Inoculum preparation Table 1.

Recommended media, inoculum and

To obtain reproducible MICs from a gradient based Use the inoculum guide in TABLE 1. Emulsify several incubation1).
system, the stability of the gradient must be maintai- well-isolated colonies from an overnight agar plate in lêÖ~åáëã= ^Ö~ê= fåçÅìäìã fåÅìÄ~íáçå
ned throughout the critical period when the position a suitable suspension medium to achieve the specified
of the growth/inhibition edge for a particular bac- Öêçìé ãÉÇá~ pìëéÉåëáçå qìêÄáÇáíó= qÉãéÉê~íìêÉ= ^íãçëéÜÉêÉ qáãÉ=
inoculum turbidity by comparing to a McFarland
Antimicrobial Susceptibility Testing terium/antibiotic combination is determined. Due turbidity standard. For fastidious organisms such as EjÅc~êä~åÇF Eœ=O=ø`F EÜçìêëF
For In Vitro Diagnostic Use to the stability and precision of the Etest predefined pneumococci, streptococci, gonococci, anaerobes and
gradient, MIC values have been shown to be repro- Haemophilus spp., use the suspension prepared in
INTENDED USE ducible and equivalent to those of the CLSI reference broth within 15 minutes. ^ÉêçÄÉë jìÉääÉê= MKURB=k~`ä MKR================== PR=ø` ~ãÄáÉåí NSJOM
Etest is a quantitative technique for determining dilution procedures. eáåíçå EN=áÑ=ãìÅçáÇF
the antimicrobial susceptibility of Gram negative Inoculation
and Gram positive aerobic bacteria such as En- REAGENTS Soak a sterile, non-toxic swab in the inoculum
terobacteriaceae, Pseudomonas, Staphylococcus and Etest is supplied in a package of 100 or 30 (some suspension and remove excess fluid by pressing it
Enterococcus species and fastidious bacteria, such as lop^L=lopb jìÉääÉê= MKURB=k~`ä MKR PR=ø` ~ãÄáÉåí OQ=lop^====
reagents) test strips of one antimicrobial agent. against the inside wall of the test tube. Remove more eáåíçå=H=OB= QU=lopb
anaerobes, N. gonorrhoeae, S. pneumoniae, Streptococ- fluid when streaking a 90 mm plate and less for a
cus and Haemophilus species. The system comprises k~`ä
STORAGE 150 mm plate. Carefully streak the entire agar surface
a predefined antibiotic gradient which is used to All packages must be stored either at controlled room three times, rotating the plate 60 degrees each time
determine the Minimum Inhibitory Concentration temperature (18-22 °C), in a refrigerator to evenly distribute the inoculum. Alternatively, use ^å~ÉêçÄÉë _êìÅÉää~= _êìÅÉää~=çê= N PR=ø` UMJURB= OQJQUJTO=
(MIC), in μg/mL, of different antimicrobial agents (4-8 °C) or freezer (-18- -22 °C) as specified on the Retro C80 (rota-plater) to efficiently streak the ino- _äççÇ jìÉääÉê= kOLRJNMB= ÇÉéÉåÇáåÖ=
against microorganisms as tested on agar media using product label, until the given expiry date. culum over the agar surface. Allow excess moisture eáåíçå=ÄêçíÜ `lOLNMB=e O çå=íÜÉ=
overnight incubation. to be absorbed for approximately 15 to 20 minutes ëéÉÅáÉë
Etest gradient strips left over from an opened package so that the surface is completely dry before applying
SUMMARY AND EXPLANATION must be kept dry. The opened package should be the Etest gradient strips. e~ÉãçéÜáäìë= eqj jìÉääÉê= MKR================== PR=ø` RB=`l O OMJOQ
Current Antimicrobial Susceptibility Testing (AST) either re-sealed with a sealing clamp or placed in áåÑäìÉåò~É eáåíçå=çê= EN=áÑ=ãìÅçáÇF
methods are based either on quantitative dilution an airtight storage container with colour indicating Notes: eqj=ÄêçíÜ
techniques or qualitative diffusion procedures. Dilu- desiccant, and stored at the temperature stated on 1. When the inoculum and inoculation are optimal,
tion methods are based on two-fold serial dilutions the label or at -20 °C. Left-over strips in storage con- an even confluent growth will be obtained.
