Antimicrobial sensitivity testing (AST) or Antibiotic Sensitivity Testing.
Contents:
1. Need of AST
2. Bacterial Resistance
3. Preperation of test: selection of antibiotic and bacteria
4. Types of tests
5. Process of tests
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Antimicrobial sensitivity testing (AST)
1. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Antimicrobial Sensitivity
Testing(AST)
Atul Adhikari
Fourth Semester, B. Pharm.
School of Health and Allied Sciences
Pokhara University, Dhungepatan,
Lekhnath-12, Kaski , Nepal
2. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Introduction
• A laboratory test which determines how effective antibiotic
therapy is against a bacterial infections.
• The goal of antimicrobial susceptibility testing is to predict the
in vivo success or failure of antimicrobial therapy.
• Tests are performed in vitro, and measure the growth
response of an isolated organism to a particular drug or drugs.
• The test results should be used to guide antibiotic choice.
2Antimicrobial Sensitivity Testing (AST)
3. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Why Need for Testing Antimicrobial
Sensitivity??
• Bacteria have the ability to
develop resistance following
repeated or subclinical
(insufficient) doses, so more
advanced antibiotics and
synthetic antimicrobials are
continually required to
overcome them.
• Antibiotic sensitivity testing is
essential part of Medical Care
3Antimicrobial Sensitivity Testing (AST)
4. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Resistance
•intrinsic resistance and acquired resistance.
•Intrinsic resistance means that the species was resistant to an antibiotic
even before its introduction.
•Acquired resistance means that the species was originally susceptible to
an antibiotic, but later became resistant.
•Bacteria can acquire antibiotic resistance either by mutation or through
exchange of genetic material among same or closely related species
(Transformation, transduction and conjugation)
•The sudden acquisition of resistance to antibiotics poses difficulties in
treating infections.
•Resistance to several different antibiotics at the same time is even more
significant problem.
5. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Bacterial Resistance Strategies
•Several different mechanisms may work together to confer resistance
to a single antimicrobial agent:
(1) By prevention of the antimicrobial from reaching its target by
reducing its ability to penetrate into the cell
(2) via general or specific efflux pumps
(3) By inactivation of antimicrobial agents via modification or
degradation
(4) By modification of the antimicrobial target within the bacteria
6. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Preparing for Testing
• Inoculum preparation:- Suspension of usually log
phase growth cells of bacteria
- Number of test organisms can be determined using different
methods:
– Direct count (Microscopic examination)
– The optical density (OD) at 600 nm (Spectrophotometry)
– Plate count: making dilution first
6Antimicrobial Sensitivity Testing (AST)
7. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Sources of bacteria
– Indirect source
• cultured plate from pure culture
– Direct source
• Pathological specimen
• e.g. urine, a positive blood culture, or a swab of pus
Antimicrobial Sensitivity Testing (AST) 7
8. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
– Set 1: the drugs that are available in most hospitals and for
which routine testing should be carried out for every strain
– Set 2: the drugs that are tested only:
• at the special request of the physician
• or when the causative organism is resistant to the first-
choice drugs
• or when other reasons (allergy to a drug, or its
unavailability) make further testing justified
Antimicrobial Sensitivity Testing (AST) 8
Choosing the Appropriate Antibiotic
9. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Antimicrobial Sensitivity Testing (AST) 9
Set 1 Set 2
Staphylococcus Benzyl penicillin
Oxacillin
Erythromycin
Tetracycline
Chloramphenicol
Gentamicin
Amikacin
Co-trimoxazole
Clindamycin
Intestinal Ampicillin
Chloramphenicol
Co-trimoxazole
Nalidixic acid
Tetracycline
Norfloxacin
Enterobacteriaceae
Urinary
Sulfonamide
Trimethoprim
Co-trimoxazole
Ampicillin
Nitrofurantoin
Nalidixic acid
Tetracycline
Norfloxacin
Chloramphenicol
Gentamicin
Blood and tissues Ampicillin
Chloramphenicol
Cotrimoxazole
Tetracycline
Gentamicin
Cefuroxime
Ceftriaxone
Ciprofloxacin
Piperacillin
Amikacin
Pseudomonas aeruginosa Piperacillin
Gentamicin
Tobramycin
Amikacin
10. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Methods of antibiotic susceptibility
