1. Most often asked questions
Jenny Andrews

2. Current Working Party members
Medical
Scientific
Industry
Alasdair MacGowan
(President BSAC)
Bristol
Derek Brown
(Chairman)
Cambridge
Colin Booth
(Oxoid)
Gunnar Kahlmeter
(Chairman of EUCAST)
Sweden
Jenny Andrews
(Secretary)
SMDC Birmingham
Jon Hobson
(Mast)
Nizam Damani
Belfast
David Livermore
HPA, Colindale
Ian Morrissey
(GR Micro, London)
Nicholas Brown
Curtis Gemmell
Glasgow
Robin Howe
Cardiff
John Perry
Newcastle
Trevor Winstanley
Sheffield
Christopher Teale
VLA, Shrewsbury

3. Aim of the Working Party
Provide recommendations appropriate for susceptibility testing in the UK and Ireland
Continually review the recommendations, taking into account the introduction of new antibiotics and emerging mechanisms of resistance
Provide support for users of the BSAC method

4. BSAC recommendations
1991- Guide to sensitivity testing (Questionnaire- 91% would consider using a standardized method)
1998-Summer BSAC Newsletter (Standardized Disc Testing Method)
1999- Amendments and additions
2001-July
Supplement
Version 2 (website)
2005- Version 4

5. Scientists outside the UK asking for help
Abu Dhabi
Kenya
Spain
Australia
Malawi
Sri Lanka
Bermuda
Malta
Switzerland
Brazil
New Zealand
Turkey
Germany
Nigeria
Uganda
India
Pakistan
USA
Jamaica
Portugal

6. Other requests for help
Degree/projects- have given advice to 29 individuals (USA Georgia Acidovora avenae found on water melons-advice given by Trevor Winstanley)
Veterinary laboratories (Northern Ireland, Scotland, England, Turkey, Australia) [Chris Teale represents this group on the working party]
Pharmaceutical industry

7. Main topics to be discussed
Organisms
Method
Control
UTI
Respiratory
Staphylococci
Enterobacteriaceae
Enterococci
N. gonorrhoeae
Mechanisms of resistance
Etest
NEQAS
Website

8. Organisms Order of priority Comment -haemolytic streptococci 
Acinetobacter spp.
Under review
S. maltophilia
Helicobacter spp.
Refer to Reference Group
Bacillus spp.
Andrews & Wise JAC 2002;49;
Listeria spp.
SRGA recommendations
Campylobacter spp.
B. cepacia
For the future
P. multocida
Fungi (India)
Not the remit of this WP
Anaerobic organisms
In progress
M. tuberculosis
Coryneforms

9. Method Template (written and supported by Trevor Winstanley)
Preparation of inoculum
Direct sensitivity tests (blood cultures & urines)
Can Oxoid Iso-Sensitest agar be substituted by media from other manufacturers?
Disc contents not used in the UK (SRGA data)

10. Control strains
Filling the gaps in the recommendations (BSAC rolling programme) [devising intra-laboratory ranges until recommendations available]
Controls repeatedly outside the acceptable range [rolling programme](meropenem ATCC P. aeruginosa- no change; gentamicin NCTC 6571 S. aureus under review; trimethoprim NCTC & ATCC E. coli zone ranges increased 28-34mm to 30-37mm & 20-26mm to mm respectively; co-amoxiclav E. coli NCTC range reduced from mm to 12-18mm)
Using the acceptable ranges laboratories detected that one commercial supply of ciprofloxacin discs were under-dosed
Control ranges for N. gonorrhoeae ATCC 49226
Providing controls to India, Egypt

11. E. coli P. mirabilis Enterococci S. saprophyticus Group B streptococci
Organisms associated with uncomplicated UTIs
in women of child-bearing age
NB. Complicated UTIs and S. epidermidis and S. aureus (usually
associated with more serious infections)- use systemic
Zone diameter BPs
E. coli
P. mirabilis
Enterococci
S. saprophyticus
Group B streptococci

