Evaluation of antibiotic susceptibility test results: how guilty a laboratory could be?

Background: The selection of an appropriate antimicrobial is a challenging task for clinicians. The Kirby-Bauer disk diffusion method is one of the most widely practiced antimicrobial susceptibility tests (AST). It is affected by many factors among which are the media used. Mueller-Hinton agar (MHA) is the standard medium recommended in guidelines. However, these guidelines are not strictly adhered to in some developing countries. Objectives: Validation of AST results on nutrient agar (NA) medium used as a substitute for MHA by some microbiology laboratories in Alexandria, Egypt. Methods: A total of 149 clinical bacterial isolates and 3 reference strains: Staphylococcus aureus (S. aureus) ATCC (R) 25923, Escherichia coli (E. coli) ATCC (R) 25922, and Pseudomonas aeruginosa (P. aeruginosa) ATCC (R) 27853 were comparatively challenged to antibiotics employing MHA and NA. Results: All antibiotics-reference bacterial strain challenges on NA compared to MHA were unacceptable (> 3 out of limit zones in 30 consecutive days). Considering clinical isolates, the frequency of very major, major, and minor errors on NA was highest in the case of P. aeruginosa (8.98%, 4.08%, and 14.7% respectively) followed by S. aureus (7.6%, 6%, and 8.8% respectively). On the other hand, the least frequency of errors was in the case of Enterobacteriaceae (0%, 0.4%, and 3.2% respectively). Conclusions and recommendations: Using NA in AST resulted in multiple errors and the high discrepancy in results compared to MHA making it unreliable for susceptibility testing. MHA should not be replaced by NA in AST. Following guidelines and QC measures for AST must be neither bypassed nor underestimated.