EUCAST posters at ECCMID 2012

66668888066668888P682EUCAST standardised disk diffusion methodologyfor Campylobacter jejuni and C. coliE. Matuschek 1 , K. Veldman 2 , A. Hakanen 3 , S. Bengtsson 1 , M. Lehtopolku 3 , D. Mevius 2 and G. Kahlmeter 11EUCAST Laboratory for AST, Växjö, Sweden, 2 Central Veterinary Institute (CVI), Lelystad, the Netherlands3National Institute for Health and Welfare (THL), Turku, FinlandIntroductionAntimicrobial susceptibility testing of Campylobacter spp. inclinical laboratories is often performed using gradient MIC testsor disk diffusion, but standardised methodology and interpretivecriteria are often lacking. The European Committee onAntimicrobial Susceptibility Testing (EUCAST) is in the processof establishing clinical MIC breakpoints for C. jejuni and C. coli.ObjectiveThe objective of this study was to investigate if the standardEUCAST MH-F medium and disk diffusion criteria can be usedfor reproducible antimicrobial susceptibility testing of C. jejuniand C. coli.MethodsPreliminary testing was performed on 15 C. jejuni and 15 C. colifrom the Netherlands with known MIC values (brothmicrodilution) including isolates with and without resistancemechanisms. Additional testing was performed on 17 C. jejuniand 12 C. coli from Finland. All isolates were tested in triplicatefor ciprofloxacin 5 µg, erythromycin 15 µg and tetracycline 30 µg.Investigated variables are shown in Table 1.Table 1Investigated variablesMediumIncubationReading of zonesResultsUnsupplemented Mueller-Hinton agar (MH) and Mueller-Hinton agarwith 5% defibrinated horse blood and 20 mg/L β-NAD (MH-F)35, 37, 39 and 41°C24 and 44 hSmallest and largest appearing zone when tilting the plateAll tests were performed with a 0.5 McFarland inoculum and microaerobicincubation in plastic jars.The proposed EUCAST disk diffusion methodology for C. jejuniand C. coli is presented in Table 2. BothC. jejuni and C. coligrew best on MH-F plates at 41°C. All C. jejuni grew well after 24h of incubation, whereas some C. coli required 44 h beforeinhibition zones could be read. Swarming was avoided by dryingplates before inoculation.All isolates with MICs above the epidemiological cut off (ECOFF)were identified as non-wild type also with the disk diffusion test(Figure 1), irrespective of whether the smallest or largest zonewas used. The results were reproducible within and between thesites. The standard deviation for triplicate tests ranged from 0.4-1.7 mm, with the largest variation for inhibition zones read after44 h of incubation. Examples of combined inhibition zonedistributions from several sites are shown in Figure 2.No of isolatesNo of isolatesNo of isolatesNo of isolatesReproducible disk diffusion testing of C. jejuni and C. coli can beperformed using the EUCAST MH-F media. Swarming waseffectively avoided by pre-drying of plates. Disk diffusioncorrelated well to MIC determination and reliably distinguishedbetween wild-type and non-wild type isolates. Further evaluationof the methodology is currently performed at several laboratoriesin Europe.40353025201510180160140120100807060504030201050121086420806040200ConclusionsTable 2EUCAST proposed disk diffusion methodology for Campylobacter jejuni andCampylobacter coli .Mueller-Hinton agar with 5% defibrinated horse blood and 20 mg/L β-NAD (MH-F)Medium(Plates should be dried before incubation to avoid swarming, either atroom temperature (20-22°C) over night or at 35°C for 1-2 hours.)Inoculum McFarland 0.5IncubationReading of zonesCiprofloxacin 5 µg vs. MIC, Campylobacter jejuni and coli57 clinical isolates tested in duplicate1010ECOFF: WT ≤ 1 mg/L1012Campylobacter jejuni with ciprofloxacin 5 µg414 clinical isolates121412141614161816182022182024202226Erythromycin 15 µg vs. MIC, Campylobacter jejuni30 clinical isolates tested in duplicateECOFF: WT ≤ 4 mg/L2422282628303234Inhibition zone diameter (mm)Campylobacter coli with ciprofloxacin 5 µg170 clinical isolates3024322634Inhibition zone diameter (mm)28Inhibition zone diameter (mm)Microaerobic environment41°C24 hours ± 30 minutes(C. coli with non-sufficient growth after 24 h incubation are reincubatedimmediatly and read after totally 40-48 h incubation.)EUCAST standard reading instructions:Read MH-F plates from the front with the lid removed illuminated withreflected light. Zone edges should be read at the point of completeinhbition as judged by the unaided eye.3630383640323842344044364642483844504046MIC(mg/L)≥32481684210.50.25≤0.12MIC(mg/L)≥12864321684210.550No of isolatesNo of isolatesNo of isolatesNo of isolates1098765432103530252015105050454035302520151050605040302010Tetracycline 30 µg vs. MIC, Campylobacter jejuni and coli29 clinical isolates tested in duplicate1010ECOFF: WT ≤ 2 mg/LErythromycin 15 µg vs. MIC, Campylobacter coli27 clinical isolates tested in duplicate1012Campylobacter jejuni with tetracycline 30 µg409 clinical isolates12141214161416101214161820222426283032343638404244184616481850202218202420222624222826Campylobacter coli with tetracycline 30 µg168 clinical isolates24302832263034Inhibition zone diameter (mm)ECOFF: WT ≤ 16 mg/L28Inhibition zone diameter (mm)Figure 1. Inhibition zone distributions for C.jejuni and C. coli with MIC values as colouredbars. Inhibition zones were read according to EUCAST standard reading instructions at onesite on MH from two manufacturers. Data for erythromycin are presented separately, due todifferent ECOFFs.3236303438Inhibition zone diameter (mm)364038404244464850010121416182022242628303234363840424446485032423444364638485040MIC(mg/L)≥12864321684210.50.250.12MIC(mg/L)≥12832168421Inhibition zone diameter (mm)Inhibition zone diameter (mm)For more information, please contact:erika.matuschek@ltkronoberg.seFigure 2. Combined inhibition zone distributions for ciprofloxacin and tetracycline from 4-6 sites for C. jejuni and C. coli, respectively.

