M59Epidemiological Cutoff Values for Antifungal Susceptibility Testing
This document includes epidemiological cutoff values and quality
control tables developed according to criteria provided in the
Clinical and Laboratory Standards Institute guideline M57.
A CLSI supplement for global application.
2nd Edition
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M59, 2nd ed.
January 2018
Replaces M59, 1st ed.
Epidemiological Cutoff Values for Antifungal Susceptibility Testing
Shawn R. Lockhart, PhD, D(ABMM)
Philippe J. Dufresne, PhD (RMCCM)
Mike Birch, PhD
Mariana Castanheira, PhD
Ana Espinel-Ingroff, PhD, MS
Jeff Fuller, PhD, FCCM, D(ABMM)
Mahmoud A. Ghannoum, PhD, EMBA, FIDSA
Kerian K. Grande Roche, PhD
John D. Turnidge, MD, BS, FRACP, FRCPA, FASM
Thomas J. Walsh, MD
Nathan P. Wiederhold, PharmD
Abstract
Clinical and Laboratory Standards Institute document M59Epidemiological Cutoff Values for Antifungal Susceptibility
Testing includes epidemiological cutoff values (ECVs) and quality control tables developed following the guidelines described
in CLSI document M57.1
These ECVs are valid only when developed following guidelines described in CLSI document M571 and when minimal
inhibitory concentrations/minimal effective concentrations are generated according to the CLSI reference broth dilution methods
described in CLSI documents M272 and M38.3
Clinical and Laboratory Standards Institute (CLSI). Epidemiological Cutoff Values for Antifungal Susceptibility Testing.
2nd ed. CLSI supplement M59 (ISBN 1-56238-840-1 [Print]; ISBN 1-56238-841-X [Electronic]). Clinical and Laboratory
Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087 USA, 2018.
The Clinical and Laboratory Standards Institute consensus process, which is the mechanism for moving a document through
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M59, 2nd ed.
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Suggested Citation
CLSI. Epidemiological Cutoff Values for Antifungal Susceptibility Testing. 2nd ed. CLSI supplement M59.
Wayne, PA: Clinical and Laboratory Standards Institute; 2018.
Previous Edition:
April 2016
ISBN 1-56238-840-1 (Print)
ISBN 1-56238-841-X (Electronic)
ISSN 1558-6502 (Print)
ISSN 2162-2914 (Electronic) Volume 38, Number 5
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Contents
Abstract .................................................................................................................................................... i
Committee Membership ........................................................................................................................ iii
Foreword .............................................................................................................................................. vii
Terminology ........................................................................................................................................... ix
Table 1. Epidemiological Cutoff Values for In Vitro Susceptibility Testing of Various
Candida spp. With No Breakpoints ........................................................................................................ 1
Table 2. Epidemiological Cutoff Values for In Vitro Susceptibility Testing of Various
Cryptococcus spp. With No Breakpoints ................................................................................................ 3
Table 3. Epidemiological Cutoff Values for In Vitro Susceptibility Testing of Various
Aspergillus spp. With No Breakpoints .................................................................................................... 5
Table 4. Epidemiological Cutoff Values for In Vitro Susceptibility Testing of
Candida spp. With Breakpoints .............................................................................................................. 7
Glossary. Antifungal Agent Abbreviation(s), Route(s) of Administration, and Drug Class .................. 9
References ............................................................................................................................................. 11
The Quality Management System Approach ........................................................................................ 12
Related CLSI Reference Materials ....................................................................................................... 13
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Foreword
With the development of standard methodologies for testing susceptibility of fungal species to several
antifungal agents, minimal inhibitory concentration (MIC)/minimal effective concentration (MEC)
distributions are available to determine epidemiological cutoff values (ECVs) for Candida spp.,
Cryptococcus spp., and Aspergillus spp. for antifungal agents. The ECVs provided as supplemental
information in this document were established using the guidelines published in CLSI document M57.1 The
ECV is the MIC or MEC value that defines the upper limit of the wild-type (WT) distribution and is useful
for distinguishing between WT isolates without intrinsic or acquired resistance mechanisms and non-wild-
type isolates harboring intrinsic or acquired resistance mechanisms. Users of CLSI documents M27,2 M60,4
M38,3 and M615 should be aware that ECVs do not classify isolates as treatable (susceptible) or nontreatable
(resistant) as breakpoints do. In lieu of breakpoints, ECVs alone can be useful to clinicians when deciding
whether to treat a patient with a certain agent (see CLSI document M571); however, they do not predict
therapeutic response. For ECVs to be clinically useful, the MIC or MEC should be determined by following
the broth microdilution procedure for yeasts (see CLSI document M272) or the broth microdilution
procedure for filamentous fungi (see CLSI document M383).
