should be reported as “susceptible, increased
Imipenem-relebactam 3
Note Note Note NoteB exposure” (I). When the screen is positive (oxacillin zone diameter <20 mm, or benzylpenicillin MIC >0.06 mg/L), see
Meropenem (indications other than 2 2 NoteA NoteA flow chart below.
meningitis) 2. Meropenem is the only carbapenem used for meningitis.
Meropenem (meningitis) 0.25 0.25 NoteA NoteA 3/B. The addition of a beta-lactamase inhibitor does not add clinical benefit.
Meropenem-vaborbactam 3
Note3 Note3 NoteB NoteB
C. For isolates with an oxacillin 1 µg zone <9 mm, determine the MIC. For isolates with an oxacillin zone ≥9 mm, report
susceptible without further testing.

52
Streptococcus pneumoniae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Monobactams MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Aztreonam - - - -

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin - - - - A. The norfloxacin disk diffusion test can be used to screen for fluoroquinolone resistance. See Note B.
Delafloxacin IE IE IE IE B. Isolates categorised as screen negative can be reported susceptible to moxifloxacin and as "susceptible increased
exposure" (I) to levofloxacin. Isolates categorised as screen positive should be tested for susceptibility to individual
Levofloxacin 0.001 2 5 50A 16A
A
agents or reported resistant.
Moxifloxacin 0.5 0.5 5 22 22A
Nalidixic acid (screen only) NA NA NA NA
Norfloxacin (screen only) NA NA 10 10B 10B
Ofloxacin - - - -

Aminoglycosides MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Amikacin - - - -
Gentamicin - - - -
Netilmicin - - - -
Tobramycin - - - -

Glycopeptides and MIC breakpoints Disk Zone diameter Notes

lipoglycopeptides (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Dalbavancin IE IE IE IE 1. Resistant isolates are rare or not yet reported. The identification and antimicrobial susceptibility test result on any such
Oritavancin IE IE IE IE isolate must be confirmed and the isolate sent to a reference laboratory.

Teicoplanin1 2 2 30 17A 17A

A. Non-wild type isolates were not available when developing the disk diffusion method.
Telavancin IE IE IE IE
Vancomycin1 2 2 5 16A 16A

53
Streptococcus pneumoniae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Macrolides, lincosamides and MIC breakpoints Disk Zone diameter Notes

streptogramins (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Azithromycin 0.251 0.251 NoteA NoteA 1/A. Erythromycin can be used to screen for macrolide resistance in Streptococcus pneumoniae . Isolates categorised as
Clarithromycin 0.251 0.251 NoteA NoteA susceptible can be reported susceptible to azithromycin, clarithromycin and roxithromycin. Isolates categorised as
resistant should be tested for susceptibility to individual agents or reported resistant.
Erythromycin 0.251 0.251 15 22A 22A
1 1 A
2. Inducible clindamycin resistance can be detected by antagonism of clindamycin activity by a macrolide agent. If not
Roxithromycin 0.5 0.5 Note NoteA detected, then report as tested according to the clinical breakpoints. If detected, then report as resistant.
Telithromycin 0.25 0.25 15 23 23
Clindamycin2 0.5 0.5 2 19B 19B B. Place the erythromycin and clindamycin disks 12-16 mm apart (edge to edge) and look for antagonism (the D
Quinupristin-dalfopristin - - - - phenomenon) to detect inducible clindamycin resistance.

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doxycycline 11 11 NoteA NoteA 1/A. Tetracycline can be used to screen for resistance in tetracycline agents. Isolates categorised as susceptible can be
Eravacycline IE IE IE IE reported susceptible to doxycycline and minocycline. Isolates categorised as resistant should be tested for susceptibility
to individual agents or reported resistant.
Minocycline 0.51 0.51 30 24A 24A
1 1 A
Tetracycline 1 1 30 25 25A
Tetracycline (screen only)
Tigecycline IE IE IE IE

Oxazolidinones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Linezolid 2 2 10 22 22
Tedizolid IE IE IE IE

54
Streptococcus pneumoniae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Chloramphenicol1 Note1 Note1 NoteA NoteA 1/A. Efficacy for this species is uncertain. ECOFFs can be used to distinguish wild-type isolates from isolates with
Colistin - - - - acquired resistance (MIC >8 mg/L; zone diameter <21 mm for the chloramphenicol 30 µg disk). For chloramphenicol
treatment in meningitis, see table of dosages.
Daptomycin IE IE IE IE
2. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.
Fosfomycin iv IE IE IE IE
Fosfomycin oral - - - -
Fusidic acid - - - -
Lefamulin 0.5 0.5 5 12 12
Metronidazole - - - -
Nitrofurantoin (uncomplicated UTI only) - - - -
Nitroxoline (uncomplicated UTI only) - - - -
Rifampicin 0.125 0.125 5 22 22
Spectinomycin - - - -
Trimethoprim (uncomplicated UTI only) - - - -
Trimethoprim-sulfamethoxazole 2 1 2 1.25-23.75 13 10

55
Streptococcus pneumoniae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Streptococcus pneumoniae: Flow chart based on the oxacillin screen test for beta-lactam resistance See the EUCAST warning on the use of
benzylpenicillin gradient tests at
mechanisms to reduce the number of specific tests for beta-lactam agents http://www.eucast.org/warnings/.

Oxacillin 1 µg zone diameter ≥20 mm Oxacillin 1 µg zone diameter <20 mm

(or benzylpenicillin MIC ≤0.06 mg/L) (or benzylpenicillin MIC >0.06 mg/L)

Mechanism: excludes all beta-lactam resistance mechanisms Mechanism: beta-lactam resistance detected

Report susceptible (S) to beta-lactam agents for which clinical Report: resistant (R) to benzylpenicillin (meningitis) and phenoxymethylpenicillin (all indications).
breakpoints are available, including those with “Note”, and those
with meningitis breakpoints. Exception: Cefaclor is reported For benzylpenicillin (indications other than meningitis), perform and interpret MIC according to
“susceptible, increased exposure” (I). breakpoints.

No further testing required. For other beta-lactam agents, see below.

Oxacillin 1 µg zone diameter 9-19 mm Oxacillin 1 µg zone diameter <9 mm

Report susceptible (S) without further testing to: ampicillin, amoxicillin and piperacillin (without Perform susceptibility testing for the relevant agent and
and with beta-lactamase inhibitor), cefepime, cefotaxime, ceftaroline, ceftobiprole, interpret according to breakpoints.
ceftriaxone, imipenem and meropenem.
This guidance is also valid for meningitis breakpoints.
For other beta-lactam agents, perform susceptibility testing for the relevant agent and
interpret according to breakpoints.

This guidance is also valid for meningitis breakpoints.

56
Viridans group streptococci EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

In endocarditis, refer to national or international endocarditis guidelines for breakpoints for viridans group streptococci.

MIC determination (broth microdilution according to ISO standard 20776-1)
Medium: Mueller-Hinton broth + 5% lysed horse blood and 20 mg/L β-NAD (MH-F broth)
Inoculum: 5x105 CFU/mL
Incubation: Sealed panels, air, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information.
Quality control: Streptococcus pneumoniae ATCC 49619. For agents not covered by this strain, see
EUCAST QC Tables.
Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L β-NAD (MH-F)
Inoculum: McFarland 0.5
Incubation: 5% CO2, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the front of the plate
with the lid removed and with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further information.
Quality control: Streptococcus pneumoniae ATCC 49619. For agents not covered by this strain, see EUCAST QC
Tables.

This group of bacteria includes many species, which can be grouped as follows:
S. anginosus group: S. anginosus, S. constellatus, S. intermedius
S. mitis group: S. australis, S. cristatus, S. infantis, S. massiliensis, S. mitis, S. oligofermentans, S. oralis, S. peroris, S. pseudopneumoniae, S. sinensis
S. sanguinis group: S. sanguinis, S. parasanguinis, S. gordonii
S. bovis group: S. equinus, S. gallolyticus (S. bovis), S. infantarius, S. lutetiensis, S. pasteurianus
S. salivarius group: S. salivarius, S. vestibularis, S. thermophilus
S. mutans group: S. mutans, S. sobrinus

Penicillins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin 0.25 2 1 unit 21 12 1/A. Benzylpenicillin (MIC or disk diffusion) can be used to screen for beta-lactam resistance in viridans group
Benzylpenicillin (screen only) 0.251 0.251 1 unit 21A 21A streptococci. Isolates categorised as screen negative can be reported susceptible to beta-lactam agents for which clinical
breakpoints are listed (including those with “Note”). Isolates categorised as screen positive should be tested for
Ampicillin 0.5 2 2 21 15
susceptibility to individual agents or reported resistant.
Ampicillin-sulbactam2 Note1,3 Note1,3 NoteA,B NoteA,B 2. The addition of a beta-lactamase inhibitor does not add clinical benefit.
A,B
Amoxicillin 0.5 2 Note NoteA,B 3/B. For benzylpenicillin screen negative isolates, susceptibility can be inferred from benzylpenicillin or ampicillin. For
Amoxicillin-clavulanic acid2 Note1,3 Note1,3 NoteA,B NoteA,B benzylpenicillin screen positive isolates, susceptibility is inferred from ampicillin.
1,3 1,3 A,B
Piperacillin Note Note Note NoteA,B
1,3 1,3 A,B
Piperacillin-tazobactam 2
Note Note Note NoteA,B
Ticarcillin
Ticarcillin-clavulanic acid2 IE IE IE IE
Temocillin - - - -
Phenoxymethylpenicillin IE IE IE IE
Oxacillin - - - -
Cloxacillin - - - -
Dicloxacillin - - - -
Flucloxacillin - - - -
Mecillinam oral (pivmecillinam) - - - -
(uncomplicated UTI only)

57
Viridans group streptococci EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Cephalosporins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Cefaclor - - - - 1. The addition of a beta-lactamase inhibitor does not add clinical benefit.
Cefadroxil - - - -
Cefalexin - - - - A. Benzylpenicillin (MIC or disk diffusion) can be used to screen for beta-lactam resistance in viridans group streptococci.
See Note 1/A on penicillins.
Cefazolin - - - -
Cefepime 0.5 0.5 30 25A 25A
Cefiderocol IE IE IE IE
Cefixime - - - -
Cefotaxime 0.5 0.5 5 23A 23A
Cefoxitin IE IE IE IE
Cefpodoxime - - - -
Ceftaroline - - - -
Ceftazidime - - - -
Ceftazidime-avibactam - - - -
Ceftibuten - - - -
Ceftobiprole - - - -
Ceftolozane-tazobactam1, S. anginosus IE IE IE IE
group
Ceftriaxone 0.5 0.5 30 27A 27A
Cefuroxime iv 0.5 0.5 30 26A 26A
Cefuroxime oral - - - -

Carbapenems MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doripenem 1 1 NoteA NoteA 1. For susceptibility testing purposes, the concentration of relebactam is fixed at 4 mg/L.
Ertapenem 0.5 0.5 Note A
NoteA 2/B. The addition of a beta-lactamase inhibitor does not add clinical benefit.
Imipenem 2 2 NoteA NoteA
A. Benzylpenicillin (MIC or disk diffusion) can be used to screen for beta-lactam resistance in viridans group streptococci.
Imipenem-relebactam2 21 21 NoteA,B NoteA,B See Note 1/A on penicillins.
A A
Meropenem 2 2 Note Note
Meropenem-vaborbactam2 Note2 Note2 NoteB NoteB

Monobactams MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Aztreonam - - - -

58
Viridans group streptococci EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin - - - - 1/B. Moxifloxacin has been used in oral follow-up treatment of endocarditis caused by viridans group streptococci. There
Delafloxacin, S. anginosus group 0.03 0.03 NoteA NoteA are no clinical breakpoints but acquired resistance (isolates with MIC >0.5 mg/L; zone diameter <21 mm for the
moxifloxacin 5 µg disk) should be excluded. When excluded, the isolate should be reported “devoid of fluoroquinolone
Levofloxacin IE IE IE IE
resistance mechanisms”, but not as susceptible to moxifloxacin.
Moxifloxacin Note1 Note1 NoteB NoteB
Nalidixic acid (screen only) NA NA NA NA A. A disk diffusion test awaits action from the responsible pharmaceutical company.
Norfloxacin (uncomplicated UTI only) - - - -
Ofloxacin - - - -

Aminoglycosides1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Amikacin Note2 Note2 - - 1. Viridans group streptococci are intrinsically resistant to aminoglycosides and aminoglycoside monotherapy is
Gentamicin (test for high-level Note2 Note2 - - ineffective. There is likely to be synergy between aminoglycosides and penicillins or glycopeptides against streptococci
aminoglycoside resistance) without acquired high-level aminoglycoside resistance. All testing is therefore to distinguish between intrinsic and high-
level acquired resistance.
Netilmicin Note2 Note2 - -
2. Gentamicin can be used to screen for high-level aminoglycoside resistance (HLAR).
Tobramycin Note2 Note2 - -
Negative test: Isolates with gentamicin MIC ≤128 mg/L. The isolate is wild type for gentamicin and low-level intrinsic
resistant. For other aminoglycosides, this may not be the case. Synergy with penicillins or glycopeptides can be expected
if the isolate is susceptible to the penicillin or glycopeptide.
Positive test: Isolates with gentamicin MIC >128 mg/L. The isolate is high-level resistant to gentamicin and other
aminoglycosides except streptomycin. There will be no synergy with penicillins or glycopeptides.

Glycopeptides and MIC breakpoints Disk Zone diameter Notes

lipoglycopeptides (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Dalbavancin1, S. anginosus group 0.1252,3 0.1252 NoteA NoteA 1. Resistant isolates are rare or not yet reported. The identification and antimicrobial susceptibility test result on any such
1
Oritavancin , S. anginosus group 0.25 2,3
0.25 2
Note A
NoteA isolate must be confirmed and the isolate sent to a reference laboratory.
2. MICs must be determined in the presence of polysorbate-80 (0.002% in the medium for broth dilution methods; agar
Teicoplanin1 2 2 30 16B 16B
dilution methods have not been validated). Follow the manufacturer's instructions for commercial systems.
Telavancin IE IE IE IE
3. Isolates susceptible to vancomycin can be reported susceptible to dalbavancin and oritavancin.
Vancomycin1 2 2 5 15B 15B
A. Disk diffusion criteria have not been defined and an MIC method should be used.
B. Non-wild type isolates were not available when developing the disk diffusion method.

59
Viridans group streptococci EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Macrolides, lincosamides and MIC breakpoints Disk Zone diameter Notes

streptogramins (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Azithromycin IE IE IE IE 1. Inducible clindamycin resistance can be detected by antagonism of clindamycin activity by a macrolide agent. If not
Clarithromycin IE IE IE IE detected, then report as tested according to the clinical breakpoints. If detected, then report as resistant.
Erythromycin IE IE 15 IE IE
A. Place the erythromycin and clindamycin disks 12-16 mm apart (edge to edge) and look for antagonism (the D
Roxithromycin IE IE IE IE phenomenon) to detect inducible clindamycin resistance.
Telithromycin IE IE IE IE
Clindamycin1 0.5 0.5 2 19A 19A
Quinupristin-dalfopristin IE IE IE IE

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doxycycline - - - -
Eravacycline 0.125 0.125 20 17 17
Minocycline - - - -
Tetracycline - - - -
Tigecycline IE IE IE IE

Oxazolidinones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Linezolid IE IE IE IE
Tedizolid, S. anginosus group 0.5 0.5 2 18 18

60
Viridans group streptococci EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Chloramphenicol - - - - 1/A. Rifampicin has been used in oral follow-up treatment of endocarditis caused by viridans group streptococci. There
Colistin - - - - are no clinical breakpoints but acquired resistance (isolates with MIC >0.25 mg/L; zone diameter <21 mm for the
rifampicin 5 µg disk) should be excluded. When excluded, the isolate should be reported “devoid of rifampicin resistance
Daptomycin - - - -
mechanisms”, but not as susceptible to rifampicin.
Fosfomycin iv - - - -
Fosfomycin oral - - - -
Fusidic acid - - - -
Lefamulin IE IE IE IE
Metronidazole - - - -
Nitrofurantoin (uncomplicated UTI only) - - - -
Nitroxoline (uncomplicated UTI only) - - - -
Rifampicin Note1 Note1 NoteA NoteA
Spectinomycin - - - -
Trimethoprim (uncomplicated UTI only) - - - -
Trimethoprim-sulfamethoxazole - - - -

61
Haemophilus influenzae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1)
Medium: Mueller-Hinton broth + 5% lysed horse blood and 20 mg/L β-NAD (MH-F broth)
Inoculum: 5x105 CFU/mL
Incubation: Sealed panels, air, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information.
Quality control: Haemophilus influenzae ATCC 49766. For agents not covered by this strain and for control
of the inhibitor component of beta-lactam inhibitor combinations, see EUCAST QC Tables.
Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L β-NAD (MH-F)
Inoculum: McFarland 0.5
Incubation: 5% CO2, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the front of the plate
with the lid removed and with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further information.
Quality control: Haemophilus influenzae ATCC 49766. For agents not covered by this strain and for control of the
inhibitor component of beta-lactam inhibitor-combination disks, see EUCAST QC Tables.

