The study was funded by the intramural research grant given to Dr. Ayush Gupta by AIIMS Bhopal. We acknowledge the contribution of laboratory technicians and resident doctors who performed and read the tests diligently during routine and emergency hours.

The study, funded by the intramural research grant given to Dr. Ayush Gupta by AIIMS Bhopal, was approved by the Institutional Human Ethics Committee (IHEC) vide letter no: IHEC- LOP/2022/IL072.
NOTE: A sample volume of 5 ml was used based on studies done by Quesada et al.25 and Munoz-Davila et al.27.
1. Standard inoculum protocol (SIP) for bacterial identification using aMIAST
<ol>
	<li>Wear clean g...

Accelerated Antimicrobial Susceptibility Testing in Blood Culture Bottles

<ol>
	<li>Rudd, K. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=regional,+and+national+sepsis+incidence+and+mortality,+1990&#8211;2017:+analysis+for+the+Global+Burden+of+Disease+Study.">regional, and national sepsis incidence and mortality, 1990&#8211;2017: analysis for the Global Burden of Disease Study.</a> Lancet. 395 (10219), 200-211 (2020).</li><li>Ikuta, K. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Global+mortality+associated+with+33+bacterial+pathogens+in+2019:+a+systematic+analysis+for+the+Global+Burden+of+Disease+Study+2019.">Global mortality associated with 33 bacterial pathogens in 2019: a systematic analysis for the Global Burden of Disease Study 2019.</a> Lancet. 400 (10369), 2221-2248 (2022).</li><li>Liu, V. X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+timing+of+early+antibiotics+and+hospital+mortality+in+sepsis.">The timing of early antibiotics and hospital mortality in sepsis.</a> Am J Resp Crit Care Med. 196 (7), 856-863 (2017).</li><li>European Committee on Antimicrobial Susceptibility testing. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Methodology-EUCAST+rapid+antimicrobial+susceptibility+testing+(RAST)+directly+from+positive+blood+culture+bottles.+Version+4.0.">Methodology-EUCAST rapid antimicrobial susceptibility testing (RAST) directly from positive blood culture bottles. Version 4.0.</a> EUCAST. European Committee on Antimicrobial Susceptibility testing. , (2023).</li><li>Clinical and Laboratory Standards Institute. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Performance+standards+for+antimicrobial+susceptibility+testing.+33rd+ed.">Performance standards for antimicrobial susceptibility testing. 33rd ed.</a> CLSI. Clinical and Laboratory Standards Institute. , (2023).</li><li>European Committee on Antimicrobial Susceptibility testing. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Methodology-EUCAST+rapid+antimicrobial+susceptibility+testing+(RAST)+directly+from+positive+blood+culture+bottles.+Version+1.0.">Methodology-EUCAST rapid antimicrobial susceptibility testing (RAST) directly from positive blood culture bottles. Version 1.0.</a> EUCAST. European Committee on Antimicrobial Susceptibility testing. , (2018).</li><li>European Committee on Antimicrobial Susceptibility testing. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Zone+diameter+breakpoints+for+rapid+antimicrobial+susceptibility+testing+(RAST)+directly+from+positive+blood+culture+bottles.+Version+1.0.">Zone diameter breakpoints for rapid antimicrobial susceptibility testing (RAST) directly from positive blood culture bottles. Version 1.0.</a> EUCAST. European Committee on Antimicrobial Susceptibility testing. , (2018).</li><li>European Committee on Antimicrobial Susceptibility testing. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Zone+diameter+breakpoints+for+rapid+antimicrobial+susceptibility+testing+(RAST)+directly+from+positive+blood+culture+bottles.+Version+6.1.">Zone diameter breakpoints for rapid antimicrobial susceptibility testing (RAST) directly from positive blood culture bottles. Version 6.1.</a> EUCAST. European Committee on Antimicrobial Susceptibility testing. , (2023).</li><li>Soo, Y. T., Waled, S. N. M. B., Ng, S., Peh, Y. H., Chew, K. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+EUCAST+rapid+antimicrobial+susceptibility+testing+(RAST)+directly+from+blood+culture+bottles.">Evaluation of EUCAST rapid antimicrobial susceptibility testing (RAST) directly from blood culture bottles.