1st Edition M61 E Performance Standards for AntifLungal Susceptibility Testing of Filamentous Fungi P M A S This document provides updated quality control tables for the Clinical and Laboratory Standards Institute antifungal susceptibility testing documents M38 and M51. A CLSI supplement for global application. Clinical and Laboratory Standards Institute Setting the standard for quality in medical laboratory testing around the world. The Clinical and Laboratory Standards Institute (CLSI) is a not-for-profit membership organization that brings together the varied perspectives and expertise of the worldwide laboratory community for the advancement of a common cause: to foster excellence in laboratory medicine by developing and implementing medical laboratory standards and guidelines that help laboratories fulfill their responsibilities with efficiency, effectiveness, and global applicability. E Consensus Process Consensus—the substantial agreement by materially affected, competent, and interested parties—is core to the development of all CLSI documents. It does not always connote unanimous agreement but does mean that the participants in the development of a consensus document have considered and resLolved all relevant objections and accept the resulting agreement. Commenting on Documents P CLSI documents undergo periodic evaluation and modification to keep pace with advances in technologies, procedures, methods, and protocols affecting the laboratory or health care. CLSI’s consensus process depends on experts who volunteer to serve as contributing authors and/or as participants M in the reviewing and commenting process. At the end of each comment period, the committee that developed the document is obligated to review all comments, respond in writing to all substantive comments, and revise the draft document as appropriate. Comments on published CLSI documents are equally essential and may be submitted by anyone, at any time, on any document. All comments are managed according to the consensus process by a committee of experts. A Appeal Process When it is believed that an objection has not been adequately considered and responded to, the process for appeal, documented in theS CLSI Standards Development Policies and Processes, is followed. All comments and responses submitted on draft and published documents are retained on file at CLSI and are available upon request. Get Involved—Volunteer! Do you use CLSI documents in your workplace? Do you see room for improvement? Would you like to get involved in the revision process? Or maybe you see a need to develop a new document for an emerging technology? CLSI wants to hear from you. We are always looking for volunteers. By donating your time and talents to improve the standards that affect your own work, you will play an active role in improving public health across the globe. For additional information on committee participation or to submit comments, contact CLSI. Clinical and Laboratory Standards Institute 950 West Valley Road, Suite 2500 Wayne, PA 19087 USA P: +1.610.688.0100 F: +1.610.688.0700 www.clsi.org [email protected] M61, 1st ed. November 2017 Replaces M51-S1 Performance Standards for Antifungal Susceptibility Testing of Filamentous Fungi Barbara D. Alexander, MD, MHS E Gary W. Procop, MD, MS Philippe Dufresne, PhD (RMCCM) Jeff Fuller, PhD, FCCM, D(ABMM) Mahmoud A. Ghannoum, PhD, EMBA, FIDSA L Kimberly E. Hanson, MD, MHS Denise Holliday, MT(ASCP) Nicole M. Holliday, BA Luis Ostrosky-Zeichner, MD, FACP, FIDSA, FSHEA P Audrey N. Schuetz, MD, MPH, D(ABMM) Nathan P. Wiederhold, PharmD Adrian M. Zelazny, PhD, D(ABMM) M Abstract Clinical and Laboratory Standards Institute document M61—Performance Standards for Antifungal Susceptibility Testing of Filamentous Fungi provides information to use with the testing procedures in CLSI documents M381 and M51.2 A The tabular information in this document includes the most current information for antifungal agent selection, results interpretation, and quality control and is valid only when the methodology is followed as described in the current editions of CLSI documents M381 and M51.2 Any previously published tables should be replaced with these new tables. Changes since the last edition appear in boldface type. Clinical and LaboratoryS Standards Institute (CLSI). Performance Standards for Antifungal Susceptibility Testing of Filamentous Fungi. 