of antibiotics in broth or agar media. These methods tainers can be used until the expiry date if correctly 2. McFarland turbidity standards do not guarantee píêÉéíçÅçÅÅìë= jìÉääÉê= jìÉääÉê= MKR================== PR=ø` RB=`l O OMJOQ
generate the MIC value i.e. Minimum Inhibitory stored and handled. Ensure that the batch number correct number of viable cells in the suspension. éåÉìãçåá~É= eáåíçå=H=RB= eáåíçå=ÄêçíÜ EN=áÑ=ãìÅçáÇF
Concentration of a given antibiotic in μg/mL that and expiry date are marked on the storage container. Perform colony counts regularly to verify that the ~åÇ= ëÜÉÉé=ÄäççÇ
will inhibit the growth of a particular bacterium inoculum procedure gives the correct number of píêÉéíçÅçÅÅá=OF
under defined experimental conditions. Prevent moisture from penetrating into or forming viable cells in CFU/mL. Please refer to the QUA-
kÉáëëÉêá~= d`J~Ö~ê= jìÉääÉê= MKR PR=ø` RB=`l O OMJOQ
within the package or storage container. Etest strips LITY CONTROL section.
The MIC value is not an exact entity and the “true” must be kept dry. ÖçåçêêÜçÉ~É Ä~ëÉ=H= eáåíçå=ÄêçíÜ
MIC is between the lowest concentration that Application ÇÉÑáåÉÇ=
inhibits the organism’s growth and the next lower HANDLING Check that the inoculated agar surface is completely ëìééäÉãÉåíë
concentration. Even under the best of controlled Before using the Etest gradient strips from an unope- dry before applying Etest gradient strips.
conditions, a dilution test may not give the same ned package, visually inspect to ensure the package Open the package and handle the Etest strips as de- Notes:
endpoint each time it is performed. The reproduci- is intact. Do not use the Etest gradient strips if the scribed under HANDLING. A template can be used 1. Please consult Etest Technical Manual for further highest value on the MIC scale. When the inhi-
bility of the conventional dilution test is within ± 1 package has been damaged. to optimally position Etest strips in an equidistant information on specific applications. bition ellipse is below the strip (does not intersect
two-fold dilution of the endpoint. The MIC value pattern on an agar plate. Four to six (maximum) 2. Includes ß-haemolytic Streptococci groups A, B, the strip), report the MIC < the lowest value on
obtained from a standardised CLSI procedure can be Allow the original package or storage container to Etest strips can be placed on a 150 mm agar plate C and G and viridans group S. mutans, S. mitis, S. the MIC scale.
regarded as the reference criterium for defining the reach room temperature before opening (+4 °C/ (Figure 2a). For single MICs, one or two strips can sanguis and S .bovis. • Organisms such as staphylococci, Acinetobacter
susceptibility of a microorganism. approx. 30 minutes, -20 °C/ approx. 60 minutes). be used on a 90 mm agar plate (Figure 2b). Strip 3. Use well defined and high quality medium that spp., anaerobes and gonococci may be susceptible
Ensure that moisture condensing on the outer placement is automatically optimised when using supports good growth. The brand chosen should to sulbactam, tazobactam or clavulanic acid per
PRINCIPLES OF USE surface has evaporated completely before opening the Simplex C76 (Figure 6). For organisms expected to have good batch-to-batch reproducibility to se. For Etest PTc and TLc, this may result in an
The Etest gradient technology is based on a com- package. Packages stored at room temperature can be be highly susceptible, use fewer strips per 150 mm ensure that accurate and reliable MIC values are inhibition ellipse with an extended parallel band
bination of the concepts of dilution and diffusion used immediately. plate and only one on a 90 mm plate. obtained. of inhibition alongside the strip. Extrapolate the
principles for susceptibility testing. As with other 4. For trimethoprim and trimethoprim/sulfamet- upper elliptical curvature towards the strip to ob-
dilution methods, Etest directly quantifies antimicro- Open the package by carefully cutting off the top hoxazole, ensure that the brand and batch of agar tain the MIC (consult ETEST READING GUIDE,
bial susceptibility in terms of discrete MIC values. of one blister compartment, or across the top of the has a low thymine/thymidine content to minimise Figure 9).