</a> Euro J Clin Microbiol Infect Dis. 39 (5), 993-998 (2020).</li><li>Berinson, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=EUCAST+rapid+antimicrobial+susceptibility+testing+(RAST):+Analytical+performance+and+impact+on+patient+management.">EUCAST rapid antimicrobial susceptibility testing (RAST): Analytical performance and impact on patient management.</a> J Antimicrob Chemother. 76 (5), 1332-1338 (2021).</li><li>Strubbe, G., Messiaen, A. S., Vandendriessche, S., Verhasselt, B., Boelens, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=EUCAST+rapid+antimicrobial+susceptibility+testing+(RAST)+compared+to+conventional+susceptibility+testing:+implementation+and+potential+added+value+in+a+tertiary+hospital+in+Belgium.">EUCAST rapid antimicrobial susceptibility testing (RAST) compared to conventional susceptibility testing: implementation and potential added value in a tertiary hospital in Belgium.</a> Acta Clinica Belgica: Int J Clin Lab Med. 78 (5), 385-391 (2023).</li><li>Jasuja, J. K., Zimmermann, S., Burckhardt, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+EUCAST+rapid+antimicrobial+susceptibility+testing+(RAST)+for+positive+blood+cultures+in+clinical+practice+using+a+total+lab+automation.">Evaluation of EUCAST rapid antimicrobial susceptibility testing (RAST) for positive blood cultures in clinical practice using a total lab automation.</a> Euro J Clin Microbiol Infect Dis. 39 (7), 1305-1313 (2020).</li><li>Martins, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rapid+antimicrobial+susceptibility+of+Enterobacteriaceae+by+disk+diffusion+directly+from+blood+culture+bottles+using+the+EUCAST+RAST+breakpoints.">Rapid antimicrobial susceptibility of Enterobacteriaceae by disk diffusion directly from blood culture bottles using the EUCAST RAST breakpoints.</a> J Glob Antimicrob Resist. 22, 637-642 (2020).</li><li>Ekwall-Larson, A., Fr&#246;ding, I., Mert, B., &#197;kerlund, A., &#214;zenci, V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Analytical+performance+and+potential+clinical+utility+of+EUCAST+rapid+antimicrobial+susceptibility+testing+in+blood+cultures+after+four+hours+of+incubation.">Analytical performance and potential clinical utility of EUCAST rapid antimicrobial susceptibility testing in blood cultures after four hours of incubation.</a> Microbiol Spectr. 11 (2), e500122 (2023).</li><li>Cerrudo, V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Usefulness+of+EUCAST+rapid+antibiotic+susceptibility+breakpoints+and+screening+cut-off+values+directly+from+blood+cultures+for+the+inference+of+&#946;-lactam+resistance+mechanisms+in+Enterobacterales.">Usefulness of EUCAST rapid antibiotic susceptibility breakpoints and screening cut-off values directly from blood cultures for the inference of &#946;-lactam resistance mechanisms in Enterobacterales.</a> JAC-Antimicrob Resist. 5 (1), 017 (2023).</li><li>Shan, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+the+EUCAST+rapid+antimicrobial+susceptibility+test+for+enterobacterales-containing+blood+cultures+in+China.">Evaluation of the EUCAST rapid antimicrobial susceptibility test for enterobacterales-containing blood cultures in China.</a> J Clin Microbiol. 60 (4), e0255921 (2022).</li><li>Jonasson, E., Matuschek, E., Kahlmeter, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+EUCAST+rapid+disc+diffusion+method+for+antimicrobial+susceptibility+testing+directly+from+positive+blood+culture+bottles.">The EUCAST rapid disc diffusion method for antimicrobial susceptibility testing directly from positive blood culture bottles.</a> J Antimicrob Chemother. 75 (4), 968-978 (2020).</li><li>Tay&#351;i, M. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Implementation+of+the+EUCAST+rapid+antimicrobial+susceptibility+test+(RAST)+directly+from+positive+blood+culture+bottles+without+the+advanced+identification+systems.">Implementation of the EUCAST rapid antimicrobial susceptibility test (RAST) directly from positive blood culture bottles without the advanced identification systems.</a> J Antimicrobial Chemotherapy. 77 (4), 1020-1026 (2022).</li><li>Gupta, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+prospective+study+evaluating+the+effect+of+a+&#8216;Diagnostic+Stewardship+Care-Bundle&#8217;+for+automated+blood+culture+diagnostics.">A prospective study evaluating the effect of a &#8216;Diagnostic Stewardship Care-Bundle&#8217; for automated blood culture diagnostics.