Transcript Antimicrobial Disks

Standards for Antimicrobial
Disk Susceptibility Tests
D
Dr Maryam Sotoudeh
Tehran heart center
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OBJECTIVE
This document describes
• Indications for Performing Susceptibility Tests
• preparation of Mueller-Hinton Agar Medium
• Turbidity Standard for Inoculum Preparation
• Inoculum Preparation
• Inoculation of Test Plates
• Storage of Antimicrobial Disks
• Reading Plates and Interpreting Results
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Indications for Performing
Susceptibility Tests
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The responsibility of the microbiology laboratory includes :
1.Microbial detection and isolation
2.Determination of microbial susceptibility to
antimicrobial agents.
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Which organisms?
• Many bacteria, have unpredictable susceptibilities to
antimicrobial agents.so their susceptibilities can be
measured in vitro to help guide the selection of the
most appropriate antimicrobial agent.(Oxacillin for staph.
aureous )
• Susceptibility tests are not performed on bacteria that
are predictably susceptible to antimicrobial agent
commonly used to treated infection . (penicillin for Group
A β-hemolytic streptococcus)
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Which drugs?
• Organism identification or group (no vancomycin
for gr- bacilli)
• Antimicrobial Susceptibility tests methods
(cefotaxim resistance in P.aeroginosa cannot be
detected by disk diffusion)
• Site of infection
(Nitrofurantoin only achieve effective level in the
urinary tract)
• Availability of Antimicrobial agent
• Cost of individual antibiotics
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Disk diffusion method
(Kirby-bauer test)
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Disk diffusion method (Kirby-bauer test):
• provides the greatest
flexibility and costeffectiveness.
• Widely used since 1966 when
the first standard method was
originally described by Bauer
et al.
• It is appropriate for rapidly
growing organisms and
certain fastidious bacterial
pathogens.
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Disk diffusion testing (Kirby-bauer test):
• It is depends on the formation
of a gradient of antimicrobial
concentration as the
antimicrobial agent diffuses
radially into the agar.
• The drug concentration
decrease at increasing stances
from the disk .
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Disk diffusion method components:
1. McFarland 0.5 standard suspension of
bacteria (for Inoculum preparation)
2. Mueller-Hinton agar plate
3. Filter paper disk containing a specific
amount (not concentration ) of
antibiotic
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Standard preparation
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The number of bacteria tested must bestandardized
regardless of susceptibility method used.
• Too few bacteria
false-susceptible
• Too many bacteria
false-resistant
The most widely used method of inoculums
standardization is McFarland turbidity standards.
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McFarland standards
preparation:
• Add specific volume of 1%
sulfuric acid and 1.175%
barium chloride with constant
stirring to maintain a
suspension .
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McFarland standards
preparation:
• McFarland 0.5 standards preparation:
99.5 ml of 1% sulfuric acid and 0.5 ml of 1.175%
barium chloride .
• aliquots suspension in 4- to 6-mL into screwcap tubes of the same size as used in
growing or diluting the bacterial inoculum.
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• tubes should be tightly
sealed and stored in the
dark at room temperature.
• The suspension should be
vigorously agitated on a
mechanical vortex mixer
before each use and
inspected for a uniformly
turbid appearance.
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• If large particles
appear, the standard
should be replaced
• The barium sulfate
standards should be
replaced or their
densities verified
monthly
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• McFarland standards should have
an optical density (O.D.) of 0.08-0.1 at 625
nm.
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McFarland Standard No.
0.5
1
2
3
4
Barium chloride (ml)
0.05
0.1
0.2
0.3
0.4
Sulfuric acid (ml)
9.95
9.9
9.8
9.7
9.6
Approx. cell density
(1X10^8 CFU/mL)
1.5
3
6
9
12
Transmittance at
wavelength of 600 nm
74.3
55.6
35.6
26.4
21.5
Absorbance at wavelength
of 600 nm
0.132
0.257
0.451
0.582 0.669
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Inoculum Preparation
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Inoculum Preparation
Growth
Method
Direct Colony
Suspension
Method
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Growth Method
At least 3 to 5 well-isolated colonies of the
same morphological type are selected from
an agar plate culture
The top of each colony is touched with a
loop, and transferred into a tube containing
4 to 5 mL of a suitable broth medium, such
as tryptic soy broth.
The broth culture is incubated at 35 °C until
it achieves or exceeds the turbidity of the
0.5 McFarland standard (usually 2 to 6
hours).
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Important : let sterilized loop cool before pick up your sample
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• The turbidity of broth culture is
adjusted with sterile saline or
broth
•
To perform this step properly,
either a photometric device
can be used or, if done
visually, adequate light is
needed to visually compare the
inoculum tube and the 0.5
McFarland standard against a
card with a white background
and contrasting black lines.