However, in using a predefined, stable and conti- foil pouch. When handling Etest strips manually, antagonism of the activity of trimethoprim and • If inhibition ellipses for clindamycin, erythromy-
nuous antibiotic concentration gradient, Etest MIC grip only the handle of the strip i.e. the area labelled sulphonamides. cin or chloramphenicol "dip" at the endpoint,
values can be more precise and reproducible than E. Do not touch the surface of the strip with the 5. The inherent calcium content in Mueller Hinton extrapolate the MIC at the initial indentation, i.e.
results obtained from conventional procedures based antibiotic gradient, i.e. the side opposite the MIC agar may vary between brands and batch to batch. 0.5-1 dilution above the intersection.
on discontinuous two-fold serial dilutions. scale (Figure 1, B). Strips can be placed in an Etest Perform quality control of agar plates on a batch • For fosfomycin showing numerous (>5 ) macro-
applicator tray until ready to use (Figure 3). The to batch basis to qualify it for use, particularly for colonies in the inhibition ellipse, read the MIC at
Although processed like the disc diffusion test, i.e. vacuum pen Nema C88™ (AB BIODISK) can be Figure 2b. Template for 2 testing of daptomcyin. complete inhibition. A few (< 5) colonies can be
Figure 2a. Template for 6
similar inoculum preparation, choice of agar media used to efficiently apply Etest strips either from the strips per 150 mm plate. strips per 90 mm plate. 6. Ensure that an efficient anaerobic system is used ignored. When zone edges are hazy, read the MIC
and incubation conditions, Etest is not a diffusion applicator tray or the original foam cartridge (Figure to achieve rapid anaerobiosis to avoid false resis- at 80% inhibition.
method and differs totally in concept from conven- 4). The foam cartridges carrying the Etest strips tant results with metronidazole. • For quinupristin/dalfopristin and linezolid, hazy
tional disc methods. The Etest antimicrobial concen- Etest strips can be applied to the inoculated agar
should be directly loaded onto the automatic applica- surface with forceps, a manual applicator, Nema 7. Ensure the agar plate is incubated for the recom- and trailing growth for staphylococci and entero-
tration gradient is preformed, predefined and stable, tor instrument Simplex C76™ (AB BIODISK). mended period before reading, especially for cocci should be read 90% inhibition as judged by
and is not dependent on diffusion. C88 (Figure 5) or Simplex C76 (Figure 6). Position
the Etest gradient strip with the MIC scale facing delayed expression of resistance and slow growing the naked eye. Read isolated macrocolonies in the
PRECAUTIONS AND WARNINGS upwards (towards the opening of the plate) and the and fastidious organisms. inhibition ellipse at complete inhibition.
Etest is a thin, inert and non-porous plastic strip. • Etest is intended for in vitro diagnostic use only. • Vancomycin inhibition ellipses can be slim. Read
One side of the strip (A) carries the MIC reading concentration maximum nearest the rim of the plate
• Although based on a simple procedure, Etest (Figure 2a). INTERPRETATION OF RESULTS the actual intersection at the strip and not growth
scale in μg/mL and a two or three-letter code on the should only be used by trained personnel. Reading the MIC "hugging" the side of the strip.
handle to designate the identity of the antibiotic. A • Etest should be used strictly according to the After the required incubation period (Table 1),
predefined exponential gradient of antibiotic, dried procedures described herein. and only when an even lawn of growth is distinctly Interpretation
and stabilised, is immobilised on the other surface • Aseptic procedures and precautions against visible, read the MIC value where the edge of the MIC breakpoints for defining interpretive categories
of the strip (B) with the concentration maximum at microbiological hazards should be used when inhibition ellipse intersects the side of the strip. Do as published by the CLSI, USA and/or your national
a, and the minimum at b (Figure 1). The gradient handling bacterial specimens. not read the plate if the culture appears mixed or if reference group may be used for interpreting Etest
covers a continuous concentration range across 15 the lawn of growth is too light or too heavy; repeat MIC values.
two-fold dilutions of a conventional MIC method. PROCEDURES the test.