06688668866886688P676Antimicrobial susceptibility testing of Listeria monocytogeneswith EUCAST breakpoints: A multi‐laboratory study.Karen Bowker 1 , Jenny Åhman 2 , Olav Natås 3 , Israel Nissan 4 , Pia Littauer 5 and Erika Matuschek 21Dept of Microbiology, Southmead Hospital, Bristol, United Kingdom, 2 EUCAST Laboratory for AST, Växjö, Sweden3Dept of Medical Microbiology, Stavanger University Hospital, Norway4Government Central Laboratories, Jerusalem, Israel, 5 Dept of Clinical Microbiology, Hvidovre Hospital, DenmarkIntroductionThe European Committee on Antimicrobial Susceptibility Testing(EUCAST) has recently proposed clinical MIC breakpoints basedon epidemiological cut-off (ECOFF) values for Listeriamonocytogenes.ObjectiveThe objective of this study was to establish corresponding zonediameter breakpoints based on the EUCAST Mueller-HintonFastidious medium (MH-F) in a multi-laboratory study and tovalidate the use of a gradient test for MIC determination usingbroth microdilution (BMD) as reference.MethodsA total of 129 clinical isolates of L. monocytogenes werecollected from five sites in Denmark, Israel, Norway, Swedenand the United Kingdom. Antimicrobial susceptibility testing wasperformed against ampicillin, benzylpenicillin, erythromycin,meropenem and trimethoprim-sulfamethoxazole. Disk diffusionwas performed for all isolates at all sites on Mueller-Hinton agarwith 5% defibrinated horse blood and 20 mg/L β-NAD (MH-F)according to EUCAST methodology. Media (commercial and inhouseprepared plates) and disks from different manufacturerswere used at the various sites. MIC determination wasperformed with BMD (TREK Diagnostics/Thermo FisherScientific) and Etest (bioMérieux) at Southmead Hospital, UK.BMD was performed on custom panels containing MH broth with5% lysed horse blood (by repeated freezing and thawing) and 20mg/L β-NAD (MH-F broth) and Etest was performed on MH-Fmedia. All data were analysed by EUCAST.ResultsAll L. monocytogenes isolates grew well within 16-20 hours ofincubation on the MH-F medium. The correlation between BMDand Etest MICs was excellent, with 99.4% of Etest values within± 1 dilution of the BMD values. Zone diameter breakpoints wereestablished (Table 1) in such a way that the MIC ECOFFcorresponded to the zone diameter distribution ECOFF for eachantibiotic agent (examples in Figure 1a). Reproducibilitybetween the sites was good (Figure 1b) and small variations ininhibition zones were mainly due to variations in media and disksfrom different manufacturers.Table 1EUCAST clinical MIC breakpoints for Listeria monocytogenesand corresponding zone diameter breakpoints.EUCAST Clinical Breakpoint Table v 2.0MIC breakpoint Disk Zone diameterAntibiotic agent(mg/L) content breakpoint (mm)S ≤ R > (µg) S ≥ R

6688Susceptibility testing of ten antibiotics against Corynebacterium spp. determined bybroth microdilution, Etest and EUCAST disk diffusion methodsC. Salas *1, C. Karlsson 2 , A. Åkerlund3 , C. RodríguezMirones 1 , E. Matuschek 2 ,L. Martíneznez-Martínez1,4 , G. Kahlmeter 21Servicio de Microbiología, Hosp. Univ. Marqués de Valdecilla, Santander, Spain. 2 EUCAST Laboratory for Antimicrobial Susceptibility Testing, Växjö,Sweden. 3 Department of Clinical and Experimental Medicine, Linköping University, Sweden. 4 Fac. de Medicina, Universidad de Cantabria, Spain.[Revised] AbstractMaterial and MethodsObjective: EUCAST has not yet defined breakpoints forclinical categories of clinically relevant antibiotics forCorynebacterium. In this study, the performance of threemethods for susceptibility testing of five Corynebacteriumspecies has been evaluated.Methods: The activity of penicillin G (PNG), ciprofloxacin(CIP), moxifloxacin (MOX), gentamicin (GEN),vancomycin (VAN), clindamycin (CLI), tetracycline (TET),linezolid (LNZ), rifampin (RIF) and cotrimoxazole (SXT)against 60 Corynebacterium spp. (12 isolates each of thefollowing species: C. striatum, C. amycolatum, C. jeikeium,C. urealyticum and C. pseudodiphtheriticum) weredetermined using BMD (broth microdilution with cationadjustedMueller-Hinton broth with 3% laked horseblood), or on solid medium MH-F (Mueller-Hinton agarwith 5% defibrinated horse blood and 20 mg β-NAD/L) byEtest and disk diffusion (disk contents as defined byEUCAST). BMD was performed in one lab in Spain, Etestin one lab in Sweden and disk diffusion in three labs (onein Spain and two in Sweden). Plates were incubated at 35ºCin air (microdilution) or 5% CO 2 (agar media) and readafter 16-20 h or, in case of insufficient growth, afteranother 24 h.Results: Microdilution results could be read after 16-20 hincubation for all species but C. pseudodiphtheriticum. EtestMICs and inhibition zones could be determined at 16-20 hfor all 12 C. striatum, but incubation for 40-44 h wasneeded to a varying degree for other species. Essentialagreement (EA, that in ±1 dilution) between microdilutionand Etest was: PNG (81,7%), CIP (77,9%), MOX (49,1%),GEN (83,0%), VAN (96,6%), CLI (61,0%), TET (59,3%),LNZ (71,1%), RIF (88,3%) and SXT (42,4%). For species,EA were: C. jeikeium (84,2%), C. striatum (77,5%), C.amycolatum (73,3%), C. ureatlyticum (60,8%) and C.pseudodiphtheriticum (58,5%). Correlation between BMDMICs and inhibition zones was good, i.e. isolates with highMICs had small inhibition zones and viceversa. Correlationbetween inhibition zones from three labs was overall good,even when zones had to be read after another 24 h.Conclusions: Growth of Corynebacterium spp. on MH-Fdiffers between species and it is sometimes necessary toincubate plates for longer than the standard 16-20 h. Thereis a good correlation between BMD and Etest forvancomycin. More studies on MIC/zone correlation onspecies-identified Corynebacterium must be performedbefore breakpoints (or ECOFFs) can be established.BackgroundEUCAST has not yet established specific criteria forclinical