1st ed. CLSI supplement M61 (ISBN 1-56238-832-0 [Print]; ISBN 1-56238-833-9 [Electronic]). Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087 USA, 2017. The Clinical and Laboratory Standards Institute consensus process, which is the mechanism for moving a document through two or more levels of review by the health care community, is an ongoing process. Users should expect revised editions of any given document. Because rapid changes in technology may affect the procedures, methods, and protocols in a standard or guideline, users should replace outdated editions with the current editions of CLSI documents. Current editions are listed in the CLSI catalog and posted on our website at www.clsi.org. If you or your organization is not a member and would like to become one, or to request a copy of the catalog, contact us at: Telephone: +1.610.688.0100; Fax: +1.610.688.0700; E-Mail: [email protected]; Website: www.clsi.org. M61, 1st ed. Copyright ©2017 Clinical and Laboratory Standards Institute. Except as stated below, any reproduction of content from a CLSI copyrighted standard, guideline, companion product, or other material requires express written consent from CLSI. All rights reserved. Interested parties may send permission requests to E [email protected]. CLSI hereby grants permission to each individual member or purchaser to make a single reproduction of this publication for use in its laboratory procedures manual at a single site. To request permission to use this publication in any other manner, e-mail [email protected]. L Suggested Citation CLSI. Performance Standards for Antifungal Susceptibility TPesting of Filamentous Fungi. 1st ed. CLSI supplement M61. Wayne, PA: Clinical and Laboratory Standards Institute; 2017. Previous Edition: M51-S1: May 2010 M A S ISBN 1-56238-832-0 (Print) ISBN 1-56238-833-9 (Electronic) ISSN 1558-6502 (Print) ISSN 2162-2914 (Electronic) Volume 37, Number 16 ii M61, 1st ed. Contents Abstract .................................................................................................................................................... i Committee Membership ........................................................................................................................ iii Foreword .............................................................................................................................................. vii Abbreviations and Acronyms ............................................................................................................. viii Table 1. Recommended Minimal Inhibitory Concentration or Minimal Effective Concentrations and Modes for Quality Control and Reference Strains for Broth Dilution Antifungal SusEceptibility Testing Procedures .................................................................................................................................. 1 Table 2. Recommended Zone Diameter Limits and Modes for Quality Control and Reference Strains for Disk Diffusion Antifungal Susceptibility Testing Procedures .............................................. 4 Table 3. Solvents and Diluents for Preparation of Stock Solutions of AntifLungal Agents ..................... 6 References ............................................................................................................................................... 7 The Quality Management System Approach .......................................................................................... 8 P Related CLSI Reference Materials ......................................................................................................... 