Materials provided Being a fully quantitative MIC method, Etest enables
A B • 100 or 30 Etest strips of one antibiotic Etest MIC endpoints are usually clear-cut although the laboratory to report the exact MIC value together
Figure 3. Picking up a Figure 4. Etest strips can
• 1 package insert gradient strip from the tray be used directly from the different growth/inhibition patterns may be seen. with the interpretive category. Etest generates MIC
Antibiotic using a manual applicator cartridge with Nema C88 values from a continuous scale and can give results
a • 1 desiccant capsule Please consult the guidelines below and illustrations
code
256 • Table 2 (separate enclosure) in the ETEST READING GUIDE (Figures 1 to 20 in-between conventional two-fold dilutions i.e. half
192
128 (next page). dilutions. An Etest MIC value which falls between
96
64
48
Materials required but not provided standard two-fold dilutions must be rounded up to
32
24
• Agar plates (90 mm or 150 mm) with the appro- IMPORTANT READING OBSERVATIONS the next upper two-fold value before categorisation.
16
12
priate susceptibility test media (Table 1) • For bactericidal drugs e.g. ß-lactams, always read
8 • Inoculum suspension media (Table 1) the MIC at the point of complete inhibition of Example: Benzylpenicillin MIC (μg/mL) breakpoints
MIC Reading 6 Exponential
scale
4
3 antimicrobial • Swabs (sterile, non-toxic and not too tightly all growth, including hazes, microcolonies and for Streptococcus pneumoniae are:
(μg/mL)
2
1.5 gradient spun), test tubes, and scissors isolated colonies. Tilt the plate and/ or use a S I R
1.0
.75 • Forceps, Etest manual applicator or Biotools™ magnifying glass to carefully examine endpoints, ≤ 0.06 0.12-1 ≥2
.50
.38 (Retro C80™, Nema C88, Simplex C76) Figure 5. Applying the Figure 6. Simplex C76 auto- especially for pneumococci, streptococci, entero-
.25 gradient strip to the agar matic applicator cocci, fusobacteria, Acinetobacter and Stenotrop- An Etest MIC of 1 μg/mL is reported as interme-
.19
.125
• McFarland 0.5 and 1 turbidity standards surface using Nema C88
.094
.064
• Incubator (35 ± 2 °C), anaerobic jar or chamber homonas spp. diate (I) while 1.5 is rounded up to 2 μg/mL and the
.047
.032
or CO2 enriched chamber (Table 1) Ensure that the whole strip is in complete contact • For bacteriostatic drugs e.g. trimethoprim/sul- category reported as resistant (R).
.023
.016 b • Quality control organisms with the agar surface. Do not place the strip upside famethoxazole, read trailing endpoints at 80%
• Storage containers with colour indicating desic- down as no inhibition ellipse will form since the inhibition, i.e. the first point of significant MIC results for a quality control (QC) strain that fall
Figure 1: Etest gradient configuration cant capsules, or pouches and/or sealing clamps antibiotic will not diffuse across the non-porous inhibition as judged by the naked eye. a half dilution below the lower QC limit should be
• Additional technical information from plastic strip. If air pockets are seen under the strip, • Excessively wet plates prior to inoculation, rounded up to the next upper two-fold value before
When an Etest gradient strip is applied to an ino- [Link]/ Etest Technical Manual remove them by pressing gently on the strip (with- insufficient drying before applying strips and/or establishing QC compliance. Similarly, MIC results
culated agar surface, there is immediate and effective out moving it) with the applicator tip or forceps, unevenly streaked surfaces may give non-conflu- that are a half dilution above the upper limit show
transfer of the preformed antibiotic gradient on the Agar Medium working from the lowest concentration upwards. ent growth, jagged ellipse edges and uneven MIC non-QC compliance.
