This primarily includes what performance metrics will be essential to lessen the exposure of contamination from hospitals or biomedical research units, and secondarily, what advances will be necessary to reduce the incorporation of sophisticated external circuits, pumps, and pneumatic systems in maintaining the flow continuity in microfluidic platform To address these issues, the paper-based detection system seems to be an attractive approach in developing a cost-effective, automated, and incinerable platform for the determination of susceptibility. Kalashnikov M., Lee J.C., Campbell J., Sharon A., Sauer-Budge A.F. Careers. Evaluator device with broth microdilution and E test device from AB Biodisk for antimicrobial susceptibility testing of Enterobacteriaceae [abstract P859], Program and abstracts of the 18th Annual Meeting of the European Congress on Clinical Microbiololgy and Infectious Diseases (Barcelona). Nineteenth informational supplement M100-S19, Evaluation of the BIOMIC video reader for determining interpretive categories of isolates on the basis of disk diffusion susceptibility results, Comparison and evaluation of Osiris and Sirscan 2000 antimicrobial susceptibility systems in the clinical microbiology laboratory, Susceptibility testing instrumentation and computerized expert systems for data analysis and interpretation, Clinical impact of rapid in vitro susceptibility testing and bacterial identification, Clinical and financial benefits of rapid bacterial identification and antimicrobial susceptibility testing, Selection of antimicrobial agents for routine testing in a clinical microbiology laboratory, Development of in vitro susceptibility testing criteria and quality control parameters; approved guideline, Selection criteria for an antimicrobial susceptibility testing system, Class II special controls guidance document: antimicrobial susceptibility test (AST) systems; guidance for industry and FDA, International Organization for Standardization, Clinical laboratory testing and in vitro diagnostic test systemssusceptibility testing of infectious agents and evaluation of performance of antimicrobial susceptibility test devices. The present and future role of microfluidics in biomedical research. Furthermore, to avoid the indiscriminate use of antibiotics and the evolution of antibiotic resistance, the dosage scheme should also consider the method of antibiotic administration (e.g., oral versus intravenous (IV) administration) and the site of infection, along with the AST results [95]. 2014 Apr 12;174(15):382. doi: 10.1136/vr.102169. Disk diffusion test. The occurrence of disinfectant and antibiotic-resistant genes in Escherichia coli isolated from chickens in Egypt. A rise in antibiotic resistance is a certainty, therefore we must develop technologies that will permit rapid AST (within an hour) and are non-invasive (saliva- or urine-based) or minimally invasive. A recent, international standard on susceptibility test device evaluation proposes similar but not identical criteria for acceptable accuracy [23]. Furthermore, SBCSs combine detection, gram status, and identification in blood culture (BC) instruments, thus ensuring the evaluation of susceptibility within 812 h, whereas the conventional blood culture system requires up to 48 h because of incubation for colony generation and susceptibility testing. . doi: 10.1371/journal.pone.0223467. One of the significant advantages of the Etest is its sensitivity; it can detect extended-spectrum beta-lactamase (ESBL), even in a trace amount [55]. FQR = fluoroquinolone resistant. DL IST card covers nearly 200 types of antibiotics with multi-level concentration While the earliest association of humans and antimicrobial agents may have come about through casual and later purposeful contact with soil laden with antibiotic-producing strains of Streptomyces and other Actinomyces, the first method for assessing antimicrobic susceptibility was developed by Fleming (1929) after his serendipitous . Microdilution panels are typically prepared using dispensing instruments that aliquot precise volumes of preweighed and diluted antibiotics in broth into the individual wells of trays from large volume vessels. The high priority bacteria included vancomycin-resistant Enterococcus faecium, methicillin-resistant Staphylococcus aureus (MRSA), clarithromycin-resistant Helicobacter pylori, fluoroquinolone-resistant Campylobacter spp., penicillin-resistant Streptococcus pneumoniae, ampicillin-resistant Haemophilus influenzae, and fluoroquinolone-resistant Shigella spp. View Antibiotic Sensitivity Testing Lab.docx from BIO 150 at Northern Virginia Community College. Would you like email updates of new search results? << /Length 5 0 R /Filter /FlateDecode >> Although the use of dyes is simple and easy over other