Four commercially available in vitro test systems (Candifast, E-test, Mycototal and spiral-gradient end point method), agar diffusion with 25-micrograms fluconazole paper test discs and 15-micrograms test tablets and agar dilution were compared with the microbroth dilution method for fluconazole susceptibility testing of 145 clinical isolates. In addition, the culture media provided or recommended by the manufacturers of the test systems were compared with high-resolution (HR) antifungal test medium. With all currently available culture media, growth problems (inhibition or delayed growth of the clinical isolates) occurred with solid or semisolid media. With minor improvements, HR medium demonstrated the most reproducible and comparable results (supplementation with asparagine and deletion of sodium hydrogen carbonate). The best correlation with microdilution was obtained by the agar dilution method (> 95% concordance) followed by the spiral-gradient end point method (85%), Candifast (83%), Mycototal (81%) and the E-test (78%). Regression analysis demonstrated good correlation between agar diffusion and micro-/agar dilution (r > 0.9).

This paper gives a proposal for a standardised agar diffusion susceptibility testing method with 25 micrograms fluconazole discs. The methodology compiles the results of several years of work to develop a reliable and reproducible routine-method for the microbiology laboratory. In this proposal, in addition, the critics and experiences of a collaborative study for susceptibility testing of fluconazole with 21 laboratories from Germany and Austria are included.

In bacteriology, the Etest has a broad field of application in bacteriology and is recently available for the antimycotics fluconazole and itraconazole. By means of the presence of gradient concentrations of the active substance on the carrier material, it is possible to obtain reproducible MICs of the antimycotic substances. The results of susceptibility testing of 326 clinical yeast isolates with the Etest were compared to those MICs obtained by microdilution and agar dilution. A 100% concordance of the MIC markers (mode-, MIC50- and MIC90-value, standard deviation of the mean log2-MIC-dilution steps) was given when compared by a +/- 1 MIC-dilution step range with microdilution and by +/- 2 MIC-dilution steps with agar dilution; species dependent all strains were within 2 x standard deviation of the individual MIC-mean of the species. By comparison of the individual MIC-values maximum differences of +/- 6 MIC-dilution steps were obtained, where 70% of all results were within +/- 2 MIC-dilution steps, and more than 92% of all strains were within +/- 3 MIC-dilution steps. The Pearson's correlation coefficients show a good agreement of the Etest with microdilution (r = 0.92) resp., agar dilution (r = 0.88) demonstrate, however, clearly insufficient correlations (r < 0.65) to the reference methods, for species with difficult to read Etest inhibition zones (e.g., Candida glabrata, Candida krusei, Candida parapsilosis). The differences between the proposed test methods recommended by the NCCLS and the working group "Clinical Mycology" of the German Speaking Mycological Society (AG-KMYK) are tabled.

Four commercially available in vitro test systems (Candifast, E-test, Mycototal, Spiral-Gradient Endpoint Method), agardiffusion with 25 micrograms fluconazole paper test discs and 15 micrograms test tablets, and agardilution were compared to the microbroth dilution method by fluconazole susceptibility testing of 145 clinical isolates. In addition, the culture media provided or recommended by the manufacturers of the test systems were compared to the high resolution (HR) antifungal test medium. With all currently available culture media growth problems (inhibition or delayed growth of the clinical isolates) occurred with solid or semi-solid media. With minor improvements, HR medium demonstrated the most reproducible and comparable results (supplementation with asparagine and deletion of sodium hydrogen carbonate). Best correlation to microdilution was obtained by the agardilution method > (95% concordance) followed by the spiral gradient endpoint method (85%), Candifast (83%), Mycototal (81%) and the E-test (78%). Regression analysis demonstrated good correlation between agardiffusion and micro-/agardilution(r > 0.9).