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<img src="../logo.svg" class="logo" alt=""><h1>How to apply EUCAST rules</h1>
<small class="dont-index">Source: <a href="https://github.com/msberends/AMR/blob/HEAD/vignettes/EUCAST.Rmd" class="external-link"><code>vignettes/EUCAST.Rmd</code></a></small>
<div class="d-none name"><code>EUCAST.Rmd</code></div>
</div>
<div class="section level2">
<h2 id="introduction">Introduction<a class="anchor" aria-label="anchor" href="#introduction"></a>
</h2>
<p>What are EUCAST rules? The European Committee on Antimicrobial
Susceptibility Testing (EUCAST) states <a href="https://www.eucast.org/expert_rules_and_intrinsic_resistance/" class="external-link">on
their website</a>:</p>
<blockquote>
<p><em>EUCAST expert rules are a tabulated collection of expert
knowledge on intrinsic resistances, exceptional resistance phenotypes
and interpretive rules that may be applied to antimicrobial
susceptibility testing in order to reduce errors and make appropriate
recommendations for reporting particular resistances.</em></p>
</blockquote>
<p>In Europe, a lot of medical microbiological laboratories already
apply these rules (<a href="https://www.eurosurveillance.org/content/10.2807/1560-7917.ES2015.20.2.21008" class="external-link">Brown
<em>et al.</em>, 2015</a>). Our package features their latest insights
on intrinsic resistance and unusual phenotypes (v3.3, 2021).</p>
<p>Moreover, the <code><a href="../reference/eucast_rules.html">eucast_rules()</a></code> function we use for this
purpose can also apply additional rules, like forcing
<help title="ATC: J01CA01">ampicillin</help> = R in isolates when
<help title="ATC: J01CR02">amoxicillin/clavulanic acid</help> = R.</p>
</div>
<div class="section level2">
<h2 id="examples">Examples<a class="anchor" aria-label="anchor" href="#examples"></a>
</h2>
<p>These rules can be used to discard impossible bug-drug combinations
in your data. For example, <em>Klebsiella</em> produces beta-lactamase
that prevents ampicillin (or amoxicillin) from working against it. In
other words, practically every strain of <em>Klebsiella</em> is
resistant to ampicillin.</p>
<p>Sometimes, laboratory data can still contain such strains with
ampicillin being susceptible to ampicillin. This could be because an
antibiogram is available before an identification is available, and the
antibiogram is then not re-interpreted based on the identification
(namely, <em>Klebsiella</em>). EUCAST expert rules solve this, that can
be applied using <code><a href="../reference/eucast_rules.html">eucast_rules()</a></code>:</p>
<div class="sourceCode" id="cb1"><pre class="downlit sourceCode r">
<code class="sourceCode R"><span><span class="va">oops</span> <span class="op">&lt;-</span> <span class="fu"><a href="https://rdrr.io/r/base/data.frame.html" class="external-link">data.frame</a></span><span class="op">(</span></span>
<span> mo <span class="op">=</span> <span class="fu"><a href="https://rdrr.io/r/base/c.html" class="external-link">c</a></span><span class="op">(</span></span>
<span> <span class="st">"Klebsiella"</span>,</span>
<span> <span class="st">"Escherichia"</span></span>
<span> <span class="op">)</span>,</span>
<span> ampicillin <span class="op">=</span> <span class="st">"S"</span></span>
<span><span class="op">)</span></span>
<span><span class="va">oops</span></span>
<span><span class="co">#&gt; mo ampicillin</span></span>
<span><span class="co">#&gt; 1 Klebsiella S</span></span>
<span><span class="co">#&gt; 2 Escherichia S</span></span>
<span></span>
<span><span class="fu"><a href="../reference/eucast_rules.html">eucast_rules</a></span><span class="op">(</span><span class="va">oops</span>, info <span class="op">=</span> <span class="cn">FALSE</span><span class="op">)</span></span>
<span><span class="co">#&gt; mo ampicillin</span></span>
<span><span class="co">#&gt; 1 Klebsiella R</span></span>
<span><span class="co">#&gt; 2 Escherichia S</span></span></code></pre></div>
<p>A more convenient function is
<code><a href="../reference/mo_property.html">mo_is_intrinsic_resistant()</a></code> that uses the same guideline,
but allows to check for one or more specific microorganisms or
antibiotics:</p>
<div class="sourceCode" id="cb2"><pre class="downlit sourceCode r">
<code class="sourceCode R"><span><span class="fu"><a href="../reference/mo_property.html">mo_is_intrinsic_resistant</a></span><span class="op">(</span></span>
<span> <span class="fu"><a href="https://rdrr.io/r/base/c.html" class="external-link">c</a></span><span class="op">(</span><span class="st">"Klebsiella"</span>, <span class="st">"Escherichia"</span><span class="op">)</span>,</span>
<span> <span class="st">"ampicillin"</span></span>
<span><span class="op">)</span></span>
<span><span class="co">#&gt; [1] TRUE FALSE</span></span>
<span></span>
<span><span class="fu"><a href="../reference/mo_property.html">mo_is_intrinsic_resistant</a></span><span class="op">(</span></span>
<span> <span class="st">"Klebsiella"</span>,</span>
<span> <span class="fu"><a href="https://rdrr.io/r/base/c.html" class="external-link">c</a></span><span class="op">(</span><span class="st">"ampicillin"</span>, <span class="st">"kanamycin"</span><span class="op">)</span></span>