interpretation of susceptibility testing results forCorynebacterium spp.In this study, we have compared three different methods(broth microdilution, disk-diffusion and gradient-diffusion)to study the in vitro activity of ten antimicrobial agentsagainst five of the more clinically relevant species ofcorynebacteria.We aimed to obtain information aboutperformance of the assays and on the agreement of resultsobtained with every methodology.Bacterial isolates: 60 clinical isolates (12 isolates perspecies), including C. striatum, C. amycolatum, C.jeikeium, C. urealyticum and C. pseudodiphtheriticum.Susceptibility testing:Broth-microdilution:In-house prepared microdilution plates using cationadjustedMueller-Hinton broth with 3% laked horseblood. The following 10 antibiotics were tested:penicillin G (PNG), ciprofloxacin (CIP), moxifloxacin(MOX), gentamicin (GEN), vancomycin (VAN),clindamycin (CLI), tetracycline (TET), linezolid(LIN), rifampin (RIF) and cotrimoxazole (SXT).Plates were incubated at 35±2ºC and read after anincubation in air for 16-20 h.Disk diffusion:EUCAST method, using Mueller-Hinton agar with5% of defibrinated horse blood and 20 mg β-NAD/L(Mueller-Hinton F).ResultsPercentages of strains growing in Mueller-Hinton broth (microdilution) and on Mueller-Hinton F(gradient diffusion) at 20/44 h.Essential agreement (%) (in ±1 dilution) between MICs of 10 agents against Corynebacterium spp.determined by gradient diffusion (Etest) with broth microdilution as referencePNG CIP MOX GEN VAN CLIN TET LIN RIF SXT% agreementper speciesC. striatum 83.3 83.3 50.0 91.7 91.7 91.7 66.7 75.0 75.0 66.7 77.5C. amycolatum 83.3 100 16.7 100 100 83.3 66.7 83.3 91.7 8.3 73.3C. jeikeium 91.7 100 83.3 91.7 100 83.3 66.7 75.0 100 66.7 84.2C. urealyticum 75.0 75.0 58.3 83.3 100 25.0 25.0 66.7 75.0 25.0 60.8C. pseudodiph. 75.0 27.3 36.4 45.4 90.9 18.2 90.9 54.5 100 45.4 58.5% agreementper antibiotic 81.7 77.9 49.1 83.0 96.6 61.0 59.3 71.1 88.3 42.4The following disks were evaluated: PNG 1 unit, CIP 5μg, MOX 5 μg, GEN 10 μg, VAN 5 μg, CLI 2 μg, TET30 μg, LIN 10 μg, RIF 5 μg and SXT 1.25-23.75 μg.Gradient diffusion:The EUCAST method for disk diffusion was also used,with Etest strips of the same agents considered in thetwo other assays.Agar plates (both disk diffusion and gradient diffusionmethods) were incubated in 5% CO 2 for 16-20 h.When growth was insufficient at that time, incubationwas extended for 24 h (total incubation in these cases:40-44 h.).S. pneumoniae ATCC 49619 and S. aureus ATCC29213 were used as quality control strains.C. striatum ATCC 6940 and C. urealyticum ATCC43042 were also included in the study.ConclusionsNo of readingsNo of readings807060504030201001614121086420Moxifloxacin 5 µg vs. MIC (BMD)Corynebacterium spp, 60 isolates tested at three sites10Tetracycline 30 µg vs. MIC (BMD)Corynebacterium spp, 60 isolates tested at three sites10121214141616181820202222242426262828Inhibition zone diameter (mm)3032Inhibition zone diameter (mm) Growth on MH-F differs between Corynebacterium species. For some organisms, it is necessary toincubate plates for longer than the standard 16-20 h, up to 40-44h.There is a good correlation between BMD/Etest for vancomycin, and to a lesser extent (>80%) forpenicillin, gentamicin and rifampin.Correlation between MIC/disk difussion was good with small inhibiton zones corresponding tohigh MICs. More studies must be performed before breakpoints (or ECOFFs) can be established.A good correlation among inhibition zones determined by disk diffussion in the three participatinglaboratories was noted.303432363438364038424044MIC(mg/L)>161684210.50.250.120.060.031684210.50.250.12Examples of combined inhibition zone distributions for Corynebacterium spp.from the three sites with corresponding MIC values as coloured bars.Carlos Salas VeneroE-mail: csalas@humv.es

The Brucella blood agar for disc diffusionantimicrobial susceptibility testing– reproducibility results for Clostridium difficile ATCC 700057U. S. Justesen 1 , L. T. Erikstrup 2 , T. K. Danielsen 1 , E. Matuschek 3 and G. Kahlmeter 31) Department of Clinical Microbiology, Odense University Hospital, Odense,2) Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark and3) EUCAST Laboratory for Antimicrobial Susceptibility Testing, Växjö, Sweden.Introduction and PurposeResultsThe EUCAST disk diffusion antimicrobial susceptibilitytesting method for fastidious organisms is based onthe Mueller-Hinton fastidious agar (MH-F). In a pilotstudy, most anaerobic bacteria did not grow wellenough on MH-F to permit antimicrobialsusceptibility testing (Justesen et al.). We decided toinvestigate whether or not the Brucella Blood Agarsupplemented with hemin and vitamin K (BBA),recommended for antimicrobial susceptibility testingof anaerobic bacteria with gradient strips, might alsobe suited for disk diffusion testing of C. difficile.Table 1. Zone diameter mean values and ranges are shown in the table.Antimicrobial agent Inhibition zone diameters (mm) for Clostridium difficile ATCC 700057Piperacillin/tazobactam(30/6 μg)Meropenem(10 μg)Metronidazole(5 μg)Clindamycin(2 μg)Day 1 and 2 at 37°C(10% CO 2, 10% H 2and 80% N 2)(n=12)27.5 (25.7-28.3)26.7 (25.6-28.2)29.7 (28.7-30.1)29.7 (28.9-30.2)38.7 (37.6-40.9)35.5 (35.3-36.4)10.3 (10.1-10.5)10.3 (9.6-10.9)5% CO 2(10% H 2, 85% N 2and 37°C)(n=12)35°C(10% CO 2, 10% H 2and 80% N 2)(n=12)26.0 (25.2-26.3) 26.5 (25.7-27.3)31.4 (30.5-32.1) 31.5 (30.9-31.8)38.6 (37.6-39.7) 38.9 (38.2-40.6)10.8 (10.4-11.1) 11.8 (10.8-12.3)MethodsPenicillin G(1 U)Vancomycin(5 μg)6.0 (6.0) NO ZONE6.0 (6.0) NO ZONE23.1 (22.5-24.0)25.5 (24.5-26.3)8.3 (6.0-9.0) 6.4 (6.0-8.2)23.0 (22.6-23.7) 23.5 (23.1-24.3)C. difficile ATCC 700057 was tested with Etest(bioMérieux, Craponne, France) gradient strips(piperacillin/tazobactam, meropenem,metronidazole, clindamycin, penicillin G,vancomycin, moxifloxacin