molecular techniques, the requirement of a high-resolution A charge-coupled device camera (CCD) and sophisticated instruments for signal amplification and observation are restricted to resource-limited areas. Pour over surface of nutrient agar plate, let gel. Antimicrobial susceptibility of Brachyspira hyodysenteriae determined by a broth microdilution method. It also determines the ability of the drug to kill the bacteria. Several emerging methods, such as microfluidic-based optical and electrochemical AST have been critically evaluated. Khan Z.A., Siddiqui M.F., Park S. Progress in antibiotic susceptibility tests: A comparative review with special emphasis on microfluidic methods. Van Boeckel T.P., Gandra S., Ashok A., Caudron Q., Grenfell B.T., Levin S.A., Laxminarayan R. Global antibiotic consumption 2000 to 2010: An analysis of national pharmaceutical sales data. Applied Veterinary Bacteriology and Mycology: Bacteriological Techniques. Integrated microfluidic devices, generally referred to as micro total analysis systems (TAS), are proficient in performing molecular diagnostics [76]. At times, the intermediate result can also mean that certain variables in the susceptibility test may not have been properly controlled, and that the values have fallen into a buffer zone separating susceptible from resistant strains [13, 20]. Fast Antibiotic Susceptibility Testing (FASTest) based on single cell growth rate measurements. False-positive results due to changes in physical parameters are also a major problem. The https:// ensures that you are connecting to the Another possible explanation requires considering the mode of antibiotic action. What is Nephelometry,and a fully automated Nephlometer analyzer for protein a University Institute of Pharmaceutical Sciences. The following are available online at https://www.mdpi.com/2075-4418/9/2/49/s1. Coupling fluorescent/colorimetric tools with the ubiquitous and ever-evolving smartphones will enable us with on-site monitoring, real-time database updates, and the generation of an antibiotic susceptibility map to help us understand the geographical prevalence of resistance. Report of an international collaborative study. Thus, the understanding of the genetic makeover and the morpho-anatomical changes in bacteria are of prime importance to counteracting the resistance mechanism. The concentration dependence within the latter group was even weaker than linear, which may indicate the existence of a range of susceptibility of the test organism to these antibiotics, rather than a single cut-off concentration. [11]. Kirby Bauer Antibiotic Sensitivity Test PRINCIPLE Antibiotic discs are placed over the lawn of test organism on the surface of media. The WalkAway utilizes standard size microdilution trays that are hydrated and inoculated manually and then placed in one of the incubator slots in the instrument. An alternative test that can be performed is the determination of the amount of antibiotic required to either inhibit the growth of organism or to kill the organism which is done by incubating a fixed concentration of the organism in increasing concentrations of antibiotics and checking for growth after 24h of incubation.. Bethesda, MD 20894, Web Policies Similarly, bioluminescence or ATP bioluminescence assay (ATP-BLA) is an enzyme-based approach mediated by luciferase enzyme that converts luciferin substrate to oxyluciferin in the presence of ATP, leading to an emission of light [87]. Federal government websites often end in .gov or .mil. Skov R., Smyth R., Larsen A.R., Bolmstrom A., Karlsson A., Mills K., Frimodt-Moller N., Kahlmeter G. Phenotypic detection of methicillin resistance in Staphylococcus aureus by disk diffusion testing and Etest on Mueller-Hinton agar. Hence, efforts to expand our understanding, especially for the development of a user-friendly device with multiplexing, would be valuable. The threat of antimicrobial resistance in developing countries: Causes and control strategies. (b) Etest gradient disk diffusion, adapted from Sader [30], under terms of the Creative Commons attribution license. The Kirby-Bauer test deemed to be effective in determining the susceptibility of microbes. 2011 Dec;6(4):CL2-43. Digital PCR-High Resolution Melt analysis (HRM)-based bacterial identification from mixed bacterial samples, reproduced with permission from [71], published by American Chemical Society, 2017. MIC measurement cannot be determined from this qualitative test, which simply classifies the isolate as susceptible, intermediate or resistant. Use of old or outdated information from the original editions of FDA-approved drug labels or older CLSI tables could represent a serious shortcoming in the reporting of patients' results. Epub 2019 Mar 2. Pasteur, Lister, Koch, and Ehrlich were listed as the pioneers in the field of bacteriology, and they worked on the concept of macrodilution [32]. 