testing :
Various methods of antibiotic susceptibility testing are:
1. Diffusion methods/Qualitative Methods
2. Dilution methods/Quantitative Methods
3. Automated Susceptibility Tests
4.Newer Non-Automated Susceptibility Tests (E-Test)
5. Molecular/Genetic Techniques
10Antimicrobial Sensitivity Testing (AST)
11. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Disc diffusion method : The Kirby-Bauer test
Antibiotic-impregnated filter disc
Susceptibility test against more than one antibiotics
by measuring size of “inhibition zone ”
11Antimicrobial Sensitivity Testing (AST)
12. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Disk Diffusion Test
Prepare inoculum
suspension
Select colonies
12Antimicrobial Sensitivity Testing (AST)
13. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Standardize inoculum
Suspension as per Mac farland standard Mix well
Prepare the Material for
Inoculation
13Antimicrobial Sensitivity Testing (AST)
14. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Remove sample
Swab plate
Swab the plate with optimal
sample
14Antimicrobial Sensitivity Testing (AST)
15. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Select disks
Select the Disks and Apply
15Antimicrobial Sensitivity Testing (AST)
16. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Incubate Overnight
16Antimicrobial Sensitivity Testing (AST)
17. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Disc Diffusion Method
Place the appropriate drug-
impregnated disc on the surface
of the inoculated agar plate
Invert the plates and incubate
them at 35 oC, (18-24 h)
Measure the diameters of
inhibition zone in mm
Measurement of the diameters of
inhibition zone
Measure from the edge where
the growth stats,
17Antimicrobial Sensitivity Testing (AST)
18. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Disc Diffusion Method
Reporting the Results
Interpretation of results
By comparing with the
diameters with “standard
tables”
Susceptible
Intermediate susceptible
Resistant
18Antimicrobial Sensitivity Testing (AST)
19. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
• Minimum Inhibition Concentration (MIC)
– The lowest concentration of antimicrobial agent that inhibits
bacterial growth/ multiplication
• Minimum Bactericidal Concentration (MBC) or
Minimum Lethal Concentration (MLC)
– The lowest concentration of antimicrobial agent that allows
less than 0.1% of the original inoculum to survive
Dilution Method
19Antimicrobial Sensitivity Testing (AST)
20. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Dilution methods/Quantitative
Methods:
• In these tests MIC is determined.
• Bacterial isolate is subjected to various dilutions of antibiotics.
• The highest dilution of antibiotic that has inhibited the
growth of bacteria is considered as MIC.
• These tests can be performed on broth or agar.
1. Broth dilution methods
2. Agar dilution methods
20Antimicrobial Sensitivity Testing (AST)
21. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
1. Broth dilution methods
a. Macrobroth dilution MIC tests
b. Microbroth dilution MIC tests
• The Broth dilution method involves subjecting the isolate to a series
of concentrations of antimicrobial agents in a broth environment.
• Microdilution testing uses about 0.05 to 0.1 ml total broth volume
and can be conveniently performed in a microtiter format.
• Macrodilution testing uses broth volumes at about 1.0 ml in
standard test tubes.
• For both of these broth dilution methods, the lowest concentration
at which the isolate is completely inhibited (as evidenced by the
absence of visible bacterial growth) is recorded as the minimal
inhibitory concentration or MIC.
21Antimicrobial Sensitivity Testing (AST)
22. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Creating Dilutions
Fig: Macrobroth dilution
23. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Select Micro titration plate and prepare
inoculum
Prepare inoculum
suspension
Micro dilution MIC
tray 23Antimicrobial Sensitivity Testing (AST)
24. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Dilute & mix inoculum
suspension
24Antimicrobial Sensitivity Testing (AST)
25. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Pour inoculum into reservoir and
inoculate MIC tray
25Antimicrobial Sensitivity Testing (AST)
26. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Incubate overnight
26Antimicrobial Sensitivity Testing (AST)
27. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
- +
64
32
16
8
4
2
1
>64
0.5
>64
Read
MICs
27Antimicrobial Sensitivity Testing (AST)
28. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
2.Agar dilution
• A procedure similar to broth dilution is agar dilution.