12. UTI
Cotrimoxazole – because of blood and skin disorders associated with this combination there are no BSAC recommendations CSM recommendations: cotrimoxazole should only be used for UTIs when there is evidence of susceptibility and a good reason to prefer this combination to a single antibiotic.
Trimethoprim– John Washington: enterococci should be regarded as resistant because they utilise exogenous folate in vivo which is absent from the medium used for testing, therefore isolates appear falsely susceptible in vitro to trimethoprim and co-trimoxazole
An exhaustive search of the literature was unable to support the hypothesis of Washington
Recommendations now available for trimethoprim

13. UTI
Gaps – often antibiotics used systemically therefore use these recommendations
Coliforms absent from the recommendations-where distribution is not good and there is overlap between the susceptible and resistant populations (e.g. cephalexin).
ID to species level is essential for applying expert rules (for amoxicillin/ampicillin/co-amoxiclav, `These interpretative standards apply only to E. coli and P. mirabilis and not species that have chromosomal penicillinases (Klebsiella spp.) or those that typically have inducible AmpC (e.g. Enterobacter spp., Citrobacter spp. And Serratia spp.’)
`In the absence of a definitive ID, use the recommendations most appropriate for the presumptive ID, accepting that on some occasions the interpretation may be incorrect. A more cautious approach is to use the systemic recommendations.’

14. Respiratory H. influenzae: Interpretation of amoxicillin/co-amoxiclav and cefuroxime
Isolates with zone diameters 2-3 mm smaller than the zone diameter BP for co-amoxiclav reported S to amoxicillin & cefuroxime (including NEQAS specimen 5853 [co-amoxiclav MIC 0.5 mg/L MIC BP 1 mg/L]
Zone diameter BPs reviewed and amended
Currently there are occasional enquiries from laboratories regarding isolates with borderline susceptibility to the three agents (Becky Walker undertaking a higher degree to elucidate the mechanisms of resistance to the -lactam antibiotics)

15. Respiratory
S.pneumoniae: Interpretation of resistance to penicillin - `Organisms with a penicillin MIC  1 mg/L are considered susceptible to -lactam antibiotics except in infections of the central nervous system.’
Recommendations for S. pneumoniae v trimethoprim- MIC 50 8 mg/L; MIC90 >128 mg/L; MIC BP 0.5 mg/L

16. Respiratory
Interpretation of susceptibility of H. influenzae to cefaclor- Professor MacGowan `The pK/pD data indicates cefaclor has borderline activity against H. influenzae, even for community use (free drug T>MIC of 25% with 250 mg and 37% with 500 mg dosing, suggested conservative T>MIC for cephalosporins in the community practice is 40-50%; MIC50 = 2 mg/L, MIC90 = 8 mg/L, MIC BP 1 mg/L). The outcome of infection will be difficult to predict and susceptibility testing is likely to have limited value.’

17. Staphylococci
Recommendations using cefoxitin to detect resistance in S. aureus
General problems with detection of methicillin resistance (possible penicillinase hyper-producing isolates – PCR or latex for confirmation of resistance)
Using -lactams other than meticillin/oxacillin/cefoxitin to detect resistance `Staphylococci exhibiting resistance to meticillin/oxacillin/cefoxitin should be regarded as resistant to other penicillins, cephalosporins, carbapenems and combinations of -lactam and -lactamase inhibitors’ Applies to S. saprophyticus

18. Staphylococci
Mupirocin: Harbath et al suggest that there is a need to detect LLR because there is an association with persistence of carriage.
Risk factors for persistent carriage of methicillin-resistant Staphylococcus aureus. Harbath et al Clin Infect Dis Dec; 31(6):1380-5
Method developed by the BSAC using a 20 g mupirocin disc.
Availability of discs

19. Teicoplanin 30 ug disc with CNS - Cambridge35
MIC 0.5 – 4 mg/L
MIC 0.5–4mg/L 30
MIC 8-64 mg/L
MIC 8–64mg/L 25 20
Number of isolates 15 10 5 6 8 10 12 14 16 18 20 22 24 26 28 30
Zone diameter (mm)