9 M A S v M61, 1st ed. Foreword Users of CLSI documents M381 and M512 and this document should recognize that the standard methods described in CLSI documents are reference methods. These methods may be used for:  Routine antifungal testing of patient isolates to guide therapy  Evaluating commercial devices that will be used in medical laboratories  Testing new agents or systems by drug or device manufacturers Results generated by reference methods, such as those provided in CLSI documents, may be used by E regulatory authorities to evaluate commercial susceptibility testing device performance as part of the approval process. Regulatory clearance indicates that the commercial susceptibility testing device provides results that are substantially equivalent to those generated using reference methods for the organisms and antimicrobial agents described in the device manufacturer’s approved package insert. L NOTE: Fungal taxonomy has undergone major changes in recent years with the dual (asexual and sexual stages) nomenclature having been abolished and the constant reclassification and renaming of fungal species that result from improved molecular characterization.3 Species names listed in CLSI document M381 were revised to reflect the most recent taxonomic changePs based on classification according to DNA bar coding at the time of publication. For more information regarding updated fungal species reclassification, refer to publicly available information.4 Overview of Changes M This document replaces the previous edition of the approved supplement M51-S1, published in 2010, and incorporates information from CLSI document M38-A2. Several changes were made in this edition, including:  General: A – Combined supplemental information from M38-A2 (broth dilution susceptibility testing of filamentous fungi) and M51-S1 (disk diffusion testing of filamentous fungi) into one informational supplement, which has been recoded as M61 – Deleted theS glossary with abbreviations, routes of administration, and drug classes for antifungal agents  Tables: – Moved Table 1 from M38-A2 (Solvents and Diluents for Preparation of Stock Solutions of Antifungal Agents) to M61, where it is now Table 3, and added information for isavuconazole – Updated QC ranges for itraconazole and posaconazole for Candida parapsilosis and added QC ranges for isavuconazole in Table 1 – Moved Table 4 from M38-A2 (Recommended MIC or MEC Limits for QC and Reference Strains for Broth Dilution Procedures) to M61, where it is now Table 1, and revised the title (Recommended Minimal Inhibitory Concentration or Minimal Effective Concentrations and Modes for Quality Control and Reference Strains for Broth Dilution Antifungal Susceptibility Testing Procedures) – Moved Table 1 from M51-S1 (Tentative Zone Diameter Epidemiological Cutoff Values [ECV] and Corresponding Minimal Inhibitory Concentration [MIC] or Minimal Effective Concentration [MEC] for Filamentous Fungi) to CLSI document M59,5 the supplement to CLSI document M576 vii M61, 1st ed. Table 1. Recommended Minimal Inhibitory Concentration or Minimal Effective Concentrations and Modes for Quality Control and Reference Strains for Broth Dilution Antifungal Susceptibility Testing Procedures MICs/ MIC/ MECs MIC/MEC MEC Within Incubation Antifungal Range, Mode, Range, Time, Organism Purpose Agent µg/mL µg/mL % hours* Paecilomyces variotii QC Amphotericin B 1–4 2 100 48 ATCC®† MYA-36301,2 Isavuconazole 0.06–0.5 0.12 96.7 48 E Itraconazole 0.06–0.5 0.12 100 48 Posaconazole 0.03–0.25 0.06 99.5 48 Voriconazole 0.015– 0.06 100 48 0.12 Reference (MEC)‡ Anidulafungin ≤0.015 N/A 100 24 L Candida parapsilosis QC Amphotericin B 0.5–4 2 91.7 48 ATCC® 220193,4 Anidulafungin 0.5–2 1 95 24 Caspofungin 0.25–1 0.5 96.7 24 Caspofungin 0.5–4 1 92.9 48 P Fluconazole 1–4 2 98.1 48 Flucytosine 0.12–0.5 0.25 97.9 48 Isavuconazole 0.03–0.12 0.03 98.3 48 Itraconazole 0.06–0.5 0.25 97.5 48 Ketoconazole 0.06–0.5 0.12 98.3 48 M Micafungin 0.5–4 1 100 24 Posaconazole 0.03–0.25 0.12 98.8 48 Ravuconazole 0.03–0.25 0.06 98.3 48 Voriconazole 0.03–0.25 0.06 100 48 Candida krusei QC Amphotericin B 1–4 2 100 48 