</a> J Glob Antimicrob Resist. 34, 119-126 (2023).</li><li>Siddiqui, F., Gupta, A., Purwar, S., Saigal, S., Sharma, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+prospective+study+to+reduce+turnaround+time+of+microbiologically+positive+blood+cultures+in+patients+with+sepsis+in+intensive+care+unit.">A prospective study to reduce turnaround time of microbiologically positive blood cultures in patients with sepsis in intensive care unit.</a> Indian J Med Microbiol. 40 (4), 541-546 (2022).</li><li>Gherardi, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparative+evaluation+of+the+Vitek-2+Compact+and+Phoenix+systems+for+rapid+identification+and+antibiotic+susceptibility+testing+directly+from+blood+cultures+of+Gram-negative+and+Gram-positive+isolates.">Comparative evaluation of the Vitek-2 Compact and Phoenix systems for rapid identification and antibiotic susceptibility testing directly from blood cultures of Gram-negative and Gram-positive isolates.</a> Diagnostic Microbiol Infect Dis. 72 (1), 20-31 (2012).</li><li>Lemos, T. C., Cogo, L. L., Maestri, A. C., Hadad, M., Nogueira, K. d. a. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Is+it+possible+to+perform+bacterial+identification+and+antimicrobial+susceptibility+testing+with+a+positive+blood+culture+bottle+for+quick+diagnosis+of+bloodstream+infections.">Is it possible to perform bacterial identification and antimicrobial susceptibility testing with a positive blood culture bottle for quick diagnosis of bloodstream infections.</a> Revista da Sociedade Brasileira de Medicina Tropical. 51 (2), 215-218 (2018).</li><li>Funke, G., Funke-Kissling, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Use+of+the+BD+PHOENIX+automated+microbiology+system+for+direct+identification+and+susceptibility+testing+of+gram-negative+rods+from+positive+blood+cultures+in+a+three-phase+trial.">Use of the BD PHOENIX automated microbiology system for direct identification and susceptibility testing of gram-negative rods from positive blood cultures in a three-phase trial.</a> J Clin Microbiol. 42 (4), 1466-1470 (2004).</li><li>Nimer, N. A., Al-Saa&#8217;da, R. J., Abuelaish, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Accuracy+of+the+VITEK+2+system+for+a+rapid+and+direct+identification+and+susceptibility+testing+of+Gram+negative+rods+and+Gram-positive+cocci+in+blood+samples.">Accuracy of the VITEK 2 system for a rapid and direct identification and susceptibility testing of Gram negative rods and Gram-positive cocci in blood samples.</a> East Mediterr Health J. 22 (3), 193-200 (2016).</li><li>Quesada, M. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Performance+of+VITEK-2+Compact+and+overnight+MicroScan+panels+for+direct+identification+and+susceptibility+testing+of+Gram-negative+bacilli+from+positive+FAN+BacT/ALERT+blood+culture+bottles.">Performance of VITEK-2 Compact and overnight MicroScan panels for direct identification and susceptibility testing of Gram-negative bacilli from positive FAN BacT/ALERT blood culture bottles.</a> Clin Microbiol Infect. 16 (2), 137-140 (2010).</li><li>De Cueto, M., Ceballos, E., Martinez-Martinez, L., Perea, E. J., Pascual, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Use+of+positive+blood+cultures+for+direct+identification+and+susceptibility+testing+with+the+Vitek+2+system.">Use of positive blood cultures for direct identification and susceptibility testing with the Vitek 2 system.</a> J Clin Microbiol. 42 (8), 3734-3738 (2004).</li><li>Munoz-D&#225;vila, M. J., Yag&#252;e, G., Albert, M., Garc&#237;a-Lucas, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparative+evaluation+of+Vitek+2+identification+and+susceptibility+testing+of+Gram-negative+rods+directly+and+isolated+from+BacT/ALERT-positive+blood+culture+bottles.">Comparative evaluation of Vitek 2 identification and susceptibility testing of Gram-negative rods directly and isolated from BacT/ALERT-positive blood culture bottles.</a> Euro J Clin Microbiol Infect Dis. 31 (5), 663-669 (2012).</li><li>European Committee on Antimicrobial Susceptibility testing. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Quality+control+criteria+for+the+implementation+of+the+RAST+method.+Version+6.0.">Quality control criteria for the implementation of the RAST method. Version 6.0.</a> EUCAST. European Committee on Antimicrobial Susceptibility testing. , (2023).</li><li>Chen, J. R., Lee, S. Y., Yang, B. H., Lu, J. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rapid+identification+and+susceptibility+testing+using+the+VITEK+2+system+using+culture+fluids+from+positive+BacT/ALERT+blood+cultures.">Rapid identification and susceptibility testing using the VITEK 2 system using culture fluids from positive BacT/ALERT blood cultures.</a> J Microbiol, Immunol Infect. 41 (3), 259-264 (2008).</li><li>Bruins, M. J., Bloembergen, P., Ruijs, G. J. H. M., Wolfhagen, M. J. H. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Identification+and+susceptibility+testing+of+Enterobacteriaceae+and+Pseudomonas+aeruginosa+by+direct+inoculation+from+positive+BACTEC+blood+culture+bottles+into+Vitek+2.">Identification and susceptibility testing of Enterobacteriaceae and Pseudomonas aeruginosa by direct inoculation from positive BACTEC blood culture bottles into Vitek 2.</a> J Clin Microbiol. 42 (1), 7-11 (2004).</li><li>Lupetti, A., Barnini, S., Castagna, B., Nibbering, P. H., Campa, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rapid+identification+and+antimicrobial+susceptibility+testing+of+Gram-positive+cocci+in+blood+cultures+by+direct+inoculation+into+the+BD+Phoenix+system.">Rapid identification and antimicrobial susceptibility testing of Gram-positive cocci in blood cultures by direct inoculation into the BD Phoenix system.</a> Clin Microbiol Infect. 16 (7), 986-991 (2010).</li><li>Barreales, A., Lara, M., Hern&#225;ndez, I., D&#237;ez, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rapid+identification+and+susceptibility+testing+of+Gram-positive+cocci+in+BacT/ALERT+blood+cultures+by+direct+inoculation+into+the+Vitek+2+system.">Rapid identification and susceptibility testing of Gram-positive cocci in BacT/ALERT blood cultures by direct inoculation into the Vitek 2 system.</a> Rev Esp Quimioter. 24 (3), 131-135 (2011).</li></ol>

Using DIP, we successfully identified the RR-GNs with considerable diagnostic accuracy. The mean TTI after positive flagging of aBC was only 507 min (~ 8.5 h). Thus, when done in conjunction with the EUCAST RAST method for AST determination, it can give isolate identification at 8 h AST reading time. This approach has the potential to implement the EUCAST RAST method obviating the need for mass spectrometry-based identification. This is a boon for the low-resource settings who wish to implement the EUCAST RAST method in ...

Sepsis, an important global health problem, is defined as life-threatening organ dysfunction due to a dysregulated host response to infection. The Global Burden of Diseases Study estimated that there were 48.9 million cases of sepsis and 11 million sepsis-related deaths worldwide in 2017, which accounted for almost 20% of all global deaths1. Around 2/3rd of bloodstream infections (BSI) causing mortality are due to gram-negative bacterial pathogens2. The leading causes of mortality amongst gram-negatives (GN) are Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii,&#160;which account for around 40% of cases amongst 33 bacterial pathogens2.
Blood cultures remain the gold standard for diagnosing BSI, and rapid microbial identification along with antimicrobial susceptibility testing (AST) results is the key to management. It has been estimated that there is a 9% increase in odds of mortality with each-hour delay in instituting appropriate antimicrobials in sepsis3. The turnaround time (TAT) of microbiologically positive blood culture reports with AST results is around 48-72 h with the available microbiological tools in resource-limited settings, even with automated systems. As a result of this subpar TAT, broad-spectrum antimicrobials are used empirically, contributing to the burgeoning problem of antimicrobial resistance (AMR). Recognizing this dire need to reduce TAT for microbiological culture techniques for sepsis, EUCAST and CLSI are moving towards performing AST directly from positively flagged blood culture bottles (+aBC)4,5.