and tigecycline) on BBA(Becton Dickinson, Heidelberg, Germany) accordingto the manufacturer’s instructions. Thecorresponding disk (EUCAST disk strength) wasincluded on each plate (Oxoid, Basingstoke, UK). Alltests were repeated twelve times. I.e. twelve plateswere incubated day 1 at 37°C in an anaerobeenvironment (10% CO 2 , 10% H 2 and 80% N 2 ) for 24hours with each antimicrobial agent to assess intradayvariability. This was repeated day 2 to assessinter-day variability. Etest results were comparedwith the acceptable ranges for ATCC 700057(reference agar dilution testing, CLSI guideline M11-A7). Twelve plates with disks only were alsoincubated at 5% CO 2 (10% H 2 and 85% N 2 ) at 37°Cand another twelve plates at 35°C with 10% CO 2 ,10% H 2 and 80% N 2 . Also; the effect of thioglycollateversus saline 0.85% for inoculum preparation andprereduction of the BBA plates were investigated forvancomycin, metronidazole, moxifloxacin andclindamycin (Figure 1).Moxifloxacin(5 μg)Tigecycline(15 μg)23.0 (22.4-23.6)22.7 (21.8-23.7)34.5 (34.0-34.9)33.1 (32.2-34.6)Figure 1.Clostridium difficile ATCC 700057, McFarland 1.0on BBA with clindamycin 2 μg (DA 2),metronidazole 5 μg (MTZ 5), vancomycin 5 μg (VA5) and moxifloxacin 5 μg (MXF 5) disks. Growth isconfluent on the BBA.All Etest results were within acceptable rangesand the intra- and inter-day variability was

Disk diffusion an,microbial suscep,bility tes,ng of Clostridium difficile L. T. Erikstrup 1,2 , T. K. Danielsen 3 , V. Hall 4 , K. Fuursted 1 , G. Kahlmeter 5 , and U. S. Justesen 3 1) Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark 2) InsCtute of Clinical Medicine, Aarhus University, Aarhus, Denmark 3) Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark, 4) Anaerobe Reference Unit, University Hospital of Wales, Cardiff, Wales, 5) EUCAST Laboratory for AnCmicrobial SuscepCbility TesCng, Växjö, Sweden. Introduc,on and Purpose Results The clinical significance of Clostridium difficile and the emergence of decreased suscep,bility towards metronidazole and vancomycin have highlighted the importance of an,microbial suscep,bility tes,ng of C. difficile and the importance of having a simple tes,ng method for the rou,ne laboratory. The aim of our study was to evaluate disk diffusion for suscep,bility tes,ng of C. difficile by comparing disk diffusion zone diameters with MICs from gradient tests. MIC (mg/L)MIC (mg/L)MIC (mg/L)MIC (mg/L)MIC (mg/L) Methods Consecu,ve clinical and toxigenic isolates of C. difficile (n=211) were collected from pa,ents with diarrhoea hospitalised at Aarhus University Hospital (n=110) in 2008 and from Odense University Hospital (n=101) in 2010. Furthermore, ten clinical isolates of C. difficile from the University Hospital of Wales with Figure 1. Distribu,on of inhibi,on zone diameters (disk diffusion method) and MICs (gradient test) for 221 isolates of C. difficile tested against metronidazole (5 μg disk), vancomycin (5 μg disk), moxifloxacin (5 μg disk), and clindamycin (2 μg disk). Each isolate is represented in the zone diameter histogram in a colour represen,ng its MIC value. known reduced suscep,bility to either metronidazole (n=4, MIC 1.5, 2, 2, 3 mg/L, ECOFF ≤ 2 mg/L) or vancomycin (n=6, MIC 1.5, 2, 2, 2, 3, 3 mg/L, ECOFF ≤ 2 mg/L) were included. MIC determina,on was performed by gradient test. Etest strips (bioMérieux, Craponne, France) with metronidazole, vancomycin, moxifloxacin, and clindamycin were placed on Brucella Blood Agar supplemented with hemin and vitamin K (Becton Dickinson, Heidelberg, Germany) A total of 221 clinical isolates of C. difficile from Denmark and Wales were tested. The distribu,on of inhibi,on zone diameters and MICs for C. difficile isolates towards metronidazole, vancomycin, moxifloxacin, and clindamycin are illustrated in the histograms (Figure 1). The four isolates with known reduced suscep,bility to metronidazole were clearly separated from the wild type by 9 mm. The six isolates with known reduced suscep,bility to vancomycin had zone diameters between 15 to 19 mm as compared to the consecu,ve clinical isolates from Denmark which all had zone diameters above 18 mm. Bivariable regression analysis showed an acceptable to excellent correla,on between the log-­transformed MIC versus the untransformed zone diameter, thus the R 2 was 0.75 for metronidazole, 0.55 for vancomycin, 0.97 for moxifloxacin and 0.63 for clindamycin. according to the manufacturer’s instruc,ons. Disk diffusion was performed with Oxoid disks (Oxoid, Basingstoke, UK) with vancomycin (5 Conclusion μg), metronidazole (5 μg), moxifloxacin (5 μg) and clindamycin (2 μg) on Brucella Blood Agar. Plates were incubated at 37°C in an anaerobic atmosphere (10% CO 2 , 10% H 2 and 80% N 2 ) for 24 hours. The zone diameter was read at 100% inhibi,on. For most reference strains, almost regardless of species and an,microbial agent, the aggregated inhibi,on zone values, of repeated tes,ng, form a distribu,on most o`en covering 6-­‐8 mm [1]. For the 221 clinical isolates of C. difficile tested towards metronidazole, vancomycin, moxifloxacin, and clindamycin we found that for each MIC value, the inhibi,on zones varied from 0 to 8 mm with the majority exhibi,ng 5 to 6 mm varia,on. Therefore, we conclude that there is an excellent agreement between disk diffusion zone diameter and the MIC as measured by Etest and consequently we recommend the disk diffusion method as a reliable op,on for an,microbial suscep,bility tes,ng of C. difficile. Zone diameter breakpoints can now be established by EUCAST Correspondence References Corresponding author: Lise Tornvig Erikstrup E-­‐mail: liseerik@rm.dk Poster 681, ECCMID, London 2012 1. Kronvall G, Giske CG, Kahlmeter G. Seqng interpre,ve breakpoints for an,microbial suscep,bility tes,ng using disk diffusion. Int. J. An,microb. Agents. 2011 Oct;38(4):281–90.