EUCAST breakpoints have been defined for H. influenzae only. Clinical data for other Haemophilus species are scarce. MIC distributions for H. parainfluenzae are similar to those for H. influenzae. In the absence of specific breakpoints,
the H. influenzae MIC breakpoints can be applied to H. parainfluenzae.

Penicillins1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin IE IE IE IE 1/A. The benzylpenicillin 1 unit disk diffusion screening test shall be used to exclude beta-lactam resistance mechanisms.
Benzylpenicillin (screen only)1 NA NA 1 unit 12A,B 12A,B When the screen is negative (zone diameter ≥12 mm) all penicillins for which clinical breakpoints are available, including
those with “Note”, can be reported susceptible without further testing, except for amoxicillin oral and amoxicillin-clavulanic
Ampicillin (indications other than 1 1 2 18A,B 18A,B
2 acid oral, which if reported, should be reported “susceptible, increased exposure” (I). When the screen is positive (zone
meningitis)
diameter <12 mm), see flow chart below.
Ampicillin (meningitis)2 IE IE IE IE
2. Beta-lactamase positive isolates can be reported resistant to ampicillin, amoxicillin and piperacillin without inhibitors.
Ampicillin-sulbactam 13,4 13,4 NoteA,D NoteA,D Tests based on a chromogenic cephalosporin can be used to detect the beta-lactamase.
Amoxicillin iv (indications other than 2 2 NoteA,E NoteA,E 3. For susceptibility testing purposes, the concentration of sulbactam is fixed at 4 mg/L.
meningitis)2 4/D. Susceptibility can be inferred from amoxicillin-clavulanic acid iv.
Amoxicillin iv (meningitis)2 IE IE IE IE 5. For susceptibility testing purposes, the concentration of clavulanic acid is fixed at 2 mg/L.
Amoxicillin oral 2 0.001 2 NoteA,F NoteA,F 6. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L.
Amoxicillin-clavulanic acid iv 25 25 2-1 15A,B 15A,B
5 5 A,B B. Read the outer edge of zones where an otherwise clear inhibition zone contains an area of growth around the disk,
Amoxicillin-clavulanic acid oral 0.001 2 2-1 50 15A,B
see pictures below.
Piperacillin2 IE IE IE IE
C. ATU relevant only if the benzylpenicillin 1 unit disk screen is positive (zone diameter <12 mm).
Piperacillin-tazobactam 0.256 0.256 30-6 27A,B 27A,B 26-28B,C E. Susceptibility can be inferred from ampicillin.
Ticarcillin F. Isolates susceptible to ampicillin can be reported "susceptible, increased exposure” (I) to amoxicillin oral. Isolates
Ticarcillin-clavulanic acid IE IE IE IE resistant to ampicillin can be reported resistant to amoxicillin oral.
Temocillin IE IE IE IE
Phenoxymethylpenicillin IE IE IE IE
Oxacillin - - - -
Cloxacillin - - - -
Dicloxacillin - - - -
Flucloxacillin - - - -
Mecillinam oral (pivmecillinam) - - - -
(uncomplicated UTI only)

62
Haemophilus influenzae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Cephalosporins1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Cefaclor - - - - 1/A. The benzylpenicillin 1 unit disk diffusion screening test shall be used to exclude beta-lactam resistance mechanisms.
Cefadroxil - - - - When the screen is negative (zone diameter ≥12 mm) all cephalosporins for which clinical breakpoints are available,
including those with “Note”, can be reported susceptible without further testing, except for cefuroxime oral, which if
Cefalexin - - - -
reported, should be reported “susceptible, increased exposure” (I). When the screen is positive (zone diameter <12 mm),
Cefazolin - - - -
see flow chart below.
Cefepime 0.25 0.25 30 28A,B 28A,B 28-33B,C 2. See table of dosages for dosing for different indications.
Cefiderocol IE IE IE IE 3/C. ATU relevant only if the benzylpenicillin 1 unit disk screen is positive (zone diameter <12 mm).
Cefixime 0.125 0.125 5 26A,B 26A,B
B. Read the outer edge of zones where an otherwise clear inhibition zone contains an area of growth around the disk,
Cefotaxime (indications other than 0.125 0.125 5 27A,B 27A,B 25-27B,C
meningitis) see pictures below.
D. For benzylpenicillin 1 unit disk screen positive isolates (inhibition zone <12 mm), determine the MIC.
Cefotaxime (meningitis) 0.125 0.125 5 27A,B 27A,B 25-27B
Cefoxitin IE IE IE IE
Cefpodoxime 0.25 0.25 10 26A,B 26A,B 26-29B,C
A A
Ceftaroline 0.03 0.03 Note Note
Ceftazidime - - - -
Ceftazidime-avibactam - - - -
Ceftibuten 1 1 30 25A,B 25A,B
Ceftobiprole IE IE IE IE
Ceftolozane-tazobactam (pneumonia)2 0.5 0.5 30-10 23A,B 23A,B 22-23B,C
Ceftriaxone (indications other than 0.125 0.125 30 32A,B 32A,B 31-33B,C
meningitis)
Ceftriaxone (meningitis) 0.125 0.125 30 32A,B 32A,B 31-33B
3 A,B A,B
Cefuroxime iv 1 2 2 30 27 25 25-27B,C
Cefuroxime oral 0.001 1 30 50A,B 27A,B 25-27B,C

63
Haemophilus influenzae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Carbapenems1,2 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doripenem 1 1 10 23A,B 23A,B 1/A. The benzylpenicillin 1 unit disk diffusion screening test shall be used to exclude beta-lactam resistance mechanisms.
Ertapenem 0.5 0.5 10 23A,B 23A,B When the screen is negative (zone diameter ≥12 mm) all carbapenems for which clinical breakpoints are available,
including those with “Note”, can be reported susceptible without further testing. When the screen is positive (zone
Imipenem 2 2 10 20A,B 20A,B 6-19B,C
3 3 3 E E
diameter <12 mm), see flow chart below.
Imipenem-relebactam Note Note Note Note 2. Meropenem is the only carbapenem used for meningitis.
Meropenem (indications other than 2 2 10 20A,B 20A,B 3/E. The beta-lactamases produced by the organism either do not modify the parent carbapenem or are not affected by
meningitis) the inhibitor. Therefore the addition of the beta-lactamase inhibitor does not add clinical benefit.
Meropenem (meningitis) 0.25 0.25 NoteA NoteA
Meropenem-vaborbactam 3
Note3 Note3 NoteE NoteE B. Read the outer edge of zones where an otherwise clear inhibition zone contains an area of growth around the disk,
see pictures below.
C. ATU relevant only if the benzylpenicillin 1 unit disk screen is positive (zone diameter <12 mm).
D. For benzylpenicillin 1 unit disk screen positive isolates (inhibition zone <12 mm), determine the MIC for meropenem.

Monobactams MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Aztreonam IE IE IE IE

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin (indications other than 0.06 0.06 5 30A 30A A. The nalidixic acid disk diffusion test can be used to screen for fluoroquinolone resistance. See Note C.
meningitis) B. Susceptibility can be inferred from the nalidixic acid screening test.
Ciprofloxacin (meningitis) 0.03 0.03 5 NoteB NoteB C. Isolates categorised as screen negative can be reported susceptible to ciprofloxacin, levofloxacin, moxifloxacin and
Delafloxacin IE IE IE IE ofloxacin. Isolates categorised as screen positive should be tested for susceptibility to individual agents or reported
resistant.
Levofloxacin 0.06 0.06 5 30A 30A
A
Moxifloxacin 0.125 0.125 5 28 28A
Nalidixic acid (screen only) NA NA 30 23C 23C
Norfloxacin (uncomplicated UTI only) - - - -
Ofloxacin 0.06 0.06 5 30A 30A

Aminoglycosides MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Amikacin IE IE IE IE
Gentamicin IE IE IE IE
Netilmicin IE IE IE IE
Tobramycin IE IE IE IE

64
Haemophilus influenzae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Glycopeptides and MIC breakpoints Disk Zone diameter Notes

lipoglycopeptides (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Dalbavancin - - - -
Oritavancin - - - -
Teicoplanin - - - -
Telavancin - - - -
Vancomycin - - - -

Macrolides1, lincosamides and MIC breakpoints Disk Zone diameter Notes

streptogramins (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Azithromycin Note1 Note1 NoteA NoteA 1/A. Clinical evidence for the efficacy of macrolides in H. influenzae respiratory infections is conflicting due to high
Clarithromycin Note 1
Note 1
Note A
NoteA spontaneous cure rates. Should there be a need to test any macrolide against this species, the epidemiological cut-offs
(ECOFFs) should be used to detect strains with acquired resistance. The ECOFFs for each agent are: azithromycin 4
Erythromycin Note1 Note1 NoteA NoteA
mg/L, clarithromycin 32 mg/L, erythromycin 16 mg/L and telithromycin 8 mg/L. There are insufficient data available to
Roxithromycin Note1 Note1 NoteA NoteA establish an ECOFF for roxithromycin.
1 1 A
Telithromycin Note Note Note NoteA
Clindamycin - - - -
Quinupristin-dalfopristin - - - -

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doxycycline 11 11 NoteA NoteA 1/A. Tetracycline can be used to screen for resistance in tetracycline agents. Isolates categorised as susceptible to
Eravacycline IE IE IE IE tetracycline can be reported susceptible to doxycycline and minocycline. Isolates categorised as resistant to tetracycline
should be tested for susceptibility to individual agents or reported resistant.
Minocycline 11 11 30 24A 24A
Tetracycline 21 21 30 25A 25A
Tigecycline IE IE IE IE

Oxazolidinones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Linezolid - - - -
Tedizolid - - - -

65
Haemophilus influenzae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Chloramphenicol1 2 2 30 28 28 1. For chloramphenicol treatment in meningitis, see table of dosages.
Colistin - - - - 2. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.
Daptomycin - - - -
Fosfomycin iv IE IE IE IE
Fosfomycin oral - - - -
Fusidic acid - - - -
Lefamulin IE IE IE IE
Metronidazole - - - -
Nitrofurantoin (uncomplicated UTI only) - - - -
Nitroxoline (uncomplicated UTI only) - - - -
Rifampicin (for prophylaxis only) 1 1 5 18 18
Spectinomycin - - - -
Trimethoprim (uncomplicated UTI only) - - - -
Trimethoprim-sulfamethoxazole 2 0.5 1 1.25-23.75 23 20

Examples of inhibition zones for H. influenzae and a beta-lactam agent where an otherwise clear inhibition zone contains an area of growth around the disk.
Read the outer edge of zones where an otherwise clear inhibition zone contains an area of growth around the disk.

66
Haemophilus influenzae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Haemophilus influenzae: Flow chart based on the benzylpenicillin (PCG) screen test for beta-lactam resistance mechanisms to
reduce the number of specific tests for beta-lactam agents
To take full advantage of the procedure, include the amoxicillin-clavulanic acid 2-1 µg disk, but read and interpret only on beta-lactamase positive isolates.

PCG 1 unit zone diameter ≥12 mm PCG 1 unit zone diameter <12 mm
Mechanism: excludes all beta-lactam resistance mechanisms Mechanism: beta-lactamase and/or PBP3 mutations

Report susceptible (S) to beta-lactam agents for which clinical breakpoints are Further testing: test for beta-lactamase.
available, including those with “Note”, and those with meningitis breakpoints.
Exception: Oral amoxicillin, oral amoxicillin-clavulanic acid and oral cefuroxime In meningitis, determine the MIC for the agent considered for clinical
are reported “susceptible, increased exposure” (I). use and interpret according to the clinical breakpoints.

No further testing required.

Beta-lactamase positive Beta-lactamase negative

Mechanisms: beta-lactamase with or without PBP3 mutations Mechanism: PBP3 mutations

Report resistant (R) to ampicillin, amoxicillin and piperacillin (without Perform susceptibility testing for the relevant agents and interpret according
beta-lactamase inhibitor). to breakpoints.

For other beta-lactam agents, read the amoxicillin-clavulanic acid 2-1 For cefepime, cefpodoxime and imipenem, if PCG 1 unit <12 mm and
µg disk and interpret as below. susceptible by agent disk diffusion test, determine the MIC of the agent and
interpret according to the clinical breakpoints.

Amoxicillin-clavulanic acid 2-1 µg ≥15 mm Amoxicillin-clavulanic acid 2-1 µg <15 mm

Mechanism: beta-lactamase only Mechanisms: beta-lactamase and PBP3 mutations

Report susceptible (S) to agents (other than ampicillin, amoxicillin and piperacillin)
for which clinical breakpoints are available, including those with “Note”, and those
with meningitis breakpoints.
Exception: Oral amoxicillin-clavulanic acid and oral cefuroxime are reported
“susceptible, increased exposure” (I).
Perform susceptibility testing for the relevant agents and interpret according to breakpoints.
For cefepime, cefpodoxime and imipenem, if PCG 1 unit <12 mm and susceptible by agent disk
diffusion test, determine the MIC of the agent and interpret according to the clinical breakpoints.

67
Moraxella catarrhalis EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1)
Medium: Mueller-Hinton broth + 5% lysed horse blood and 20 mg/L β-NAD (MH-F broth)
Inoculum: 5x105 CFU/mL
Incubation: Sealed panels, air, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information.
Quality control: Haemophilus influenzae ATCC 49766. For agents not covered by this strain and for control
of the inhibitor component of beta-lactam inhibitor combinations, see EUCAST QC Tables.
Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L β-NAD (MH-F)
Inoculum: McFarland 0.5
Incubation: 5% CO2, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the front of the plate
with the lid removed and with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further information.
Quality control: Haemophilus influenzae ATCC 49766. For agents not covered by this strain and for control of the
inhibitor component of beta-lactam inhibitor-combination disks, see EUCAST QC Tables.

