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The European Commi/ee on An1microbial Suscep1bility Tes1ng (EUCAST)

– se>ng interna1onal breakpoints

Gunnar Kahlmeter EUCAST and ESCMID

EUCAST presenta?on 1.  An?microbial suscep?bility tes?ng main principles 2.  MIC wild type distribu?ons, ECOFFs and their usefulness. 3.  Clinical breakpoints 4.  EUCAST – structure, remit, na?onal commiPees (NACs) 5.  EUCAST SubcommiPees 6.  Disk diffusion AST and valida?on of method 7.  EUCAST Website 8.  Manufacturer´s capability and ways to improve quality 9.  The future

1. An?microbial Suscep?bility Tes?ng – main principles and methods

Methods for suscep1bility tes1ng

1.   Phenotypic test methods –  MIC determina1on (broth micro dilu1on, gradient tests, disk diffusion, automated and

semiautomated systems such as Vitek2, Phoenix, Microscan) –  based on an1microbial ac1vity (MIC) and breakpoints

–  Predict suscep?bility and resistance –  Quan?fiable –  Require high degree of standardisa?on –  Breakpoints require agreement


2.   Genotypic test methods –  detec?on of a specific resistance gene (PCR) or its product

•  mecA, vanA, vanB, … betalactamase, PBP2a –  whole genome sequencing

•  bioinforma?cs and huge databases

–  Predict resistance, not sensi?vity –  Not quan?fiable –  Useful for epidemiological purposes.


3.   By deduc1on – ”expert rules” –  If MRSA then report all betalactam an?bio?cs R – or soon not?

If ESBL-‐posi?ve, then report betalactam an?bio?cs R – but not any longer! If erythromycin-‐resistant, then report all macrolide an?bio?cs as R;

–  Some rules predict suscep1bility, others resistance. –  Not quan1fiable. –  Unreliable

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Phenotypic suscep1bility tes1ng is based on

MIC + breakpoints

Agreement Standardisa?on

MIC is a rela?ve measure, influenced by inoculum, pH, ca?ons, incuba?on ?me,

temperature, and more -‐

which can be standardised to the extent where it appears absolute!

MIC

MIC determina1on Broth microdilu1on according to the

ISO-‐standard 16 8 4 2 1 .5 .25 .12 .06 .03 C

Surrogate MIC determina?on

Gradient MIC test: Several manufacturers: bioMerieux (Etest) Oxoid (M.I.C.E.) Liofilchem (MIC-strip)

Disk diffusion

Agar dilution

Which mehods can be automated? •  Broth microdilu?on (BMD)

–  Micro Scan, Phoenix, Vitek2 •  Agar dilu?on

–  Semi-‐automated in-‐house •  Gradient tests

–  Semi-‐automated (inocula?on, applica?on, reader) –  Etest (bioMerieux),

M.I.C.E. (Thermofisher), MIC Test Strip (Liofilchem)

•  Disk diffusion (or tablet diffusion) –  Semi-‐automated (automated 6 – 8 h) –  Biomic, Sirscan, Osiris

More surrogate methods

Surrogate methods •  All surrogate methods must be calibrated to the ISO-‐standardised broth microdilu?on method for MIC-‐determina?on.

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2. MIC wild type distribu?ons, ECOFFs and their usefulness.

ECOFF Epidemiological cutoff

MIC-‐concentra?on defined to dis?nguish between organisms without and with resistance

mechanisms to the agent in ques?on.

• Wild type ≤X mg/L (ECOFF) •  Non wild type >X mg/L

ECOFF – to dis?nguish wild type organisms from non-‐wild type organisms

ECOFF

MIC distribu1ons on EUCAST website •  >25 000 MIC distribu?ons •  Up to 100 000 MIC-‐values per distribu?on •  Data from many inves?gators (1 – 100 per distrib.) •  Data from many ?me periods (1950 -‐ ) •  Data from many geographical areas and projects

(USA, Europe, Australia, Far East, South America, Sentry, Mys?c, etc)

•  Data of mul?ple origin (Human clinical data, Surveillance programs, Veterinarian data, Wild life, Food safety programs)

•  Database secure on three servers in different parts of Dusseldorf under the official responsibility of EUCAST and ESCMID.