plastic carrier surface into the agar matrix. A stable, Ensure that the agar plate has a depth of 4.0 ± 0.5 Small bubbles will not affect results. Once applied, intersections. Repeat the test if MIC endpoints
continuous and exponential gradient of antibiotic mm, pH 7.3 ± 0.1 and fulfils quality specifications. the strip cannot be moved because of instantaneous are difficult to read. QUALITY CONTROL
concentrations is formed directly underneath the The medium and supplements will depend on the release of antibiotic into the agar. • When macrocolonies are present within the To check the performance of Etest reagents, quality
strip. After incubation, whereby bacterial growth organism groups being tested (Table 1). Additional ellipse for bactericidal agents, read all macrocolo- of media, inoculum and procedure used, test app-
becomes visible, a symmetrical inhibition ellipse technical information on media can be obtained Incubation nies within 1-3 mm from the strip (consult ETEST ropriate quality control strains as outlined under
centred along the strip is seen. The MIC value is read from [Link]. Incubate the agar plates in an inverted position READING GUIDE, Figure 15). PROCEDURE. The reagents and test procedure are
from the scale in terms of μg/mL where the ellipse (lid down) in stacks no higher than 5, according to • When growth occurs along the entire strip i.e. no considered satisfactory if MIC values obtained fall
edge intersects the strip. conditions outlined in TABLE 1. inhibition ellipse is seen, report the MIC as ≥ the within the quality control specifications provided
(TABLE 2, separate enclosure). Chemotherapy. ETEST READING GUIDE
4. Jorgensen, J. H. et al. (1994). Detection of
Do not report patient results when quality control penicillin and extended spectrum cephalosporin ORGANISM RELATED EFFECTS WARRANTY AND
results are outside the stated QC ranges. Frequency resistance among S. pneumoniae clinical isolates DISCLAIMER
of quality control testing should be established by using Etest. Journal of Clinical Microbiology EXPRESS LIMITED WARRANTY AND
the individual laboratory. Guidelines are provided in 5. Citron D. M. et al. (1991). Evaluation of Etest DISCLAIMER
CLSI Antimicrobial Susceptibility Testing documents for susceptibility testing of anaerobic bacteria.
M7, M11 and M100 series. Journal of Clinical Microbiology .
AB BIODISK expressly warrants that
6. Sanchez M. et al. (1993). Etest, an antimicrobial
Etest quality control ranges may not be identical to susceptibility testing method with broad clinical Etest will determine the MIC of the
CLSI specifications in all cases. Etest QC ranges are and epidemiological application. The Antimicro- X antimicrobial agent on each test strip, if
based on extensive data generated from QC testing of bic Newsletter. the procedures, precautions and limitations
a large number of reagent lots over several years and 7. Schulz J. E. et al. (1993). Reliability of the Etest indicated in this package insert are strictly
include data from multi-site studies. Consult TABLE for detection of ampicillin, vancomycin, and X complied with. If the test strip does not do
2 for QC specifications. high-level aminoglycoside resistance in Enterococ- so, AB BIODISK shall refund the cost of
cus spp. Journal of Clinical Microbiology. X the product or replace the defective test
Perform regular colony counts to verify the density 8. Baker C. N. et al. (1994). Optimizing testing of
of the inoculum suspension in terms of CFU/mL methicillin resistant Staphylococcus spp. Diagnostic
Figure 1. Ignore swarming. Figure 2. Ignore haemolysis; Figure 3. Tilt plate or use Figure 4. Scrutinise ß-lactam strips.