Penicillins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin - - - - 1. Most M. catarrhalis produce beta-lactamase, although beta-lactamase production is slow and may give weak results
Ampicillin -1 -1 - - with in vitro tests. Beta-lactamase producers should be reported resistant to penicillins and aminopenicillins without
inhibitors.
Ampicillin-sulbactam 12,3 12,3 NoteA NoteA
2. For susceptibility testing purposes, the concentration of sulbactam is fixed at 4 mg/L.
Amoxicillin -1 -1 - -
3/A. Susceptibility can be inferred from amoxicillin-clavulanic acid.
Amoxicillin-clavulanic acid 14 14 2-1 19 19 4. For susceptibility testing purposes, the concentration of clavulanic acid is fixed at 2 mg/L.
1
Piperacillin - -1 - -
Piperacillin-tazobactam Note3 Note3 NoteA NoteA
Ticarcillin
Ticarcillin-clavulanic acid IE IE IE IE
Temocillin IE IE IE IE
Phenoxymethylpenicillin - - - -
Oxacillin - - - -
Cloxacillin - - - -
Dicloxacillin - - - -
Flucloxacillin - - - -
Mecillinam oral (pivmecillinam) - - - -
(uncomplicated UTI only)

68
Moraxella catarrhalis EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Cephalosporins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Cefaclor - - - -
Cefadroxil - - - -
Cefalexin - - - -
Cefazolin - - - -
Cefepime 4 4 30 20 20
Cefiderocol IE IE IE IE
Cefixime 0.5 0.5 5 21 21
Cefotaxime 1 2 5 20 17
Cefoxitin IE IE IE IE
Cefpodoxime IP IP 10 IP IP
Ceftaroline IE IE IE IE
Ceftazidime - - - -
Ceftazidime-avibactam - - - -
Ceftibuten IE IE IE IE
Ceftobiprole IE IE IE IE
Ceftolozane-tazobactam IE IE IE IE
Ceftriaxone 1 2 30 24 21
Cefuroxime iv 4 8 30 21 18
Cefuroxime oral 0.001 4 30 50 21

Carbapenems MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doripenem1 1 1 10 30 30 1. Resistant isolates are rare or not yet reported. The identification and antimicrobial susceptibility test result on any such
Ertapenem1 0.5 0.5 10 29 29 isolate must be confirmed and the isolate sent to a reference laboratory.
2/A. The beta-lactamases produced by the organism either do not modify the parent carbapenem or are not affected by
Imipenem1 2 2 10 29 29
the inhibitor. Therefore the addition of the beta-lactamase inhibitor does not add clinical benefit.
Imipenem-relebactam2 Note2 Note2 NoteA NoteA
Meropenem1 2 2 10 33 33
Meropenem-vaborbactam2 Note2 Note2 NoteA NoteA

Monobactams MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Aztreonam IE IE IE IE

69
Moraxella catarrhalis EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin 0.125 0.125 5 31A 31A A. The nalidixic acid disk diffusion test can be used to screen for fluoroquinolone resistance. See Note B.
Delafloxacin IE IE IE IE B. Isolates categorised as screen negative can be reported susceptible to ciprofloxacin, levofloxacin, moxifloxacin and
ofloxacin. Isolates categorised as screen positive should be tested for susceptibility to individual agents or reported
Levofloxacin 0.125 0.125 5 29A 29A
A
resistant.
Moxifloxacin 0.25 0.25 5 26 26A
Nalidixic acid (screen only) NA NA 30 23B 23B
Norfloxacin (uncomplicated UTI only) - - - -
Ofloxacin 0.25 0.25 5 28A 28A

Aminoglycosides MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Amikacin IE IE IE IE
Gentamicin IE IE IE IE
Netilmicin IE IE IE IE
Tobramycin IE IE IE IE

Glycopeptides and MIC breakpoints Disk Zone diameter Notes

lipoglycopeptides (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Dalbavancin - - - -
Oritavancin - - - -
Teicoplanin - - - -
Telavancin - - - -
Vancomycin - - - -

Macrolides, lincosamides and MIC breakpoints Disk Zone diameter Notes

streptogramins (mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Azithromycin 0.251 0.251 NoteA NoteA 1/A. Erythromycin can be used to screen for macrolide resistance in Moraxella catarrhalis. Isolates categorised as
Clarithromycin 0.251 0.251 NoteA NoteA susceptible can be reported susceptible to azithromycin, clarithromycin and roxithromycin. Isolates categorised as
resistant should be tested for susceptibility to individual agents or reported resistant.
Erythromycin 0.25 0.25 15 23A 23A
Roxithromycin 0.51 0.51 NoteA NoteA
Telithromycin 0.25 0.25 15 23 23
Clindamycin - - - -
Quinupristin-dalfopristin - - - -

70
Moraxella catarrhalis EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doxycycline 11 11 NoteA NoteA 1/A. Tetracycline can be used to screen for resistance in tetracycline agents. Isolates categorised as susceptible to
Eravacycline IE IE IE IE tetracycline can be reported susceptible to doxycycline and minocycline. Isolates categorised as resistant to tetracycline
should be tested for susceptibility to individual agents or reported resistant.
Minocycline 11 11 30 25A 25A
1 1 A
Tetracycline 2 2 30 26 26A
Tigecycline IE IE IE IE

Oxazolidinones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Linezolid - - - -
Tedizolid - - - -

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Chloramphenicol Note1 Note1 NoteA NoteA 1/A. For topical use of chloramphenicol, see table of topical agents.
Colistin - - - - 2. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.
Daptomycin - - - -
Fosfomycin iv IE IE IE IE
Fosfomycin oral - - - -
Fusidic acid - - - -
Lefamulin IE IE IE IE
Metronidazole - - - -
Nitrofurantoin (uncomplicated UTI only) - - - -
Nitroxoline (uncomplicated UTI only) - - - -
Rifampicin - - - -
Spectinomycin - - - -
Trimethoprim (uncomplicated UTI only) - - - -
Trimethoprim-sulfamethoxazole 2 0.5 1 1.25-23.75 18 15

71
Neisseria gonorrhoeae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

For comments on dosages related to breakpoints, see the table of dosages.

Disk diffusion criteria for antimicrobial susceptibility testing of Neisseria gonorrhoeae have not yet been defined and an
MIC method should be used. If a commercial MIC method is used, follow the manufacturer´s instructions. Laboratories
with few isolates are encouraged to refer these to a reference laboratory for testing.

Penicillins1 MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Benzylpenicillin (surrogate agent)1 0.061 1 1. Always test for beta-lactamase (tests based on a chromogenic cephalosporin can be used). If beta-lactamase positive, report
Ampicillin 1
Note1 Note1 resistant to ampicillin and amoxicillin. If beta-lactamase negative, determine the MIC of benzylpenicillin. Infer the susceptibility to
ampicillin and amoxicillin from the benzylpenicillin MIC (do not report benzylpenicillin susceptibility).
Ampicillin-sulbactam IE IE
Amoxicillin1 Note1 Note1
Amoxicillin-clavulanic acid IE IE
Piperacillin - -
Piperacillin-tazobactam - -
Ticarcillin
Ticarcillin-clavulanic acid - -
Temocillin IE IE
Phenoxymethylpenicillin - -
Oxacillin - -
Cloxacillin - -
Dicloxacillin - -
Flucloxacillin - -
Mecillinam oral (pivmecillinam) - -
(uncomplicated UTI only)

72
Neisseria gonorrhoeae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Cephalosporins MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Cefaclor - -
Cefadroxil - -
Cefalexin - -
Cefazolin - -
Cefepime - -
Cefiderocol IE IE
Cefixime 0.125 0.125
Cefotaxime 0.125 0.125
Cefoxitin IE IE
Cefpodoxime - -
Ceftaroline - -
Ceftazidime - -
Ceftazidime-avibactam - -
Ceftibuten - -
Ceftobiprole - -
Ceftolozane-tazobactam - -
Ceftriaxone 0.125 0.125
Cefuroxime iv - -
Cefuroxime oral - -

Carbapenems MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Doripenem IE IE
Ertapenem IE IE
Imipenem IE IE
Imipenem-relebactam IE IE
Meropenem IE IE
Meropenem-vaborbactam IE IE

Monobactams MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Aztreonam IE IE

73
Neisseria gonorrhoeae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Fluoroquinolones MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Ciprofloxacin 0.03 0.06
Delafloxacin IE IE
Levofloxacin IE IE
Moxifloxacin IE IE
Nalidixic acid (screen only) NA NA
Norfloxacin (uncomplicated UTI only) - -
Ofloxacin 0.125 0.25

Aminoglycosides MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Amikacin - -
Gentamicin - -
Netilmicin - -
Tobramycin - -

Glycopeptides and lipoglycopeptides MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Dalbavancin - -
Oritavancin - -
Teicoplanin - -
Telavancin - -
Vancomycin - -

Macrolides, lincosamides and MIC breakpoints Notes

streptogramins (mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Azithromycin Note1 Note1 1. Azithromycin is always used in conjunction with another effective agent. For testing purposes with the aim of detecting acquired
Clarithromycin - - resistance mechanisms, the ECOFF is 1 mg/L.
Erythromycin - -
Roxithromycin - -
Telithromycin - -
Clindamycin - -
Quinupristin-dalfopristin - -

74
Neisseria gonorrhoeae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Tetracyclines MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Doxycycline IE IE
Eravacycline IE IE
Minocycline IE IE
Tetracycline 0.5 0.5
Tigecycline IE IE

Oxazolidinones MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Linezolid - -
Tedizolid - -

Miscellaneous agents MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Chloramphenicol - -
Colistin - -
Daptomycin - -
Fosfomycin iv - -
Fosfomycin oral - -
Fusidic acid - -
Lefamulin IE IE
Metronidazole - -
Nitrofurantoin (uncomplicated UTI only) - -
Nitroxoline (uncomplicated UTI only) - -
Rifampicin - -
Spectinomycin 64 64
Trimethoprim (uncomplicated UTI only) - -
Trimethoprim-sulfamethoxazole - -

75
Neisseria meningitidis EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Disk diffusion criteria for antimicrobial susceptibility testing of Neisseria meningitidis have not yet been defined and an
MIC method should be used. If a commercial MIC method is used, follow the manufacturer´s instructions.

Penicillins1 MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Benzylpenicillin (all indications) 0.25 0.25 1. All breakpoints pertain to iv administration.
Ampicillin (indications other than meningitis) 0.125 1
Ampicillin (meningitis) IE IE
Ampicillin-sulbactam IE IE
Amoxicillin (indications other than meningitis) 0.125 1
Amoxicillin (meningitis) IE IE
Amoxicillin-clavulanic acid - -
Piperacillin - -
Piperacillin-tazobactam - -
Ticarcillin
Ticarcillin-clavulanic acid - -
Temocillin - -
Phenoxymethylpenicillin - -
Oxacillin - -
Cloxacillin - -
Dicloxacillin - -
Flucloxacillin - -
Mecillinam oral (pivmecillinam) - -
(uncomplicated UTI only)

76
Neisseria meningitidis EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Cephalosporins MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Cefaclor - - 1. Resistant isolates are rare or not yet reported. The identification and antimicrobial susceptibility test result on any such isolate
Cefadroxil - - must be confirmed and the isolate sent to a reference laboratory.
Cefalexin - -
Cefazolin - -
Cefepime - -
Cefiderocol IE IE
Cefixime - -
Cefotaxime (all indications)1 0.125 0.125
Cefoxitin - -
Cefpodoxime - -
Ceftaroline - -
Ceftazidime - -
Ceftazidime-avibactam - -
Ceftibuten - -
Ceftobiprole - -
Ceftolozane-tazobactam - -
Ceftriaxone (all indications including prophylaxis) 1 0.125 0.125
Cefuroxime iv - -
Cefuroxime oral - -

Carbapenems1,2 MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Doripenem Note2 Note2 1. Resistant isolates are rare or not yet reported. The identification and antimicrobial susceptibility test result on any such isolate
Ertapenem IE IE must be confirmed and the isolate sent to a reference laboratory.
2. Breakpoints for serious N. meningitidis systemic infections (meningitis with or without septicemia) have been determined for
Imipenem Note2 Note2
meropenem only.
Imipenem-relebactam3 Note2,3 Note2,3 3. The addition of the beta-lactamase inhibitor does not add clinical benefit.
Meropenem (all indications)1,2 0.25 0.25
Meropenem-vaborbactam3 Note2,3 Note2,3

Monobactams MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Aztreonam - -

77
Neisseria meningitidis EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Fluoroquinolones MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Ciprofloxacin (all indications, including meningitis and 0.016 0.016
prophylaxis)
Delafloxacin IE IE
Levofloxacin IE IE
Moxifloxacin IE IE
Nalidixic acid (screen only) NA NA
Norfloxacin (uncomplicated UTI only) - -
Ofloxacin IE IE

Aminoglycosides MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Amikacin - -
Gentamicin - -
Netilmicin - -
Tobramycin - -

Glycopeptides and lipoglycopeptides MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Dalbavancin - -
Oritavancin - -
Teicoplanin - -
Telavancin - -
Vancomycin - -

Macrolides, lincosamides and MIC breakpoints Notes

streptogramins (mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Azithromycin - -
Clarithromycin - -
Erythromycin - -
Roxithromycin - -
Telithromycin - -
Clindamycin - -
Quinupristin-dalfopristin - -

78
Neisseria meningitidis EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Tetracyclines MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Doxycycline - - 1. Tetracycline can be used to predict susceptibility to minocycline for prophylaxis against N. meningitidis infections.
Eravacycline IE IE
Minocycline (prophylaxis only) 11 11
1
Tetracycline (screen only) 2 21
Tigecycline IE IE

Oxazolidinones MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Linezolid - -
Tedizolid - -

Miscellaneous agents MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Chloramphenicol (meningitis)1 2 2 1. For chloramphenicol treatment in meningitis, see table of dosages.
Colistin - -
Daptomycin - -
Fosfomycin iv - -
Fosfomycin oral - -
Fusidic acid - -
Lefamulin - -
Metronidazole - -
Nitrofurantoin (uncomplicated UTI only) - -
Nitroxoline (uncomplicated UTI only) - -
Rifampicin (prophylaxis only) 0.25 0.25
Spectinomycin - -
Trimethoprim (uncomplicated UTI only) - -
Trimethoprim-sulfamethoxazole - -

79
Anaerobic bacteria EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
For species not listed below, see EUCAST Guidance Document on how to test and interpret results when there are no breakpoints
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (agar dilution)
Medium: Fastidious Anaerobe Agar + 5% defibrinated horse blood (FAA-HB)
Inoculum: 105 CFU/spot
Incubation: Anaerobic environment, 35-37ºC, 48h
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent where a noticeable
difference is seen in visible growth between the test and control plate.
Quality control: Bacteroides fragilis ATCC 25285 and Clostridium perfringens ATCC 13124.
Clostridium perfringens. For control of the inhibitor component of beta-lactam inhibitor combinations, see
EUCAST QC Tables.
See disk diffusion methodology for how to monitor the anaerobic atmosphere with Clostridium perfringens
DSM 25589.
Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Fastidious Anaerobe Agar + 5% defibrinated horse blood (FAA-HB). The plates should be dried prior to
inoculation (at 20-25°C overnight or at 35°C, with the lid removed, for 15 min).
Inoculum: McFarland 1.0
Incubation: Anaerobic environment, 35-37ºC, 18±2h
Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the front of the plate
with the lid removed and with reflected light. See pictures below and the EUCAST Reading Guide for disk diffusion of
anaerobic bacteria for further information.
Quality control: Bacteroides fragilis ATCC 25285 and Clostridium perfringens ATCC 13124. For control of the inhibitor
component of beta-lactam inhibitor combination disks, see EUCAST QC Tables.
Clostridium perfringens DSM 25589 with a metronidazole 5 µg disk to monitor the anaerobic atmosphere.

Bacteroides spp.
Breakpoints for Bacteroides spp. are also valid for Parabacteroides spp. and for Phocaeicola dorei/vulgatus (previously named Bacteroides dorei/vulgatus ).