•  Ownership: –  Sosware and administra?on: ESCMID/EUCAST –  Database: individual ownership of original data

Mycobacterium tuberculosis MIC wild type distribu?on

ECOFF = 2 mg/L

The use of ECOFFs •  As a tool in the determina?on of clinical breakpoints

–  To avoid dividing wild type MIC distribu?ons of important target organisms –  As a surrogate clinical breakpoint when Pk/Pd data is incomplete and clinical data

pertain only to wild type organisms

•  For sensi1ve detec1on of (screening for) resistance –  oxacillin to detect all penicillin-‐R in S. pneumoniae –  cefoxi?n to detect methicillin resistance in S. aureus –  benzylpenicillin to detect all betalactam resistance in H.influenzae –  pefloxacin to detect quinolone resistance in Salmonella spp –  meropenem to screen for KPC in Enterobacteriaceae

•  For surveillance of an1microbial resistance when clinical breakpoints… –  are not sensi?ve enough –  have not been determined –  change over ?me –  differ between systems (CLSI, FDA, EUCAST etc) –  differ between humans, cows, pigs, birds, fish and camels.

•  to exclude resistance –  food safety – in the development of func?onal foods

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3. Clinical breakpoints Clinical breakpoints vs. ECOFFs

ECOFF MIC-‐concentra?on (and surrogate) defined to dis?nguish between organisms with and without resistance mechanisms to the agent in ques?on. •  Wild type ≤X mg/L (ECOFF) •  Non wild type >X mg/L

Clinical breakpoints •  An MIC concentra?on (and surrogate) to dis?nguish between likely clinical

success and failure •  S ≤Y mg/L (ECOFF) •  R >Y mg/L

Clinical breakpoints MIC-‐concentra?ons defined by man to dis?nguish treatable from non-‐treatable organisms by categorising organisms as…

•  Suscep?ble (S ≤X mg/L) •  Intermediate (I) •  Resistant (R >Y mg/L) (CLSI terminology R≥)

A compromise Clinical breakpoints

Many inves?gators Many MIC-‐values

S I R

─  Dose and mode of administra?on ─  Clinical targets (indica?ons) ─  Target organisms (indica?ons) ─  MIC distribu?ons of target organisms ─  Resistance mechanisms of clinical importance in target

organisms ─  Pharmacokine?cs of agent in target pa?ents ─  Pharmacodynamics of agent in rela?on to target

organism ─  Clinical outcome data for target infec?ons

Tools for determining clinical breakpoints

1. Medicines agencies (EMA, FDA) 2. Breakpoint commiPees

Colleagues who know bePer

Breakpoints are determined by:

Pharmaceu?cal companies AST companies

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In the beginning there was one table for everything…… One MIC breakpoint and one zone diameter breakpoint to fit all

CLSI S1 (First Supplement, 1981)

NCCLS First Supplement, 1981 -‐ “useful for anything that would grow”

1.  EUCAST – structure, remit, na?onal commiPees (NACs)

Breakpoint committees 1970 - 2001

CommiPee Country Disk diffusion BSAC United Kingdom Yes

CA-‐SFM France Yes

CRG The Netherlands No

DIN Germany Yes

NWGA Norway No

SRGA Sweden Yes

NCCLS (CLSI) USA Yes

The breakpoint commiPees did not agree…

•  …not because we disagreed •  …but we were out of sync •  …and did not communicate with each other •  …and we all knew best

Enterobacteriaceae 1975 – 2001 Committee Amoxicillin Cefotaxime Piperacillin-tazob.

BSAC (UK) 8 / 16 2 / 2 16 / 16

CA-SFM (F) 4 / 16 4 / 32 8 / 64

CRG (NL) 2 / 16 4 / 8 0.25 / 4

DIN (D) 2 / 8 2 / 8 0.12 / 1

NCCLS (USA) 8 / 16 8 / 32 16 / 64

NWGA (N) 0.5 / 8 1 / 2 8 / 16

SRGA (S) 1 / 8 0.5 / 1 16 / 16

We mostly managed to come up with different breakpoints.