MIC 0.064 μg/mL read the inhibition of growth. a magnifying glass to see endpoints for pneumococci for
of viable cells. For example, dilute the inoculum Microbiology and Infectious Disease. MIC 0.032 μg/mL. pin-point colonies and hazes, hazes and microcolonies.
suspension 1:1000 and subculture 1 μL onto the re- 9. Tenover F. C. et al. (1996). Evaluation of com- e.g. enterococci, pneumococci, MIC 2 μg/mL. AB BIODISK makes no other
fusobacteria, and Stenotropho-
commended agar (Table 1). An acceptable inoculum mercial methods for determining antimicrobial monas spp. MIC 1 μg/mL.
warranties, expressed or implied,
should give approximately 100 to 500 colonies, i.e. 1 susceptibility of S. pneumoniae. Journal of Clinical including the implied warranty
to 5 x 108 CFU/mL. Microbiology. DRUG RELATED EFFECTS of merchantability or fitness for
10. Rosenblatt J. E. et al. (1995). Evaluation of the particular purpose.
McFarland turbidity standards do not guarantee the Etest for susceptibility testing of anaerobic bacte-
correct number of viable cells in CFU/mL. ria. Diagnostic Microbiology and Infectious Disease.
Any change or modification of the product
EXPECTED VALUES Note: instructions may affect results. AB BIODISK
Antibiotic susceptibility levels for different biological Extensive Etest references based on peer reviewed shall not be liable for any damages
populations of bacteria are no longer predictable due literature are available from PubMed (internet). resulting from product tampering, variance
to progressive development of resistance. Thus, the in transportation, stated storage, handling,
laboratory should use the expected MIC values of BIBLIOGRAPHY testing procedures, precautions and other
the different antibiotics for the quality control strains 1. FDA Draft, Review Criteria for Assessment of instructions of the most recently revised
to ensure that testing procedures are satisfactory and Antimicrobial Susceptibility Testing Devices.
that clinical results obtained are reasonably accurate. Food and Drug Administration, Division of version of the package insert.
Clinical Laboratory Devices, May 1991, revised
PERFORMANCE CHARACTERISTICS February 2003. Etest® and the Etest gradient strip are
Etest performance characteristics for different anti- 2. Lorian, V. Antibiotics in Laboratory Medicine. 5th Figure 5. Bactericidal agents Figure 6. Bactericidal agents; Figure 7. Bacteriostatic agents; Figure 8. Linezolid; read at registered trademarks of AB BIODISK.
biotic/organism groups have been established using Ed. 2005. Williams & Wilkins, USA. give sharp MIC endpoints. read at complete inhibition of read at 80% inhibition. 90% inhibition (ignore finer Simplex C76™ is a pending trademark
3. Murray, P.R. et al. Manual of Clinical Microbio- MIC 0.064 μg/mL. hazes and microcolonies. MIC 1.5 μg/mL. hazes and pinpoint colonies).
comparative evaluations at external clinical sites and MIC 1.5 μg/mL. MIC 0.75 μg/mL. and the instrument and the foam cartridge
in-house testing. These studies have shown that Etest logy. 9th Ed. 2001. ASM Press. carrying Etest are patented products of AB
MICs correlate with the CLSI reference agar dilution 4. CLSI, 2006. Methods for dilution antimicrobial BIODISK.
and/or broth microdilution method, depending on susceptibility tests for bacteria that grow aerobically. Biotools™, Retro C80™ and Nema C88™
the organism tested. Etest is considered to be in es- Approved Standard, M7-A7.
are pending trademarks of AB BIODISK.
sential agreement (EA) with the CLSI method when 5. CLSI, 2007. Methods for dilution antimicrobial
MIC values from both procedures show an EA of ≥ susceptibility tests of anaerobic bacteria. Approved
90% within ±1 dilution. Standard, M11-A7.
Product specifications, performance characteristics 6. CLSI Performance standards for antimicrobial
(organism groups cleared for clinical use), inter- susceptibility testing. M100 latest series.
pretive criteria, quality control specifications, and
limitations are provided in TABLE 2.

The Etest reference database comprises more than

3000 scientific references that have demonstrated
substantial equivalence between Etest and reference
MIC dilution methods for a wide variety of organism
groups.