2. Moreover, an inability to test a wide range of clinically relevant bacteria (e.g., S. pneumonia), antimicrobial agents (e.g., vancomycin), and heteroresistant isolates, as well as a limited panel capacity and the high cost of instruments and consumables, are all significant issues that restrict these systems from frequent analysis [66]. Plates are incubated for 1624 h at 35C prior to determination of results. Resistant Intermediate Susceptible Amikacin 10 g 11 12-13 . A sensitivity analysis is a test that determines the "sensitivity" of bacteria to an antibiotic. about navigating our updated article layout. Kirby Bauer tests also known as the Disc diffusion test is used for antibiotic susceptibility testing. Vitek and Pheonix detect growing bacteria on the basis of turbidity, whereas comparable automated systems like MicroScan WalkAway (Beckman Coulter, Inc. Atlanta, Georgia, USA) and Sensititre ARIS 2X (are based on fluorescence emission of the growing bacteria. Kassim A., Omuse G., Premji Z., Revathi G. Comparison of Clinical Laboratory Standards Institute and European Committee on Antimicrobial Susceptibility Testing guidelines for the interpretation of antibiotic susceptibility at a University teaching hospital in Nairobi, Kenya: A cross-sectional study. Dip a sterile swab into the suspension and rotate it against the side of the tube above the fluid level in order to remove . In 1929, Alexander Fleming performed the serial dilution technique to understand the activity of antibiotics. official website and that any information you provide is encrypted In this article, the authors review the socio-economic burden and emergence of antibiotic resistance. Patel J.B., Tenover F.C., Turnidge J.D., Jorgensen J.H. The MicroScan WalkAway (Siemens Healthcare Diagnostics) is a large self-contained incubator/reader device that can incubate and analyze 4096 microdilution trays. Baltekin ., Boucharin A., Andersson D.I., Elf J. Adding to this, the same group was able to evaluate multiple antibiotic sensitivities in real-time in polymicrobial culture bacterial strains (namely, E. coli, P. aeruginosa, and K. pneumoniae) simultaneously. L. Barth Reller, Melvin Weinstein, James H. Jorgensen, Mary Jane Ferraro, Antimicrobial Susceptibility Testing: A Review of General Principles and Contemporary Practices, Clinical Infectious Diseases, Volume 49, Issue 11, 1 December 2009, Pages 17491755, https://doi.org/10.1086/647952. Incubate: antibiotic will diffuse into medium as cells grow. In the 1950s, experiments by Gould and Bowie (1952) and Stokes (1955) enabled the differentiation between susceptible and resistant bacteria through the multiple disk diffusion technique [21,22]. . When the culture media is supplemented with antibiotic and resazurin, a uniform intense blue color is obtained in the beginning. Broth dilution tests. Manufacturers of commercially prepared panels have attempted to deal with this problem by offering a number of different standard panel configurations, or by including fewer dilutions of each drug in a single panel [19]. Antibiotic susceptibility testing , ACT antimicrobial susceptibility testing, inoculation and drug sensitivity, Kirby bauer Antibiotic Sensitivity Testing, Antimicrobial susceptibility test and assay bls 209. Free access to premium services like Tuneln, Mubi and more. Optimal interpretation of MICs requires knowledge of the pharmacokinetics of the drug in humans, and information on the likely success of a particular drug in eradicating bacteria at various body sites [20]. It is important that the tables used for susceptibility test interpretations represent the most current criteria. The two basic types of dilution are microdilution and macrodilution, wherein broth and agar are the most commonly used mediums. Methods of assay. Lehninger Principles of Biochemistry 7th Edition David L Nelson, Michael M. Cox. Therefore, rapid diagnostic plays a pivotal role in the treatment of bacterial infection. E-TEST. The principal disadvantages of the macrodilution method were the tedious, manual task of preparing the antibiotic solutions for each test, the possibility of errors in preparation of the antibiotic solutions, and the relatively large amount of reagents and space required for each test. 8600 Rockville Pike Bondi A., Jr., Spaulding E.H., Smith D.E., Dietz C.C. Similarly, resazurin can be utilized in colorimetric detection. Colorimetric detection and multiplexing are the attractive features of these techniques. Gould J.C. Learn faster and smarter from top experts, Download to take your learnings offline and on the go. Bernardo K., Pakulat N., Macht M., Krut O., Seifert H., Fleer S., Hnger F., Krnke M. Identification and discrimination of Staphylococcus