CLSI in session

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EUCAST Steering CommiPee in session 2002. Breakpoints by EUCAST •  CommiPee members with many competences

-‐ in EUCAST there are 60 experts in na?onal groups + many external expert commiPees.

•  When a new agent is evaluated, exis?ng related agents are reviewed as part of the process.

•  Consistency over ?me – “corporate” memory.

•  Breakpoint commiPees can decide to review, and when relevant, revise breakpoints independantly of pharmaceu?cal companies or medicines agencies.

4. EUCAST – structure, remit, na?onal commiPees (NACs)

EUCAST General Committee All European Countries + Australia + USA + …

EUCAST Steering Committee

Subcommittees Antifungals Anaerobes

Expert Rules and Intrinsic Resistance Detection of resistance mechanisms

The relationship between phenotype and genotype

Na?onal Breakpoint CommiPees D, F, N, NL, S, UK

Expert groups

•  Scien?sts from the fields of clinical microbiology and infec?ous diseases and mostly represent na?onal commiPees.

•  Observers from EMA and ECDC

•  Industry is invited to present “their case” but is not part of the decision

EUCAST Steering CommiPee •  To determine clinical breakpoints for bacteria and fungi

together with EMA.

•  To determine epidemiological cut-off values (ECOFFs) for bacteria and fungi

•  To develop and standardise AST in Europe (methods, QC, education)

•  To act as an expert committee for EMA, ECDC, EFSA and ESCMID.

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EUCAST decision process •  Steering Committee evaluates available data and proposes breakpoints

(and other decisions).

•  Consultation with general committee members and national committees on proposed decision – revision of the proposal.

•  Public consultation (EUCAST webpage) after which criticism and responses are published – revision of proposed decision.

•  Final decision (and for breakpoints rationale document.

A breakpoint decision on a new agent normally takes 5 Steering CommiPee

mee?ngs = 1 year

Breakpoints from EUCAST –  Existing agents - harmonization of European breakpoints (2002 –

2008) for antibiotics commonly used and available in most countries: Penicillins, cephalosporins, carbapenems, aminoglycosides, fluoroquinolones, tetracyclines, glycopeptides, macrolides etc

–  New agents - together with EMA (2003 - ) –  Daptomycin –  Tigecycline –  Doripenem –  Telavancin –  Ceftaroline –  Ceftobiprole –  Bedaquiline, Delaminid –  New glycopeptides, cefalosporineinhibitor agents, and more

•  Review of established breakpoints (2009 - ): Glycopeptides, Carbapenems, Colistin, Doripenem

Denmark

Finland

Poland

France

Germany

Spain

Portugal

Greece

Italy Turkey

Switzer- land

Austria

Czech Republic

Estonia

Latvia Lithuania

Belarus

Ukraine

Romania Hungary

Slovakia Moldova

Bulgaria

Russia

Ireland Great Britain

Monte- negro

Serbia Slovenia

Croatia Bosnia- Herze- govina Mace-

donia Albania

Norway

Nether- lands

Malta

Belgium Luxembourg

Sweden

Implementa1on of EUCAST breakpoints, August 2014

>50%

<10% 10-50%

No information

Australia Iceland Israel Countries not on this map:

% Laboratories

South Africa USA Brazil Morocco

EUCAST regular review of breakpoints?

•  New resistance mechanisms •  New agent in class •  New clinical data •  Extended indications •  Change in dosing or administration •  Change in target organisms

Review •  Glycopep?des •  Carbapenems •  Colis?n – ongoing (together with CLSI and others) •  Fluoroquinolones -‐ ongoing •  Tigecycline -‐ ongoing •  Aminoglycosides -‐ planned

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An?bio?cs without breakpoints •  Spiramycin •  Josamycin •  Cefoperazone-‐sulbactam •  ….