IMPORTANT OBSERVATIONS Figure 9. ß-lactamase inhibitors Figure 10. Trim/sulfa; read at Figure 11. Tigecycline; read at Figure 12. Polypeptides; read
1. Indications for use (performance data) for various e.g. tazobactam; extrapolate 80% inhibition (ignore lawn 80% inhibition (ignore trailing at the bottom of the ”dip” if
the upper curvature to the strip. of haze within the ellipse). microcolonies or hazes). colonies are absent.
organism groups according to the specified MIC 3 μg/mL. Stenotrophomonas spp. MIC 0.25 μg/mL. MIC 0.38 μg/mL.
recommendations are shown in TABLE 2. MIC 0.19 μg/mL.
2. Occasionally, certain antibiotic/bacterium com-
binations may give unusual results. In these cases, Antimicrobial Susceptibility Testing
judgement of the MIC endpoint may be difficult RESISTANCE MECHANISM RELATED EFFECTS For In Vitro Diagnostic Use
© Copyright AB BIODISK 2007-07 (75001964-MH0277)
for inexperienced personnel. However, individuals
can be trained through regular use of quality con-
trol strains, Etest reading guides and comparisons
with experienced personnel to correctly assess
MIC endpoints.
3. Being agar based, Etest has been shown to cor-
relate best with the reference agar dilution. Corre- 256
192
lations have been shown with the reference broth 128
96
microdilution whenever an agar dilution reference 64
48
is absent. 32
24
16
4. As with all AST data, Etest results are in vitro 12
8
values only and may provide an indication of the 6
organism’s potential in vivo susceptibility. The use X 4
3
2
of results to guide therapy selection must be the 1.5
1.0
sole decision and responsibility of the attending Figure 13. Small colony vari- Figure 14. Isolated colonies Figure 15. Isolated colonies for Figure 16. Trailing growth (ha- .75
.50
physician who should base judgement on the ants and bactericidal agents; for oxacillin represent hetero- carbapenems may represent zes, microcolonies, macroco- .38
read at complete inhibition. resistant subpopulations i.e. resistant subpopulations e.g. lonies) represent VISA/hVISA. .25
particular medical history and knowledge of the MIC 32 μg/mL. ORSA. MIC 48 μg/mL. KPC. MIC 8 μg/mL. MIC 8 μg/mL.
.19
.125
patient, pharmacokinetics/pharmacodynamics of .094
.064
the antibiotic and clinical experience in treating .047
.032
infections caused by the particular bacterial TECHNICAL AND HANDLING EFFECTS .023
.016
pathogen with the antibiotic, dose and dosing
regimen being considered.
5. For details of specific interpretive limitations and/
or limitations on the clinical use of an antibiotic
in various therapeutic situations, please refer to
the tables and footnotes of MIC interpretive
standards in the latest CLSI AST documents for
dilution procedures (M7, M11 and M100 series).

REFERENCES
1. Bolmström, A. et al. (1988). A Novel Techni-
que for Direct Quantification of Antimicrobial
Susceptibility of Microorganisms. ICAAC, poster
1209. Manufacturer
2. Baker, C. N. et al. (1991). Comparison of the Figure 17. Intersection in- Figure 18. Uneven intersec- Figure 19. Ignore a thin line of Figure 20. Complete growth AB BIODISK
between markings, read the tions; read the higher value. If growth alongside the strip. around the whole strip edge. Dalvägen 10
Etest to Agar Dilution, Broth Microdilution, and 169 56 Solna, Sweden
upper value. MIC 0.19 μg/mL. >1 dilution, repeat the test. MIC 0.25 μg/mL. MIC ≥ 256 μg/mL.
Agar Diffusion Susceptibility Testing Techniques MIC 0.5 μg/mL. Tel. +46-(0)8-730 07 60
by Using a Special Challenge Set of Bacteria. Fax. +46-(0)8-83 81 58
Journal of Clinical Microbiology. etest @[Link]
3. Brown, D. F. J. and Brown, L. (1991). Evalua- [Link]
tion of the Etest, a novel method of quantifying
antimicrobial activity. Journal of Antimicrobial