showed a lower agreement of 94% for erythromycin as well, but observed no very major errors for trimethoprim-sulfamethoxazole. Some other studies on direct methods for AST showed some very major errors for trimethoprim-sulfamethoxazole [15, 16, 18], but only Kerremans et al. [13] found a very high percentages of very major errors for this antibiotic in GPC, but not in GNR. Therefore, we conclude

that the direct Phoenix method using SSTs can be used to reliably report results of AST for GPC, except for trimethoprim-sulfamethoxazole and erythromycin. The direct method of AST for GNR showed very good agreement with conventional methods for both Enterobacteriaceae and Pseudomonas species, comparable to the routinely used method, with essential agreements and categorical agreements of over 95% for all antibiotics check details tested (see table 3). Both very major errors occurred with trimethoprim-sulfamethoxazole Tucidinostat datasheet in Pseudomonas aeruginosa strains that were correctly identified. For these strains, it would never be considered an adequate treatment, due to intrinsic resistance. These errors thus would not have clinical

consequences. Funke et al. [18] also described a categorical agreement of 99.0%, which is comparable with or higher than results from studies on other direct methods of AST [7, 13–16, 26]. Therefore, we conclude that also for GNR, results of the direct Phoenix method for AST can be used to guide antibiotic therapy in bloodstream infections. The strains tested in this study are a representative

sample of the strains most frequently encountered in clinical practice. A limitation of the study is the low number of tested Enterococcus and Pseudomonas strains (3 and 7, respectively), however, both groups show very good agreement, with only few errors. Inoculating ID and AST broth by using SSTs can be performed as soon as blood culture bottles are taken out of the BACTEC system and takes approximately 30 minutes, whereas a subculture Tangeritin takes up to 24 hours. Therefore, by using the direct method, results of ID and AST can be available up to 23.5 hours earlier than with the routinely used method. Conclusions From these results we conclude that AST by inoculating Phoenix panels with bacteria harvested directly from positive blood culture bottles is as reliable as using bacteria from a subculture on agar, with the exception of results for erythromycin and trimethoprim-sulfamethoxazole in Staphylococcus and Enterococcus spp., which should not be reported due to their low agreement. Results of ID of Enterobacteriaceae were shown to be very reliable. ID of Staphylococcus and Enterococcus spp. was not performed with the direct method. Caution is warranted about interpretation of results of Enterococcus and Pseudomonas spp., of which only a CA4P limited number of strains was tested.