• Agar dilution method follows the principle of establishing the
lowest concentration of the serially diluted antibiotic concentration
at which bacterial growth is still inhibited.
• One concentration of antibiotic per plate
• Possible for several different strains per plate
28Antimicrobial Sensitivity Testing (AST)
64 uGu/ml 32 ug/ml 16 ug/ml
29. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Antimicrobial Sensitivity Testing (AST) 29
Procedure
• Inoculation of bacterial inoculum
• Using a replicating inoculator device called “A Steers-Foltz
replicator”
• Delivers 0.001 ml of bacterial inoculum
• Incubation
Spot of growth
MIC
30. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Broth Dilution Method are Technically
Difficult
• Disadvantages :
– Only one antibiotic
& one organism can
be tested each time
– Time-consuming
• Solutions
– Agar dilution method
– Disc diffusion method
– Micro broth dilution
method
30Antimicrobial Sensitivity Testing (AST)
31. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Etest
• Etest is a well established AST
method around the world. The
Etest technique comprises a
predefined gradient of
antibiotic concentrations on a
plastic strip, and can be used
to determine the Minimum
Inhibitory Concentration (MIC)
of antibiotics, antifungal
agents and antimycobacterial
agents.
31Antimicrobial Sensitivity Testing (AST)
32. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Antimicrobial Gradient Testing
E-test
Read plates
after
recommended
Incubation Read MIC
where elipse
intersects
scale
32Antimicrobial Sensitivity Testing (AST)
33. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
• The Etest system comprises a predefined and
continuous concentration gradient of different
antimicrobial agents, which when applied to
inoculated agar plates and incubated, create ellipses
of microbial inhibition.
• The MIC is determined where the ellipse of inhibition
intersects the strip, and is easily read off the MIC
reading scale on the strip.
33Antimicrobial Sensitivity Testing (AST)
34. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Antimicrobial Sensitivity Testing (AST) 34
MIC on a strip
35. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Antibiotic Sensitivity testing can be
done with automation
35Antimicrobial Sensitivity Testing (AST)
36. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
VITEK 2 Automates Reporting of
Resistance
• VITEK 2 system is the Advanced
Expert System (AES), a software
which validates and interprets
susceptibility test results, and
detects antibiotic resistance
mechanisms.
• The AES Expert System is the most
developed software system in this
field, and is capable of identifying
even emerging and low-level
resistance.
36Antimicrobial Sensitivity Testing (AST)
37. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
GENOTYPIC METHODS
• Less practiced method
• test for the specific genes that
confer antibiotic resistance.
• Polymerase chain reaction (PCR)
• DNA hybridization.
37Antimicrobial Sensitivity Testing (AST)
38. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Interpretation of Susceptibility Test
Results
• Optimal interpretation of MICs requires knowledge of the
pharmacokinetics of the drug in humans, and information on
the likely success of a particular drug in eradicating bacteria at
various body sites .
• Both MIC values and disk diffusion zone diameters must be
interpreted using a table of values that relate to proven
clinical efficacy of each antibiotic and for various bacterial
species.
• Standard charts and values are provided by CLSI, EUCAST, etc.
38Antimicrobial Sensitivity Testing (AST)
39. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
REFERENCES
• Stephen P and Norman A (2005) Pharmaceutical
Microbiology, Replica Press Pvt. Ltd., India, pp 196-
201.
• Michael E. Aulton (2011) the Design And
Manufacture of Medicines, Churchill Livingstone
Elsevier., London, pp 207-12.
• URL: http://www.eucast.org/
39Antimicrobial Sensitivity Testing (AST)
40. Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
Department of Pharmacy
Pokhara University
School of Health and Allied Sciences
THANKYOU
40Antimicrobial Sensitivity Testing (AST)