aureus strains using matrix-assisted laser desorption/ionization-time of flight mass spectrometry. eCollection 2019. Antibiotic Sensitivity Tests Hari Krishnan K. Looks like youve clipped this slide to already. Kreidl P, Kirchner T, Fille M, Heller I, Lass-Flrl C, Orth-Hller D. PLoS One. 2020 Dec 11;25(24):5848. doi: 10.3390/molecules25245848. Jorgensen J.H., Turnidge J.D., Washington J.A., Murray P.R., Pfaller M.A., Tenover F.C., Baron E.J., Yolken R.H. Phelps E.B. The antibiotic which inhibits the growth to a large (greater) extent is concluded to be the best one to treat the infection by the said microbe. These benefits are best realized when coupled with extended laboratory staffing schedules, and real-time, electronic transmission of verified results. Progression in optical imaging has developed various image sensors with high sensitivity and resolution that are capable of biological analysis. However, newer or emerging mechanisms of resistance require constant vigilance regarding the ability of each test method to accurately detect resistance. K Hari Krishnan II MBBS (2009-'11) Tirunelveli Medical College Tirunelveli, Tamilnadu, India. In the past decades, numerous conventional and automated strategies have been successfully embraced to diagnose the ever-increasing antibiotic resistance in bacteria [77]. An official website of the United States government. Stokes E.J. Finally, the challenges related with AST and its outlook in the future are presented. By accepting, you agree to the updated privacy policy. A test done to check the effectiveness of a drug against a bacterium and to select the best drug that acts against the bacterium. wrote and edited the manuscript. Rapid identification and susceptibility testing of uropathogenic microbes via immunosorbent ATP-bioluminescence assay on a microfluidic simulator for antibiotic therapy. This method has been well standardized for most fastidious bacteria [13]. AI and Machine Learning Demystified by Carol Smith at Midwest UX 2017, Pew Research Center's Internet & American Life Project, Harry Surden - Artificial Intelligence and Law Overview, No public clipboards found for this slide. 3. The turbidimetric method is characterized by a series of tubes containing different concentrations of antibiotics in a liquid culture medium inoculated with the test microorganism.Reading data obtained after incubation provides a curve displaying the antibiotic concentration with turbidity. Search for other works by this author on: Department of Pathology, The University of Texas Health Science Center, Reprints or correspondence: Dr James H. Jorgensen, Dept of Pathology, University of Texas Health Science Center, 7703 Floyd Curl Dr, San Antonio, TX 78229-7750 (, Departments of Medicine, Massachusetts General Hospital and Harvard Medical School, Antibiotic sensitivity testing: report of an international collaborative study, Antibacterial susceptibility tests: dilution and disk diffusion methods, Current techniques for antibiotic susceptibility testing, Clinical and Laboratory Standards Institute, Methods for dilution antimicrobial susceptibility testing for bacteria that grew aerobically. MR = meticillin resistant. On the antibacterial action of cultures of a penicillium, with special reference to their use in the isolation of B. influenzae. Then, an overview of several emerging approaches such as fluorescent, colorimetric, and electrochemical microfluidic sensors, with their related caveats, are discussed (Supplementary Table S2). Mohan R., Sanpitakseree C., Desai A.V., Sevgen S.E., Schroeder C.M., Kenis P.J.A. Report of Advisory Committee on Official Water Standards. In this proof-of-principle study, we demonstrate the operation with four antibiotics and mixed samples with combinations of seven species. The system is more limited with a 45-well card and does not include S. pneumoniae . [68]. The prominent events in the generation of bacterial resistance include inactivation of the porin channel, modification of antibiotic targets, and neutralizing antibiotic efficacy through enzymatic action [3]. Standardized methods and quality control limits for agar and broth microdilution susceptibility testing of Mycoplasma pneumoniae, Mycoplasma hominis, and Ureaplasma urealyticum. Growth is determined by fluorescence measurement after 1824 h of incubation. Apart from that, other potential limitations include: experimental space, tedious dilution steps (macrodilution), the possibility of false positive results due to long incubation times [43], chances of cross-contamination, bacterial incompatibility for growth, and the inability of discriminating viable and nonviable bacteria. Following overnight incubation at 35C, the tubes were examined for visible bacterial growth as evidenced by turbidity. Webster T.A., Sismaet