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Automazione ed EUCAST
Stefania Stefani
Dipartimento di Scienze Biomediche
e Biotecnologiche
UNICT
Automazione - Palermo - Dicembre 2014
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• formed in 1996 and reorganised in 2001
• Represents all European countries.
• Determines breakpoints for all antimicrobials with activity
against bacteria and fungi.
• Involves expert groups to determine breakpoints for fastidious • Involves expert groups to determine breakpoints for fastidious
bacteria (Neisseria, Helicobacter, Clostridium difficile, Listeria,
Mycobacteria).
• Disk diffusion test since December 2009.
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EUCAST tasks
• To harmonise breakpoints for existing antimicrobials, to
determined breakpoints for new antimicrobials, to revise
breakpoints when needed.
• To define wild type MIC distributions (and ECOFFs) for all
common bacteria and fungi for all antimicrobialscommon bacteria and fungi for all antimicrobials
• To standardise AST methodology across Europe
• To recommend QA schemes (internal and external)
• To liaise with national and international organisations involved
in antimicrobial resistance
• To advise European authorities on issues related antimicrobial
resistance.
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� Il cardine di tutti i Il cardine di tutti i saggi di saggi di
sensibilitàsensibilità (ovviamente dei metodi (ovviamente dei metodi
fenotipici, ma indirettamente anche fenotipici, ma indirettamente anche
degli altri) è la degli altri) è la MICMIC.
Saggi di sensibilità : MIC Saggi di sensibilità : MIC
Automazione - Palermo - Dicembre 2014
� I I breakpointbreakpoint servono servono
per interpretare i per interpretare i saggi di saggi di
sensibilitàsensibilità..
� La La MICMIC è alla base è alla base
della determinazione della determinazione
dei dei breakpointbreakpoint.
MICMICMICMIC
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N. isolatiN. isolati
S. aureusS. aureus
Basso Alto Livello
Resistenza microbiologicaResistenza microbiologica
BREAKPOINT
microbiologico
Automazione - Palermo - Dicembre 2014
MICMIC
CIPROCIPROClassificazione
microbiologica
Basso
livello
Resistenza Resistenza
microbiologicamicrobiologica
Alto
livello
WildWild--typetype
selvaggiselvaggi
moderato
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Resistenza batterica: definizione Resistenza batterica: definizione
clinicaclinica
N. isolati
S. aureus
BREAKPOINT
clinici
Definiti in base a:
- breakpoint microbiol.
- farmacocinetica
- efficacia clinica
BREAKPOINT
microbiol.
Automazione - Palermo - Dicembre 2014
MIC
CIPRO
WT
ClassificazioneClassificazione
clinicaclinica
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Nessun problema?
Il processo di semplificazione voluto
dalle agenzie (EUCAST e CLSI) ha
soddisfatto pienamente le nostre
aspettative?
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Discrepanze tra sistemi
automatici e metodiche di
riferimentoriferimento
Glicopeptidi e S.aureus
Resistenze ai beta-lattamici, colistine
e tigeciclina in Gramneg
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Glycopeptides
EUCAST
4.0/2014
CLSI
2010
MIC breakpoints
(mg/L)
MIC breakpoints
(mg/L)
Staphylococcus
aureus
≤S >R S I R
Vancomycin 2 2 ≤2 4-8 ≥16
≤ ≥Teicoplanin 2 2 ≤8 16 ≥32
Telavancin (MRSA) 1 1
CoNS MIC breakpoints
(mg/L)
MIC breakpoints
(mg/L)
Vancomycin 2 2 ≤4 8-16 ≥32
Teicoplanin 4 4 ≤8 16 ≥32
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Da CLSI ad EUCAST . maggio 2011
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Automazione - Palermo - Dicembre 2014
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MRSA – EUCAST 2014
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EUCAST guideline for the detection of resistance mechanisms
and specific resistances of clinical and/or epidemiological
importance
Glycopeptide non susceptible S.aureus
Importance of detection of resistance
Required for antimicrobial susceptibility
categorization
YES
categorization
Infection control YES
Public Health YES
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1) Recommended method for MIC detection
2) Recommended methods for NS (GRSA, GISA
and hGISA) detection
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UN ALTRO ESEMPIO
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Ertapenem, imipenem and
meropenem distribution in Klebsiella
pneumoniae – EUCAST 2014