ATCC® 62583,4 Anidulafungin 0.03–0.12 0.06 97.5 48 A Caspofungin 0.12–1 0.5 98.8 24 Caspofungin 0.25–1 0.5 97.5 48 Fluconazole 16–128 32 100 48 Flucytosine 8–32 16 99.6 48 Isavuconazole 0.12–0.5 0.12 94.2 48 S Itraconazole 0.25–1 0.5 100 48 Ketoconazole 0.25–1 0.5 99.6 48 Micafungin 0.12–0.5 0.25 99 48 Posaconazole 0.12–1 0.5 99.6 48 Ravuconazole 0.25–1 0.5 100 48 Voriconazole 0.12–1 0.5 100 48 Aspergillus flavus Reference Amphotericin B 0.5–4 ND 100 48 ATCC® 2043045,6,§ Itraconazole 0.25–0.5 ND 100 48 Posaconazole 0.06–0.5 ND 100 48 Ravuconazole 0.5–4 ND 100 48 Voriconazole 0.5–4 ND 100 48 QC Isavuconazole 0.5–4 1 95.8 48 A. flavus Reference Amphotericin B 1–8 2 98.8 48 ATCC® MYA-36311 Posaconazole 0.12–1 0.5 97.1 48 Voriconazole 0.5–2 1 98.3 48 Aspergillus fumigatus Reference Amphotericin B 0.5–4 2 98.7 48 ATCC® MYA-36261,2 Itraconazole 0.25–2 1 95.7 48 Voriconazole 0.25–1 0.5 100 48 Reference (MEC)‡ Anidulafungin ≤0.015 N/A 100 24 ©Clinical and Laboratory Standards Institute. All rights reserved. 1 M61, 1st ed. Table 1. (Continued) MICs/ MIC/ MECs MIC/MEC MEC Within Incubation Antifungal Range, Mode, Range, Time, Organism Purpose Agent µg/mL µg/mL % hours* A. fumigatus Reference Amphotericin B 0.5–4 2 99.2 48 ATCC® MYA-36271 Itraconazole ≥16 ≥16 95 48 Voriconazole 0.25–1 0.5 99.2 48 Aspergillus terreus Reference Amphotericin B 2–8 4 98.3 48 ATCC® MYA-36331,2 Voriconazole 0.25–1 0.5 99.2 48 E Reference (MEC)‡ Anidulafungin ≤0.015 N/A 99.6 24 Fusarium Reference Amphotericin B 2–8 4 99.6 48 verticillioides Itraconazole >16 >16 97.9 48 (moniliforme) Posaconazole 0.5–2 1 98.1 48 ATCC® MYA-36291,2 Voriconazole 1–4 2 100 48 L F. verticillioides Reference (MIC) ‡ Anidulafungin >8 N/A 97.5 48 (moniliforme) ATCC®† MYA-36291,2 Fusarium solani Reference (MIC)‡ Anidulafungin >8 N/A 96.7 48 P ATCC® MYA-36362 Scedosporium Reference Amphotericin B 4–16 8 98.8 72 apiospermum Posaconazole 1–4 2 98.3 72 ATCC® MYA-36355,6 Voriconazole 0.5–2 1 100 72 S. apiospermum Reference (MEC)‡ Anidulafungin 1–4 2 96.7 48–72 M ATCC® MYA-36342 Trichophyton Reference Ciclopirox 0.5–2 1 97.5 96 mentagrophytes¶ Griseofulvin 0.12–0.5 0.25 96.3 96 MRL 1957 Itraconazole 0.03–0.25 0.06 96.2 96 ATCC® MYA-44397 Posaconazole 0.03–0.25 0.06 95.2 96 Terbinafine 0.002– 0.004 97.9 96 A 0.008 Voriconazole 0.03–0.25 0.06 95.2 96 Trichophyton rubrum¶ Reference Ciclopirox 0.5–2 1 97.5 96 MRL 666 Fluconazole 0.5–4 1 95.2 96 ATCC® MYA-44387 Voriconazole 0.008– 0.015 96.1 96 S 0.06 * MIC ranges correspond to the indicated incubation time. In some cases, MIC ranges are also available by the macrodilution method (48 hours only) and after 24 hours by the microdilution method.8-10 One of the QC isolates should be used per standard QC testing procedures (see CLSI document M3811). † ATCC® is a registered trademark of the American Type Culture Collection. ‡ Although the anidulafungin concentration range in the study was 0.015 to 32 µg/mL, off-scale MICs >32 µg/mL from that study are reported in Table 1 as >8 µg/mL to be consistent with the recommended routine testing range for this compound.2 § The MIC ranges for A. flavus ATCC® 204304 are based on data from a collaborative study5,6 that were not obtained according to the CLSI document M2312 process. However, A. flavus is the only mould for which reproducible reference limits for ravuconazole have been established, so it is included in Table 1. ¶ Ninety-six hours or until good growth (confluent hyphal growth covering the bottom of the well) is obtained in the growth control well.13 Abbreviations: ATCC®, American Type Culture Collection; MEC, minimal effective concentration; MIC, minimal inhibitory concentration; N/A, not applicable; ND, not determined; QC, quality control. NOTE: Information in boldface type is new or modified since the previous edition. 