Overview of Changes
This document replaces the previous edition of the approved document, M59, 1st ed., published in 2016.
Several changes were made in this edition, including:
Table 1. Epidemiological Cutoff Values for In Vitro Susceptibility Testing of Candida spp.
With No Breakpoints:
Title revised as: “Epidemiological Cutoff Values for In Vitro Susceptibility Testing of Various
Candida spp. With No Breakpoints”
Added ECVs for posaconazole and fluconazole and various Candida spp.
Deleted footnote (*) and renumbered all subsequent footnotes
Added a footnote (*) regarding the need to validate other susceptibility testing methods against the
reference broth microdilution method (see CLSI document M272) before reporting ECVs
Added a footnote (§) regarding the species included with ECVs for C. parapsilosis complex
Added a footnote (¶) regarding the timeframe for adopting posaconazole ECVs
Table 2. Epidemiological Cutoff Values for In Vitro Susceptibility Testing of Cryptococcus spp.
With No Breakpoints:
Title revised as: “Epidemiological Cutoff Values for In Vitro Susceptibility Testing of Various
Cryptococcus spp. With No Breakpoints”
New table with footnotes and references added with ECVs for various Cryptococcus spp.
Subsequent tables renumbered
Table 3 (formerly Table 2). Epidemiological Cutoff Values for In Vitro Susceptibility Testing of
Aspergillus spp. With No Breakpoints:
Title revised as: “Epidemiological Cutoff Values for In Vitro Susceptibility Testing of Various
Aspergillus spp. With No Breakpoints”
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Deleted footnote (*) and renumbered all subsequent footnotes
Added a footnote (‡) regarding the need to validate other susceptibility testing methods against the
reference broth microdilution method (see CLSI document M383) before reporting ECVs
Table 4 (formerly Table 3). Epidemiological Cutoff Values for In Vitro Susceptibility Testing of
Candida spp. With Breakpoints:
Added ECVs for fluconazole and voriconazole for various Candida spp.
Revised footnote (*) to remove redundant information
Added a footnote (§) regarding the need to validate other susceptibility testing methods against the
reference broth microdilution method (see CLSI document M272) before reporting ECVs
Added a footnote (¶) regarding the timeframe for adopting posaconazole and voriconazole ECVs
Added a footnote (#) regarding the species included with ECVs for C. parapsilosis complex
Glossary. Antifungal Agent Abbreviation(s), Route(s) of Administration, and Drug Class:
Added footnote (‡) regarding the availability of IV itraconazole in the United States
Request for antifungal susceptibility testing data from fungal pathogens needed for the
development of ECVs to be included in future editions of M59:
The Working Group on Antifungal Epidemiological Cutoff Values is requesting submission of raw
antifungal susceptibility testing data for yeasts and filamentous fungi using the protocols provided in the
most current editions of CLSI documents M27, Reference Method for Broth Dilution Antifungal
Susceptibility Testing of Yeasts, and M38, Reference Method for Broth Dilution Antifungal Susceptibility
Testing of Filamentous Fungi. This request is only for reference broth microdilution and should not
include data generated using commercially available panels. Because the data will be combined with data
from other laboratories, even a small amount of data is useful, especially for the more infrequently
identified species. All species should be identified using a molecular assay or matrix-assisted laser
desorption/ionization time-of-flight mass spectrometry.
A standardized worksheet for data submission is available on the CLSI website at
http://clsi.org/standards/micro/sub-antifungal/. This worksheet can also be requested by contacting CLSI
at [email protected]. Completed worksheets can be submitted to CLSI directly at [email protected].
NOTE: The content of this document is supported by the CLSI consensus process and does not necessarily
reflect the views of any single individual or organization.
Key Words
Epidemiological cutoff value, minimal effective concentration, minimal inhibitory concentration,
non-wild-type, wild-type
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©Clinical and Laboratory Standards Institute. All rights reserved. 1
Table 1. Epidemiological Cutoff Values for In Vitro Susceptibility Testing of
Various Candida spp. With No Breakpoints1-6
Antifungal Agent Species ECV, µg/mL*,†,‡
Amphotericin B C. albicans 2
C. glabrata 2
C. krusei 2
C. parapsilosis§ 2
C. tropicalis 2
Anidulafungin C. dubliniensis 0.12
C. lusitaniae 1
Fluconazole¶ C. dubliniensis 0.5
C. guilliermondii 8
C. lusitaniae 1
Itraconazole C. glabrata 4
C. krusei 1
C. lusitaniae 1
C. tropicalis 0.5
Micafungin C. dubliniensis 0.12
C. lusitaniae 0.5
Posaconazole# C. albicans 0.06
C. glabrata 1
C. guilliermondii 0.5
C. krusei 0.5
C. lusitaniae 0.06
C. parapsilosis§ 0.25
C. tropicalis 0.12
Voriconazole¶ C. glabrata 0.25 * The ECVs in M59 were established using broth microdilution as outlined in CLSI document M27.1 If another methodology
is used for susceptibility testing, this method must be validated against broth microdilution before using the ECVs, just as
validation of other methods must be performed before using breakpoints established using broth microdilution. † ECVs capture ≥ 97.5% of the statistically modeled population. ECVs may overlook potentially resistant isolates (NWT).
