Andreoni, S.

Faggi, Elisabetta

Farina, C.

Fazii, P.

Lombardi, G.

Manso, E.

Sanna, S.

English

Florence Research

www.elsevier.com/locate/diagmicrobioDiagnostic Microbiology and InManagement of antifungal susceptibility testing in Italy: comparativeresults of 2 nationwide surveys (1999 and 2004) in 102 Italian hospitalsClaudio Farinaa,h,4, Esther Mansob,h, Silvana Sannac,h, Gianluigi Lombardid,h,Elisabetta Faggie,h, Paolo Faziif,h, Stefano Andreonig,haUO Microbiologia, AO bOspedale San Carlo BorromeoQ, 20153 Milano, ItaliabLaboratorio Analisi Chimico-Cliniche e Microbiologia, A.O.-U bOspedali Riuniti di AnconaQ, 60100 Ancona, ItaliacDipartimento di Scienze Biomediche, Sezione di Microbiologia Sperimentale e, Clinica, Universita` degli Studi, 07100 Sassari, ItaliadLaboratorio di Microbiologia, bOspedale di Circolo e Fondazione MacchiQ, Universita` degli Studi dell’Insubria, 21100 Varese, ItaliaeDipartimento di Sanita` Pubblica, Sezione Microbiologia, Universita` degli Studi di Firenze, 50100 Firenze, ItaliafLaboratorio Analisi Chimico-Cliniche e Microbiologia, P.O. bSpirito SantoQ, 65100 Pescara, ItaliagLaboratorio di Microbiologia e Virologia, A.O. bMaggiore della Carita`Q, 28100 Novara, ItaliahMedical Mycology Committee, Associazione Microbiologi Clinici ItalianiReceived 7 April 2006; accepted 22 June 2006AbstractThe purpose of this study was to verify the standard procedures and minimum level of knowledge of Italian public laboratories involvedin the management of antifungal susceptibility testing (AST). Two nationwide surveys were performed in 1999 and 2004. One hundred andtwo Italian hospitals located in 85 provincial capitals (82.5%) participated to these surveys. In 1999, 28 (27.5%) laboratories versus 16(15.7%) in 2004 stated that they did not perform any susceptibility testing. Some discrepancies observed in the survey confirm that AST isdifficult to be correctly managed, and that it can be performed only in very well-trained centers. The great variability of the results of MICdetermination and clinical interpretation underlines the urgent need to improve knowledge about indications, method choice, andinterpretative criteria for AST both for clinical microbiologists and clinicians.D 2007 Elsevier Inc. All rights reserved.Keywords: Management; Antifungal susceptibility testing; Italy; Surveys; LaboratorySusceptibility testing for antifungal drugs is a challengefor microbiologists because of the increasing importance ofclinicians’ requests and the lack of standardization intechnology and in interpretative criteria. However, areference method for antifungal susceptibility testing(AST) of yeasts (Blanc et al., 2005) by the means of abroth dilution technique was approved in 2002 by theClinical Laboratory Standard Institute (CLSI), formerlyknown as the National Committee for Clinical LaboratoryStandards (NCCLS, 2002), and in 2003 by the EuropeanCommittee on Antimicrobial Susceptibility Testing(EUCAST, 2003).0732-8893/$ – see front matter D 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.diagmicrobio.2006.06.0174 Corresponding author. UO Microbiologia, AO bOspedale San CarloBorromeoQ, 20153 Milano, Italia. Tel.: +39-024-022-2456; fax: +39-024-022-2829.E-mail address: farina.claudio@sancarlo.mi.it (C. Farina ).The Medical Mycology Committee of the Association ofItalian Clinical Microbiologists proposed a national surveyto verify the procedures used in the clinical laboratoriesof public hospitals in Italy. In 1999 and in 2004,180 questionnaires were mailed to the directors of micro-biology laboratories of public hospitals in 103 cities all overItaly. Only public hospital laboratories in province capitalswere selected as representative of the average mycologicalknowledge of both clinicians and microbiologists.At the end of both studies, the same number ofquestionnaires (102/180, 56.7%) were returned from85/103 (82.5%) province capitals, even if the geographiclocation was different between the surveys. In 1999,28 (27.5%) laboratories versus 16 (15.7%) in 2004 statedthat they did not perform any susceptibility testing (Joneset al., 2005). On the contrary, 17 (16.7%) in 1999 versus13 (12.7%) in 2004 confirmed that AST was part of theroutine work. In 57 (55.9%) versus 73 (71.6%) hospitalsfectious Disease 57 (2007) 225–227Table 1Microbiologic criteria adopted to perform AST (2004 survey)Specimen RoutinelydoneNeverdoneUpon clinician’srequestBlood 74 4 8CSF 71 7 8Feces 3 68 15Urine 