Antimicrobial agent MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Piperacillin-tazobactam 81 81 30-6 20 20 1. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L.
Piperacillin-tazobactam, IE IE IE IE 2/A. The meropenem zone diameter breakpoint will detect all cfiA gene mediated carbapenem resistance in Bacteroides
B. thetaiotaomicron fragilis. Some isolates with an MIC of 1 mg/L may harbour the cfiA gene.
Meropenem 12 12 10 28A 28A 3/B. For information on how to use breakpoints in brackets, see https://www.eucast.org/eucastguidancedocuments/.
3 3 B,C
Clindamycin (4) (4) 2 (10) (10)B,C
C. Examine zones carefully for colonies within zones. Colonies should be taken into account when reading.
Metronidazole 4 4 5 25 25

Prevotella spp.
Antimicrobial agent MIC breakpoints Disk Zone diameter Notes
(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin 0.5 0.5 1 unit 20 20 1. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L.
Piperacillin-tazobactam 0.51 0.51 30-6 26 26
0.25 0.25 34 34 A. Examine zones carefully for colonies within zones. Colonies should be taken into account when reading.
Meropenem 10
A A
Clindamycin 0.25 0.25 2 31 31
Metronidazole 4 4 5 22 22

80
Anaerobic bacteria EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
For species not listed below, see EUCAST Guidance Document on how to test and interpret results when there are no breakpoints
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Fusobacterium necrophorum
Antimicrobial agent MIC breakpoints Disk Zone diameter Notes
(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin 0.06 0.06 1 unit 25 25 1. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L.
Piperacillin-tazobactam 0.51 0.51 30-6 32 32
0.03 0.03 35 35 A. Examine zones carefully for colonies within zones. Colonies should be taken into account when reading.
Meropenem 10
0.25 0.25 A A
Clindamycin 2 30 30
Metronidazole 0.5 0.5 5 30 30

Clostridium perfringens
Antimicrobial agent MIC breakpoints Disk Zone diameter Notes
(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin 0.5 0.5 1 unit 15 15 1. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L.
Piperacillin-tazobactam 0.51 0.51 30-6 24 24
0.125 0.125 25 25 A. Examine zones carefully for colonies within zones. Colonies should be taken into account when reading.
Meropenem 10
Vancomycin 2 2 5 12 12
Clindamycin 0.25 0.25 2 19A 19A
Metronidazole 4 4 5 16 16

Cutibacterium acnes
Antimicrobial agent MIC breakpoints Disk Zone diameter Notes
(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin 0.06 0.06 1 unit 24 24 1. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L.
Piperacillin-tazobactam 0.251 0.251 30-6 27 27
0.125 0.125 28 28 A. Examine zones carefully for colonies within zones. Colonies should be taken into account when reading.
Meropenem 10
Vancomycin 2 2 5 22 22
Clindamycin 0.25 0.25 2 26A 26A

81
Anaerobic bacteria EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
For species not listed below, see EUCAST Guidance Document on how to test and interpret results when there are no breakpoints
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Clostridioides difficile
Antimicrobial agent MIC breakpoints Disk Zone diameter Notes
(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU
Vancomycin 21 21 IP IP 1 The breakpoints are based on epidemiological cut-off values (ECOFFs) and apply to oral treatment of C. difficile
Fidaxomicin IE2 IE2 IE IE infections. There are no conclusive clinical data regarding the relation between MICs and outcomes.
2. Fidaxomicin breakpoints and ECOFF have not been set because the available data show major variation in MIC
Metronidazole 21 21 IP IP
distributions between studies.

Examples of inhibition zones for anaerobic bacteria.

a) If haze within the zone occurs, read the most obvious zone edge. Tilt the plate towards you to better define the obvious zone edge.
b) Isolated colonies within the inhibition zone should be taken into account. For clindamycin, it is particularly important to examine zones carefully for colonies growing within the zone.
c) Ignore haemolysis when reading zones.

82
Helicobacter pylori EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Disk diffusion criteria for antimicrobial susceptibility testing of Helicobacter pylori have not yet been defined and an MIC
method should be used. If a commercial MIC method is used, follow the manufacturer´s instructions.

Penicillins MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Amoxicillin oral 0.125 0.125

Fluoroquinolones MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Levofloxacin 1 1

Macrolides MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Clarithromycin 0.25 0.25

Tetracyclines MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Tetracycline 1 1

Miscellaneous agents MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Metronidazole 8 8
Rifampicin 1 1

83
Listeria monocytogenes EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1)
Medium: Mueller-Hinton broth + 5% lysed horse blood and 20 mg/L β-NAD (MH-F broth)
Inoculum: 5x105 CFU/mL
Incubation: Sealed panels, air, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information.
Quality control: Streptococcus pneumoniae ATCC 49619. For agents not covered by this strain, see
EUCAST QC Tables.
Disk diffusion (EUCAST standardised disk diffusion method )
Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L β-NAD (MH-F)
Inoculum: McFarland 0.5
Incubation: 5% CO2, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the front of the plate
with the lid removed and with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further information.
Quality control: Streptococcus pneumoniae ATCC 49619. For agents not covered by this strain, see EUCAST QC
Tables.

Penicillins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin (indications other than 1 1 1 unit 13 13
meningitis)
Benzylpenicillin (meningitis) IE IE IE IE
Ampicillin iv (all indications) 1 1 2 16 16

Carbapenems MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Meropenem (all indications) 0.25 0.25 10 26 26

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Moxifloxacin (meningitis) IE IE IE IE

Oxazolidinones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Linezolid (meningitis) IE IE IE IE

Macrolides MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Erythromycin (indications other than 1 1 15 25 25
meningitis)

84
Listeria monocytogenes EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Trimethoprim-sulfamethoxazole (all 0.06 0.06 1.25-23.75 29 29 1. Trimethoprim-sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.
indications)1

85
Pasteurella spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1)
Medium: Mueller-Hinton broth + 5% lysed horse blood and 20 mg/L β-NAD (MH-F broth)
Inoculum: 5x105 CFU/mL
Incubation: Sealed panels, air, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information.
Quality control: Haemophilus influenzae ATCC 49766. For agents not covered by this strain and for control
of the inhibitor component of beta-lactam inhibitor combinations, see EUCAST QC Tables.
Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L β-NAD (MH-F)
Inoculum: McFarland 0.5
Incubation: 5% CO2, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the front of the plate
with the lid removed and with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further information.
Quality control: Haemophilus influenzae ATCC 49766. For agents not covered by this strain and for control of the
inhibitor component of beta-lactam inhibitor-combination disks, see EUCAST QC Tables.

EUCAST breakpoints are based mainly on data for Pasteurella multocida , although some data were included for other species (P. canis, P. dagmatis and P. aerogenes ).

Penicillins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin 0.5 0.5 1 unit 17 17 1. For susceptibility testing purposes, the concentration of clavulanic acid is fixed at 2 mg/L.
Ampicillin 1 1 NoteA NoteA
A. Infer susceptibility from benzylpenicillin susceptibility.
Amoxicillin 1 1 NoteA NoteA
1 1
Amoxicillin-clavulanic acid 1 1 2-1 15 15

Cephalosporins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Cefotaxime 0.03 0.03 5 26 26

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin 0.06 0.06 5 27A 27A A. The nalidixic acid disk diffusion test can be used to screen for fluoroquinolone resistance. See Note B.
Levofloxacin 0.06 0.06 5 27 A
27A B. Isolates categorised as screen negative can be reported susceptible to ciprofloxacin and levofloxacin. Isolates
categorised as screen positive should be tested for susceptibility to individual agents or reported resistant.
Nalidixic acid (screen only) NA NA 30 23B 23B

86
Pasteurella spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doxycycline 1 1 NoteA NoteA A. Susceptibility to doxycycline can be inferred from the tetracycline disk diffusion screening test.
Tetracycline (screen only) NA NA 30 24A 24A

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Trimethoprim-sulfamethoxazole 1 0.25 0.25 1.25-23.75 23 23 1. Trimethoprim-sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.

87
Campylobacter jejuni and C. coli EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1)
Medium: Mueller-Hinton broth + 5% lysed horse blood and 20 mg/L β-NAD (MH-F broth)
Inoculum: 5x105 CFU/mL
Incubation: Microaerobic environment, 41±1ºC, 24h. Isolates with insufficient growth after 24h incubation
are reincubated immediately and MICs read after a total of 40-48h incubation.
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information.
Quality control: Staphylococcus aureus ATCC 29213 (standard conditions for staphylococci)
Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L β-NAD (MH-F). The MH-F plates should be
dried prior to inoculation to reduce swarming (at 20-25°C overnight or at 35°C, with the lid removed, for 15 min).
Inoculum: McFarland 0.5
Incubation: Microaerobic environment, 41±1ºC, 24h. Isolates with insufficient growth after 24h incubation are
reincubated immediately and inhibition zones read after a total of 40-48h incubation.
Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the front of the plate
with the lid removed and with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further information.
Quality control: Campylobacter jejuni ATCC 33560

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin 0.001 0.5 5 50 26

Macrolides MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Azithromycin Note1 Note1 NoteA NoteA 1/A. Susceptibility to azithromycin and clarithromycin can be inferred from erythromycin.
Clarithromycin Note1 Note1 NoteA NoteA
Erythromycin, C. jejuni 41 41 15 20A 20A
1 1 A
Erythromycin, C. coli 8 8 15 24 24A

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doxycycline Note1 Note1 NoteA NoteA 1/A. Susceptibility to doxycycline can be inferred from tetracycline.
Tetracycline 21 21 30 30A 30A

88
Corynebacterium spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
other than C. diphtheriae and C. ulcerans
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Breakpoints for C. diphtheriae and C. ulcerans are listed in a separate table.

MIC determination (broth microdilution according to ISO standard 20776-1)
Medium: Mueller-Hinton broth + 5% lysed horse blood and 20 mg/L β-NAD (MH-F broth)
Inoculum: 5x105 CFU/mL
Incubation: Sealed panels, air, 35±1ºC, 18±2h. Isolates with insufficient growth after 16-20h incubation are
reincubated immediately and MICs read after a total of 40-44h incubation.
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information.
Quality control: Streptococcus pneumoniae ATCC 49619. For agents not covered by this strain, see
EUCAST QC Tables.
Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L β-NAD (MH-F)
Inoculum: McFarland 0.5
Incubation: 5% CO2, 35±1ºC, 18±2h. Isolates with insufficient growth after 16-20h incubation are reincubated
immediately and inhibition zones read after a total of 40-44h incubation.
Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the front of the plate
with the lid removed and with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further information.
Quality control: Streptococcus pneumoniae ATCC 49619. For agents not covered by this strain, see EUCAST QC
Tables.

Penicillins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin 0.125 0.125 1 unit 29 29

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin 0.001 1 5 50 25
Moxifloxacin 0.5 0.5 5 25 25

Aminoglycosides MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Gentamicin IE IE IE IE

Glycopeptides MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Vancomycin 2 2 5 17A 17A A. Non-wild type isolates were not available when developing the disk diffusion method.

89
Corynebacterium spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
other than C. diphtheriae and C. ulcerans
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Macrolides and lincosamides MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Erythromycin 1. Inducible clindamycin resistance may occur in Corynebacterium spp. This can be detected by antagonism of
Clindamycin1 0.5 0.5 2 20 20 clindamycin activity by a macrolide agent. The clinical significance is unknown. There is currently no recommendation for
testing.

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Tetracycline 2 2 30 24 24

Oxazolidinones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Linezolid 2 2 10 25 25

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Rifampicin 0.06 0.06 5 30 30

90
Corynebacterium diphtheriae and C. ulcerans EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1)
Medium: Mueller-Hinton broth + 5% lysed horse blood and 20 mg/L β-NAD (MH-F broth)
Inoculum: 5x105 CFU/mL
Incubation: Sealed panels, air, 35±1ºC, 18±2h. Isolates with insufficient growth after 16-20h incubation are
reincubated immediately and MICs read after a total of 40-44h incubation.
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information.
Quality control: Streptococcus pneumoniae ATCC 49619. For agents not covered by this strain, see
EUCAST QC Tables.
Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L β-NAD (MH-F)
Inoculum: McFarland 0.5
Incubation: 5% CO2, 35±1ºC, 18±2h. Isolates with insufficient growth after 16-20h incubation are reincubated
immediately and inhibition zones read after a total of 40-44h incubation.
Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the front of the plate
with the lid removed and with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further information.
Quality control: Streptococcus pneumoniae ATCC 49619. For agents not covered by this strain, see EUCAST QC
Tables.

Penicillins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin 0.001 1 1 unit 50 12 1/A. Isolates "susceptible, increased exposure” (I) to benzylpenicillin can be reported susceptible to amoxicillin. Isolates
Amoxicillin 11 11 NoteA NoteA resistant to benzylpenicillin should be tested for susceptibility to amoxicillin or reported resistant.

Cephalosporins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Cefotaxime 0.0011 21 5 50A 15A 1/A. Susceptibility to cefotaxime can be inferred from benzylpenicillin.

Carbapenems MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Meropenem 0.251 0.251 10 24A 24A 1/A. Isolates "susceptible, increased exposure” (I) to benzylpenicillin can be reported susceptible to meropenem. Isolates
resistant to benzylpenicillin should be tested for susceptibility to meropenem or reported resistant.

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin 0.001 0.5 5 50 24

91
Corynebacterium diphtheriae and C. ulcerans EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Macrolides and lincosamides MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Erythromycin 0.06 0.06 15 24 24 1. Wild-type C. ulcerans is less susceptible to clindamycin.
Clindamycin, C. diphtheriae 1 0.5 0.5 2 15 15

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doxycycline 0.51 0.51 NoteA NoteA 1/A. Susceptibility to doxycycline can be inferred from tetracycline.
Tetracycline 1 1 30 24 24

Oxazolidinones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Linezolid 2 2 10 25 25

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Rifampicin 0.06 0.06 5 24 24 1. Trimethoprim-sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.
Trimethoprim-sulfamethoxazole 1 0.5 0.5 1.25-23.75 23 23

92
Aerococcus sanguinicola and A. urinae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1) 1
Medium: Mueller-Hinton broth + 5% lysed horse blood and 20 mg/L β-NAD (MH-F broth)
Inoculum: 5x105 CFU/mL
Incubation: Sealed panels, air, 35±1ºC, 18±2h. Isolates with insufficient growth after 16-20h incubation are
reincubated immediately and MICs read after a total of 40-44h incubation.
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information.
Quality control: Streptococcus pneumoniae ATCC 49619. For agents not covered by this strain, see
EUCAST QC Tables.
1
For fluoroquinolones, agar dilution may produce clearer endpoints.
Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L β-NAD (MH-F)
Inoculum: McFarland 0.5
Incubation: 5% CO2, 35±1ºC, 18±2h. Isolates with insufficient growth after 16-20h incubation are reincubated
immediately and inhibition zones read after a total of 40-44h incubation.
Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the front of the plate
with the lid removed and with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further information.
Quality control: Streptococcus pneumoniae ATCC 49619. For agents not covered by this strain, see EUCAST QC
Tables.

Penicillins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin 0.125 0.125 1 unit 21 21 1/A. Infer susceptibility from ampicillin susceptibility.
Ampicillin 0.25 0.25 2 26 26
Amoxicillin Note1 Note1 NoteA NoteA

Carbapenems MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Meropenem 0.25 0.25 10 31 31

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin (uncomplicated UTI only) 2 2 5 21A 21A 1. Susceptibility can be inferred from ciprofloxacin susceptibility.
1 1 B
Levofloxacin (uncomplicated UTI only) 2 2 Note NoteB
A. Susceptibility can be inferred from the norfloxacin disk diffusion screening test. See Note C.
Norfloxacin (screen only) NA NA 10 17C 17C
B. Susceptibility can be inferred from the ciprofloxacin susceptibility or the norfloxacin disk diffusion screening test. See
Note C.
C. The norfloxacin disk diffusion test can be used to screen for fluoroquinolone resistance.

93
Aerococcus sanguinicola and A. urinae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Glycopeptides MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Vancomycin 1 1 5 16A 16A A. Non-wild type isolates were not available when developing the disk diffusion method.

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Nitrofurantoin (uncomplicated UTI only) 16 16 100 16 16
Rifampicin 0.125 0.125 5 25 25

94
Kingella kingae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1)
Medium: Mueller-Hinton broth + 5% lysed horse blood and 20 mg/L β-NAD (MH-F broth)
Inoculum: 5x105 CFU/mL
Incubation: Sealed panels, air, 35±1ºC, 18±2h. Isolates with insufficient growth after 16-20h incubation are
reincubated immediately and inhibition zones read after a total of 40-44h incubation.
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information.
Quality control: Haemophilus influenzae ATCC 49766. For agents not covered by this strain, see EUCAST
QC Tables.
Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton agar + 5% defibrinated horse blood and 20 mg/L β-NAD (MH-F)
Inoculum: McFarland 0.5
Incubation: 5% CO2, 35±1ºC, 18±2h. Isolates with insufficient growth after 16-20h incubation are reincubated
immediately and inhibition zones read after a total of 40-44h incubation.
Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the front of the plate
with the lid removed and with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further information.
Quality control: Haemophilus influenzae ATCC 49766. For agents not covered by this strain, see EUCAST QC Tables.