•  Currently EUCAST is preparing a list of “all” globally available an?bio?cs with the ra?onale for why they were not given breakpoints

Bacteria without breakpoints •  Aerococcus spp -‐ 2015 •  Kingella kingae -‐ 2015 •  M.tuberculosis -‐ ongoing •  Ac?nomyces spp •  Nocardia spp •  ….

NAC

EUCAST encourages all countries to form a National AST Committee (NAC).

A document describing a prototype NAC is available on website.

NAC •  Antimicrobial susceptibility testing

–  Coherent strategy at national level –  Implementation of breakpoints and methods –  Education (national workshops, websites) –  Translation of documents –  Liaison and consultation with EUCAST – via the General Committee

and open consultations –  Liaison with other national groups involved in antimicrobial

stewardship or surveillance of resistance. –  QA

•  (Antimicrobial Policies) •  (Antimicrobial Resistance Surveillance) •  (Antimicrobial Consumption and Stewardship)

Denmark

Finland

Poland

France

Germany

Spain Portugal

Greece

Italy Turkey

Switzer- land

Austria

Czech Republic

Estonia

Latvia

Lithuania Belarus

Ukraine

Romania Hungary

Slovakia Moldova

Bulgaria

Russia

Ireland Great Britain

Monte- negro

Serbia Slovenia

Croatia Bosnia- Herze- govina Mace-

donia Albania

Norway

Nether- lands

Malta

Belgium Luxembourg

Sweden

Na1onal AST Commi/ees (NACs), August 2014 Yes

No In the process of forming a NAC

No information

Australia Iceland Israel Countries not on this map: South Africa USA Brazil Morocco

5. EUCAST SubcommiPees

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EUCAST SubcommiPees •  An?fungal suscep?bility tes?ng

(Current chair Maiken Arendrup)

–  Candida species, Aspergillus species –  Amfotericin, conazoles, fungins –  Methods for MIC-‐tes?ng of Candidae and Aspergillus

•  Suscep?bility tes?ng of anaerobes •  Expert rules and intrinsic resistance •  The detec?on of resistance mechanisms of clinical and/or

public health importance •  The rela?onship between phenotypic and genotypic detec?on

or resistance and its impact in rou?ne clinical microbiology

EUCAST SubcommiPee to report on role of whole genome sequencing in an?microbial suscep?bility tes?ng of bacteria

•  determine the sensi?vity and specificity of WGS and compare to rou?ne standard phenotypic AST.

•  determine how WGS may be applied in rou?ne clinical laboratory prac?ce and the likely implica?ons for phenotypic and other genotypic methods of AST now in use.

•  determine the clinical implica?ons of WGS in an?microbial suscep?bility tes?ng.

•  determine the epidemiological implica?ons of use of WGS in an?microbial suscep?bility tes?ng.

•  determine the principles of how the result of WGS for AST would be best presented to clinical users.

•  understand the drivers and barriers to rou?ne use.

6. EUCAST disk diffusion and valida?on of method

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EUCAST and CLSI disk diffusion methods are very similar. Suscep1bility tes1ng media differ slightly.

•  Mueller-‐Hinton agar (MH) Enterobacteriaceae, Pseudomonas, staphylococci and enterococci

•  Mueller-‐Hinton agar with 5% horse blood and 20 mg/L β-‐NAD (MH-‐F) for fas?dious organisms: S. pneumoniae and other streptococci, Haemophilus influenzae, Moraxella, Pasteurella, Listeria monocytogenes, Campylobacter, Corynebacterium, Aerococcus, Kingella kingae

EUCAST and CLSI disk diffusion methods are very similar. But there are some differences:

CLSI •  HTM for Haemophilus and Sheep blood

plate and Streptococci •  Some 30 mcg disk strengths •  Valida?on in one lab on medium and disks

from one manufacturer. •  VME and ME play important roles. •  QC ranges established in 6-‐7 labs and

involves several manufacturers.

EUCAST •  MH-‐F (5% defibrinated horse blood +

Beta-‐NAD) for all fas?dious bacteria •  Several 30 mcg disks have been

changed for 5 and 10 mcg disks •  Valida?on includes medium from 3 or

more manufacturers and disks from at least 2 manufacturers.

