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Chapter 128 : Susceptibility Test Methods: Yeasts and Filamentous Fungi

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Abstract:

This chapter deals with systemic infections caused by spp. other than , spp., and other filamentous fungi (molds). The development of the Clinical and Laboratory Standards Institute (CLSI) reference method M27-A3 has improved the reproducibility of in vitro antifungal susceptibility data and facilitated the establishment of interpretive breakpoints for the triazoles fluconazole, itraconazole, and voriconazole and the echinocandins. Based on historical data and the pharmacokinetics of flucytosine, interpretive breakpoints for flucytosine and spp. also have been established. Some correlation has been suggested between amphotericin B Minimal Inhibitory Concentration (MIC) results obtained by nonstandardized methods and clinical outcome. Unfortunately, most M27-A amphotericin B MICs for yeasts are within a very narrow range, precluding a clear discrimination between susceptible and potentially resistant isolates. The CLSI Subcommittee on Antifungal Susceptibility Testing has developed reference methods for broth macro- and microdilution susceptibility testing of yeasts and mold and more recently a disk diffusion method for yeasts and a proposed disk diffusion method for molds. The European Committee on Antifungal Susceptibility Testing (EUCAST) has developed a modified broth microdilution method for yeast and has developed breakpoints for itraconazole and fluconazole to be applied to this method. Some commercial methods have been approved for the antifungal susceptibility testing of spp. and there is a move towards consensus in the standardized methodology employed in the United States and Europe. This should help to improve surveillance of resistance patterns worldwide and help in the development of universal clinically relevant breakpoints.

Citation: Johnson E, Espinel-Ingroff A, Pfaller M. 2011. Susceptibility Test Methods: Yeasts and Filamentous Fungi, p 2020-2037. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch128

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Antifungal Agents
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Fungal Infections
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Candida albicans
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References

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Tables

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TABLE 1

Methods used for antifungal susceptibility testing

Citation: Johnson E, Espinel-Ingroff A, Pfaller M. 2011. Susceptibility Test Methods: Yeasts and Filamentous Fungi, p 2020-2037. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch128
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TABLE 2

CLSI M27-A3 document broth dilution guidelines for antifungal susceptibility testing of yeasts

Data from reference .

Citation: Johnson E, Espinel-Ingroff A, Pfaller M. 2011. Susceptibility Test Methods: Yeasts and Filamentous Fungi, p 2020-2037. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch128
Generic image for table
TABLE 3

MIC ranges for QC and reference isolates for CLSI broth macrodilution and microdilution methods

Data from CLSI documents M27-S3 ( ) and M38-A2 ( ). NA, not available (for yeasts) or not applicable (for molds).

After 4 days of incubation.

After 72 h of incubation.

Citation: Johnson E, Espinel-Ingroff A, Pfaller M. 2011. Susceptibility Test Methods: Yeasts and Filamentous Fungi, p 2020-2037. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch128
Generic image for table
TABLE 4

Zone diameters for QC isolates for CLSI disk diffusion method

Data from CLSI document M44-S3 ( ).

—, zone diameters not established due to lack of interlaboratory reproducibility.

Citation: Johnson E, Espinel-Ingroff A, Pfaller M. 2011. Susceptibility Test Methods: Yeasts and Filamentous Fungi, p 2020-2037. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch128
Generic image for table
TABLE 5

CLSI M44-A2 document guidelines for antifungal disk diffusion susceptibility testing of spp.

Data from CLSI M44-A2 ( ).

Citation: Johnson E, Espinel-Ingroff A, Pfaller M. 2011. Susceptibility Test Methods: Yeasts and Filamentous Fungi, p 2020-2037. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch128
Generic image for table
TABLE 6

Interpretive MIC breakpoints and corresponding zone diameters for in vitro susceptibility testing of species with CLSI-recommended methods

Subject to modification. Consult the latest CLSI supplements for currently validated breakpoints.

Method performed as described in CLSI document M27-A3 ( ).

Method performed as described in CLSI document M44-A2 ( ); NA, not available.

Fluconazole breakpoints apply to both 24- and 48-h readings. Isolates of are assumed to be intrinsically resistant to fluconazole. The results of fluconazole susceptibility testing of this species (zone diameter and MIC) should not be interpreted using this scale.

There is no Resistant category assigned to the echinocandins; isolates with MICs higher than 2.0 mg/ml may be described as nonsusceptible.

Citation: Johnson E, Espinel-Ingroff A, Pfaller M. 2011. Susceptibility Test Methods: Yeasts and Filamentous Fungi, p 2020-2037. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch128
Generic image for table
TABLE 7

Optical density ranges for filamentous fungi

Data from CLSI document M38-A2 ( ). Suspensions are diluted 1:50 in the standard medium to produce an inoculum density twice that of the final required density (0.4 × 10 to 5 × 10 CFU/ml).

Citation: Johnson E, Espinel-Ingroff A, Pfaller M. 2011. Susceptibility Test Methods: Yeasts and Filamentous Fungi, p 2020-2037. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch128
Generic image for table
TABLE 8

CLSI M38-A2 document guidelines for broth dilution antifungal susceptibility testing of filamentous fungi

Data from reference .

Citation: Johnson E, Espinel-Ingroff A, Pfaller M. 2011. Susceptibility Test Methods: Yeasts and Filamentous Fungi, p 2020-2037. In Versalovic J, Carroll K, Funke G, Jorgensen J, Landry M, Warnock D (ed), Manual of Clinical Microbiology, 10th Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816728.ch128

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