3 26 57Pharyngeal swab 10 54 22Nasal swab 8 57 21Sputum 18 42 26Sterile fluids 32 28 26Vaginal exudate 11 39 17Urethral exudate 14 54 18Skin and annexes 14 55 17CSF=cerebrospinal fluid.Table 2Manual testing (2004)ATB Fungus 12 (15.2%)Etest 8 (10.1%)Candifast 5 (6.3%)Sensititre 38 (48.1%)Etest + Sensititre 5 (6.3%)ATB Fungus + Sensititre 5 (6.3%)Fungitest 4 (5.1%)ATB Plus 1 (1.3%)ATB Fungus +Etest 1 (1.3%)Total 79C. Farina et al. / Diagnostic Microbiology and Infectious Disease 57 (2007) 225–227226(in 1999 and 2004, respectively), AST was performed onlyin selected clinical cases.AST was performed on the basis either of clinician’srequest in 27/57 (47.4%) versus 29/73 (39.7%) or ofmicrobiologist’s decision in the remaining cases (in 1999and 2004, respectively). Table 1 reports when and whichkind of clinical specimen is considered suitable for AST incase of a positive culture.Comparing results of 1999 versus 2004, disk diffusionwas used in 6 (8.1%) versus 1 (1.2%) laboratory; manualsystems for MIC detection were performed by 58 (78.4%)versus 82 (95.3%) laboratories. Ten (13.5%) versus 3 (3.6%)laboratories declared to use both systems. The adoptedcommercial methods are reported in Table 2. MICs wereevaluated according to the CLSI M27-A2 document. Eleven(10.8%) versus 3 (3.6%) laboratories adopted differentdiagnostic techniques in association.Tested drugs are generally representative of the usedcommercial kits.Sixty of seventy-four (81.1%) versus 70/86 (81.4%) ofthe laboratories declared to report to clinicians all the testeddrugs (in 1999 and in 2004, respectively), whereas 5 (6.7%)versus 6 (7.0%) considered the AST results an exclusivelaboratory testing not to be transmitted to clinicians.However, 9 (12.2%) versus 10 (13.7%) (in 1999 and in2004, respectively) laboratories confirmed to report toclinicians only the results of selected drugs such asamphotericin B, flucytosine, fluconazole, itraconazole,and ketoconazole.The recent development of new antimycotic drugsimproved the rates of recovery from systemic mycoses.ASTs are more frequently requested by clinicians; however,they still represent a true challenge for microbiologists,particularly because of the lack of standardization ininterpretative criteria.In a similar survey performed in 1992 on 94 laboratoriesin 73 province capitals, 18.1% of participants performedAST on all isolates, whereas 54.3% only in some cases(Farina et al., 1995).Disk diffusion technique was the most commonly usedmethod (30.9%) in 1992, although occasionally, thelaboratory did not follow standard procedures. This wasespecially true for the choice of medium, because veryoften, only either Sabouraud dextrose agar or blood agarwas used. Commercial kits were very often used, whereasautomated systems were not so common (7.4%).Most laboratories (76.1%) reported to clinicians all thetested antifungal drugs, regardless of their clinical use(systemic or local), of the isolated fungus, and of the clinicalspecimen; 8.5% of laboratories did not report any result, andthe remaining 15.4% only reported some antifungal drugs(mainly flucytosine) and only in specific cases.The survey shows that the same percentage (27.5%) ofparticipants in both 1992 and 1999 declare that they do notperform AST, whereas this number decreased to 15.7% in2004. The percentage of laboratories that perform AST onall isolates (16.7%) or only in some cases (55.9%) weresimilar in 1992 and 1999. The analysis of the 2004 surveyshows that the ratio of laboratories performing ASTchanged, probably because of a better microbiologisteducation. In fact, the percentage of laboratories that neverperform AST had decreased to 12.7%, whereas 71.6% runAST in some selected cases.As in the past, in vitro tested drugs are those includedin the commercial panels. Data about the adopted criteriafor reporting of results are very similar (in both 1999 and2004) to those observed in 1992, showing that sometimesthe microbiologists do not give the clinicians an appropri-ate answer based on the clinical use of the drug (eithersystemic or local), the isolated fungus, and the clinicalspecimen type.If the interpretative criteria were often bhomemadeQ(criteria suggested by manufacturers rather than the CLSIrecommendations: 45.9% versus 54.1%, in 1992 and 1999,respectively), the last survey shows that only 5.8% oflaboratories do not follow CLSI (2002) (NCCLS, 2002) orEUCAST (2003) recommendations.Even if no fundamental changes occurred