(Wickerham Card )
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Direct Colony Suspension Method
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 As a convenient alternative method, the
inoculum can be prepared by making a direct
broth or saline suspension of isolated
colonies selected from an 18- to 24-hour agar
plate (a non selective medium, such as blood
agar, should be used).
Direct Colony Suspension Method
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 The suspension is adjusted to match the 0.5
McFarland turbidity standard as Growth Method
 This approach is the recommended method for testing
the fastidious organisms Haemophilus spp.
Neisseria gonorrhoeae, and streptococci and
for testing staphylococci for potential methicillin
or oxacillin resistance
Inoculation of Test Plates
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Standardize inoculum suspension
Mix McFarland Standard well
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Janet Fick Hindler, MCLS MT(ASCP) UCLA Medical Center Los Angeles, CA
Procedures
Adjust turbidity until it is equivalent to the 0.5
McFarland Turbidity Standard
Sample
0.5 McFarland Standard
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within 15 minutes after adjusting the turbidity, a sterile cotton swab is
dipped into the suspension.
The swab should be rotated several times and pressed firmly on the inside wall
of the tube above the fluid level to remove excess inoculum from the swab.
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The Mueller-Hinton agar plate is inoculated by streaking the swab
This procedure is repeated by streaking two more times, rotating the plate
approximately 60° each time to ensure an even distribution of inoculum.
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Procedures
streak a lawn of bacteria on Mueller-Hinton agar
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As a final step, the rim of the agar is swabbed
The lid may be left ajar for 3 to 5 minutes, but no more than 15 minutes, to allow for any
excess surface moisture to be absorbed before applying the drug-impregnated disks.
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NOTE:
Extremes in inoculum density must be avoided.
 Never use undiluted overnight broth cultures or
other unstandardized inocula for streaking plates.
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MEDIUM
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Mueller-Hinton medium
• The most frequent basal culture
medium for testing bacteria that grow
aerobically.
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Preparation of MuellerHinton Agar
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Preparation of agar medium
1) Prepare MHA ,according to the
manufacturer's instructions, using
distilled water or deionized water.
2) Heat with frequent agitation and boil to
dissolve the medium completely. Sterilize
by autoclaving at 121°C for 15 min.
3) Immediately after autoclaving, allow it to
cool in a 45 to 50 °C water bath
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• The pH of each batch of Mueller-Hinton
agar should be checked when the medium
is prepared.
• It should be 7.2 - 7.4 at room temperature
after gelling.
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The pH can be checked by one of the
following means:
• Macerate a sufficient amount of agar
to submerge the tip of a pH electrode.
• Allow a small amount of agar to
solidify around the tip of a pH
electrode in a beaker or cup.
• Use a properly calibrated surface
electrode
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Pouring the Culture Plates
Pour the freshly prepared and cooled medium into glass
or plastic, flat-bottomed petri dishes on a Level, horizontal
surface to give a uniform depth of approximately 4 mm. 43
Volume of agar medium
Pour 60 to 70 mL of
medium for plates with
diameters of 150 mm
Pour 25 to 30 mL of
medium for plates with
diameters of 100 mm
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• The agar medium should be allowed to
cool to room temperature and, unless
the plate is used the same day, stored
in a refrigerator (2 to 8 °C).
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•
Plates should be used within
seven days after preparation
unless adequate precautions,
such as wrapping in plastic, have
been taken to minimize drying of
the agar.
• A representative sample of each
batch of plates should be
examined for sterility by
incubating at 30 to
35 °C for 24 hours or longer
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• Plates may be stored
in the refrigerator
inside airtight plastic
bags at 2-8°C for up
to 4 weeks.
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Moisture
• If, just before use, excess surface
moisture is present, the plates should be
placed in an incubator (35 °C) or a laminar
flow hood at room temperature with lids
ajar until excess surface moisture is lost
by evaporation (usually 10 to 30 minutes).
•
• The surface should be moist, but no
droplets of moisture should be apparent
on the surface of the medium or on the
petri dish covers when the plates are
inoculated.
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Application of Disks to
Inoculated Agar Plates
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The predetermined battery of antimicrobial disks is
dispensed onto the surface of the agar plate.
Each disk must be pressed down to ensure complete contact
with the agar surface.
Disks are no closer than 24 mm from center to center.
no more than 12 disks should be placed on one 150-mm plate
nor more than 5 disks on a 100-mm plate.
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• Because some of the drug diffuses
almost immediately, a disk should
not be relocated once it has come
into contact with the agar surface.
Instead, place a new disk in
another location on the agar
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Application of Disks to
Inoculated Agar Plates
The plates are inverted and
placed in an incubator set to
35 °C within 15 minutes
after the disks are applied.