20. MIC and zone diameter BPs for ampicillin, amoxicillin and co-amoxiclav for interpreting the susceptibility of Enterobacteriaceae
Date
Recommendations
Before February 2003
Ampicillin & co-amoxiclav only ; MIC BPs - S 8 mg/L, R 16 mg/L; ZD S 18 mm. Laboratories commenting that many systemic isolates had zones that `straddled’ the ZD BP
After February 2003
Ampicillin, amoxicillin & co-amoxiclav; S 16 mg/L, R 32 mg/L; ZD S 14mm.
Using the modified criteria some Enterobacteriaceae with chromosomal AmpC enzyme producers were misclassified as susceptible using this criteria
January 2005
Ampicillin, amoxicillin & co-amoxiclav ; MIC BPs - S 8 mg/L, I =16 mg/L, R 16 mg/L; ZD S 15, mm = I, R  11 mm.

21. Enterobacteriaceae:Reporting LLR to fluoroquinolones
Site of infection/organism
Comment
Urines: should laboratories test ciprofloxacin or nalidixic acid
LLR to FQs (no zone to nalidixic acid 30 g disc) but S to ciprofloxacin. Using Nal alone would mean that 25-40% of isolates with LLR would be reported resistant to ciprofloxacin. The organism is probably susceptible because of the concentration of drug at the site of infection.
Salmonella infections
For ciprofloxacin there is clinical evidence to indicate a poor response in systemic infections caused by Salmonella spp. With reduced susceptibility to FQs (ciprofloxacin MICs mg/L). This reduced susceptibility is most reliably detected with nalidixic acid 30 g disc.

22. Enterococci Recommendations for tetracycline
Detection of glycopeptide susceptibility – usually solved if plates incubated for 24 h to allow micro-colonies to be visualised

23. N. gonorrhoeae
2002 GRASP survey showed that resistance to ciprofloxacin had risen to 9.8%, indicating that the target of >95% efficacy in first-line therapy was no longer achievable.
Recommendations for cefixime(oral) & ceftriaxone (intramuscular)
Availability of ceftriaxone 5 g discs
Which cephalosporin for gonorrhoea? Professor Catherine Ison et al on behalf of the North Thames Audit group.
This report underscores the use of cefixime and ceftriaxone, but finds that cefuroxime is a poor alternative

24. Detection of mechanisms of resistance
ESBLs
BSAC web site ( method of detection and link to HPA recommendations
FQR
Nalidixic acid to detect resistance in H. influenzae, M. catarrhalis, N. gonorrhoeae, N. meningitidis- footnotes to tables recommend 30 g nalidixic acid disc
-lactamase
H. influenzae. M. catarrhalis, staphylococci, methods of detection see BSAC web site ( David Livermore’s Power Point presentation: Detection of beta-lactamase mediated resistance. October 2004
Dissociated resistance
BSAC web site ( in the BSAC Standardized Disc Susceptibility Method section, Additional Methods

25. Etest
Availability of method for testing by the BSAC methodology ( in the BSAC Standardized Disc Susceptibility Method section, Additional Methods, The use of Etests with BSAC methodology
Do we run a course for use of Etest

26. NEQAS
Derek Brown at Addenbrookes and the SMDC in Birmingham are the reference laboratories for MIC testing by BSAC methodology
Questions arise when laboratories do not get the expected result (often occurs with organisms with borderline susceptibility)
The Working Party tries to investigate the problems

27. Website Availability of latest version
Automatic notification of changes
Would it be possible to have a Word file available to download

28. Final comment
2002 University of Utah, USA
I am very curious why your committee saw the need for a different disc susceptibility method. Do you find major inaccuracies in the NCCLS method? It would seem that even if your methods are equally accurate, it confuses the world community to have two different standards.
(EUCAST Harmonization - Gunnar Kahlmeter)