in indicationsand interpretation of AST from the early 1990s, manytechnical improvements have been observed. Comparedwith the 1992 survey, more attention was found in 1999 inthe choice of medium, but actually, disk diffusion is onlyC. Farina et al. / Diagnostic Microbiology and Infectious Disease 57 (2007) 225–227 227sporadically used. Commercial kits were very frequentlyused: the 2004 data confirm the 1999 results (95.3% versus78.4%, respectively), showing the particular trend of theItalian market. Few laboratories (10/74, 13.5%) used morethan 1 technique.The situation in Italy is quite similar to the one in theUnited States: Sensititre and Etest together dominate themarket (64.5%), and a similar distribution between the 2techniques is observed in both Countries. In fact, Sensititreis the most commonly used technique in both Italy (60.7%)and the United States (59%), followed by Etest (18.7%versus 15%) (Espinel-Ingroff et al., 1998). ATB Fungus isonly used by 15.2% of the Italian laboratories, and only1.2% perform disk diffusion methods. On the contrary, inFrance, the most frequently used methods are ATB Fungusand Etest (56% and 41%, respectively), or a combination of2 or more methods (38%), and 10% of laboratories performagar diffusion testing (Blanc et al., 2005).In conclusion, it seems that Italy largely prefers newtechnologies, confirming the interest in the progresses inthe field and the presence of an important commercialmarket. However, AST is difficult to be correctly managed,and it could be performed in particular clinical cases onlyin very well-trained centers, even if standardization is nowlargely better than in the past (Negroni et al., 2000; Reillyet al., 1999). Moreover, the low level of criticism inreporting the results suggests that mycology have to betaught both as a microbiologic and technical discipline andas a part of infectious disease programs, to improveknowledge about indications, method choice, and interpre-tative criteria for AST both for clinical microbiologists andclinicians. This concern is confirmed by several nationwidesurveys in Italy (Farina et al., 2000) and in France (Eloyet al., 2005).ReferencesBlanc V, Eloy O, Sanchez R, Mallie´ M (2005) Antifungal susceptibilitytesting in 62 French hospitals. J Mycol Me´d 15:197–210.Eloy O, Blanc V, Mallie´ M, Decousse JW, Pina P, Allouch PY (2005)Identification and antifungal susceptibility testing of two strains ofCandida in 95 French hospitals. J Mycol Me´d 15:117–126.Espinel-Ingroff A, Barchiesi F, Hazen KC, et al (1998) Standardization ofantifungal susceptibility testing and clinical relevance. Med Mycol36(S1):68–78.European Committee on Antimicrobial Susceptibility Testing (2003)Method for the determination of minimum inhibitory concentration(MIC) by broth dilution of fermentative yeasts. Clin Microbiol Infect9:1–8.Farina C, Picerno G, Medical Mycology Committee of AMCLI (1995)Status of medical mycology in clinical laboratories in Italy. Alpe AdriaMicrobiol J 3:197–209.Farina C, Mazzoni A, Andreoni S, Faggi E, Fazii P, Lombardi G, Manso E(2000) Gestione dei test di chemiosensibilitia` agli antifungini in Italia.Microbiol Med 15:420–425.Jones RN, Fritsche TR, CAP-MRC Members (2005) Accuracy forantibacterial and antifungal susceptibility tests: report from the Collegeof American Pathologists (CAP) Microbiology Proficiency SurveyProgram for 2004–2005. 45th Interscience Conference on AntimicrobialAgents and Chemotherapy, Washington, DC, December 16–19, posterD-1654/75.National Committee for Clinical Laboratory Standards (NCCLS) (2002)Reference method for broth dilution antifungal susceptibility testing ofyeasts. Approved Standard M27-A2, (2nd ed.)Wayne (PA)7 NationalCommittee for Clinical Laboratory Standards.Negroni R, Ellis D, Bulmer G, et al (1998) Teaching medical mycology inthe year 2000. Med Mycol 36(S1):106–108.Reilly AA, Salkin IF, McGinnis MR, et al (1999) Evaluation of mycologylaboratories proficiency testing. J Clin Microbiol 37:2297–2305.

Management of antifungal susceptibility testing in Italy: comparative results of 2 nationwide surveys (1999 and 2004) in 102 Italian hospitals.

https://flore.unifi.it/bitstream/2158/333785/1/4.%20Diagnostic%20microbiol%20inf%20disease%202007.pdf

Management of antifungal susceptibility testing in Italy: comparative results of 2 nationwide surveys (1999 and 2004) in 102 Italian hospitals.

Abstract

Similar works

Full text

Available Versions

Florence Research