Penicillins1 MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Benzylpenicillin 0.03 0.03 1 unit 25 25 1. Beta-lactamase positive isolates can be reported resistant to benzylpenicillin and to ampicillin and amoxicillin without
Ampicillin 0.062 0.062 NoteA NoteA inhibitors. Tests based on a chromogenic cephalosporin can be used to detect the beta-lactamase. Beta-lactam
resistance mechanisms other than beta-lactamase production have not yet been described for K. kingae .
Amoxicillin 0.1252 0.1252 NoteA NoteA
2. Susceptibility can be inferred from benzylpenicillin susceptibility.
Amoxicillin-clavulanic acid Note3 Note3 NoteB NoteB 3/B. The intrinsic activity of clavulanic acid in K. kingae is such that the organism is inhibited by 2 mg/L clavulanic acid.
Therefore no breakpoints for amoxicillin-clavulanic acid can be given.

A. Infer susceptibility from benzylpenicillin susceptibility.

Cephalosporins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Cefotaxime 0.125 0.125 5 27 27
Ceftriaxone 0.06 0.06 30 30 30
Cefuroxime iv 0.5 0.5 30 29 29

Carbapenems MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Meropenem 0.03 0.03 10 30 30

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin 0.06 0.06 5 28 28
Levofloxacin 0.125 0.125 5 28 28

95
Kingella kingae EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Macrolides and lincosamides MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Azithromycin 0.251 0.251 NoteA NoteA 1. Susceptibility can be inferred from erythromycin susceptibility.
Clarithromycin 0.51 0.51 NoteA NoteA
0.5 0.5 20 20 A. Infer susceptibility from erythromycin susceptibility.
Erythromycin 15
Clindamycin - - - -

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doxycycline 0.51 0.51 NoteA NoteA 1/A. Tetracycline can be used to screen for resistance in tetracycline agents. Isolates categorised as susceptible can be
Tetracycline 0.5 0.5 30 28 28 reported susceptible to doxycycline. Isolates categorised as resistant should be tested for susceptibility to doxycycline or
reported resistant.

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Rifampicin 0.5 0.5 5 20 20 1. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.
Trimethoprim-sulfamethoxazole 1 0.25 0.25 1.25-23.75 28 28

96
Aeromonas spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1) Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton broth Medium: Mueller-Hinton agar
Inoculum: 5x105 CFU/mL Inoculum: McFarland 0.5
Incubation: Sealed panels, air, 35±1ºC, 18±2h Incubation: Air, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the back of the plate
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information. against a dark background illuminated with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further
Quality control: Pseudomonas aeruginosa ATCC 27853. For agents not covered by this strain, see information.
EUCAST QC Tables. Quality control: Pseudomonas aeruginosa ATCC 27853. For agents not covered by this strain, see EUCAST QC
Tables.

Cephalosporins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Cefepime 1 4 30 27 24
Ceftazidime 1 4 10 24 21

Monobactams MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Aztreonam 1 4 30 29 26

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin 0.25 0.5 5 27 24
Levofloxacin 0.5 1 5 27 24

97
Aeromonas spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Trimethoprim-sulfamethoxazole 1 2 4 1.25-23.75 19A 16A 1. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.

A. Read the obvious zone edge and disregard haze or growth within the inhibition zone (see pictures below).

Examples of inhibition zones for Aeromonas spp. with trimethoprim-sulfamethoxazole.

a-c) Read the obvious zone edge and disregard haze or growth within the inhibition zone.

98
Achromobacter xylosoxidans EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1) Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton broth Medium: Mueller-Hinton agar
Inoculum: 5x105 CFU/mL Inoculum: McFarland 0.5
Incubation: Sealed panels, air, 35±1ºC, 18±2h Incubation: Air, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the back of the plate
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information. against a dark background illuminated with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further
Quality control: Pseudomonas aeruginosa ATCC 27853. For agents not covered by this strain and for information.
control of the inhibitor component of beta-lactam inhibitor combinations, see EUCAST QC Tables. Quality control: Pseudomonas aeruginosa ATCC 27853. For agents not covered by this strain and for control of the
inhibitor component of beta-lactam inhibitor combination disks, see EUCAST QC Tables.

Penicillins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Piperacillin-tazobactam 41 41 30-6 26 26 1. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L.

Carbapenems MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Meropenem 1 4 10 26 20

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Trimethoprim-sulfamethoxazole 1 0.125 0.125 1.25-23.75 26A 26A 1. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.

A. There may be growth within the inhibition zone. The density of growth may vary from a fine haze to substantial growth
(see pictures below). If any zone edge can be seen, ignore growth within the inhibition zone and read the zone diameter.

Examples of inhibition zones for Achromobacter xylosoxidans with trimethoprim-sulfamethoxazole.

a-b) An outer zone can be seen. Read the outer zone edge and interpret according to the breakpoints.
c) Growth up to the disk and no sign of inhibition zone. Report resistant.

99
Vibrio spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1) Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton broth Medium: Mueller-Hinton agar
Inoculum: 5x105 CFU/mL Inoculum: McFarland 0.5
Incubation: Sealed panels, air, 35±1ºC, 18±2h Incubation: Air, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the back of the plate
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information. against a dark background illuminated with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further
Quality control: Escherichia coli ATCC 25922. For agents not covered by this strain and for control of the information.
inhibitor component of beta-lactam inhibitor combinations, see EUCAST QC Tables. Quality control: Escherichia coli ATCC 25922. For agents not covered by this strain and for control of the inhibitor
component of beta-lactam inhibitor combination disks, see EUCAST QC Tables.

Breakpoints are valid for V. alginolyticus, V. cholerae, V. fluvialis, V. parahaemolyticus and V. vulnificus .

Penicillins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Piperacillin-tazobactam 11 11 30-6 26 26 1. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L.

Cephalosporins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Cefotaxime 0.25 0.25 5 21 21
Cefotaxime, V. fluvialis IE IE IE IE
Ceftazidime 1 1 10 22 22

Carbapenems MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Meropenem 0.5 0.5 10 24 24

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin 0.25 0.25 5 23A 23A A. Susceptibility to ciprofloxacin and levofloxacin can be inferred from the pefloxacin disk diffusion screening test.
Levofloxacin 0.25 0.25 5 23A 23A
Pefloxacin (screen only) NA NA 5 22A 22A

100
Vibrio spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Macrolides MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Azithromycin 4 4 15 16A 16A 1/A. Susceptibility to azithromycin (and erythromycin when azithromycin is not available) is inferred from the erythromycin
Erythromycin (screen only)1 NA NA 15 12A 12A disk diffusion test.

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doxycycline 0.5 0.5 NoteA NoteA 1/A. Susceptibility to doxycycline (and tetracycline when doxycycline is not available) is inferred from the tetracycline disk
Tetracycline (screen only)1 NA NA 30 20A 20A diffusion test.

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Trimethoprim-sulfamethoxazole 1 0.25 0.25 1.25-23.75 21 21 1. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.

101
Bacillus spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
except B. anthracis
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1) Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton broth Medium: Mueller-Hinton agar
Inoculum: 5x105 CFU/mL Inoculum: McFarland 0.5
Incubation: Sealed panels, air, 35±1ºC, 18±2h Incubation: Air, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the back of the plate
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information. against a dark background illuminated with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further
Quality control: Staphylococcus aureus ATCC 29213. For agents not covered by this strain, see EUCAST information.
QC Tables. Quality control: Staphylococcus aureus ATCC 29213. For agents not covered by this strain, see EUCAST QC Tables.

This genus includes several species. The most frequent species belong to the Bacillus cereus complex (B. cereus, B. thuringiensis, B. mycoides and B. weihenstephanensis ). The breakpoints are not validated for B. anthracis .

Carbapenems MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Imipenem 0.5 0.5 10 30 30
Meropenem 0.25 0.25 10 25 25

Fluoroquinolones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ciprofloxacin 0.001 0.5 5 50A 23A A. The norfloxacin disk diffusion test can be used to screen for fluoroquinolone resistance. See Note B.
Levofloxacin 0.001 1 5 50 A
23A B. Isolates categorised as screen negative can be reported "susceptible increased exposure" (I) to ciprofloxacin and
levofloxacin. Isolates categorised as screen positive can be reported resistant to ciprofloxacin and levofloxacin.
Norfloxacin (screen only) NA NA 10 21B 21B

Glycopeptides MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Vancomycin 2 2 5 10A 10A A. Non-wild type isolates were not available when developing the disk diffusion method.

102
Bacillus spp. EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
except B. anthracis
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Macrolides and lincosamides MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Erythromycin 0.5 0.5 15 24 24
Clindamycin 1 1 2 17 17

Oxazolidinones MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Linezolid 2 2 10 22 22

103
Burkholderia pseudomallei EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

MIC determination (broth microdilution according to ISO standard 20776-1) Disk diffusion (EUCAST standardised disk diffusion method)
Medium: Mueller-Hinton broth Medium: Mueller-Hinton agar
Inoculum: 5x105 CFU/mL Inoculum: McFarland 0.5
Incubation: Sealed panels, air, 35±1ºC, 18±2h Incubation: Air, 35±1ºC, 18±2h
Reading: Unless otherwise stated, read MICs at the lowest concentration of the agent that completely Reading: Unless otherwise stated, read zone edges as the point showing no growth viewed from the back of the plate
inhibits visible growth. See ”EUCAST Reading Guide for broth microdilution” for further information. against a dark background illuminated with reflected light. See ”EUCAST Reading Guide for disk diffusion” for further
Quality control: Escherichia coli ATCC 25922. For agents not covered by this strain and for control of the information.
inhibitor component of beta-lactam inhibitor combinations, see EUCAST QC Tables. Quality control: Escherichia coli ATCC 25922. For agents not covered by this strain and for control of the inhibitor
component of beta-lactam inhibitor combination disks, see EUCAST QC Tables.

Penicillins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Amoxicillin-clavulanic acid 0.0011 81 20-10 50 22 1. For susceptibility testing purposes, the concentration of clavulanic acid is fixed at 2 mg/L.

Cephalosporins MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Ceftazidime 0.001 8 10 50 18

Carbapenems MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Imipenem 2 2 10 29 29
Meropenem 2 2 10 24 24

Tetracyclines MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Doxycycline 0.001 2 NoteA NoteA A. Isolates categorised as screen negative can be reported "susceptible increased exposure" (I) to doxycyline. Isolates
Tetracycline (screen only) NA NA 30 23A 23A categorised as screen positive can be reported resistant to doxycycline.

104
Burkholderia pseudomallei EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Miscellaneous agents MIC breakpoints Disk Zone diameter Notes

(mg/L) content breakpoints (mm) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU (µg) S≥ R< ATU Lettered notes relate to the disk diffusion method.
Chloramphenicol 0.001 8 30 50 22 1. Trimethoprim:sulfamethoxazole in the ratio 1:19. Breakpoints are expressed as the trimethoprim concentration.
Trimethoprim-sulfamethoxazole 1 0.001 4 1.25-23.75 50A 17A
A. There may be growth within the inhibition zone. The density of growth may vary from a fine haze to substantial growth
(see pictures below). If any zone edge can be seen, ignore growth within the inhibition zone and read the zone diameter.

Examples of inhibition zones for Burkholderia pseudomallei with trimethoprim-sulfamethoxazole.

a-b) An outer zone can be seen. Read the outer zone edge and interpret according to the breakpoints.
c) Growth up to the disk and no sign of inhibition zone. Report resistant.

105
Burkholderia cepacia complex EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes

EUCAST has not determined breakpoints for Burkholderia cepacia complex organisms since accurate and reproducible methods for antimicrobial susceptibility testing are
lacking due to technical difficulties encountered with these species and the lack of convincing clinical outcome correlates.
Users are referred to the EUCAST Guidance Document on Burkholderia cepacia complex.

Burkholderia cepacia complex currently includes at least 21 closely related species: B. ambifaria (genomovar VII), B. anthina (genomovar VIII), B. arboris (BCC3), B.
cepacia (genomovar I), B. cenocepacia (genomovar III), B. contaminans (group K, BBC AT), B. diffusa (BCC2), B. dolosa (genomovar VI), B. lata (group K), B. latens
(BCC1), B. metallica (BCC8), B. multivorans (genomovar II), B. paludis , B. pseudomultivorans , B. pyrrocinia (genomovar IX), B. seminalis (BCC7), B. stabilis (genomovar
IV), B. stagnalis (BCC B), B. territorii (BCC L), B. ubonensis (genomovar X), B. vietnamiensis (genomovar V).

106
Legionella pneumophila EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes

EUCAST has not determined breakpoints for Legionella pneumophila as there is no established reference method or any documentation of clinical outcome related to
antimicrobial susceptibility testing.
Users are referred to the EUCAST Guidance Document on Legionella pneumophila susceptibility testing.

107
Mycobacterium tuberculosis EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Expert Rules and Expected Phenotypes
For abbreviations and explanations of breakpoints, see the Notes sheet

Listed breakpoints have been set in parallel with marketing authorisation by EMA. Breakpoints for other agents have not yet been established. Infections with M. tuberculosis are always treated with two or more
agents.

MIC determination using broth microdilution according to the EUCAST reference method for the Mycobacterium tuberculosis complex
Medium: Middlebrook 7H9 with 10% OADC in polystyrene plates
Inoculum: 1x105 CFU/mL
Incubation: Plates sealed with a plastic lid, air, 36±1°C, 7-21 days
Reading: At the earliest time point (7, 14 or 21 days) when the 1% growth control shows visible growth, read MICs at the lowest concentration of the agent that completely inhibits visible growth
Quality control: Mycobacterium tuberculosis H37Rv ATCC 27294

The Mycobacterium tuberculosis complex includes different species and variants such as M. tuberculosis var. tuberculosis , M. tuberculosis var. africanum and M. tuberculosis var. bovis. Breakpoints have only
been established for M. tuberculosis var. tuberculosis .

Antimicrobial agent MIC breakpoints Notes

(mg/L) Numbered notes relate to general comments and/or MIC breakpoints.
S≤ R> ATU
Bedaquiline 0.251 0.251 1. Breakpoints were determined on MICs performed on Middlebrook 7H11/7H10 medium. The comparability of tests performed by
Delamanid 0.06 0.06 other media has not been established. There is ongoing work to review breakpoints using the EUCAST reference method
(described above).
Pretomanid Note2 Note2
2. A provisional screen value of ≤2 mg/L can be used for antimicrobial susceptibility testing with Mycobacteria Growth Indicator
Tube (MGIT, Becton Dickinson). There are insufficient MIC data with the reference method to set a clinical breakpoint.

108
Topical agents EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
Screening cut-off values for detection of phenotypic resistance
In the absence of clinical data on outcome related to MIC of infecting organisms, EUCAST has not been able to determine relevant clinical breakpoints for topical use of antimicrobial agents. Laboratories
are advised to either use the regular breakpoints or the cut-off values listed below to distinguish between organisms without and with acquired resistance mechanisms (for further details see EUCAST
Guidance Document on www.eucast.org). When reporting the susceptibility of agents for topical use, clarify that results refer to topical use only.

Screening cut-off values for

(for polymyxin B)
Chloramphenicol
the detection and reporting

(screen only)1
Nalidixic acid

Ciprofloxacin

Levofloxacin

Retapamulin
(screen only)

(screen only)

Fusidic acid

(framycetin)
Tobramycin

Norfloxacin
Gentamicin

Pefloxacin

Bacitracin
Neomycin

Mupirocin
Ofloxacin
of phenotypic resistance.