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MICs and outcome
Type of
infection
Antibiotic
regimen
IMP
mg/L
MEM
mg/L
ERT
mg/L
Ak
mg/L
CIP
mg/L
Mechanism
of resistance
Outcome
Bacteremia Meropenem
+amikacin
1 0.12 1 1 0.03 VIM-1 Death
SSTIs Ciprofoxacin
+amikacin
0.25 0.06 0.25 32 0.03 VIM-1 Cure
EU
.AB
.20
14
.05
1 D
ate
of
pre
pa
rati
on
Ma
y 2
01
4
IAI Cefepime
+amikacin
2 2 8 0.5 32 VIM-1+SHV12 Relapse, change, cure
Bacteremia Ertapenem 1 2 4 0.5 32 VIM-1+SHV-
12
Breaktrough bacteremia
and death
cUTI Imipenem 0.06 0.06 0.25 1 0.03 VIM-1+TEM-1 Relapse, change, cure
cUTI Meropenem 0.06 0.5 0.5 4 0.03 VIM-1 Relapse, change, death
cUTI Imipenem
+levofloxacin
2 2 2 1 32 VIM-1+SHV-
12
Relapse, not changed,
cure
Falcone et al., J Clin Microbiol 2009;47:3514
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• Modificazioni di permeabilità della membranaesterna (perdita di porine) associati aiperproduzione di cefalosporinasi o ESBL
• Up-regulation dei sistemi di efflusso associati a
Meccanismi di resistenza ai carbapenemi
Le carbapenemasi sono β-lattamasi che idrolizzano lepenicilline, nella maggior parte dei casi le cefalosporine,e in maniera variabile i carbapenemi e i monobattami.Questi ultimi non sono idrolizzati dalle metallo-β-lattamasi• Up-regulation dei sistemi di efflusso associati a
• iperproduzione di cefalosporinasi o ESBL
• Produzione di carbapenemasi:
– β-lattamasi inibite dall’ac. clavulanico (classe A)
– Metallo-β-lattamasi (classe B)
– Oxacillinasi a spettro esteso (classe D)
lattamasi
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KPC in K. pneumoniaeand E. coli
MBLs (IMP and VIM) in P. aeruginosa
Carbapenemasi nei Gram-negativi
MBLs (VIM and NDM) negli Enterobatteri
OXA-23/24/58 in Acinetobacter
OXA-48 in K. pneumoniaeand E. coli
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December 2013
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Rapid antimicrobial susceptibility
testing methods
five different ways to accelerate susceptibility testing in clinical diagnostics:
1. bypassing conventional culture by direct detection of the pathogen or
resistance mechanism in the primary sample;
2. bypassing plate or broth culture dependent susceptibility testing
(secondary culture); (secondary culture);
3. avoiding time consuming work steps/methods;
4. increasing the sensitivity to the detection of the infectious agent; that
means detecting the infectious agent in earlier disease stages at lower
viral or microbial loads;
5. earlier detection of an evolving drug resistance during treatment in
spreading less susceptible quasispecies.Automazione - Palermo - Dicembre 2014
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Molecular Antimicrobial Resistant
Detection Methods
1a Nucleic acid amplificationNucleic acid amplification
1b DNA hybridizationDNA hybridization--basedbased1b DNA hybridizationDNA hybridization--basedbased
1c Next generation sequencing Next generation sequencing
NGSNGS
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1. Molecular testing methods:
Polymerase chain reaction (qPCR, multiplex-PCR, LAMP)
DNA-probe hybridization (microarrays/Luminex xMAP
assays)
Next generation sequencing (NGS, WGS)
Recently developed rapid AST methods.
2. Fluorescence in situ hybridization (FISH):
peptide nucleic acid (PNA) Probes
3. Mass spectrometry based methods:
mass spectrometric beta-lactamase assays,
PCR/electrospray ionization mass spectrometry (PCR/ESI
MS), minisequencing.
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Frickmann H et al. 2014 BioMed Research InternAutomazione - Palermo - Dicembre 2014
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1a. Nucleic Acid Amplification Methods.
quantitative real-time PCR (qPCR)
• rapidly and simultaneously identification of multiple pathogens in a clinical
specimen and accurately detection of resistance genes within a remarkably
shorter time (4–6 hours).
• most of the available commercial qPCR assays detect the presence :• most of the available commercial qPCR assays detect the presence :
mecA/mecC genes, which confer methicillin resistance in S. aureus;
vanA/vanB genes, which confer glycopeptide resistance;
ESβL genes that encode extended-spectrum β-lactamases
RIF/INH genes which confer rifampicin/isoniazide in M. tuberculosis
• affordable, sensitive, specific, user friendly, not space demanding, and
deliverable qPCR has found various applications in point-of-care testing (POCT).