P1092ECCMID 2012JMI LaboratoriesNorth Liberty, IA, USAwww.jmilabs.com319.665.3370, fax 319.665.3371helio-sader@jmilabs.comAntimicrobial Susceptibility and Species Identification ofCorynebacterium spp. Strains Collected in Europe andUSA Medical Centers (2006-2010)HS SADER, PR RHOMBERG, RN JONES, J ÅHMAN, E MATUSCHEK, G KAHLMETERJMI Laboratories, North Liberty, Iowa, USA; EUCAST Laboratory for Antimicrobial Susceptibility TestingAbstractObjectives: To evaluate the antimicrobial susceptibility ofCorynebacterium spp. clinical strains collected fromEuropean and USA medical centers. The accuracy ofspecies identifications performed at local labs was alsoassessed.Methods: 121 Corynebacterium strains were collectedfrom serious infections between 2006 and 2010 as part ofthe SENTRY Antimicrobial Surveillance Program from 15and 18 medical centers in 9 European countries and USA,respectively. The strains were susceptibility (S) tested bythe CLSI broth microdilution method in cation-adjustedMueller-Hinton broth against numerous antimicrobialagents. MIC results were interpreted according to CLSIM45 breakpoint criteria. There are yet no criteria fromEUCAST. Species identifications were performed byMALDI-TOF methodology using the Bruker Biotypersystem.Results: Isolates were from bacteremia (53.6%), skin andskin structure (17.3%), pneumonia (12.7%), among otherinfection sites. Vancomycin (100.0% S) and daptomycin(99.1% S) showed potent activity against Corynebacteriumwith MIC 50/90 of 0.25/0.5 and ≤0.06/0.25 mg/L, respectively.C. jeikeium and C. urealyticum species groupsdemonstrated lower S rates, 0.0% for penicillin and 36.8-40.0% for gentamicin, compared to other Corynebacteriumspecies groups (see Table). 61 of 121 strains (50.4%)were identified to species level by the clinical laboratoriesand species identification was confirmed by the MALDI-TOF analysis on 47 (77.0%) of those strains. Theremaining 14 strains had incorrect species (12) or genus(2 strains, Brevibacterium and Microbacterium). Among the60 strains submitted as unspeciated Corynebacterium, 51(85.0%) strains were confirmed as Corynebacterium andidentified to species level, while the remaining 9 strainswere identified to a different genus (Brevibacterium [3],Microbacterium [2], Dermabacter [1], Rhodococcus [1],Staphylococcus [1], Turicella [1]) by the MALDI-TOFanalysis.Conclusions: Antimicrobial resistance differences amongCorynebacterium species were noted with higher ratesamong the C. jeikeium and C. urealyticum species groups.Identification to the species level in clinical laboratories forCorynebacterium remains a challenge; however, theMALDI-TOF method appears to generate more completeand accurate identifications to be compared toantimicrobial-S profiles.Organism/speciesMIC 50 (mg/L) / % susceptible(no. tested)DAP ERY GENT PEN VANCAll Corynebacterium spp.(110)≤0.06/99.1 >2/24.6 ≤2/80.9 1/51.8 0.25/100.0C. amycolatum (33) ≤0.06/100.0 >2/27.3 ≤2/84.9 1/63.3 0.5/100.0C. jeikeium (19) 0.12/100.0 2/10.5 >8/36.8 >4/0.0 0.5/100.0C. striatum (37) ≤0.06/99.3 >2/24.3 ≤2/97.3 1/56.8 0.25/100.0C. urealyticum (5) ≤0.06/100.0 >2/40.0 >8/40.0 >4/0.0 0.5/100.0Other Corynebacterium≤0.06/100.0 2/31.3 ≤2/100.0 0.25/93.8 0.25/100.0spp. (16)DAP = daptomycin, ERY = erythromycin, GENT = gentamicin, PEN = penicillin, VAN = vancomycin.IntroductionThe genus Corynebacterium is composed of at least 67species of which many are medically important. WhenGram's stained, corynebacteria are slightly curved Grampositiverods with one end slightly wider giving theappearance of a club shape and clusters on the slide give aChinese letter type appearance. Corynebacteria areaerobic, non-spore forming, catalase positive and usuallynon-motile.Many species of corynebacteria are part of the normal floraof the skin which makes the correlation with clinicalsignificance (cause of infection) difficult when they areisolated from specimens. Corynebacteria should beidentified to species level only if isolated from normallysterile body sites or when they are alone or the predominantpathogen from an adequately collected clinical sample,especially when matched with a Gram's stain report. Manyautomated systems and biochemical reaction methods havebeen developed and optimized for the identification ofclinically relevant Corynebacterium species.One new method for the identification of bacterial speciesunder development is the use of Matrix Assisted LaserDesorption Ionization-Time of Flight (MALDI-TOF) massspectrometry to measure the unique molecular fingerprint ofa tested organism and compare to the extensive storeddatabase to determine the identity to the species level.Materials and MethodsBacterial isolates: 121 Corynebacterium strains werecollected between 2006 and 2010 from serious infectionsand submitted to the SENTRY Antimicrobial SurveillanceProgram. Fifteen participant medical centers were locatedin Europe (Belgium, France, Germany, Ireland, Italy, Spain,Sweden, Switzerland and United Kingdom) and 18 werelocated in the United States (USA). The isolates werecollected primarily from bloodstream (53.6%) followed bylower numbers from skin and skin structure infections(17.3%), pneumonia (12.7%), and other infection sites.Identification: Local microbiology laboratories in eachmedical center performed species identifications oncoryneform pathogens as per local SOP criteria andmethods. Upon receipt at JMI Laboratories (North Liberty,Iowa, USA) each strain was reviewed for colony morphologyand tested by Gram’s stain and Vitek or Vitek 2 using ANIcards for identification, as necessary. Definitiveidentification was assigned from testing