Colistin
Report resistant (R) for isolates
Organisms with MIC above or inhibition
zone diameter below the cut-off
value. Otherwise report
susceptible (S).
Disk content (µg) 10 10 5 10 30 5 5 5 30 - 10 10 - 200 -
MIC (mg/L) 2 2 - - - 0.125 0.25 0.25 16 2 - 8 - - -
Enterobacterales
Zone diameter (mm) 17 16 24 - - Note1 Note1 Note1 17 - - 12 - - -
MIC (mg/L) 8 2 - - - 0.5 2 2 ND 4 - ND - - -
P. aeruginosa
Zone diameter (mm) 15 18 - - - 26 18 ND ND - - ND - - -
MIC (mg/L) 4 4 - - - 1 0.5 1 ND 2 - ND - - -
Acinetobacter spp.
Zone diameter (mm) 17 17 - - - 21 23 ND ND - - ND - - -
MIC (mg/L) 2 2 - - - 1 0.5 1 16 - 0.5 1 ND 12 0.5
S. aureus
Zone diameter (mm) 18 18 - 17 - Note1 Note1 Note1 18 - 24 14 ND 302 ND
MIC (mg/L) - - - - - 4 2 4 8 - ND - ND - -
S. pneumoniae
Zone diameter (mm) - - - 10 - Note1 Note1 Note1 21 - ND - ND - -
Streptococcus groups MIC (mg/L) - - - - - 2 2 4 8 - 32 - ND 0.5 0.125
A, B, C and G Zone diameter (mm) - - - 12 - Note1 Note1 Note1 21 - ND - ND ND ND
MIC (mg/L) 4 8 - - - 0.06 0.06 0.06 2 - ND ND - - -
H. influenzae
Zone diameter (mm) ND ND - - 23 Note1 Note1 Note1 28 - ND ND - - -
MIC (mg/L) ND ND - - - 0.125 0.125 0.25 2 - ND ND - - -
M. catarrhalis
Zone diameter (mm) ND ND - - 23 Note1 Note1 Note1 31 - ND ND - - -

Notes
1. Screening agent for detection of fluoroquinolone resistance (pefloxacin for Enterobacterales , norfloxacin for Gram-positive organisms and nalidixic acid for H. influenzae and M. catarrhalis) .
2. Breakpoints for nasal decontamination S ≤1, R >256 mg/L (S ≥30, R <18 mm for the mupirocin 200 µg disk). Isolates in the I category are associated with short term suppression (useful preoperatively) but, unlike fully susceptible isolates, long term
eradication rates are low.
ND = No ECOFF available.

109
PK-PD (Non-species related) breakpoints EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
For abbreviations and explanations of breakpoints, see the Notes sheet

These breakpoints are used only when there are no species-specific breakpoints or other recommendations (a dash or a note) in the species-specific tables.
If the MIC is greater than the PK-PD resistant breakpoint, advise against use of the agent.
If the MIC is less than or equal to the PK-PD susceptible breakpoint, suggest that the agent can be used with caution. The MIC may also be reported although this is not essential. Include a note that the guidance is
based on PK-PD breakpoints only, and include the dosage on which PK-PD breakpoint is based.
More information is available in the EUCAST Guidance Document on how to test and interpret results when there are no breakpoints.

Penicillins MIC breakpoints Notes

(mg/L)
S≤ R>
Benzylpenicillin 0.25 2 1. For susceptibility testing purposes, the concentration of sulbactam is fixed at 4 mg/L.
Ampicillin 2 8 2. For susceptibility testing purposes, the concentration of clavulanic acid is fixed at 2 mg/L.
3. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L.
Ampicillin-sulbactam 21 81
Amoxicillin 2 8
Amoxicillin-clavulanic acid 22 82
Piperacillin 8 16
Piperacillin-tazobactam 83 163
Ticarcillin
Ticarcillin-clavulanic acid 82 162
Temocillin 8 8
Phenoxymethylpenicillin IE IE
Oxacillin IE IE
Cloxacillin IE IE
Dicloxacillin IE IE
Flucloxacillin IE IE
Mecillinam oral (pivmecillinam) IE IE
(uncomplicated UTI only)

110
PK-PD (Non-species related) breakpoints EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
For abbreviations and explanations of breakpoints, see the Notes sheet

Cephalosporins MIC breakpoints Notes

(mg/L)
S≤ R>
Cefaclor IE IE 1. Broth microdilution MIC determination must be performed in iron-depleted Mueller-Hinton broth and specific reading instructions
Cefadroxil IE IE must be followed. For testing conditions and reading instructions, see http://www.eucast.org/guidance_documents/.
Cefalexin IE IE 2. Based on PK-PD target for Gram-negative organisms.
3. For susceptibility testing purposes, the concentration of avibactam is fixed at 4 mg/L.
Cefazolin 1 2
4. Breakpoints are based on ceftolozane data.
Cefepime 4 8 5. For susceptibility testing purposes, the concentration of tazobactam is fixed at 4 mg/L.
Cefiderocol 21 21
Cefixime IE IE
Cefotaxime 1 2
Cefoxitin IE IE
Cefpodoxime IE IE
Ceftaroline 0.52 0.52
Ceftazidime 4 8
Ceftazidime-avibactam 83 83
Ceftibuten IE IE
Ceftobiprole 4 4
Ceftolozane-tazobactam 44.5 44.5
Ceftriaxone 1 2
Cefuroxime iv 4 8
Cefuroxime oral IE IE

Carbapenems MIC breakpoints Notes

(mg/L)
S≤ R>
Doripenem 1 2 1. For susceptibility testing purposes, the concentration of relebactam is fixed at 4 mg/L.
Ertapenem 0.5 0.5 2. For susceptibility testing purposes, the concentration of vaborbactam is fixed at 8 mg/L.
Imipenem 2 4
Imipenem-relebactam 21 21
Meropenem 2 8
Meropenem-vaborbactam 82 82

Monobactams MIC breakpoints Notes

(mg/L)
S≤ R>
Aztreonam 4 8

111
PK-PD (Non-species related) breakpoints EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
For abbreviations and explanations of breakpoints, see the Notes sheet

Fluoroquinolones MIC breakpoints Notes

(mg/L)
S≤ R>
Ciprofloxacin 0.25 0.5
Delafloxacin IE IE
Levofloxacin 0.5 1
Moxifloxacin 0.25 0.25
Nalidixic acid (screen only) IE IE
Norfloxacin IE IE
Ofloxacin 0.25 0.5

Aminoglycosides MIC breakpoints Notes

(mg/L)
S≤ R>
Amikacin 1 1
Gentamicin 0.5 0.5
Netilmicin IE IE
Tobramycin 0.5 0.5

Glycopeptides and lipoglycopeptides MIC breakpoints Notes

(mg/L)
S≤ R>
Dalbavancin 0.251 0.251 1. For broth microdilution MIC determination, the medium must be supplemented with polysorbate-80 to a final concentration of
Oritavancin IE IE 0.002%.
Teicoplanin IE IE
Telavancin IE IE
Vancomycin IE IE

Macrolides, lincosamides and streptogramins MIC breakpoints Notes

(mg/L)
S≤ R>
Azithromycin IE IE
Clarithromycin IE IE
Erythromycin IE IE
Roxithromycin IE IE
Telithromycin IE IE
Clindamycin IE IE
Quinupristin-dalfopristin IE IE

112
PK-PD (Non-species related) breakpoints EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01
For abbreviations and explanations of breakpoints, see the Notes sheet

Tetracyclines MIC breakpoints Notes

(mg/L)
S≤ R>
Doxycycline IE IE 1. For tigecycline broth microdilution MIC determination, the medium must be prepared fresh on the day of use.
Eravacycline IE IE
Minocycline IE IE
Tetracycline IE IE
Tigecycline 0.51 0.51

Oxazolidinones MIC breakpoints Notes

(mg/L)
S≤ R>
Linezolid 2 2
Tedizolid IE IE

Miscellaneous agents MIC breakpoints Notes

(mg/L)
S≤ R>
Chloramphenicol IE IE
Colistin IE IE
Daptomycin IE IE
Fosfomycin iv IE IE
Fosfomycin oral (uncomplicated UTI only) 8 8
Fusidic acid IE IE
Lefamulin 0.25 0.25
Metronidazole IE IE
Nitrofurantoin IE IE
Nitroxoline IE IE
Rifampicin IE IE
Spectinomycin IE IE
Trimethoprim IE IE
Trimethoprim-sulfamethoxazole IE IE

113
Dosages used to define breakpoints EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01

EUCAST breakpoints are based on the following dosages (see section 8 in Rationale Documents). Alternative dosing regimens may result in equivalent exposure. The table should not be used
as a guidance for dosing in clinical practice as dosages can vary widely by indication. It does not replace specific national, regional or local dosing guidelines. However, if national practices
significantly differ from those listed below, EUCAST breakpoints may not be valid. Situations where less antibiotic is given as standard or high dose should be discussed locally or regionally.

Uncomplicated UTI: acute, sporadic or recurrent lower urinary tract infections (uncomplicated cystitis) in patients with no known relevant anatomical or functional abnormalities within the
urinary tract or comorbidities.

Penicillins Standard dosage High dosage Uncomplicated UTI Special situations

Benzylpenicillin 0.6 g (1 MU) x 4 iv 1.2 g (2 MU) x 4-6 iv Meningitis caused by S. pneumoniae:
For a dose of 2.4 g (4 MU) x 6 iv, isolates with MIC ≤0.06 mg/L are susceptible.

Pneumonia caused by S. pneumoniae: breakpoints are related to dosage:

For a dose of 1.2 g (2 MU) x 4 iv, isolates with MIC ≤ 0.5 mg/L are susceptible.
For a dose of 2.4 (4 MU) g x 4 iv or 1.2 g (2 MU) x 6 iv, isolates with MIC ≤1 mg/L are
susceptible.
For a dose of 2.4 g (4 MU) x 6 iv, isolates with MIC ≤2 mg/L are susceptible.

Ampicillin 2 g x 3 iv 2 g x 4 iv Meningitis: 2 g x 6 iv
Ampicillin-sulbactam iv (2 g ampicillin + 1 g sulbactam) x 3 iv (2 g ampicillin + 1 g sulbactam) x 4 iv

Ampicillin-sulbactam oral None None 0.75 g x 2 oral

Amoxicillin iv 1 g x 3-4 iv 2 g x 6 iv Meningitis: 2 g x 6 iv
Amoxicillin oral 0.5 g x 3 oral 0.75-1 g x 3 oral 0.5 g x 3 oral
Amoxicillin-clavulanic acid iv (1 g amoxicillin + 0.2 g clavulanic (2 g amoxicillin + 0.2 g clavulanic
acid) x 3-4 iv acid) x 3 iv
Amoxicillin-clavulanic acid oral (0.5 g amoxicillin + 0.125 g (0.875 g amoxicillin + 0.125 g (0.5 g amoxicillin + 0.125 g Amoxicillin-clavulanic acid has separate breakpoints for systemic infections and
clavulanic acid) x 3 oral clavulanic acid) x 3 oral clavulanic acid) x 3 oral uncomplicated UTI. When amoxicillin-clavulanic acid is reported for uncomplicated UTI,
the report must make clear that the susceptibility category is only valid for uncomplicated
UTI.
Piperacillin 4 g x 4 iv 4 g x 4 iv High dosage for more serious infections.
by extended 3-hour infusion
Piperacillin-tazobactam (4 g piperacillin + 0.5 g tazobactam) (4 g piperacillin + 0.5 g tazobactam) A lower dosage of (4 g piperacillin + 0.5 g tazobactam) x 3 iv, 30-minute infusion, is
x 4 iv 30-minute infusion or x 4 iv by extended 3-hour infusion adequate for some infections such as complicated UTI, intraabdominal infections and
x 3 iv by extended 4-hour infusion diabetic foot infections, but not for infections caused by isolates resistant to third-
generation cephalosporins.
Ticarcillin
Ticarcillin-clavulanic acid (3 g ticarcillin + 0.1-0.2 g clavulanic (3 g ticarcillin + 0.1 g clavulanic acid)
acid) x 4 iv x 6 iv
Temocillin 2 g x 2 iv 2 g x 3 iv The 2 g x 2 iv dose has been used in the treatment of uncomplicated UTI caused by
bacteria with beta-lactam resistance mechanisms.
Phenoxymethylpenicillin 0.5-2 g x 3-4 oral None
depending on species and/or infection
type
Oxacillin 1 g x 4 iv Dosages vary by indication
Cloxacillin 0.5 g x 4 oral or 1 g x 4 iv Dosages vary by indication Meningitis: 2 g x 6 iv
Dicloxacillin 0.5-1 g x 4 oral or 1 g x 4 iv Dosages vary by indication
Flucloxacillin 1 g x 3 oral or 2 g x 4 iv Dosages vary by indication Meningitis: 2 g x 6 iv
(or 1 g x 6 iv)
Mecillinam oral (pivmecillinam) None None 0.2-0.4 g x 3 oral

1
Dosages used to define breakpoints EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01

Cephalosporins Standard dosage High dosage Uncomplicated UTI Special situations

Cefaclor 0.25-0.5 g x 3 oral 1 g x 3​ oral Staphylococcus spp.: Minimum dose 0.5 g x 3 oral
depending on species and/or infection
type
Cefadroxil 0.5-1 g x 2 oral None 0.5-1 g x 2 oral
Cefalexin 0.25-1 g x 2-3 oral None 0.25-1 g x 2-3 oral
Cefazolin 1 g x 3 iv 2 g x 3 iv
Cefepime 1 g x 3 iv or 2 g x 2 iv 2 g x 3 iv Severe P. aeruginosa infections: 2 g x 3 with extended 4-hour infusion
Cefiderocol 2 g x 3 iv over 3 hours None
Cefixime 0.2-0.4 g x 2 oral None 0.2-0.4 g x 2 oral Uncomplicated gonorrhoea: 0.4 g oral as a single dose
Cefotaxime 1 g x 3 iv 2 g x 3 iv Meningitis: 2 g x 4 iv
S. aureus: High dose only
Cefpodoxime 0.1-0.2 g x 2 oral None 0.1-0.2 g x 2 oral

Ceftaroline
Ceftazidime
Ceftazidime-avibactam
Ceftibuten
Ceftobiprole
Ceftolozane-tazobactam (intra-
abdominal infections and UTI)
Ceftolozane-tazobactam (hospital
acquired pneumonia, including
ventilator associated pneumonia)
Ceftriaxone
0.6 g x 2 iv over 1 hour
1 g x 3 iv
(2 g ceftazidime + 0.5 g avibactam) x 3 iv over 2 hours
0.4 g x 1 oral
0.5 g x 3 iv over 2 hours
(1 g ceftolozane + 0.5 g tazobactam) x
3 iv over 1 hour
(2 g ceftolozane + 1 g tazobactam)
x 3 iv over 1 hour
2 g x 1 iv
0.6 g x 3 iv over 2 hours S. aureus in complicated skin and skin structure infections: There is some PK-PD
evidence to suggest that isolates with MICs of 4 mg/L could be treated with high dose.
2 g x 3 iv or 1 g x 6 iv
None
None
None
None
2 g x 2 iv or 4 g x 1 iv Meningitis: 2 g x 2 iv or 4 g x 1 iv
S. aureus: High dose only
Uncomplicated gonorrhoea: 0.5-1 g im as a single dose

Cefuroxime iv 0.75 g x 3 iv 1.5 g x 3 iv

Cefuroxime oral 0.25 g x 2 oral 0.5 g x 2 oral 0.25 g x 2 oral

Carbapenems Standard dosage High dosage Uncomplicated UTI Special situations

Doripenem 0.5 g x 3 iv over 1 hour 1 g x 3 iv over 1 hour HAP/VAP* due to non-fermenting Gram-negative pathogens (such as Pseudomonas spp.
and Acinetobacter spp.) should be treated with 1 g x 3 iv over 4 hours.
Ertapenem 1 g x 1 iv over 30 minutes None
Imipenem 0.5 g x 4 iv over 30 minutes 1 g x 4 iv over 30 minutes
Imipenem-relebactam (0.5 g imipenem + 0.25 g relebactam) None
x 4 iv over 30 minutes
Meropenem 1 g x 3 iv over 30 minutes 2 g x 3 iv over 3 hours Meningitis: 2 g x 3 iv over 30 minutes (or 3 hours)
Meropenem-vaborbactam (2 g meropenem + 2 g vaborbactam) x 3 iv over 3 hours
* HAP/VAP = hospital-acquired pneumonia/ventilator-associated pneumonia