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Application of Disks to
Inoculated Agar Plates
• With the exception of
 Haemophilus spp.
 N. Gonorrhoeae
 streptococci
the plates should not be incubated in an
increased CO2 atmosphere, because the
interpretive standards were developed by using
ambient air incubation
and CO2 will significantly alter the size of the
inhibitory zones of some agents.
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Storage of Antimicrobial
Disks
• Cartridges containing commercially prepared paper
disks are generally packaged to ensure appropriate
anhydrous conditions.
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Storage of Antimicrobial
Disks
• Refrigerate the containers at 8 °C or below
• or freeze at -14 °C or below, in a freezer until
needed of use.
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Storage of Antimicrobial
Disks
• Sealed packages of disks that contain
drugs from the β-lactam class should be
stored frozen, except for a small working
supply, which may be refrigerated for at
most one week.
• Some labile agents (e.g., imipenem,
cefaclor, and clavulanic acid
combinations) may retain greater
stability if stored frozen until the day of
use.
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Antimicrobial Disks
The unopened disk containers
should be removed from the
refrigerator or freezer one to two
hours before use
so they may equilibrate to room
temperature before opening.
This procedure minimizes the
amount of condensation that
occurs when warm air contacts
cold disks.
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• a disk-dispensing apparatus,
should be fitted with a tight
cover and supplied with an
adequate desiccant.
• The dispenser should be
allowed to warm to RT before
opening.
• When not in use, the
dispensing apparatus
containing the disks should
always be refrigerated
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• Only those disks that have not
reached the manufacturer’s
expiration date stated on the label
may be used. Disks should be
discarded on the expiration date
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Incubate overnight
Add disks
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Janet Fick Hindler, MCLS MT(ASCP) UCLA Medical Center Los Angeles, CA
Reading Plates and
Interpreting Results
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READING AND MEASUREMENT OF
ZONES OF INHIBITION
• The zone of inhibition is uniformly
circular point at which no growth
is visible to the unaided eye
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Reading Plates
• Zones are measured to the
nearest whole millimeter,
using sliding calipers or a
ruler, which is held on the
back of the inverted petri
plate.
• The petri plate is held a few
inches above a black, nonreflecting background .
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If oxacillin is being tested against Staphylococcus spp.
or vancomycin against Enterococcus spp., 24 hours of
incubation are required before reporting as susceptible
other agents can be read and reported at 16 to 18
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hours. Transmitted light (plate held up
Modify methods for fastidious bacteria
If blood was added to the agar base (as with streptococci), the zones are
measured from the upper surface of the agar illuminated with reflected light,
with the cover removed.
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• Record the presence of individual
colonies (arrow) within zones of
inhibition.
• Purity of the isolate must be
confirmed
• If the isolate was pure, the
individual colonies are resistant
mutants of the same SPP. and
report as resistant
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• Ignore occurrence of fuzzy/hazy
zones (arrow)in 2 instances:
1.Swarming of proteous SPP
2.In Sulfonamid and trimethoprim disks
,antagonists in the medium may
allow some slight growth; therefore,
ignore slight growth (20% or less of
the lawn of growth) and measure the
more obvious margin to determine
the zone diameter
• In other instances haze of growth
should not be ignored.
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Common interpretation
problems
• If individual colonies
are apparent, the
inoculum was too light
and the test must be
repeated
• Do not read plates on
which growth of test
bacteria have isolated
colonies or less than
semi-confluent growth
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Do not read zones of
inhibition of two
adjacent disks that
overlap to the
extent that
measurement of
the zone diameter
cannot be made.
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Do not read zones
showing distortion from
circular .
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Common interpretation problems
An agar gel that is too thick leads to smaller zones
Solution:Use McFarland 0.5/ photometer
Source: http://www.who.int/csr/resources/publications/drugresist/WHO_CDS_CSR_RMD_2003_6/en/
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Interpretation of Disk
Diffusion Test Results
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• A classification based on an in vitro response of
an organism to an antimicrobial agent at levels of
that agent corresponding to blood or tissue levels
attainable with usually prescribed doses of that
agent
• Interpretive categories have been established by
CLSI(clinical and laboratory standard institute
),formerly as NCCLS (national committee for
clinical laboratory standards), including:
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In vitro estimates of antimicrobial
activity
• Susceptible : implies that an infection
due to a specific isolate can be treated
with recommended dosage of antibiotic.
• Resistant : implies that the isolate will
not respond to achievable
concentration of the antibiotic using
normal doses.
• Intermediate : implies that an infection
due to a specific isolate can be treated
with an antibiotic if treated with high
doses or if the infections in an anatomic
site where the antibiotic is concentrated
. (β-lactam AB in urine).
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