on the BrukerBiotyper system using the MALDI-TOF methodology.Susceptibility testing: Antimicrobial susceptibility testing wasperformed by Clinical and Laboratory Standards Institute(CLSI) broth microdilution methods in validated, panelsmanufactured by Thermo Fisher Scientific (formerly TREKDiagnostics Systems; Cleveland, Ohio, USA). The testmedium was cation-adjusted Mueller-Hinton brothsupplemented with 2.5-5.0% lysed horse blood withincubation at 37 ºC for 24 hours. CLSI interpretive criteriawere used to categorize the isolates as susceptible,intermediate and resistant as described in the M45document; European Committee on AntimicrobialSusceptibility Testing (EUCAST) has not yet definedinterpretive criteria. The quality control organismStreptococcus pneumoniae ATCC 49619 was concurrentlytested; all QC results were within published limits.Results• Among the collection of Corynebacterium strainsassembled, only 61 of the 121 strains (50.4%) wereidentified to the species level by the clinicalmicrobiology laboratories due to local standardoperating procedures or by limited abilities of theautomated/biochemical identification systems utilizedin the monitored European or USA medical centers.• Accuracy to species level among these identifiedisolates as confirmed by the MALDI-TOF method was73.8% (45/61) agreement, 23.0% (14/61) had incorrectCorynebacterium species assigned and 3.3% (2/61)had an incorrect genus (Table 1).• Most common incorrect species identificationsobserved were C. jeikeium → C. amycolatum (5), C.xerosis → C. striatum (3) and C. striatum → C.amycolatum (2). Incorrect genus identification wasobserved only twice; once each as C. afermentans →Brevibacterium casei and C. jeikeium →Staphylococcus warneri (Table 1).• Among the 60 unspeciated Corynebacterium strainsstudied, 51 (85.0%) demonstrated a good identificationto species level using the MALDI-TOF method, while 9strains (15.0%) were confirmed as other Gram-positivebacilli including; Brevibacterium (3), Microbacterium(3), Dermabacter, Rhodococcus and Turicella (oneeach, Table 1).• Greatest in vitro potency against the collection (110Corynebacterium spp; Table 2) was observed withtigecycline (MIC 50/90 , ≤0.03/0.06 mg/L), daptomycin(MIC 50/90 , ≤0.06/0.25 mg/L), linezolid (MIC 50/90 ,0.25/0.25 mg/L) and vancomycin (MIC 50/90 , 0.25/0.5mg/L).• Based on CLSI M45 breakpoint criteria forCorynebacterium, highest resistance rates wereobserved for ciprofloxacin (73.7%), followed bytrimethoprim/sulfamethoxazole (71.6%), erythromycin(65.5%) and ceftriaxone (63.6%; Table 2).• Analysis by sub-groups showed C. jeikeium and C.urealyticum species groups had reduced susceptibilityrates for penicillin (0.0%) and gentamicin (36.8-40.0%)compared to other Corynebacterium spp. groups.Table 1. Summary of identification (ID) discords between MALDI-TOF and other methods for Corynebacterium species isolates from European andUSA medical centers between 2006-2010.Corynebacterium misidentificationsGenus misidentificationsSite ID MALDI-TOF ID (no.) Site ID MALDI-TOF ID (no.)C. jeikeium → C. afermentans C. afermentans → Brevibacterium caseiC. jeikeium → C. amycolatum (5) C. jeikeium → Staphylococcus warneriC. minutissimum → C. aurimucosum Unspeciated Corynebacterium → Brevibacterium casei (2)C. pseudodiptheriticum → C. propinquum Unspeciated Corynebacterium → Brevibacterium iodinumC. striatum → C. amycolatum (2) Unspeciated Corynebacterium → Dermobacter hominisC. striatum → C. aurimucosum Unspeciated Corynebacterium → Microbacterium maritypicumC. xerosis → C. striatum (3) Unspeciated Corynebacterium → Microbacterium oxydansUnspeciated Corynebacterium → Microbacterium spp.Unspeciated Corynebacterium → Rhodococcus erythropolisUnspeciated Corynebacterium → Turicella otitidisTable 2. Activity of 13 antimicrobial agents when tested againstCorynebacterium species isolates from European and USA medicalcenters between 2006-2010.Organism (no. tested)/MIC (mg/L)% susceptible /% resistantAntimicrobial agentMIC 50 MIC 90 CLSI aAll Corynebacterium spp. (110)Ceftriaxone 4 >8 26.4 / 63.6Ciprofloxacin >4 >4 20.9 / 73.7Clindamycin >2 >2 - b / -Daptomycin ≤0.06 0.25 99.1 / -Erythromycin >2 >2 24.6 / 65.5Gentamicin ≤2 >8 80.9 / 14.6Linezolid 0.25 0.25 100.0 / -Penicillin 1 >4 51.8 / 41.8Piperacillin/tazobactam 16 >64 - / -Tetracycline ≤2 >8 75.5 / 23.6Tigecycline ≤0.03 0.06 - / -Trimethoprim/sulfamethoxazole >2 >2 28.4 / 71.6Vancomycin 0.25 0.5 100.0 / -Corynebacterium amycolatum (33)Ceftriaxone 1 >8 57.6 / 30.3Ciprofloxacin >4 >4 15.2 / 75.8Clindamycin >2 >2 - / -Daptomycin ≤0.06 0.12 100.0 / -Erythromycin >2 >2 27.3 / 66.7Gentamicin ≤2 8 84.9 / 3.0Linezolid 0.12 0.25 100.0 / -Penicillin 1 >8 63.6 / 33.3Piperacillin/tazobactam ≤0.5 >64 - / -Tetracycline ≤2 ≤2 93.9 / 6.1Tigecycline ≤0.03 0.12 - / -Trimethoprim/sulfamethoxazole >2 >2 36.4 / 63.6Vancomycin 0.5 0.5 100.0 / -Corynebacterium jeikeium (19)Ceftriaxone >8 >8 0.0 / 100.0Ciprofloxacin >4 >4 10.5 / 89.5Clindamycin >2 >2 - / -Daptomycin 0.12 0.25 100.0 / -Erythromycin 2 >2 10.5 / 63.2Gentamicin >8 >8 36.8 / 63.2Linezolid 0.25 0.5 100.0 / -Penicillin >4 >4 0.0 / 94.8Piperacillin/tazobactam >64 >64 - / -Tetracycline ≤2 >8 84.2 / 15.8Tigecycline ≤0.03 0.06 - / -Trimethoprim/sulfamethoxazole >2 >2 0.0 / 100.0Vancomycin 0.5 0.5 100.0 / -Corynebacterium striatum (37)Ceftriaxone 8 >8 0.0 / 94.6Ciprofloxacin >4 >4 8.1 / 83.8Clindamycin >2 >2 - / -Daptomycin ≤0.06 0.12 97.3 / -Erythromycin >2 >2 24.3 / 70.3Gentamicin ≤2 4 97.3 / 0.0Linezolid 0.25 0.25 100.0 / -Penicillin 1 >4 56.8 / 29.7Piperacillin/tazobactam 16 >64 - / -Tetracycline >8 >8 46.0 / 51.4Tigecycline ≤0.03 