<span><span class="op">)</span></span>
<span><span class="co">#&gt; [1] TRUE FALSE</span></span></code></pre></div>
<p>EUCAST rules can not only be used for correction, they can also be
used for filling in known resistance and susceptibility based on results
of other antimicrobials drugs. This process is called <em>interpretive
reading</em>, is basically a form of imputation, and is part of the
<code><a href="../reference/eucast_rules.html">eucast_rules()</a></code> function as well:</p>
<div class="sourceCode" id="cb3"><pre class="downlit sourceCode r">
<code class="sourceCode R"><span><span class="va">data</span> <span class="op">&lt;-</span> <span class="fu"><a href="https://rdrr.io/r/base/data.frame.html" class="external-link">data.frame</a></span><span class="op">(</span></span>
<span> mo <span class="op">=</span> <span class="fu"><a href="https://rdrr.io/r/base/c.html" class="external-link">c</a></span><span class="op">(</span></span>
<span> <span class="st">"Staphylococcus aureus"</span>,</span>
<span> <span class="st">"Enterococcus faecalis"</span>,</span>
<span> <span class="st">"Escherichia coli"</span>,</span>
<span> <span class="st">"Klebsiella pneumoniae"</span>,</span>
<span> <span class="st">"Pseudomonas aeruginosa"</span></span>
<span> <span class="op">)</span>,</span>
<span> VAN <span class="op">=</span> <span class="st">"-"</span>, <span class="co"># Vancomycin</span></span>
<span> AMX <span class="op">=</span> <span class="st">"-"</span>, <span class="co"># Amoxicillin</span></span>
<span> COL <span class="op">=</span> <span class="st">"-"</span>, <span class="co"># Colistin</span></span>
<span> CAZ <span class="op">=</span> <span class="st">"-"</span>, <span class="co"># Ceftazidime</span></span>
<span> CXM <span class="op">=</span> <span class="st">"-"</span>, <span class="co"># Cefuroxime</span></span>
<span> PEN <span class="op">=</span> <span class="st">"S"</span>, <span class="co"># Benzylenicillin</span></span>
<span> FOX <span class="op">=</span> <span class="st">"S"</span>, <span class="co"># Cefoxitin</span></span>
<span> stringsAsFactors <span class="op">=</span> <span class="cn">FALSE</span></span>
<span><span class="op">)</span></span></code></pre></div>
<div class="sourceCode" id="cb4"><pre class="downlit sourceCode r">
<code class="sourceCode R"><span><span class="va">data</span></span></code></pre></div>
<table class="table">
<thead><tr class="header">
<th align="left">mo</th>
<th align="center">VAN</th>
<th align="center">AMX</th>
<th align="center">COL</th>
<th align="center">CAZ</th>
<th align="center">CXM</th>
<th align="center">PEN</th>
<th align="center">FOX</th>
</tr></thead>
<tbody>
<tr class="odd">
<td align="left">Staphylococcus aureus</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">S</td>
<td align="center">S</td>
</tr>
<tr class="even">
<td align="left">Enterococcus faecalis</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">S</td>
<td align="center">S</td>
</tr>
<tr class="odd">
<td align="left">Escherichia coli</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">S</td>
<td align="center">S</td>
</tr>
<tr class="even">
<td align="left">Klebsiella pneumoniae</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">S</td>
<td align="center">S</td>
</tr>
<tr class="odd">
<td align="left">Pseudomonas aeruginosa</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">S</td>
<td align="center">S</td>
</tr>
</tbody>
</table>
<div class="sourceCode" id="cb5"><pre class="downlit sourceCode r">
<code class="sourceCode R"><span><span class="fu"><a href="../reference/eucast_rules.html">eucast_rules</a></span><span class="op">(</span><span class="va">data</span><span class="op">)</span></span></code></pre></div>
<table class="table">
<thead><tr class="header">
<th align="left">mo</th>
<th align="center">VAN</th>
<th align="center">AMX</th>
<th align="center">COL</th>
<th align="center">CAZ</th>
<th align="center">CXM</th>
<th align="center">PEN</th>
<th align="center">FOX</th>
</tr></thead>
<tbody>
<tr class="odd">
<td align="left">Staphylococcus aureus</td>
<td align="center">-</td>
<td align="center">S</td>
<td align="center">R</td>
<td align="center">S</td>
<td align="center">S</td>
<td align="center">S</td>
<td align="center">S</td>
</tr>
<tr class="even">
<td align="left">Enterococcus faecalis</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">R</td>
<td align="center">R</td>
<td align="center">R</td>
<td align="center">S</td>
<td align="center">R</td>
</tr>
<tr class="odd">
<td align="left">Escherichia coli</td>
<td align="center">R</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">R</td>
<td align="center">S</td>
</tr>
<tr class="even">
<td align="left">Klebsiella pneumoniae</td>
<td align="center">R</td>
<td align="center">R</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">R</td>
<td align="center">S</td>
</tr>
<tr class="odd">
<td align="left">Pseudomonas aeruginosa</td>
<td align="center">R</td>
<td align="center">R</td>
<td align="center">-</td>
<td align="center">-</td>
<td align="center">R</td>
<td align="center">R</td>
<td align="center">R</td>
</tr>
</tbody>
</table>
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