•  VME and ME play minor roles. •  QC ranges developed in 1 – 3 labs and

validated in >5 others.

MIC (mg/L)

(2 data sources)

Breakpoints ECOFF MIC S≤1, R>2 mg/L WT≤1 mg/L Zone diameter S≥25, R<22 mm

0

2

4

6

8

10

12

14

16

6 8 10

12

14

16

18

20

22

24

26

28

30

32

34

36

38

40

No

of is

olat

es

Inhibition zone diameter (mm)

Tetracycline 30 µg vs. MIC S. pneumoniae, 115 clinical isolates

≥16

8

4

2

1

0.5

0.25

0.12

0.06

0

2

4

6

8

10

12

6 8 10

12

14

16

18

20

22

24

26

28

30

32

34

36

38

40

No

of is

olat

es


Campylobacter jejuni Erythromycin 15 µg vs. MIC

30 clinical isolates tested in duplicate

≥128

64

32

16

8

4

2

1

0.5

ECOFF: WT≤ 4 mg/L

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0

10

20

30

40

50

60

6 8 10

12

14

16

18

20

22

24

26

28

30

32

34

36

38

40

No

of is

olat

es


Benzylpenicillin 1 unit vs. PBP mutations H. influenzae, 104 β-lactamase negative clinical isolates

Positive Negative

Breakpoints Benzylpenicillin zone diameter (screen) S≥12, R<12 mm

PBP mutations

7. EUCAST Websites EUCAST websites are •  www.eucast.org •  Free of charge •  No login •  Updated weekly •  Newsflow (RSS) •  MIC wild type distribu?ons •  >50 000 visits/month

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The ra?onale for each breakpoint decision is published

Click on antibiotic for Rationale Document

Click on MIC breakpoint for MIC distributions

Click on zone breakpoint for zone diameter distributions

Links in EUCAST breakpoint table

Terminology in EUCAST tables

− dash

Suscep?bility tes?ng not recommended – do not report or report “R” without tes?ng. Intrinsic resistance (or intrinsic insufficient ac?vity).

IE (insufficient evidence)

The suscep?bility category (S, I or R) of organisms without resistance mechanisms cannot be determined. Do not report or report “IE with an MIC” -‐ categorical interpreta?on not possible.

Terminology in EUCAST tables

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8. The manufacturers •  EUCAST regularly updates a document where manufacturers

declare their ability to meet EUCAST standards.

9. The Future Will there be interna?onally agreed breakpoints?

•  If as a concerted ac?on – who takes the ini?a?ve? –  WHO, UN, ISO? –  EUCAST or CLSI? –  Financing? Business model?

•  If by evolu?on and “survival of the fiPest” – is it then EUCAST or CLSI when judged on…

•  Science/credibility? •  Decision model? •  Influence/transparence? •  Availability to the interna?onal community?

The End

Thank you for invi?ng me! And for listening!

In conclusion -‐ EUCAST •  Profession together with regulatory authori?es. •  Steering commiPee and a General CommiPee with European and

across-‐oceans representa?on. •  Funded by ESCMID and ECDC. •  Industry consulta?ve role. •  Decision by consensus. •  Five mee?ngs per year. •  Regulatory mandate (EMA and Na?onal Medicines Agencies). •  Clinical breakpoints and ECOFFs. •  Ra?onale for decisions published. •  Documents free of charge (on web).

Examples of species/an?bio?c combina?ons where the clinical breakpoint is much higher than the ECOFF Antibiotic Species ECOFF≤ EUCAST S≤ Meropenem**

E.coli K.pneumoniae

0.125 0.125

2 2

S. pneumoniae 0.016 2 H. influenzae 0.25 2

Ciprofloxacin*** E. coli K. pneumoniae etc

0.064 0.5

Cefotaxime E. coli 0.25 1 Cefepime K. pneumoniae 0.125 1 Benzylpenicillin S. pyogenes 0.064 0.25 Ampicillin S. pneumoniae 0.064 0.5

*Clinical Break Point much higher than Epidemiological Cutoff **And with slightly different values other carbapenems ***And with slightly different values other FQs