H.J., Goluch E.D. A good correlation between the electrical signal drop and the viability of P. aeruginosa cells in the presence of antibiotics was successfully demonstrated. There are 4 automated instruments presently cleared by the FDA for use in the United States. A method of calculating the numbers of B. coli from the results of dilution tests. E test, an antimicrobial susceptibility testing method with broad clinical and epidemiologic application. Molecular mechanisms of antibiotic resistance. Agar dilution follows the principle of establishing the lowest concentration of the consecutively diluted antibiotic concentration at which bacterial growth is still inhibited. The collaboration of academic research and commercial firms with transparent technology distribution might offer a compelling solution for multiplexing and for more-straightforward fabrication. Front Microbiol. Evaluation of four newer antimicrobial agents in the Avantage susceptibility test system. Although novel drugs have shown much promise against these resistant bacteria, their rapid diagnostic is still a huge concern (Supplementary Table S1). The Etest (bioMrieux AB BIODISK) ( Figure 2) is a commercial version available in the United States. Waites K.B., Duffy L.B., Bbar C.M., Matlow A., Talkington D.F., Kenny G.E., Totten P.A., Bade D.J., Zheng X., Davidson M.K. Vergara A., Zboromyrska Y., Mosqueda N., Morosini M.I., Garca-Fernndez S., Roca I., Cantn R., Marco F., Vila J. In this review, we concisely discuss the advantages and limitations of various tools for AST (Supplementary Table S2). Athamanolap P., Hsieh K., Chen L., Yang S., Wang T.H. We've encountered a problem, please try again. Moreover, a single antibiotic was focused on susceptibility testing (i.e., penicillin). A Method for determining Sensitivity to Penicillin and Streptomycin. Rodriguez F.D., Simonsson P., Alling C. A method for maintaining constant ethanol concentrations in cell culture media. Elavarasan T., Chhina S.K., Ash M.P., Sankaran K. Resazurin reduction based colorimetric antibiogram in microfluidic plastic chip. K Hari Krishnan Tirunelveli Medical College. Beyond the brain localization of complex traits: Distributed white matter markers of personality. There are several aspects of this in vitro testing that are important to understand. 6-2 The antibiotic disk sensitivity test. (0.04 units) is used in comparison to sensitivity disks (10 units). This site needs JavaScript to work properly. In . The MIC is determined by the intersection of the lower part of the ellipse shaped growth inhibition area with the test strip. With this principle we derive a single . The amplified target can be confirmed for the presence of resistance genes through electrophoresis, southern blotting, restriction fragment-length polymorphism, single-strand conformation polymorphism (SSCP), DNA fingerprinting, molecular beacons, and other DNA sequencing analysis methods (Figure 3) [68,69]. In LAMP, the gene of interest is amplified at a constant temperature of 6065 C using a Bst DNA polymerase instead of Taq polymerase because of strong strand displacement activity (required in isothermal techniques) [70]. Discovery, research, and development of new antibiotics: The WHO priority list of antibiotic-resistant bacteria and tuberculosis. Demonstration of sensors for antibacterial susceptibility testing involving (a) an optical microfluidics biosensor, showing optical detection of microbial cultures, reproduced with permission from [83], published by RCS Advances, 2015; and (b) an electrochemical biosensor, detection was based on hybridization of the target bacterial 16S rRNA with a detector probe, adapted with permission from Liu [86] (under terms of the Creative Commons attribution license). School of Mechanical Engineering, Korea University of Technology and Education, Cheonan, Chungnam 31253, Korea; Received 2019 Mar 18; Accepted 2019 Apr 28. In some cases, it has been necessary to employ special ancillary testing methods (eg, single concentration screening agars, modified Hodge test for carbapenemase production) [13] to supplement routine testing by a commercial instrument system. antibiotic sensitivity test principle and procedure. Chin C.D., Laksanasopin T., Cheung Y.K., Steinmiller D., Linder V., Parsa H., Wang J., Moore H., Rouse R., Umviligihozo G., et al. The laboratory must test and report the antimicrobial agents that are most appropriate for the organism isolated, for the site of the infection, and the institution's formulary [13, 19]. PRINCIPLE: The discs-diffusion test is based on the fact that for a given antibiotic, the size of the zone inhibition is inversely related to MIC (determined by dilution method) of the strain being tested when the test conditions are held constant. stream Real-time and rapid detection are