In 2018, EUCAST first introduced the rapid AST (RAST) method for determining AST by Kirby-Bauer disk diffusion method at short incubation times, i.e., 4 h, 6 h and 8 h, directly from +aBC6,7. The method is presently validated for determining AST for +aBCs containing one of the 8 most common causes of BSI namely E. coli, K. pneumoniae, P. aeruginosa, and A. baumannii complex&#160;amongst gram-negatives and Staphylococcus aureus, Enterococcus faecalis, E. faecium, and Streptococcus pneumoniae amongst gram-positives8.The breakpoints for AST determination at various time intervals are provided as per microbial species listed above. Hence, before categorical interpretation of AST results, microbial identification is necessary. However, the RAST standard does not specify the method to enable microbial identification within this time frame.
The majority of studies evaluating the EUCAST RAST method in their setting have used mass spectrometry-based microbial identification after short incubation on plated media to identify micro-organisms9,10,11,12,13,14,15,16,17. However, mass spectrometry instruments are not widely available, especially in low to middle-income countries (LMICs), which greatly limits the potential usefulness of this method. Few studies have reported implementation of this method in their centers without using mass spectrometry18,19,20. Tay&#351;i et al.18 reported a broad categorization of GN amongst Enterobacterales, Pseudomonas, and Acinetobacter spp. based on gram stain morphology and oxidase test before interpreting AST results. In other studies from this center, by Gupta et al.19 and Siddiqui et al.20, species-level microbial identification was done by preparing a bacterial pellet from the positively flagged blood-broth mixture and inoculating it on the conventional biochemical tests. While Tay&#351;i et al.18 did not comment upon the accuracy of microbial identification with their approach, Gupta et al.19 reported that with their approach in 165/176 (94%) cases, a RAST reportable gram-negative (RR-GN), i.e., either of E. coli, K. pneumoniae, P. aeruginosa, and A. baumannii complex. However, with the latter approach, the reading of RAST results was done retrospectively using 8 h zone diameter breakpoints only after the full incubation of conventional biochemical results i.e., 18-24 h post-inoculation, and the average time for reporting was around 2 days.
To reduce the TAT of clinical reports further, we propose an alternative methodology to enable early identification of GN present in +aBCs using aMIAST. Before the introduction of mass spectrometry-based microbial identification systems, these automated identification systems were considered the standard of care for microbial identification, where identification was enabled by colorimetric and/or fluorometric changes induced by test bacteria when inoculated in miniaturized biochemical tests harbored in a cassette and matching the results with their isolate database. The average time to identification in these systems is around 4 h to 8 h however, they are limited by the fact that the manufacturers recommend overnight growth of microbes before their respective identification cards can be inoculated. This requirement greatly limits their usefulness in reducing the time to report.
Few studies have evaluated methods to directly identify microbes from +aBCs using these automated systems21,22,23,24,25,26,27. In the case of +aBCs containing monomorphic GN, the majority of studies showed excellent concordance between direct inoculation from bacterial pellet made from positive blood-broth mixture and standard colony incubation. However, in the case of gram-positives, the concordance rates were suboptimal. As the average time to positivity of +aBCs is between 8 h and 16 h and identification of GN takes ~4 h to 8 h in an automated microbial identification system, we hypothesize that by employing direct inoculation protocol in the automated microbial identification, we can complete the clinical reporting of +aBCs with GN having a RR-GN within 24 h of sample receiving.
Setting for the study 
The present study was conducted in the clinical bacteriology laboratory of a 950-bed, academic, tertiary care institute of national importance (INI) in Central India from January to October 2023. The laboratory is equipped with a continuous blood culture monitoring system (CBCMS) and aMIAST. The bacteriology laboratory is functional round-the-clock with the availability of technicians and microbiologists for processing and reporting any positively flagged blood culture bottle (+aBCs).
