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Sensitivity testing of ciprofloxacin for Pseudomonas aeruginosa
I B Ibrahim-Elmagboul1, D M Livermore
1Department of Medical Microbiology, St Bartholomew's and the Royal London School of Medicine and Dentistry, UK. d.m.livermore@mds.qmw.ac.uk.
Abstract:
UK clinical laboratories overestimate ciprofloxacin resistance amongst Pseudomonas aeruginosa isolates, relative to the MIC breakpoint of 1 mg/L. Most tests leading to this overestimation use 1 microg discs and are by Stokes' method with the breakpoint taken as the zone radius for P. aeruginosa NCTC 10662 minus 3 mm. Aiming to reduce this error rate, we examined alternative disc breakpoints. Tests were performed for 100 P. aeruginosa isolates on three media, with breakpoints selected (i) as the zone for P. aeruginosa NCTC 10662 minus 7 mm, as recommended for ciprofloxacin by the BSAC; (ii) with reference to MIC/zone correlation lines; (iii) from natural divisions in zone distribution histograms; and (iv) so as to minimize categorization errors. Breakpoints from regression lines, and those optimized to the susceptibility distribution, reduced the proportion of susceptible organisms misreported as resistant, but the improvement was not significant (P > 0.05, chi2 test). The breakpoint of the zone radius for P. aeruginosa NCTC 10662 minus 7 mm significantly reduced (P < 0.05) the number of susceptible organisms reported as resistant, but led to 50-75% of those with low level resistance (MIC 2-4 mg/L) and 4-10% of those with high-level resistance (MIC > 4 mg/L) being classed as susceptible. Irrespective of the medium and the basis of choosing breakpoints, 5 microg ciprofloxacin discs gave a lower rate of susceptible organisms being reported as resistant than did 1 microg discs; however, the improvement was not significant (P > 0.05, chi2 test) and the 5 microg discs had the disadvantages of forming very large zones for susceptible isolates and giving some--albeit small--zones for highly resistant organisms. In conclusion, the over-reporting of resistance could be reduced by use of zone breakpoints optimized to the MIC distribution and by the use of 5 microg discs, but the case for these changes is not overwhelming; taking the breakpoint as the zone for NCTC 10662 minus 7 mm led to unacceptable numbers of resistant organisms being reported as susceptible. More fundamentally, ciprofloxacin zones and MICs are continuously distributed for P. aeruginosa isolates, so susceptibility tests cannot divide the species into discrete populations. In these circumstances, it is optimistic to expect disc and MIC categorizations to agree perfectly.
Insights
Clinical labs often misreport ciprofloxacin resistance in Pseudomonas aeruginosa. Optimizing disc breakpoints and using larger discs can reduce errors, but perfect agreement between disc and MIC tests remains challenging.
Area of Science:
- Clinical Microbiology
- Antimicrobial Resistance
- Bacterial Pathogenesis
Background:
- UK clinical laboratories frequently overestimate ciprofloxacin resistance in Pseudomonas aeruginosa isolates.
- This overestimation is often due to the use of 1 microgram discs and specific interpretations of the Stokes' method against the 1 mg/L MIC breakpoint.
Purpose of the Study:
- To investigate alternative disc breakpoints for ciprofloxacin susceptibility testing of Pseudomonas aeruginosa.
- To reduce the rate of misclassification of susceptible isolates as resistant.
Main Methods:
- Testing 100 Pseudomonas aeruginosa isolates on three different media.
- Evaluating breakpoints based on established zone radius differences (minus 3 mm and minus 7 mm), MIC/zone correlation lines, natural zone distribution divisions, and error minimization.
- Comparing the performance of 1 microgram and 5 microgram ciprofloxacin discs.
Main Results:
- Optimized breakpoints based on regression lines and susceptibility distribution showed a trend towards reducing false resistance reports, but not significantly.
- Using a breakpoint of NCTC 10662 minus 7 mm significantly reduced false resistance reports but misclassified resistant isolates as susceptible.
- 5 microgram discs resulted in fewer false resistance reports than 1 microgram discs, though not significantly, and presented challenges with very large zones for susceptible strains and small zones for resistant strains.
Conclusions:
- While optimized breakpoints and 5 microgram discs may reduce over-reporting of ciprofloxacin resistance, the improvements are not substantial.
- The breakpoint of NCTC 10662 minus 7 mm leads to an unacceptable rate of resistant organisms being classified as susceptible.
- The continuous distribution of ciprofloxacin MICs and zone diameters for Pseudomonas aeruginosa makes perfect agreement between disc diffusion and MIC testing optimistic.