possible, as 16s rRNA is highly specific for the bacterial pathogens in blood culture and does not need prior purification. The antibiotics which have threatened bacteria for decades are under grave threat themselves. Weve updated our privacy policy so that we are compliant with changing global privacy regulations and to provide you with insight into the limited ways in which we use your data. Joyce L.F., Downes J., Stockman K., Andrew J.H. Sellenriek P., Holmes J., Ferrett R., Drury R., Storch G.A. The site is secure. An intermediate result indicates that a microorganism falls into a range of susceptibility in which the MIC approaches or exceeds the level of antibiotic that can ordinarily be achieved and for which clinical response is likely to be less than with a susceptible strain. This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (NRF-2015R1C1A1A01054762). 2. May 20, 2021; promedica flower hospital npi; inventory management decisions ppt . All the proposed methods were inaccurate, unsuitable, and unreliable for routine testing because of discrepancies in results obtained from different labs [23]. Assorted studies reveal its significance in discriminating MRSA, MSSA, and other bacterial strains where susceptible and resistant bacteria have been evaluated through spectral peak analysis. Rapid antimicrobial susceptibility determination of uropathogens in clinical urine specimens by use of ATP bioluminescence. Animation . C@BrPp(e!h E-test is a laboratory test used to determine minimum inhibitory concentration (MIC) and whether or not a specific strain of bacterium or fungus is susceptible to the action of a specific antibiotic. encoding by mefA gene) has been reported [ 10 ]. Click here to review the details. The gradient diffusion method has intrinsic flexibility by being able to test the drugs the laboratory chooses. Advanced Techniques in Diagnostic Microbiology. PNS = penicillin non-susceptible. In the late 1980s, Bolmstrm and Eriksson developed this test [45]. ClaR = clarithromycin resistant. Besides several advantages, there are some limitations that cannot be ignored, primarily related to the inaccurate and inconsistent behavior of the Etest for certain antibacterial agents, such as Penicillin, ciprofloxacin, ofloxacin, and rifampicin [56]. Kim S., Masum F., Jeon J.S. Current Test Methods and Future Directions, Receive exclusive offers and updates from Oxford Academic, Lessons Learned from the Anaerobe Survey: Historical Perspective and Review of the Most Recent Data (20052007), Development and Evaluation of the Spiral Gradient Endpoint Method for Susceptibility Testing of Anaerobic Gram-Negative Bacilli. Thank you for submitting a comment on this article. Micrococci and streptococci are also inhibited by 0.04 units disc, while all coagulase-negative staphylococci are resistant. We've updated our privacy policy. Lack of standardization creates a problem in the 1960s and later Kirby and Bauer reviewed the description. Standardized disk diffusion was introduced by Bauer and Kirbys experiments in 1956, after finalizing all aspects of optimization by changing physical conditions [12]. An important task of the clinical microbiology laboratory is the performance of antimicrobial susceptibility testing of significant bacterial isolates. The Vitek 2 employs repetitive turbidimetric monitoring of bacterial growth during an abbreviated incubation period. Nevertheless, the most-practiced techniques, such as disk diffusion and microdilution, have a high chance of cross-contamination, laborious protocols, lengthy processing times, improper power supplies, and cumbersome set-ups that render their application in resource-limited regions, and unfortunately, these regions have a higher rate of resistance too [2,6]. The innovative VITEK 2 microbial identification system includes an expanded identification database, the most automated platform available, rapid results, improved confidence, with minimal training time. HHS Vulnerability Disclosure, Help The disk diffusion susceptibility method [2, 11, 12] is simple and practical and has been well-standardized. Therefore, more research work on paper microfluidic AST would be beneficial in the future. The historical perspective on conventional methods that have paved the way for modern AST like disk diffusion, Epsilometer test (Etest), and microdilution, is presented. The Novobiocin is an antibiotic interfering with the unpackaging and repackaging of DNA during DNA replication and the bacterial cell cycle. Antibiotics and Antibiotic Resistance Genes in Natural Environments. Some methods provide quantitative results (eg, minimum inhibitory concentration), and all provide qualitative assessments using the categories susceptible, intermediate, or resistant.
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