Microbial methods used here 
The workflow of the study is shown in Figure 1. The +aBCs showing monomorphic GNs (+naBC) were processed by direct inoculation of corresponding identification cards to enable identification and AST using EUCAST RAST protocol. These results were compared with the standard-of-care (SoC) method for +aBCs i.e., subculturing on conventional plated media through sheep blood agar (SBA), chocolate agar (CA), and MacConkey agar (MA), incubated aerobically for 16 h to 24 h followed by identification and AST cards given by aMIAST when isolated colonies appear. Blood cultures showing gram-positive cocci, gram-positive bacilli, budding yeast cells, and &#8805;2 different micro-organisms on initial gram staining or plated media were excluded from the study.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>ANTIMICROBIAL DISKS</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Amikacin disk 30 &#181;g</td>
			<td>Himedia, Mumbai, India</td>
			<td>SD035-1VL</td>
			<td>Antimicrobial susceptibility testing&#160;</td>
		</tr>
		<tr>
			<td>Amoxyclav disk (20/10 &#181;g)</td>
			<td>Himedia, Mumbai, India</td>
			<td>SD063-1VL</td>
			<td>Antimicrobial susceptibility testing&#160;</td>
		</tr>
		<tr>
			<td>Cefotaxime disk 5 &#181;g</td>
			<td>Himedia, Mumbai, India</td>
			<td>SD295E-1VL</td>
			<td>Antimicrobial susceptibility testing&#160;</td>
		</tr>
		<tr>
			<td>Ceftazidime disk 10 &#181;g</td>
			<td>Himedia, Mumbai, India</td>
			<td>SD062A-1VL</td>
			<td>Antimicrobial susceptibility testing&#160;</td>
		</tr>
		<tr>
			<td>Ciprofloxacin disk (5 &#181;g)</td>
			<td>Himedia, Mumbai, India</td>
			<td>SD060-1VL</td>
			<td>Antimicrobial susceptibility testing&#160;</td>
		</tr>
		<tr>
			<td>Co-Trimoxazole disk (23.75/1.25 &#181;g)</td>
			<td>Himedia, Mumbai, India</td>
			<td>SD010-1VL</td>
			<td>Antimicrobial susceptibility testing&#160;</td>
		</tr>
		<tr>
			<td>Gentamicin disk 10 &#181;g</td>
			<td>Himedia, Mumbai, India</td>
			<td>SD016-1VL</td>
			<td>Antimicrobial susceptibility testing&#160;</td>
		</tr>
		<tr>
			<td>Imipenem disk 10 &#181;g</td>
			<td>Himedia, Mumbai, India</td>
			<td>SD073-1VL</td>
			<td>Antimicrobial susceptibility testing&#160;</td>
		</tr>
		<tr>
			<td>Levofloxacin disk 5 &#181;g</td>
			<td>Himedia, Mumbai, India</td>
			<td>SD216-1VL</td>
			<td>Antimicrobial susceptibility testing&#160;</td>
		</tr>
		<tr>
			<td>Meropenem disk 10 &#181;g&#160;</td>
			<td>Himedia, Mumbai, India</td>
			<td>SD727-1VL</td>
			<td>Antimicrobial susceptibility testing&#160;</td>
		</tr>
		<tr>
			<td>Piperacillin-tazobactam disk (30/6 &#181;g)</td>
			<td>Himedia, Mumbai, India</td>
			<td>SD292E-1VL</td>
			<td>Antimicrobial susceptibility testing&#160;</td>
		</tr>
		<tr>
			<td>Tobramycin disk 10 &#181;g</td>
			<td>Himedia, Mumbai, India</td>
			<td>SD044-1VL</td>
			<td>Antimicrobial susceptibility testing&#160;</td>
		</tr>
		<tr>
			<td>ATCC Escherichia coli 25922</td>
			<td>Microbiologics, Minnesota USA</td>
			<td>0335A</td>
			<td>Recommended Gram negative bacterial strain for quality control in RAST</td>
		</tr>
		<tr>
			<td>BacT-Alert 3D 480</td>
			<td>bioMerieux, Marcy d&#8217; Etoille, France</td>
			<td>412CM8423</td>
			<td>Continuous automated blood culture system</td>
		</tr>
		<tr>
			<td>Biosafety cabinet II Type A2</td>
			<td>Dyna Filters Pvt. Limited, Pune, India</td>
			<td>DFP-2/21-22/149</td>
			<td>For protection against hazardous&#160; and infectious agents and to maintain quality control</td>
		</tr>
		<tr>
			<td>Blood agar base no. 2</td>
			<td>Himedia, Mumbai, India</td>
			<td>M834-500G</td>
			<td>Preparation of blood agar and chocolate agar</td>
		</tr>
		<tr>
			<td>Clinical Centrifuge Model SP-8BL</td>
			<td>Laby Instruments, Ambala, India</td>
			<td>HLL/2021-22/021</td>
			<td>Centrifugation at low and high speed for separation of supernatant</td>
		</tr>
		<tr>
			<td>Dispensette S Analog-adjustable bottle-top dispenser&#160;</td>
			<td>BrandTech, Essex CT, England</td>
			<td>V1200</td>
			<td>Dispensing accurate amount of saline</td>
		</tr>
		<tr>
			<td>MacConkey agar&#160;</td>
			<td>Himedia, Mumbai, India</td>