‡ If the 24-hour growth control shows insufficient growth, incubate for an additional 24 hours.
§ The ECV established for posaconazole and amphotericin B are for the C. parapsilosis species complex, which may include
isolates of C. orthopsilosis and C. metapsilosis.
¶ Fluconazole, posaconazole, and voriconazole ECVs were adopted by the Subcommittee on Antifungal Susceptibility Tests
during an electronic vote held in February 2017.
Abbreviations: ECV, epidemiological cutoff value; NWT, non-wild-type.
NOTE: Information in bold is new or modified since the previous edition.
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©Clinical and Laboratory Standards Institute. All rights reserved. 2
Table 1. (Continued)
References for Table 1
1 CLSI. Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts. 4th ed. CLSI
standard M27. Wayne, PA: Clinical and Laboratory Standards Institute; 2017.
2 Dalhoff A, Ambrose PG, Mouton JW. A long journey from minimum inhibitory concentration testing
to clinically predictive breakpoints: deterministic and probabilistic approaches in deriving breakpoints.
Infection. 2009;37(4):296-305.
3 Pfaller MA, Espinel-Ingroff A, Bustamante B, et al. Multicenter study of anidulafungin and micafungin
MIC distributions and epidemiological cutoff values for eight Candida species and the CLSI M27-A3
broth microdilution method. Antimicrob Agents Chemother. 2014;58(2):916-922.
4 Pfaller MA, Espinel-Ingroff A, Canton E, et al. Wild-type MIC distributions and epidemiological cutoff
values for amphotericin B, flucytosine, and itraconazole and Candida spp. as determined by CLSI broth
microdilution. J Clin Microbiol. 2012;50(6):2040-2046.
5 Turnidge J, Kahlmeter G, Kronvall G. Statistical characterization of bacterial wild-type MIC value
distributions and the determination of epidemiological cut-off values. Clin Microbiol Infect.
2006;12(5):418-425.
6 CLSI. Principles and Procedures for the Development of Epidemiological Cutoff Values for Antifungal
Susceptibility Testing. 1st ed. CLSI guideline M57. Wayne, PA: Clinical and Laboratory Standards
Institute; 2016.
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©Clinical and Laboratory Standards Institute. All rights reserved. 12
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
Facilities and Safety Equipment Information Management Continual Improvement
M59 covers the QSE indicated by an “X.” For a description of the other documents listed in the grid, please refer to
the Related CLSI Reference Materials section.
Org
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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 laboratory 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.
M59 covers the medical laboratory path of workflow processes indicated by an “X.” For a description of the other
documents listed in the grid, please refer to the Related CLSI Reference Materials section.
Preexamination Examination Postexamination
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M27 M27 M27 M27 M27
M38 M38 M38 M38 M38
M60 M60 M60
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©Clinical and Laboratory Standards Institute. All rights reserved. 13
Related CLSI Reference Materials M27 Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts. 4th ed., 2017. This
standard covers antifungal agent selection and preparation, test procedure implementation and interpretation, and
quality control requirements for susceptibility testing of yeasts that cause invasive fungal infections.
M38 Reference Method for Broth Dilution Antifungal Susceptibility Testing of Filamentous Fungi. 3rd ed.,
2017. This standard includes 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.
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
epidemiological cutoff values for guiding clinical decisions when testing fungal species and antifungal agent
combinations for which there are no breakpoints.
M60 Performance Standards for Antifungal Susceptibility Testing of Yeasts. 1st ed., 2017. This document
includes updated minimal inhibitory concentration, zone diameter, and quality control tables for the Clinical and
Laboratory Standards Institute antifungal susceptibility testing documents M27 and M44.
M61 Performance Standards for Antifungal Susceptibility Testing of Filamentous Fungi. 1st ed., 2017. This
document provides updated quality control tables for the Clinical and Laboratory Standards Institute antifungal
susceptibility testing documents M38 and M51.
CLSI documents are continually reviewed and revised through the CLSI consensus process; therefore, readers should refer to the
most current editions.
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