Table Of ContentAntimicrobial
Susceptibility
Testing Protocols
Antimicrobial
Susceptibility
Testing Protocols
Edited by
Richard Schwalbe
Lynn Steele-Moore
Avery C. Goodwin
Boca Raton London New York
CRC Press is an imprint of the
Taylor & Francis Group, an informa business
Employees of the Department of Health and Human Services who have contributed to the work are not representing the
views and opinions of the U.S. government.
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2007 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Printed in the United States of America on acid-free paper
10 9 8 7 6 5 4 3 2 1
International Standard Book Number-13: 978-0-8247-4100-6 (Hardcover)
This book contains information obtained from authentic and highly regarded sources. Reprinted material is quoted
with permission, and sources are indicated. A wide variety of references are listed. Reasonable efforts have been made to
publish reliable data and information, but the author and the publisher cannot assume responsibility for the validity of
all materials or for the consequences of their use.
No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or
other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any informa-
tion storage or retrieval system, without written permission from the publishers.
For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://
www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC) 222 Rosewood Drive, Danvers, MA 01923,
978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For orga-
nizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged.
Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for
identification and explanation without intent to infringe.
Library of Congress Cataloging-in-Publication Data
Antimicrobial susceptibility testing protocols / editors, Richard Schwalbe, Lynn Steele-Moore, and
Avery C. Goodwin.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8247-4100-6 (alk. paper)
ISBN-10: 0-8247-4100-5 (alk. paper)
1. Microbial sensitivity tests. 2. Drug resistance in microorganisms. I. Schwalbe, Richard. II.
Steele-Moore, Lynn. III. Goodwin, Avery C.
[DNLM: 1. Microbial Sensitivity Tests--methods. 2. Microbial Sensitivity Tests--standards.
3. Anti-Bacterial Agents. 4. Antifungal Agents. 5. Drug Resistance, Fungal. 6. Drug Resistance,
Microbial. QW 25.5.M6 A631 2007]
QR69.A57A63 2007
616.9’041--dc22 2007005182
Visit the Taylor & Francis Web site at
http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com
Dedication
This book is dedicated to Dr. Richard Steven Schwalbe,
who passed away September 1, 1998, before our textbook was completed.
All of the contributors to Antimicrobial Susceptibility Testing Protocols
respectfully and lovingly present our work as a token of our admiration
to Rick and in the hope that through our efforts we may carry on his
passion and love of susceptibility testing and microbiology.
l’chaim my friend...I miss you.
Preface
Recent reports in the lay press describing bacterial resistance to multiple antibiotics serve to
emphasize the importance of accurate susceptibility testing. The clinical microbiology laboratory
is often a sentinel for detection of drug-resistant microorganisms. Timely notification of suscepti-
bility results to clinicians can result in initiation or alteration of antimicrobial chemotherapy and
thus improve patient care. Standardized protocols require continual scrutiny to detect emerging
phenotypic resistance patterns.
The aim of Susceptibility Testing Protocols is twofold: one is to present a comprehensive, up-
to-date procedural manual that can be used by a wide variety of laboratory workers. The second
objective is to delineate the role of the clinical microbiology laboratory in integrated patient care.
Many protocols that are presented are an extrapolation of procedures approved by the Clinical and
Laboratory Standards Institute (CLSI). New procedures that are (at present) nonstandardized are
also described.
The first section of this manual addresses the basic susceptibility disciplines that are already
in place in many clinical microbiology laboratories. These include disk diffusion, macro- and
microbroth dilution, agar dilution, and the gradient method. Step-by-step protocols are provided.
Emphasis is placed on optimizing procedures for detection of resistant microorganisms. A chapter
is devoted to automated susceptibility testing, introducing the systems that are currently available
for purchase, including recent laboratory evaluations, and presents an algorithm that can be followed
by laboratory workers who are considering purchasing a new automated system.
The second section is devoted to descriptions of susceptibility protocols that may be performed
by a subset of laboratories, whether as reference centers or as part of a research protocol. Specialized
protocols such as surveillance procedures for detection of antibiotic-resistant bacteria, serum bac-
tericidal assays, time-kill curves, population analysis, and synergy testing are discussed. Emphasis
in this section is on clear descriptions of methods leading to reproducible results.
The final section of this manual includes a series of chapters designed to be used as reference
sources. Additional chapters focus on antibiotic development and design, use of an antibiogram,
and the interactions of the clinical microbiology laboratory with ancillary areas such as hospital
pharmacy, infectious disease personnel, and infection control. A table of antibiotic classes and
common “bug–drug” susceptibilities are also included.
This manual is directed to personnel engaged in the laboratory disciplines that perform in vitro
susceptibility testing, including clinical microbiology, food and agriculture microbiology, pharma-
ceuticals research, and other applied and basic research environments. It is meant to be used as a
bench manual. References are supplied at the end of each chapter to provide additional sources of
information to those individuals wishing to pursue a specific topic in greater detail.
Antibacterial Susceptibility Testing Protocols differs from other available sources of information
by its scope. Its aim is to combine an updated series of laboratory-based techniques and charts
within the context of the role of clinical microbiology in modern medicine.
We would like to acknowledge Debbi Reader Covey for her secretarial assistance and unwa-
vering support. Most of all, we would like to thank Dr. Richard S. Schwalbe for many, many things
and for the great person he was.
Lynn Steele-Moore
Avery C. Goodwin, Ph.D.
Editors
Rick Schwalbe was the director of clinical microbiology at the University of Maryland Medical
Systems and the director of clinical microbiology and virology at the Veteran’s Administration
Medical Center in Baltimore, Maryland. He was associate professor of pathology at the University
of Maryland School of Medicine. At the time of his death he was president of the Maryland ASM.
He served on the editoral board of Antimicrobial Agents and Chemotherapy and had over 100
publications.
Lynn Steele-Moore was the manager of Dr. William J. Holloway’s Infectious Disease Laboratory
at Christiana Care Health Services in Wilmington, Delaware, for 22 years. She currently is employed
by the U.S. Food and Drug Administration in Silver Spring, Maryland. Lynn and the late Dr. Richard
Schwalbe collaborated on many projects, this text being one of them. Unfortunately, Dr. Schwalbe
passed away before the text was completed. However, his contributions can be seen throughout the
text with chapters written by many of his friends. We all lovingly dedicate this text to our beloved
friend, Rick Schwalbe.
Avery C. Goodwin worked at GlaxoSmithKline on the development of antimicrobial drugs. He is
currently employed by the U.S. Food and Drug Administration in Silver Spring, Maryland, as a
microbiology reviewer in the Division of Anti-Infective and Ophthalmology Products.
Description:As directed by Congress, the FDA has legal responsibility for determining safety and efficacy of new Traditionally, antimicrobial agents have been classified based on their mechanism of action, .. The success seen with the discovery of penicillin lead to the search for other possible antibiotic-.