			<td>M008-500G</td>
			<td>Differential media for Lactose fermenters/ non-fermenters Gram negative bacilli</td>
		</tr>
		<tr>
			<td>Micropipette (100-1000 &#181;L)</td>
			<td>Axiflow Biotech Private Limited, Delhi, India</td>
			<td>NJ478162</td>
			<td>Transferring supernatant after first centrifugation, discarding supernatant after second centrifugation</td>
		</tr>
		<tr>
			<td>Micropipette tips (200-1000 &#181;L)</td>
			<td>&#8206;Tarsons Products Pvt. Ltd., Kolkata, India</td>
			<td>521020</td>
			<td>Transferring supernatant after first centrifugation, discarding supernatant after second centrifugation</td>
		</tr>
		<tr>
			<td>Mueller-Hinton agar&#160;</td>
			<td>Himedia, Mumbai, India</td>
			<td>M173-500G</td>
			<td>Antimicrobial susceptibility testing by Kirby-Bauer method of disk diffusion</td>
		</tr>
		<tr>
			<td>Nichrome loop D-4</td>
			<td>Himedia, Mumbai, India</td>
			<td>LA019</td>
			<td>For streaking onto culture media</td>
		</tr>
		<tr>
			<td>Nichrome straight wire</td>
			<td>Himedia, Mumbai, India</td>
			<td>LA022</td>
			<td>For stab inoculation</td>
		</tr>
		<tr>
			<td>Nulife sterile Gloves</td>
			<td>MRK healthcare Pvt Limited, Mumbai, India</td>
			<td></td>
			<td>For safety precautions</td>
		</tr>
		<tr>
			<td>Plain vial (Vial with red top), Advance BD vacutainer</td>
			<td>Becton-Dickinson, Cockeysville, MD, USA</td>
			<td>367815</td>
			<td>Obtaining pellet after second centrifugation</td>
		</tr>
		<tr>
			<td>Sheep blood</td>
			<td>Labline Trading Co., Hyderabad, India</td>
			<td>70014</td>
			<td>Preparation of blood agar and chocolate agar</td>
		</tr>
		<tr>
			<td>SST II tube, Advance BD vacutainer</td>
			<td>Becton-Dickinson, Cockeysville, MD, USA</td>
			<td>367954</td>
			<td>Supernatant separation in first centrifugation</td>
		</tr>
		<tr>
			<td>Sterile cotton swab (w/Wooden stick)</td>
			<td>Himedia, Mumbai, India</td>
			<td>PW005-1X500NO</td>
			<td>Lawn culture of blood culture broth for antimicrobial susceptibility testing</td>
		</tr>
		<tr>
			<td>Sterile single use hypodermic syringe 5ml/cc</td>
			<td>Nihal Healthcare, Solan, India</td>
			<td>2213805NB2</td>
			<td>Preparing aliquots from +aBC</td>
		</tr>
		<tr>
			<td>VITEK DensiCHEK McFarland reference kit</td>
			<td>bioMerieux, Marcy d&#8217; Etoille, France</td>
			<td>422219</td>
			<td>Densitometer to check the turbidity of suspension</td>
		</tr>
		<tr>
			<td>VITEK saline solution (0.45% NaCl)</td>
			<td>bioMerieux, Marcy d&#8217; Etoille, France</td>
			<td>V1204</td>
			<td>Adjustment of McFarland Standard turbidity</td>
		</tr>
		<tr>
			<td>VITEK tube stand&#160;</td>
			<td>bioMerieux, Marcy d&#8217; Etoille, France</td>
			<td>533306-4 REV</td>
			<td>Stand for proper placement of tubes before ID card inoculation</td>
		</tr>
		<tr>
			<td>VITEK tubes</td>
			<td>bioMerieux, Marcy d&#8217; Etoille, France</td>
			<td></td>
			<td>Tubes for inoculum preparation</td>
		</tr>
		<tr>
			<td>VITEK-2 Compact 60</td>
			<td>bioMerieux, Marcy d&#8217; Etoille, France</td>
			<td>VKC15144</td>
			<td>Automated identification and AST system</td>
		</tr>
		<tr>
			<td>VITEK-2 GN card</td>
			<td>bioMerieux, Marcy d&#8217; Etoille, France</td>
			<td>21341</td>
			<td>Identification of Gram negative bacilli</td>
		</tr>
	</tbody>
</table>

direct microbial identification using an automated microbial identification system to facilitate the eucast rast method without mass spectrometry

Gram-negative (GN) sepsis is a medical emergency where management in resource-limited settings relies on conventional microbiological culture techniques providing results in 3-4 days. Recognizing this delay in turnaround time (TAT), both EUCAST and CLSI have developed protocols for determining AST results directly from positively flagged automated blood culture bottles (+aBCs). EUCAST rapid AST (RAST) protocol was first introduced in 2018, where zone diameter breakpoints for four common etiological agents of GN sepsis, i.e., Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii complex can be reported. However, those clinical laboratories that have implemented this method in their routine workflow rely on mass