Mycology Susceptibility Testing Report Form
This laboratory does not perform susceptibility tests This isolate would be referred out for susceptibility testing This isolate would be referred out for additional susceptibility testing| CMPT Mycology Susceptibility Testing Report Form |
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| Laboratory Name: | Laboratory No: |
| Signature: | Specimen Number: |
| Microbial Identification: | |
| Additional Comments(check all that apply) This laboratory does not perform susceptibility tests This isolate would be referred out for susceptibility testing This isolate would be referred out for additional susceptibility testing |
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Please indicate the Antimicrobial Susceptibility Testing Method
or System used for each isolate (  ) |
|||
| Disk Diffusion |
E-Test |
Microbroth dilution |
Macrobroth dilution |
| Fungitest® |
Sensititre® Yeast-OneTM |
Other, please specify |
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| For each antimicrobial tested, please provide actual and reported result, MIC (mg/L) or zone size (mm). | |||
Antimicrobial Agent |
Actual S/I/R |
Reported |
MIC/ Zone |
Antimicrobial Agent |
Actual S/I/R |
Reported |
MIC/ |
| Amphotericin B | Voriconazole | ||||||
| Fluconazole | 5-Fluorocytosine | ||||||
| Itraconazole | Posaconazole | ||||||
| Ravuconazole | Ketoconazole | ||||||
| Anidulafungin | Micafungin | ||||||
| Caspofungin |
|
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| Signature: | Date: | ||||||
| Please
note: This Print
from Screen report form may be printed and used to
submit results to CMPT via faxing completed forms
to 604-875-4100. (This
form may not print as a single page - depends on your browser.) Currently, results may not be submitted via the CMPT web site. |