0.06 - / -Trimethoprim/sulfamethoxazole >2 >2 13.5 / 86.5Vancomycin 0.25 0.25 100.0 / -Corynebacterium urealyticum (5)Ceftriaxone 4 - 40.0 / 60.0Ciprofloxacin >4 - 0.0 / 100.0Clindamycin >2 - - / -Daptomycin ≤0.06 - 100.0 / -Erythromycin >2 - 40.0 / 60.0Gentamicin >8 - 40.0 / 60.0Linezolid 0.25 - 100.0 / -Penicillin >32 - 0.0 / 100.0Piperacillin/tazobactam >64 - - / -Tetracycline ≤2 - 100.0 / 0.0Tigecycline ≤0.03 - - / -Trimethoprim/sulfamethoxazole >2 - 0.0 / 100.0Vancomycin 0.5 - 100.0 / -Other Corynebacterium spp. (16) cCeftriaxone 1 4 50.0 / 18.8Ciprofloxacin ≤0.5 >4 81.3 / 27.8Clindamycin >2 >2 - / -Daptomycin ≤0.06 0.12 100.0 / -Erythromycin 2 >2 31.3 / 56.3Gentamicin ≤2 ≤2 100.0 / 0.0Linezolid 0.25 0.5 100.0 / -Penicillin 0.25 1 93.8 / 6.2Piperacillin/tazobactam 1 16 - / -Tetracycline ≤2 >8 87.5 / 12.5Tigecycline ≤0.03 0.06 - / -Trimethoprim/sulfamethoxazole 1 >2 87.5 / 12.5Vancomycin 0.25 0.25 100.0 / -a. Criteria as published by the FDA or CLSI [2012].b. "-" = No criteria defined.c. Includes Corynebacterium afermentans (3), C. aurimucosum (2), C. glucuronolyticum (1), C. initans (1), C.minutissimum (2), C. propinquum (3), C. pseudodiptheriticum (3), and C. singulare (1).Conclusions• Identification of Corynebacterium to the species levelremains a challenge for clinical microbiologylaboratories, due to the compromised accuracy of theautomated/biochemical systems in use. The MALDI-TOF method appears to generate more complete andaccurate identifications to the species level.• This contemporary, well characterized collection ofCorynebacterium strains can be used to predicteffective empiric therapeutic choices and shows thehigher rates of antimicrobial resistance for selectedagents among the C. jeikeium and C. urealyticumspecies groups.References1. Clinical and Laboratory Standards Institute (2012). M07-A9.Methods for dilution antimicrobial susceptibility tests forbacteria that grow aerobically; approved standard: ninthedition. Wayne, PA: CLSI.2. Clinical and Laboratory Standards Institute (2010). M45-A2.Methods for antimicrobial dilution and disk susceptibilitytesting of infrequently isolated or fastidious bacteria:second edition. Wayne, PA: CLSI.3. Clinical and Laboratory Standards Institute (2012). M100-S22. Performance standards for antimicrobial susceptibilitytesting: 22nd informational supplement. Wayne, PA: CLSI.4. Funke G, Bernard KA (2011). Coryneform Gram-PositiveRods. In Manual of Clinical Microbiology. Washington, D.C.:ASM Press.5. Wolk DM, Dunne WM, Jr. (2011). New technologies inclinical microbiology. J Clin Microbiol 49: S62-S67.

European Committee on Antimicrobial Susceptibility Testing2011-2012EUCAST General CommitteeAustralia - J TurnidgeAustria -P ApfalterBelgium - J VerhaegenBosnia - S Uzunovic-KamberovicBulgaria - K MetodievCroatia - A Tambic-AndrasevicCzech Republic - H ZemlickovaDenmark -R SkovEstonia - M IvanovaFinland - A HakanenFrance - L DubreuilGermany - B WiedemannGreece - A VatopoulosHungary -ATóthIceland - K Gustaf KristinssonIreland - M MulhernIsrael - Y KenessItaly -P VaraldoLatvia -A BalodeLithuania - J MiciulevicieneNetherlands –G KampingaNorway - M SteinbakkPoland -W HryniewiczPortugal - J Melo CristinoRomania -I coditaRussia - M SukhorukovaSerbia - L RaninSlovak Rep -M NiksSlovenia -J KolmanSpain - L Martinez MartinezSweden - B Olsson-LiljequistSwitzerland - J BilleTurkey - D GürUK - A MacGowanISC - P TulkensFESCI - D LivermorePharmaceutical Industry andSusceptibility Testing DeviceManufacturersThese groups are informed of EUCASTactivity and consulted via an e-mailnetwork open to all companies with aninterest in antimicrobial susceptibilitytesting.The EUCAST steering committeeChairman Gunnar Kahlmeter (2014)Scientific secretary, Derek Brown(2014)Clinical Data Coordinator RafaelCanton (2014)BSAC (The UK), Alasdair MacGowan(2014)CA-SFM (France), Claude-JamesSoussy / Luc Dubreuil (2014)CRG (The Netherlands) Johan Mouton(2014)NWGA (Norway), Arnfinn Sundsfjord /Martin Steinbakk (2014)SRGA (Sweden), Christian Giske (2014)EUCAST rep 1, Petra Apfalter (Austria),(2013)EUCAST rep 2, Marina Ivanova(Estonia), (2012)Luis Martinez Martinez (Spain), (fromApril 2012-2014)EUCAST rep 3, Robert Skov (Denmark),(From April 2012-2014)Questions on EUCASTWebsite:www.eucast.orge-mail:gunnar.kahlmeter@escmid.orgderek.brown222@escmid.orgrcanton.hcr@escmid.orgAppointments by ESCMID- Chairholder, Scientific Secretary and Clinical DataCoordinator (3 years)- National breakpoint committee seats on the SteeringCommittee (3 years)- Three representatives from the EUCAST generalcommittee from countries not otherwise represented on thesteering committee (2 years).Appointments by European countries- Each country with an active national breakpoint committeeappoints one representative to serve for 3 years on theSteering Committee (active national committees only, i.e.committees with >2 meetings per year, are eligible)- Countries without representatives on the SteeringCommittee may apply to the ESCMID board for a positionon the Steering Committee to serve for 2 years-- Each country appoints one representative to serve on theGeneral Committee (no set term of office).EUCAST objectivesEUCAST was set up to standardize susceptibility testing inEurope so that comparable results and interpretations areproduced.EUCAST websitesThe EUCAST websites continue to be developed andupdated, and all EUCAST breakpoints and documents arefreely available from the website. Under “SusceptibilityTesting” a new section has been added on “Calibrationand Validation” of the EUCAST disk diffusion method. Inaddition, there is a new section on “Projects and