spectrometry-based microbial identification, which is not easily available, thus precluding its implementation in resource-limited settings. To circumvent it, we evaluated a direct inoculum protocol (DIP) using a commercial automated microbial identification and antimicrobial susceptibility testing system (aMIAST) to enable early microbial identification within 8 h of positive flagging of aBC. We evaluated this protocol from January to October 2023 to identify the four RAST reportable GN (RR-GN) in the positively flagged aBC. The microbial identification results in DIP were compared with the standard inoculum preparation protocol (SIP) in aMIAST. Of 204 +aBCs with monomorphic GN (+naBC), one of the 4 RR-GN was identified in 105 +naBCs by SIP (E. coli: 50, K. pneumoniae: 20, P. aeruginosa: 9 and A. baumannii complex: 26). Of these, 94% (98/105) were correctly identified by DIP whereas major error and very major error rates were 6% (7/105) and 1.7% (4/240), respectively. When DIP for microbial identification is done using the EUCAST RAST method, provisional clinical reports can be provided within 24 h of receiving the sample. This approach has the potential to significantly reduce the TAT, enabling early institution of appropriate antimicrobial therapy.

Author Spotlight: Accelerating Diagnostic Accuracy with Direct Identification of Gram-Negatives from Blood Culture Bottles

Direct Microbial Identification using An Automated Microbial Identification System to Facilitate the EUCAST RAST Method Without Mass Spectrometry

This research aims to evaluate the diagnostic accuracy of Gram-negatives directly from positively flag blood culture bottles by automated microbial identification system. The purpose is to utilize it as a tool for early clinical reporting by EUCAST rapid antimicrobial susceptibility testing method. EUCAST RAST method was recently introduced in 2018 to enable reporting of anti-microbial susceptibility testing results within four to eight hours of positive flagging of automated blood culture bottles.It involves performing everywhere disk diffusion method directly from positively flagged bottle and reading results at either four, six, or eight hours. For clinical reporting by EUCAST RAST method, the microbial identification is a prerequisite for determining the interpretative category of AST results. The major challenge in implementing this method is early identification of the microbes within eight hours, especially in resource poor settings, which lacks mass spectrometry.We found that the direct inoculum protocol was around 94%accurate in identifying a RAST reportable Gram-negative, which includes Escherichia coli, Kiebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii complex. This approach of identifying Gram-negatives directly was around four times faster than the standard approach of identification after overnight incubation. We will now focus on assessing the impact of this approach of clinical reporting in Gram-negative sepsis on patient outcomes in terms of length of hospitalization and mortality rate.Furthermore, it can also be used as a tool to reduce anti-microbial usage to facilitate anti-microbial stewardship.

General outcomes 
During the study period, 240 +naBCs underwent identification by aMIAST using both DIP and SIP. Of these, 15% (36/240) +naBCs were found to be polymicrobial after overnight incubation on the plated media. Of the 204 +naBCs, the proportion of RR-GN identified by SIP was 51.5% (105/204). Amongst them, 47.6% (50/105) were E. coli, 19% (20/105) K. pneumoniae, 8.6% (9/105) P. aeruginosa and 24.8% (26/105) A. baumannii complex. A detailed description of...

EUCAST has developed a direct antimicrobial susceptibility testing (AST) protocol for automated blood cultures. However, its dependence on mass spectrometry-based microbial identification can be obviated by using a direct inoculum preparation protocol in an automated microbial identification system. This approach can provide AST reports within 24 h of sample collection.

Gram-negative (GN) sepsis is a medical emergency where management in resource-limited settings relies on conventional microbiological culture techniques ...