2
Dosages used to define breakpoints EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01

Monobactams Standard dosage High dosage Uncomplicated UTI Special situations

Aztreonam 1 g x 3 iv 2 g x 4 iv Severe P. aeruginosa infections: 2 g x 4 with extended 3-hour infusion

Fluoroquinolones Standard dosage High dosage Uncomplicated UTI Special situations

Ciprofloxacin 0.5 g x 2 oral or 0.4 g x 2 iv 0.75 g x 2 oral or 0.4 g x 3 iv Meningitis: 0.4 g x 3 iv
Delafloxacin 0.45 g x 2 oral or 0.3 g x 2 iv None
Levofloxacin 0.5 g x 1 oral or 0.5 g x 1 iv 0.5 g x 2 oral or 0.5 g x 2 iv
Moxifloxacin 0.4 g x 1 oral or 0.4 g x 1 iv None Meningitis: 0.4 g x 1 iv
Norfloxacin None None 0.4 g x 2 oral
Ofloxacin 0.2 g x 2 oral or 0.2 g x 2 iv 0.4 g x 2 oral or 0.4 g x 2 iv

Aminoglycosides Standard dosage High dosage Uncomplicated UTI Special situations

Amikacin 25-30 mg/kg x 1 iv None
Gentamicin 6-7 mg/kg x 1 iv None
Netilmicin 6-7 mg/kg x 1 iv None
Tobramycin 6-7 mg/kg x 1 iv None

Glycopeptides and Standard dosage High dosage Uncomplicated UTI Special situations
lipoglycopeptides
Dalbavancin 1 g x 1 iv over 30 minutes on day 1 None
If needed, 0.5 g x 1 iv over 30 minutes
on day 8
Oritavancin 1.2 g x 1 (single dose) iv None
over 3 hours
Teicoplanin 0.4 g x 1 iv Dosages vary by indication
Telavancin 10 mg/kg x 1 iv over 1 hour None
Vancomycin 0.5 g x 4 iv or 1 g x 2 iv None Based on body weight. Therapeutic drug monitoring should guide dosing.
or 2 g x 1 by continuous infusion

Macrolides, lincosamides and Standard dosage High dosage Uncomplicated UTI Special situations
streptogramins
Azithromycin 0.5 g x 1 oral or 0.5 g x 1 iv None Uncomplicated gonorrhoea: 2 g oral as a single dose
Clarithromycin 0.25 g x 2 oral Dosages vary by indication In some countries clarithromycin is available for intravenous administration at a dose of 0.5
g x 2, principally for treating pneumonia.
Erythromycin 0.5 g x 2-4 oral or 0.5 g x 2-4 iv Dosages vary by indication
Roxithromycin 0.15 g x 2 oral None
Telithromycin 0.8 g x 1 oral None
Clindamycin 0.3 g x 2 oral or 0.6 g x 3 iv Dosages vary by indication The high exposure dosing regimen pertains to the severity of the infection or drug
exposure at the site of infection.
Quinupristin-dalfopristin 7.5 mg/kg x 2 iv Dosages vary by indication

3
Dosages used to define breakpoints EUCAST Clinical Breakpoint Tables v. 13.0, valid from 2023-01-01

Tetracyclines Standard dosage High dosage Uncomplicated UTI Special situations

Doxycycline 0.1 g x 1 oral Dosages vary by indication
Eravacycline 1 mg/kg x 2 iv None
Minocycline 0.1 g x 2 oral None
Tetracycline 0.25 g x 4 oral Dosages vary by indication
Tigecycline 0.1 g loading dose None
followed by 50 mg x 2 iv

Oxazolidinones Standard dosage High dosage Uncomplicated UTI Special situations

Linezolid 0.6 g x 2 oral or 0.6 g x 2 iv None Meningitis: 0.6 g x 2 iv
Tedizolid 0.2 g x 1 oral or 0.2 g x 1 iv None

Miscellaneous agents Standard dosage High dosage Uncomplicated UTI Special situations
Chloramphenicol 1 g x 4 oral or 1 g x 4 iv 2 g x 4 oral or 2 g x 4 iv Meningitis: 2 g x 4 iv
Colistin 4.5 MU x 2 iv None
with a loading dose of 9 MU
Daptomycin (cSSTI** without concurrent 4 mg/kg x 1 iv None . .
S. aureus bacteraemia)
Daptomycin (cSSTI** with concurrent S. 6 mg/kg x 1 iv None Enterococcal bloodstream infection and endocarditis, see
aureus bacteraemia; right-sided https://www.eucast.org/eucastguidancedocuments.
infective endocarditis due to S. aureus )
Fidaxomicin 0.2 g x 2 oral None
Fosfomycin iv 16-18 g/day divided in 3-4 doses Dosages vary by indication
Fosfomycin oral None None 3 g x 1 oral as a single dose
Fusidic acid 0.5 g x 2 oral or 0.5 g x 2 iv Dosages vary by indication
Lefamulin 0.15 g x 2 iv or 0.6 g x 2 oral None
Metronidazole 0.4 g x 3 oral or 0.4 g x 3 iv Dosages vary by indication
Nitrofurantoin None None 50-100 mg x 3-4 oral Dosing is dependent on drug formulation.
Nitroxoline None None 0.25 g x 3 oral
Rifampicin 0.6 g x 1 oral or 0.6 g x 1 iv None
Spectinomycin 2 g x 1 im None
Trimethoprim None None 0.16 g x 2 oral
Trimethoprim-sulfamethoxazole (0.16 g trimethoprim + 0.8 g (0.24 g trimethoprim + 1.2 g (0.16 g trimethoprim + 0.8 g Meningitis: (5 mg/kg up to 0.48 g trimethoprim + 25 mg/kg up to 2.4 g sulfamethoxazole)
sulfamethoxazole) x 2 oral sulfamethoxazole) x 2 oral sulfamethoxazole) x 2 oral x 3 iv
or (0.16 g trimethoprim + 0.8 g or (0.24 g trimethoprim + 1.2 g
sulfamethoxazole) x 2 iv sulfamethoxazole) x 2 iv
** cSSTI = complicated skin and skin structure infection

4
 Reading guide
EUCAST disk diffusion for selected
rapidly growing anaerobic bacteria
on Fastidious Anaerobe Agar with
5% horse blood (FAA-HB)
Version 2.0
January 2023
 Changes from previous version (1.0)
Slide Change
3 Clarification that the Fastidious Anaerobe Agar should be
supplemented with 5% defibrinated horse blood (FAA-HB).

2
 Background
• This reading guide applies to the EUCAST disk diffusion
method for rapidly growing anaerobes based on
Fastidious Anaerobe Agar with 5% horse blood (FAA-
HB) and 16-20 h incubation with the following species:

– Bacteroides spp.
– Prevotella spp.
– Fusobacterium necrophorum
– Clostridium perfringens
– Cutibacterium acnes

3
 Reading of inhibition zones
• Read FAA plates from the front with the lid removed and with reflected
light.
• Hold the plate about 30 cm from the eye at a 45-degree angle to the
work bench.
• Measure zone diameters with a calliper or ruler at the point of
complete inhibition as judged by the naked eye.
– In case of double zones, read the inner zone edge.
– If faint haze within the zone occurs, disregard haze and read
the most obvious zone edge. Tilt the plate towards you to
better define the obvious zone edge.
– Ignore haemolysis and swarming when reading zones.
• Isolated colonies within the inhibition zone should be taken into account
when reading. For clindamycin, it is particularly important to
examine zones carefully for colonies growing within the zone.

4
 Bacteroides spp.

Piperacillin-tazobactam Piperacillin-tazobactam Piperacillin-tazobactam Meropenem

6 mm

Meropenem Meropenem Clindamycin Metronidazole

5
 Prevotella spp.

Benzylpenicillin Piperacillin-tazobactam Meropenem

Clindamycin Metronidazole
6
 Fusobacterium necrophorum

Benzylpenicillin Benzylpenicillin Piperacillin-tazobactam Piperacillin-tazobactam

Meropenem Clindamycin Metronidazole Metronidazole

7
 Clostridium perfringens

Benzylpenicillin Benzylpenicillin Piperacillin-tazobactam Piperacillin-tazobactam

Meropenem Vancomycin Clindamycin Metronidazole

8
 Cutibacterium acnes

Benzylpenicillin Benzylpenicillin Piperacillin-tazobactam

Meropenem Vancomycin Clindamycin

9
C. acnes grow with small colonies on FAA and growth may be pale causing poor contrast when reading.
 European Committee on Antimicrobial Susceptibility Testing
Breakpoint tables for interpretation of MICs for antifungal agents
Version 10.0, valid from 2020-02-04

Content Page
Notes 1
Guidance on reading EUCAST antifungal breakpoint tables 3
Information on technical uncertainty 4
Changes 5
Candida and Cryptococcus spp. 6
Aspergillus spp. 7
Dosages 8

This document should be cited as: “The European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs for antifungal agents, version 10.0, 2020.
http://www.eucast.org/astoffungi/clinicalbreakpointsforantifungals/.
 European Committee on Antimicrobial Susceptibility Testing
Breakpoint tables for interpretation of MICs for antifungal agents
Version 10.0, valid from 2020-02-04

Notes
1. The EUCAST tables of clinical breakpoints for antifungal agents contain clinical MIC breakpoints determined over the period 2007-2019. The EUCAST breakpoint table version 10.0 includes
corrected typographical errors, clarifications, breakpoints for new agents and/or organisms, and revised MIC breakpoints. Changes are best seen on screen or on a colour printout since cells
containing a change are yellow.

2. Numbered footnotes relating to MIC breakpoints are listed in a column on the right of the spreadsheet or below the table.

3. Antifungal agents names in blue link to EUCAST rationale documents. MIC breakpoints in blue link to EUCAST MIC distributions.

4. The document is released as a protected Excel® file suitable for viewing on screen and as an Acrobat® pdf file for printing. To utilise all functions in the Excel® file, use Microsoft TM original
programs only. The Excel® file enables users to alter the list of agents to suit the local range of agents tested locally. The content of single cells cannot be changed. Hide lines by right-clicking
on the line number and choosing "hide". Hide columns by right-clicking on the column letter and choosing "hide". If you wish to add the intermediate columns for MICs right-click on the column
letter and choose "insert". The intermediate values are inferred from the "S" and "R" breakpoints when not specified in the table.

5. EUCAST breakpoints are used to categorise results into three susceptibility categories:
S - Susceptible, standard dosing regimen: A microorganism is categorised as Susceptible, standard dosing regimen, when there is a high likelihood of therapeutic success using a standard
dosing regimen of the agent.
I - Susceptible, increased exposure: A microorganism is categorised as Susceptible, increased exposure * when there is a high likelihood of therapeutic success because exposure to the
agent is increased by adjusting the dosing regimen or by its concentration at the site of infection.
R - Resistant: A microorganism is categorised as Resistant when there is a high likelihood of therapeutic failure even when there is increased exposure.
*Exposure is a function of how the mode of administration, dose, dosing interval, infusion time, as well as distribution and excretion of the antimicrobial agent will influence the infecting
organism at the site of infection.

6. For some organism-agent combinations, results may be in an area where the interpretation is uncertain. EUCAST has designated this an Area of Technical Uncertainty (ATU). It corresponds
to an MIC value where the categorisation is doubtful. See separate page (Technical uncertainty) for more information on ATU and how to deal with results in the ATU.

7. In order to simplify the EUCAST tables, the I category is not listed. It is readily interpreted as the values between the S and the R breakpoint. For example, for MIC breakpoints listed as S ≤ 1
mg/L and R > 8 mg/L, the I category is 2-8 (technically >1-8) mg/L.

1
Notes
8. By international convention MIC dilution series are based on twofold dilutions up and down from 1 mg/L. At dilutions below 0.25 mg/L, this leads to concentrations with multiple decimal
places. To avoid having to use these in tables and documents, EUCAST has decided to use the following format (in bold): 0.125→ 0.125, 0.0625→0.06, 0.03125→0.03, 0.015625→0.016,
0.0078125→0.008, 0.00390625→0.004 and 0.001953125→0.002 mg/L.

"-" indicates that susceptibility testing is not recommended as the species is a poor target for therapy with the drug. Isolates may be reported as R without prior testing.
"IE" indicates that there is insufficient evidence that the species in question is a good target for therapy with the drug. An MIC with a comment but without an accompanying S, I or R
categorisation may be reported.
NA = Not Applicable
IP = In Preparation

2
 Guidance on reading EUCAST Antifungal Breakpoint Tables EUCAST Antifungal Clinical Breakpoint Table v. 10.0 valid from 2020-02-04

The I category is not listed but is interpreted as the values

between the S and the R breakpoints. If the S and R
breakpoints are the same value there is no I category.

Agent A: No I category
Agent B: I category: 4 mg/L
Agent G: I category: 1-2 mg/L

Area of Technical Uncertainty

See specific information on how to
handle technical uncertainty in
MIC breakpoint (mg/L) antimicrobial susceptibility testing.
Antifungal agent MIC breakpoint
(mg/L) Insufficient evidence that the
S≤ R> ATU organism or group is a good
Antimicrobial agent A 11 11 target for therapy with the agent
Antimicrobial agent B 22 4
Antimicrobial agent C IE IE No breakpoints.
Antimicrobial agent D - - Susceptibility testing
Antimicrobial agent E IP IP is not recommended
Antimicrobial agent F NA NA
Antimicrobial agent G 0.5 2 Changes from previous
Antimicrobial agent H 0.001 1 version highlighted in yellow

Notes. Numbered notes relate to general comments and/or MIC breakpoints.

1. Notes that are general comments and/or relating to MIC breakpoints. In Preparation
2. New comment
Removed comment MIC breakpoints
in blue are
linked to MIC distributions Not Applicable

Antifungal agents in blue An arbitrary "off scale" breakpoint which

are linked to EUCAST categorises wild-type organisms as
rationale documents "Susceptible - increased exposure"

3
 European Committee on Antimicrobial Susceptibility Testing
Breakpoint tables for interpretation of MICs for antifungal agents
Version 10.0, valid from 2020-02-04
How to handle technical uncertainty in antimicrobial susceptibility testing
All measurements are affected by random variation and some by systematic variation. Systematic variation should be avoided and random variation reduced as much as possible. Antimicrobial susceptibility testing (AST),
irrespective of method, is no exception.

EUCAST strives to minimise variation by providing standardised methods for MIC determination and disk diffusion and by avoiding setting breakpoints which seriously affect the reproducibility of the test. Variation in AST can be
further reduced by setting more stringent standards for manufacturers of AST material (growth medium and antifungals) and criteria for quality control of manufacturing processes and laboratory practices.

It is tempting to think that generating an MIC value will solve all problems. However, MIC measurements also have variation and a single value is not automatically correct. Even when using the reference method, MICs vary
between days and technicians. Under the best of circumstances, an MIC of 1.0 should be considered as a value between 0.5 and 2.0 mg/L. Not infrequently, there are problems with commercial testing systems including broth
microdilution tests, gradient tests and semi-automated AST devices.

Although AST in principle is straightforward for most agents and species, there are problematic areas. It is important to warn laboratories about these and the uncertainty of susceptibility categorisation. Analysis of EUCAST data
that have been generated over the years has identified such situations, called Areas of Technical Uncertainty (ATU). The ATUs are warnings to laboratory staff that there is an uncertainty that needs to be addressed before
reporting AST results to clinical colleagues. The ATU is not to be conveyed to clinical colleagues except under special circumstances and only as part of a discussion about therapeutic alternatives in difficult cases.