DataSubmission” where laboratories are invited to participate inspecific projects to develop methods.The EUCAST methodology and breakpoints for a diskdiffusion method are available on the EUCAST website andtechnical documents relating to the method have recentlybeen updated. The section on “Frequently askedquestions” about EUCAST breakpoints and methodscontinues to be expanded as questions are received.The “News” section on the website has been extended andusers can now subscribe to the EUCAST website RSSfeed. This means that EUCAST news items can beautomatically presented on other websites or in thebrowsers of individual computers.EUCAST publicationsSee www.eucast.org.EUCAST expert rulesThe Expert Rules subcommittee (chairman RolandLeclercq) has updated the EUCAST expert rules and thenew version 2.0 has been published in Clinical Microbiologyand Infection (Epub ahead of print, October 2011) and isavailable from the EUCAST website. Major modificationsinclude, among others, deletion of previous expert rules onextended spectrum β-lactamases and carbapenemasesand rewording of expert rules on quinolones with Salmonellaspp. and β-lactams with Haemophilus influenzae. Thebasisof all these modifications is explained in the publication. Thesubcommittee has achieved its objectives and has nowbeen disbanded.Antimicrobial resistance mechanismsA new subcommittee on antimicrobial resistancemechanisms of clinical and/or epidemiological importancehas recently been set up (chairman Christian Giske). Theremit is to develop practical guidelines for detection ofresistance mechanisms.EUCAST disk diffusion methodThe EUCAST disk diffusion method calibrated to EUCAST clinicalMIC breakpoints is now well established with methodology andbreakpoints (v 2.0) available on the EUCAST website. Breakpointsand the disk diffusion technique are being developed for severaladditional organisms such as Listeria monocytoenes, Pasteurellamultocida, Campylobacter spp. and Corynebacterium spp.The EUCAST MIC and zone diameter website presents MIC andzone diameter distributions of bacteria and fungi based on acontinually increasing number of distributions. Graphs showingMIC-zone diameter correlations also continue to be expanded. Thedistributions highlight wild type populations and giveepidemiological cut-off values (ECOFFs).Antifungal breakpointsThe Antifungal Susceptibility Testing (AFST) subcommittee is astanding EUCAST subcommittee dealing with all issues related tobreakpoints and susceptibility testing for fungi. The AFST SteeringCommittee currently consists of Maiken C. Arendrup, (chairman),William Hope (secretary), Cornelia Lass-Floerl, and ManuelCuenca-Estrella. Rationale documents and technical notes forCandida spp. with amphotericin, posaconazole and anidulafungin,and for Aspergillus spp. with amphotericin, itraconazole andposaconazole are now available from the EUCAST website. Arevised version of the EUCAST reference method for susceptibilitytesting of fermentative yeasts (EDEF 7.1) was recently posted onthe EUCAST website for consultation.EUCAST activities 2011-2012BreakpointsBreakpoint tables v 2.0 were published on the EUCAST website inDecember 2011. Breakpoints for various fastidious organisms arebeing developed in collaboration with relevant ESCMID studygroups and through this process breakpoints for Clostridiumdifficile, Helicobacter pylori and Listeria monocytogenes wereadded.Breakpoints for new agentsBreakpoints for new agents are set by EUCAST as part of thelicensing process through EMA. Breakpoints were set fortelavancin and several other agents are currently at various stagesof the licencing procedure.Revision of breakpointsSeveral breakpoints, including ceftibuten for Enterobacteriaceaeand Streptococcus pneumoniae, fosfomycin for Pseudomonasspp., vancomycin for coagulase-negative staphylococci,nitrofurantoin for enterococci, phenoxymethylpenicillin andtrimethoprim for group B streptococci, and amoxicillin, amoxicillinclavulanate,chloramphenicol and rifampicin for Haemophilusinfluenzae, have been revised in the light of new information.Implementation of breakpointsIn Europe, the trend from using other breakpoint guidelines tousing EUCAST breakpoints and methods continues. In the EARS-Net resistance surveillance external quality assessment exercisein May 2011, EUCAST breakpoints were used by around 50% ofparticipating laboratories, compared with around 30% a yearearlier. Several more countries are in the process of changing orplan to change to EUCAST in the near future. The interest inEUCAST breakpoints from outside Europe is highlighted byAustralia joining the EUCAST General Committee.Automated systemsThe manufacturers of automated susceptibility testing devicescontinue to implement EUCAST breakpoints in their systems.Some outstanding issues are being dealt with at a considerablyslower pace than desirable. Up-to-date information on the currentEUCAST status of manufacturers is given on the EUCASTwebsite.EUCAST structureEUCAST is a standing ESCMIDcommittee, funded by ECDC, ESCMID,and participating national breakpointcommittees. It was formed in 1996 andrestructured at the ECCMID in Milan2002. It consists of a GeneralCommittee, with representatives from allEuropean countries, and is led by anESCMID-appointed Steering Committee,which includes a Chairman, ScientificSecretary, Clinical Data Coordinator, fiveNational Breakpoint Committeerepresentatives and three representativesof the EUCAST General Committee.Decisions are made by the SteeringCommittee after consultation with theGeneral Committee and expert groups.EUCAST General Committee meeting at ECCMID 2011