Survey Instrument Changes

Form Approved OMB No. 0920-0600

Expiration Date 05/31/2016

Drug Susceptibility Test Results for M. tuberculosis Complex Isolates from the CDC Model Performance Evaluation Program

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0600)

Enter MPEP number:

Name of person completing form:

Title:

E-mail:

Please indicate the primary classification of your laboratory

Hospital

Health Department (e.g. local, county, state) Independent (non-hospital based)

Other. Please indicate:

In the last calendar year (January 1- December 31), how many isolates of M. tuberculosis complex (MTBC) did your laboratory test for drug susceptibilities? (Please exclude quality control isolates)

On what date were the MPEP cultures received in your laboratory?

What was the condition of the cultures in the panel when they arrived?

Satisfactory Broken

Other. Please indicate

What method was used in your laboratory to perform first-line drug susceptibility testing on MTBC isolates in this shipment?

Agar Proportion (Middlebrook 7H10) Agar Proportion (Middlebrook 7H11) Genotype MTBDRplus (Hain Lifescience) Genotype MTBDRsl (Hain Lifescience)

Lowenstein Jensen (LJ) proportion method MGIT system

Radiometric (Bactec 460) VersaTrek Myco

Xpert MTB/RIF (Cepheid) TREK Sensititre

Laboratory Developed Test (LDT) or other test method. Please indicate

If your laboratory performed second-line drug susceptibility testing (excluding streptomycin) on MTBC isolates in this shipment, what method was used?

We do not perform second-line testing Agar Proportion (Middlebrook 7H10) Agar Proportion (Middlebrook 7H11) Genotype MTBDRplus (Hain Lifescience) Genotype MTBDRsl (Hain Lifescience)

Lowenstein Jensen (LJ) proportion method MGIT system

Radiometric (Bactec 460) VersaTrek Myco

Xpert MTB/RIF (Cepheid) TREK Sensititre

Laboratory Developed Test (LDT) or other test method. Please indicate

If you use Middlebrook 7H10 or 7H11 for MTBC drug susceptibility testing, your media is (Select all that apply)

Purchased "commercially-prepared" containing antituberculosis drugs Prepared in-house with disks containing antituberculosis drugs Prepared in-house by reconstituting and adding antituberculosis drugs Not Applicable - We do not use Middlebrook media

Please enter your conventional drug susceptibility results for Culture 2013F

Rifampin

Resistant Susceptible Borderline Contaminated No Growth Not Done

Isoniazid low

Isoniazid high

Pyrazinamide

Ethambutol

Streptomycin

Ethionamide

Rifabutin

Amikacin

Kanamycin

Capreomycin

Ciprofloxacin

Levofloxacin

Ofloxacin

Moxifloxacin

Cycloserine

Para-Amino Salicyclic Acid

Did your laboratory perform any detection of drug resistance using a molecular method for

Culture 2013F?

Yes No

Please select the molecular method used for drug susceptibility testing for Culture 2013F.

Enter your molecular results for Culture 2013F.

Rifampin

Mutation Detected

Mutation Not Detected

No Results Not Done

Isoniazid

Pyrazinamide

Ethambutol

Streptomycin

Ethionamide

Rifabutin

Amikacin

Kanamycin

Capreomycin

Ciprofloxacin

Levofloxacin

Ofloxacin

Moxifloxacin

Cycloserine

Para-Amino Salicyclic Acid

Rifampin

Resistant Susceptible Borderline Contaminate

d

No Growth Not Done

Isoniazid low

Isoniazid high

Pyrazinamide

Ethambutol

Streptomycin

Ethionamide

Rifabutin

Amikacin

Kanamycin

Capreomycin

Ciprofloxacin

Levofloxacin

Ofloxacin

Moxifloxacin

Cycloserine

Para-Amino Salicyclic Acid

Did your laboratory perform any detection of drug resistance using a molecular method for

Culture 2013G?

Yes No

Please select the molecular method used for drug susceptibility testing for Culture 2013G.

Rifampin

Mutation Detected

Mutation Not Detected

No Results Not Done

Isoniazid

Pyrazinamide

Ethambutol

Streptomycin

Ethionamide

Rifabutin

Amikacin

Kanamycin

Capreomycin

Ciprofloxacin

Levofloxacin

Ofloxacin

Moxifloxacin

Cycloserine

Para-Amino Salicyclic Acid

Rifampin

Resistant Susceptible Borderline Contaminate

d

No Growth Not Done

Isoniazid low

Isoniazid high

Pyrazinamide

Ethambutol

Streptomycin

Ethionamide

Rifabutin

Amikacin

Kanamycin

Capreomycin

Ciprofloxacin

Levofloxacin

Ofloxacin

Moxifloxacin

Cycloserine

Para-Amino Salicyclic Acid

Did your laboratory perform any detection of drug resistance using a molecular method for

Culture 2013H?

Yes No

Please select the molecular method used for drug susceptibility testing for Culture 2013H.

Rifampin

Mutation Detected

Mutation Not Detected

No Results Not Done

Isoniazid

Pyrazinamide

Ethambutol

Streptomycin

Ethionamide

Rifabutin

Amikacin

Kanamycin

Capreomycin

Ciprofloxacin

Levofloxacin

Ofloxacin

Moxifloxacin

Cycloserine

Para-Amino Salicyclic Acid

Rifampin

Resistant Susceptible Borderline Contaminate

d

No Growth Not Done

Isoniazid low

Isoniazid high

Pyrazinamide

Ethambutol

Streptomycin

Ethionamide

Rifabutin

Amikacin

Kanamycin

Capreomycin

Ciprofloxacin

Levofloxacin

Ofloxacin

Moxifloxacin

Cycloserine

Para-Amino Salicyclic Acid

Did your laboratory perform any detection of drug resistance using a molecular method for

Culture 2013I?

Yes No

Please select the molecular method used for drug susceptibility testing for Culture 2013I.

Rifampin

Mutation Detected

Mutation Not Detected

No Results Not Done

Isoniazid

Pyrazinamide

Ethambutol

Streptomycin

Ethionamide

Rifabutin

Amikacin

Kanamycin

Capreomycin

Ciprofloxacin

Levofloxacin

Ofloxacin

Moxifloxacin

Cycloserine

Para-Amino Salicyclic Acid

Rifampin

Resistant Susceptible Borderline Contaminate

d

No Growth Not Done

Isoniazid low

Isoniazid high

Pyrazinamide

Ethambutol

Streptomycin

Ethionamide

Rifabutin

Amikacin

Kanamycin

Capreomycin

Ciprofloxacin

Levofloxacin

Ofloxacin

Moxifloxacin

Cycloserine

Para-Amino Salicyclic Acid

Did your laboratory perform any detection of drug resistance using a molecular method for

Culture 2013J.

Yes No

Please select the molecular method used for drug susceptibility testing for Culture 2013J.

Rifampin

Mutation Detected

Mutation Not Detected

No Results Not Done

Isoniazid

Pyrazinamide

Ethambutol

Streptomycin

Ethionamide

Rifabutin

Amikacin

Kanamycin

Capreomycin

Ciprofloxacin

Levofloxacin

Ofloxacin

Moxifloxacin

Cycloserine

Para-Amino Salicyclic Acid