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1.LightCycler® MRSA Advanced Test: identify MRSA direct from nasal swabs.
2.LightCycler® SeptiFast MecA Test: identify MRSA direct from blood samples.
3.LightCycler® VRE Detection Kit (RUO):
Roche Molecular Systems Inc.
3.LightCycler® VRE Detection Kit (RUO): identify vanA, vanB, vanB2/3 in VRE (req. DNA extraction).
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1.BD GeneOhm™ VanR: ID of VRE direct from perianal and/or rectal swabs.
2.BD GeneOhm™ StaphSR: detection and differentiation of MRSA/SA from blood culture,
Becton,Dickinson U.K. Ltd./Cepheid SmartCycler®
detection and differentiation of MRSA/SA from blood culture, wound and nasal swabs.
3.BD GeneOhm™ MRSA: direct detection of MRSA from nasal swab.
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GeneXpert System
•Fully integrated and automated sample preparation,
RT-PCR and detection.
• Specimens don’t need to be batched.
• <2 mins hands-on time.
• Results in <1hr
•6 targets per sample.•6 targets per sample.
•Microfluidic cartridge
Total hands-on time < 1 minute
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1. Xpert® MRSA
A comprehensive approach to MRSA infection control, capable of detecting
strains with all SCCmec types found in both healthcare-acquired and
community-acquired MRSA.
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2. Xpert® vanA/vanB
allows an immediate identification of VRE carriers from non-carriers taken from perianal and rectal swab
3. Xpert® MTB/RIF
identify Mycobacterium tuberculosis (MTB) DNA andresistance to rifampicin (RIF) by nucleic acid amplificationtechnique.
In december 2010, the WHO endorsed the test for usein TB endemic countries
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detects and differentiates the most prevalent
carbapenemases (KPC, NDM, VIM, OXA-48 and
IMP-1) in 48 minutes
4. Xpert® Carba-R
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1a. Nucleic Acid Amplification Methods.
multiplex PCRmultiplex PCR
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Unyvero Pneumonia Application (UPA) assay
multiplex end-point PCR with amplicon detection
by array hybridization developed to rapidly and
simultaneously detect from respiratory specimens:
18 bacterial species, Pneumocystis jirovecii and
22 resistance markers
(http://www.curetis.com/).
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Filmarray System
a closed diagnostic system that combines nucleic acid extraction from clinical
specimens, high-order nested multiplex PCR analysis and post-PCR DNA melting
curve analysis to identify several pathogens and susceptibility markers directly
from positive blood culture bottles in 1 h (CE IVD) marking in June 2013.
The panel includes 19 bacteria, five yeasts, and three antibiotic resistance
genes: mecA, vanA/vanB, and the KPC gene .
from positive blood culture bottles in 1 h (CE IVD) marking in June 2013.
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DNA Microarray Technology
1b. DNA probe-based hybridisation assays
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3. Next Generation Sequencing (NGS).
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• To date costs and scarcely available user-friendly bioinformatics
platforms make difficult the use of NGS technologies in diagnostic
microbiology.
• NGS technologies provide high-resolution genotyping in a short
time frame of only two to five days .time frame of only two to five days .
• Therefore, NGS/WGS in the microbiological laboratory will be the
logical next step for the routine diagnosis of infection and the
prediction of antimicrobial susceptibility, potentially replacing
traditional cultural approaches on the intermediate or long term.
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Phenotypic vs. genotypic: advantages
•Can be performed direct from clinical specimens:- Rapid.- Good for difficult to culture organisms or slow-growers.- May reduce biohazard risk.
•Potential for automation.
•Simple yes/no answer - not dependent on S/I/R categories.
•Sort out ambiguous phenotypic results.
•Good for resistance mechanisms that encode low-level resistance.
•Inform epidemiological studies.Automazione - Palermo - Dicembre 2014
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In conclusion
• Molecular assays for detection of AMR have yielded a
wealth of information.
• Unlikely to replace, but instead augment, phenotypic
susceptibility testing.
• Commercial kits seem to be promising but thorough • Commercial kits seem to be promising but thorough
evaluation in multicentre studies.
• Several choices for MRSA, VRE, ESBLs.
• For new resistance genes and mechanisms reference
laboratories are mandatory.
Automazione - Palermo - Dicembre 2014