2 ©Clinical and Laboratory Standards Institute. All rights reserved. M61, 1st ed. The Quality Management System Approach Clinical and Laboratory Standards Institute (CLSI) subscribes to a quality management system (QMS) approach in the development of standards and guidelines that facilitates project management, defines a document structure using a template, and provides a process to identify needed documents. The QMS approach applies a core set of “quality system essentials” (QSEs), basic to any organization, to all operations in any health care service’s path of workflow (ie, operational aspects that define how a particular product or service is provided). The QSEs provide the framework for delivery of any type of product or service, serving as a manager’s guide. The QSEs are: Organization Personnel Process Management Nonconforming Event Management Customer Focus Purchasing and Inventory Documents and Records Assessments E Facilities and Safety Equipment Information Management Continual Improvement M61 covers the QSE indicated by an “X.” For a description of the documents listed in the grid, please refer to the Related CLSI Reference Materials section. L Organization Customer Focus Facilities and Safety Personnel Purchasing and Inventory Equipment Process Management PDocuments and Records Information Management Nonconforming vent Management Assessments Continual Improvement E X M23 M38 M M51 M57 M59 Path of Workflow A path of workflow is the description of the necessary processes to deliver the particular product or service that the organization or entity provides. A laAboratory path of workflow consists of the sequential processes: preexamination, examination, and postexamination and their respective sequential subprocesses. All laboratories follow these processes to deliver their services, namely quality laboratory information. M61 does not cover any medical laboratory path of workflow processes. For a description of the other documents listed in the grid, pleaSse refer to the Related CLSI Reference Materials section. Preexamination Examination Postexamination Examination ordering Sample collection Sample transport Sample receipt and processing Examination Results review and follow-up Interpretation Results reporting and archiving Sample management M38 M38 M38 M38 M38 M51 M51 M51 M51 M51 M59 M59 M59 8 ©Clinical and Laboratory Standards Institute. All rights reserved. M61, 1st ed. Related CLSI Reference Materials M23 Development of In Vitro Susceptibility Testing Criteria and Quality Control Parameters. 4th ed., 2016. This document discusses the necessary and recommended data for the selection of appropriate interpretive criteria and quality control ranges for antimicrobial agents. M38 Reference Method for Broth Dilution Antifungal Susceptibility Testing of Filamentous Fungi. 3rd ed., 2017. This standard includes the antifungal agent selection, preparation of antifungal stock solutions and dilutions for testing, test procedure implementation and interpretation, and quality control requirements for susceptibility testing of filamentous fungi (moulds) that cause invasive and cutaneous fungal infections. M51 Method for Antifungal Disk Diffusion Susceptibility Testing of NondermatophyteE Filamentous Fungi. 1st ed., 2010. This document describes the guidelines for antifungal susceptibility testing by the disk diffusion method of nondermatophyte filamentous fungi (moulds) that cause invasive disease. M57 Principles and Procedures for the Development of Epidemiological Cutoff Values for Antifungal Susceptibility Testing. 1st ed., 2016. This guideline includes the criteria for developing and using L epidemiological cutoff values for guiding clinical decisions when testing fungal species and antifungal agent combinations for which there are no breakpoints. M59 Epidemiological Cutoff Values for Antifungal Susceptibility Testing. 1st ed., 2016. This document includes the epidemiological cutoff value and quality control tables developed according to criteria provided in the P Clinical and Laboratory Standards Institute guideline M57. M A S  CLSI documents are continually reviewed and revised through the CLSI consensus process; therefore, readers should refer to the most current editions. ©Clinical and Laboratory Standards Institute. All rights reserved. 9