Below are alternatives for how the ATUs can be dealt with by the laboratory. Which of these actions are chosen will depend on the situation. The type of sample (f.x. blood culture vs. mucosal culture), the number of alternative
agents available, the severity of the disease, whether or not a consultation with clinical colleagues is feasible, will influence the action taken.
• Repeat the test
This is only relevant if there is reason to suspect a technical error in the primary AST.
• Use an alternative test (perform a genotypic test)
This may be relevant if the susceptibility report leaves only few therapeutic alternatives or if the result is deemed of importance. If the organism is multi-resistant, it is advisable to perform a genotypic characterization of the
resistance mechanism to obtain more information (examples: FKS gene sequencing in Candida and CYP51A gene sequencing in A. fumigatus ).
• Downgrade the susceptibility category
If there are other therapeutic alternatives in the AST report, it is permissible to downgrade the result (from S to I, or from I to R or from S to R). However, a comment should be included and the isolate saved for further testing.
• Upgrade the susceptibility category
If there are substantial evidence that the isolate will be clinically susceptible (for example in isolates with a one-step MIC elevation above the susceptibility breakpoint AND absence of FKS mutations in a Candida isolate with
susceptible phenotype to alternative candins, or an A. fumigatus isolate with an MIC of 0.25 mg/L for posaconazole but susceptible to itraconazole) it is permissible to upgrade the result (from R to S, or from I to S). However, a
comment should be included and the isolate saved for further testing. Such a comment could be: "based upon clinical experience the isolate will be clinically susceptible to drug x despite the one-step elevated MIC".
• Include the uncertainty as part of the report
It is common practice in many other laboratory settings to include information on the uncertainty of the reported result. This can be dealt with in several alternative ways:
* For serious situations, take the opportunity to contact the clinical colleagues to explain and discuss the results.
* Categorise the result according to the breakpoints but include information about the technical difficulties and/or the uncertainty of the interpretation. In many instances, a straight “R” is less ambiguous than other
alternatives, especially when there are alternative agents.

The Area of Technical Uncertainty will typically be listed as a defined MIC value. ATUs will only be listed when obviously needed. The absence of an ATU (MIC) means that there is no immediate need for a warning. The ATUs
introduced in 2019 (v. 10.0) will be evaluated and ATUs may be added as more information develops.
Link to the guidance material available on the EUCAST website.

4
 European Committee on Antimicrobial Susceptibility Testing
Breakpoint tables for interpretation of MICs for antifungal agents
Version 10.0, 2020-02-04
General
Notes
Technical uncertainty
Candida and Cryptococcus spp.
Aspergillus spp.
Dosages
Version 10.0, valid from 2020-02-04
Changes (cells containing a change, a deletion or an addition) from v. 9.0 are marked yellow.
New or changed comments are underlined. Removed comments are shown in strikethrough font style.
• Harmonization of the Breakpoints Table document to the one for Antibacterials. Format and content changed accordingly.
• Columns for Area of Technical Uncertainty (ATU) added (MIC).
• Comments relating to high-dose therapy have been exchanged with HE (High Exposure) superscript on the antimicrobial name.
• Adoption of new breapoints for less common species taken from the respresentative type species (C. albicans for yeasts and A. fumigatus for
moulds) when the ECOFF for the combination in question is below or comparable to the breakpoint for the type species.
• The format for MICs below 0.125 mg/L has been changed as follows (0.125→0.125, 0.0625→0.06, 0.03125→0.03, 0.015625→0.016,
0.0078125→0.008, 0.00390625→0.004 and 0.001953125→0.002 mg/L).
• Definitions of susceptibility categories added (Note 4 in Candida sheet)
• Interpretation of fluconazole categories in C. glabrata (Note 4)
• New sheet describing EUCAST recommendations for how to handle technical uncertainty (ATU) in antimicrobial susceptibility testing.
• The Candida sheet has been renamed to Candida and Cryptococcus and Cryptococcus neoformans breakpoints have been added.
• Breakpoints of amphotericin and the azoles against C. albicans have been adopted for C. dubliniensis given that these species are similar in terms of
antifungal susceptibility to these agents and in terms of virulence.
• The fluconazole I and R breakpoints have been revised for C. glabrata to encompass the revised I category and the fact that new MIC data support
an ECOFF of 16 mg/L.
• Breakpoints of micafungin and anidulafungin against C. parapsilosis have been changed given that the clinical response is not statistically different
from that for other agents despite the intrinsic target gene alteration.
• Breakpoints for Amphotericin B, isavuconazole, voriconazole, and posaconazole against A. fumigatus have been changed to accommodate the new
definition of the I category.
• Breakpoints for isavuconazole against A. flavus , voriconazole against A. nidulans , and posaconazole against A. terreus have been set.
• New sheet describing the standard dosing regimen, increased exposure dosing regimen, and the dosing regimens(s) for special clinical
circumstances of antifungal with EUCAST breakpoints.
5
Candida and Cryptococcus spp. EUCAST Antifungal Clinical Breakpoint Table v. 10.0 valid from 2020-02-04

MIC method (EUCAST standardised broth microdilution method)

Medium: RPMI1640-2% glucose, MOPS buffer
5 5
Inoculum: Final 0.5x10 – 2.5x10 cfu/mL
Incubation: 18-24h
Reading: Spectrophotometric, complete (>90%) inhibition for amphotericin B but 50% growth inhibition for other compounds
Quality control: C. parapsilosis ATCC 22019 or C. krusei ATCC 6258

MIC breakpoint (mg/L)

Non-species
Candida Candida Candida Candida Candida Candida Candida Cryptococcus related Comments on the I
Antifungal agent Comments on the ATU
albicans dubliniensis glabrata krusei parapsilosis tropicalis guilliermondii neoformans breakpoints category
for Candida 1
S≤ R> ATU S≤ R> S≤ R> S≤ R> S≤ R> S≤ R> S≤ R> S≤ R> S≤ R>
No data to support an
Amphotericin B 1 1 1 1 1 1 1 1 1 1 1 1 IE IE 1 1 IE IE I category according
to the new definitions
2 2
Anidulafungin 0.03 0.03 0.06 0.06 0.06 0.06 4 4 0.06 0.06 IE IE - - IE IE
3 3 3 3 3 3 3 3 3 3 2
Caspofungin Note Note Note Note Note Note Note Note Note Note IE IE2 - - IE IE
4 2 2 See dosages table for
Fluconazole 2 4 2 4 0.001 16 - - 2 4 2 4 IE IE IE IE 2 4
appropriate dose
Isavuconazole IE IE IE IE IE IE IE IE IE IE IE IE IE IE IE IE IE IE
Itraconazole 0.06 0.06 0.06 0.06 IE2 IE2 IE2 IE2 0.125 0.125 0.125 0.125 IE2 IE2 IE IE IE IE
If S to anidulafungin, report as S and add the following
comment: "Isolates susceptible to anidulafungin with
micafungin MIC of 0.03 mg/L do not harbour an fks
Micafungin 0.016 0.016 0.03 0.03 0.03 IE5 IE5 2 2 IE5 IE5 IE5 IE5 - - IE IE mutation conferring resistance to the echinocandins".
If not S to anidulafungin, report as R and refer to
reference laboratory for fks sequencing and confirmation
of MICs.
Posaconazole 0.06 0.06 0.06 0.06 IE2 IE2 IE2 IE2 0.06 0.06 0.06 0.06 IE2 IE2 IE IE IE IE
6 7 7 7 7 7 7 7 7 2 2 4 mg/kg iv twice daily
Voriconazole 0.06 0.25 0.06 0.25 IE IE IE IE 0.125 0.25 0.125 0.25 IE IE IE IE IE IE

Notes
1. Non-species related breakpoints have been determined mainly on the basis of PK/PD data and are independent of MIC distributions of specific Candida species. They are for use only for organisms that do not have specific breakpoints.

2. The ECOFFs for these species are in general higher than for C. albicans.

3. Isolates that are susceptible to anidulafungin as well as micafungin should be considered susceptible to caspofungin, until caspofungin breakpoints have been established. EUCAST breakpoints have not yet been established for caspofungin, due to
significant inter-laboratory variation in MIC ranges for caspofungin.

4. The entire C. glabrata is in the I category. MICs against C. glabrata should be interpreted as resistant when above 16 mg/L. Susceptible category (≤0.001 mg/L) is simply to avoid missclassification of "I" strains as "S" strains.

5. MICs for C. tropicalis are 1-2 two-fold dilution steps higher than for C. albicans and C. glabrata . In the clinical study successful outcome was numerically slightly lower for C. tropicalis than for C. albicans at both dosages (100 and 150 mg daily).
However, the difference was not significant and whether it translates into a relevant clinical difference is unknown. MICs for C. krusei are approximately three two-fold dilution steps higher than those for C. albicans and, similarly, those for C.
guilliermondii are approximately eight two-fold dilutions higher. In addition, there were only a small number of cases involved these species in the clinical trials. This means there is insufficient evidence (IE) to indicate whether the wild-type population of
these pathogens can be considered susceptible to micafungin.

6. For Candida the I category is introduced to acknowledge that the increased exposure obtained by iv dosing is sufficient (potentially confirmed by TDM). There is not enough information available for the response to voriconazole of infections caused by
Candida isolates with higher MICs.

7. Strains with MIC values above the S/I breakpoint are rare or not yet reported. The identification and antifungal susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate sent to a reference laboratory. Until there
is evidence regarding clinical response for confirmed isolates with MIC above the current resistant breakpoint they should be reported resistant. A clinical response of 76% was achieved in infections caused by the species listed below when MICs were
lower than or equal to the epidemiological cut-offs. Therefore, wild type populations of C. albicans, C. dubliniensis, C. parapsilosis and C. tropicalis are considered susceptible.
6
Aspergillus spp. EUCAST Antifungal Clinical Breakpoint Table v. 10.0 valid from 2020-02-04

MIC method (EUCAST standardised broth microdilution method)

Medium: RPMI1640-2% glucose, MOPS as buffer
Inoculum: Final 1x10(5) – 2.5x10(5) cfu/mL
Incubation: 48h
Reading: Visual, complete inhibition for amphotericin B and azoles (MIC), aberrant growth endpoint for echinocandins (MEC).
Quality control: A. fumigatus ATCC 204305, A. flavus ATCC 204304, A. fumigatus F 6919, A. flavus CM 1813, C. parapsilosis ATCC 22019 (read after
18-24 h) or C. krusei ATCC 6258 (read after 18-24 h).

MIC breakpoint (mg/L)

Non-species
Comments on the I
Antifungal agent A. flavus A. fumigatus A. nidulans A. niger A. terreus related Comments on the ATU
category
breakpoints1
S≤ R> ATU S≤ R> ATU S≤ R> ATU S≤ R> S≤ R> ATU S≤ R>
No data to support an "I"
Amphotericin B - - 1 1 - - 1 1 - - IE IE category according to the
new definition of "I"

Anidulafungin IE IE IE IE IE IE IE IE IE IE IE IE
Caspofungin IE IE IE IE IE IE IE IE IE IE IE IE
Fluconazole - - - - - - - - - - - -
If voriconazole wild-type (A. flavus : voriconazole MIC ≤2 mg/L; A. fumigatus :
voriconazole MIC ≤1 mg/L) report as isavuconazole S and add the following
Isavuconazole MIC = 2 mg/L
comment: The MIC of 2 mg/L is one dilution above the S breakpoint but within the
should not be interpreted as I
Isavuconazole 1 2 2 1 2 2 0.25 0.25 IE2 IE2 1 1 IE IE
but only followed up as an
wild-type isavuconazole MIC range due to a stringent breakpoint susceptibility
breakpoint. See rationale documents for more information.
ATU
If voriconazole non wild-type report as isavuconazole R and refer to reference
laboratory for CYP51A sequencing and confirmation of MICs3."
Report as R with the following comment: "In some clinical situations (non-invasive
Itraconazole4 1 1 2 1 1 2 1 1 2 IE2,5 IE2,5 1 1 2 IE5 IE5 infections forms) traconazole can be used provided sufficient exposure is
ensured".
Micafungin IE IE IE IE IE IE IE IE IE IE IE IE
If S to itraconazole report as S and add the following comment: "The MIC is 0.25
Posaconazole MIC = 0.25
mg/L and thus one dilution above the S breakpoint due to overlapping wt and non-
4 2 2 2 2 2 2 mg/L should not be
Posaconazole IE IE 0.125 0.25 0.25 IE IE IE IE 0.125 0.25 0.25 IE IE wt populations".
interpreted as I but only as
If not S to itraconazole report as R and refer to reference laboratory for CYP51A
ATU
sequencing and confirmation of MICs.
Report as R with the following comment: "In some clinical situations (non-invasive
Voriconazole4 IE2 IE2 1 1 2 1 1 2 IE2 IE2 IE2 IE2 IE IE infections forms) voriconazole can be used provided sufficient exposure is
ensured".
Notes
1. Non-species related breakpoints have not been determined.

2. The ECOFFs for these species are in general one two-fold dilution higher than for A. fumigatus .

3. Itraconazole and posaconazole R isolates but S to voriconazole and isavuconazole are not uncommon in azole-treated patients. Refer the isolate to a reference laboratory for CYP51A sequencing and confirmation of MICs.

4. Monitoring of azole trough concentrations in patients treated for fungal infection is recommended.

5. The MIC values for isolates of A. niger and A. versicolor are in general higher than those for A. fumigatus . Whether this translates into a poorer clinical response is unknown.

7
Dosages EUCAST Antifungal Clinical Breakpoint Table v. 10.0 valid from 2020-02-04

EUCAST breakpoints are based on the following adult dosages (see section 8 in Rationale Documents). Alternative dosing regimens which result in equivalent exposure are acceptable. The table should not be considered an exhaustive guidance
for dosing in clinical practice, and does not replace specific local, national, or regional dosing guidelines.
Note: duration of treatment only indicated for loading doses, because the total duration of therapy is not only dependent on the type and site of infection but also on the underlying disease of the patient. Please consult clinical management
guidelines for recommendations on total duration.

Azoles Standard dose Increased Exposure Dose Special situations

Indicated doses are those appropriate for invasive candidiasis
800 mg x 1 for first day followed by 400 mg x 1 iv/oral
Fluconazole 800 mg x 1 iv/oral (or 12 mg/kg) Mucosal infections (Mendling et al; Mycoses. 2012;55 Suppl 3:1-13): Standard doses is 100-200 mg x 1
(or 6 mg/kg)
and increased dose 800 mg x 1 (for C. glabrata )

*Superficial infections only

200 mg x 2 for first day followed by 100*-400** mg iv/po
**Daily doses up to 200 mg x 2 may be given depending on the infection. Capsules have 30% lower
Itraconazole Target trough level***: >0.5 mg/L for prophylaxis, >1 mg/L for
bioavailability than the oral solution
therapy
***HPLC assay method and Parent compound only.
Isavuconazole 200 mg x 3 for first 2 days followed by 200 mg x 1 iv/oral
Tablets/iv: 300 mg x 2 for first day followed by 300 mg x 1
Oral suspension: 200 mg x 4 for first day or 400 mg x 2
Posaconazole
Target trough level: >0.7 mg/L for prophylaxis and >1.25
mg/L for therapy
6 mg/kg x 2 for first day followed by 4 mg/kg x 2 iv
400 mg x 2 for first day followed by 200 mg x 2 po Candida : The I-category only applies for the iv dosage (not Increased exposure can be achieved by elevated dosage (note non-linear kinetics in adults) or with a
Voriconazole
Target trough level: >0.5 mg/L for prophylaxis, 2-5.5 mg/L for the standard oral dose) proton pump inhibitor, in patients with low blood levels.
therapy

Amphotericin B formulations Standard dose Increased Exposure Dose Special situations

Increased doses up to 7 mg/kg (or even 10 mg/kg e.g. Mucorales CNS infections) can be used in
Liposomal amphotericin B 3 mg/kg x 1
specific situations.
Amphotericin B deoxycholate 1 mg/kg x 1
ABLC 5 mg/kg x1

Echinocandins Standard dose Increased Exposure Dose Special situations

Anidulafungin 200 mg x 1 for first day followed by 100 mg x 1
70 mg x 1 for first day followed by 50* mg x 1 (weight ≤ 80
Caspofungin kg)
70 mg x 1 (weight > 80 kg)
Increased dose indicated in patients not responding to standard dose
100 mg x 1 (weight >40 kg) 200 mg x 1 (weight >40 kg)
Micafungin Standard dose for chronic aspergillosis is Micafungin 150 mg x 1 (Chronic pulmonary aspergillosis:
2 mg/kg x 1 in patients weighing <40 kg 4 mg/kg x 1 in patients weighing <40 kg
rationale and clinical guidelines for diagnosis and management. Eur Resp J 2016)