Form Approved
OMB No. 0920-0600
Expiration Date: 00/00/0000
Attachment G. MPEP Mycobacterium tuberculosis Results Worksheet
Enter your drug susceptibility test results for each culture by using the data entry forms below. There is one form for entering conventional drug susceptibility results and another for entering molecular test results. You can either enter your results directly on the forms or print them out to enter results manually. Fill in other test concentrations used for each drug by using the open fields.
Drug Susceptibility Worksheet for Culture:
Drug |
Conc. μg/ml |
Resistant |
Susceptible |
Borderline |
Contaminated |
No Growth |
Not Done |
Rifampin |
1.00 |
|
|
|
|
|
|
Rifampin |
2.00 |
|
|
|
|
|
|
Rifampin |
|
|
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|
Rifampin |
|
|
|
|
|
|
|
Isoniazid |
0.10 |
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|
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|
|
|
Isoniazid |
0.20 |
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|
|
|
|
|
Isoniazid |
0.40 |
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|
|
|
|
|
isoniazid |
1.00 |
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|
|
Isoniazid |
|
|
|
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|
Isoniazid |
|
|
|
|
|
|
|
Pyrazinamide |
100.00 |
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|
|
|
|
|
Pyrazinamide |
300.00 |
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Pyrazinamide |
|
|
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Pyrazinamide |
|
|
|
|
|
|
|
Ethambutol |
2.50 |
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|
Ethambutol |
5.00 |
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|
Ethambutol |
7.50 |
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|
Ethambutol |
|
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|
Ethambutol |
|
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|
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|
Streptomycin |
1.00 |
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|
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|
Streptomycin |
2.00 |
|
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|
Streptomycin |
4.00 |
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|
Streptomycin |
10.00 |
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|
Streptomycin |
|
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Streptomycin |
|
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|
Ethionamide |
2.00 |
|
|
|
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|
Ethionamide |
5.00 |
|
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|
Ethionamide |
4.00 |
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|
Ethionamide |
10.00 |
|
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|
Ethionamide |
|
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Ethionamide |
|
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Rifabutin |
0.50 |
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Rifabutin |
|
|
|
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|
Rifabutin |
|
|
|
|
|
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|
Amikacin |
1.00 |
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Amikacin |
4.00 |
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Amikacin |
|
|
|
|
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Amikacin |
|
|
|
|
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Kanamycin |
5.00 |
|
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|
Kanamycin |
6.00 |
|
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|
Kanamycin |
|
|
|
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Kanamycin |
|
|
|
|
|
|
|
Capreomycin |
1.25 |
|
|
|
|
|
|
Capreomycin |
2.50 |
|
|
|
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|
Capreomycin |
10.00 |
|
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|
Capreomycin |
|
|
|
|
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|
Capreomycin |
|
|
|
|
|
|
|
Ciprofloxacin |
1.00 |
|
|
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|
Ciprofloxacin |
2.00 |
|
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|
Ciprofloxacin |
|
|
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Ciprofloxacin |
|
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|
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Levofloxacin |
1.50 |
|
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Levofloxacin |
|
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Ofloxacin |
2.00 |
|
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Ofloxacin |
|
|
|
|
|
|
|
Moxifloxacin |
0.25 |
|
|
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Moxifloxacin |
0.50 |
|
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Moxifloxacin |
|
|
|
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|
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|
Cycloserine |
30.00 |
|
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Cycloserine |
60.00 |
|
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Cycloserine |
|
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|
|
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|
Para-Amino Salicyclic Acid |
2.00 |
|
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|
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|
Para-Amino Salicyclic Acid |
8.00 |
|
|
|
|
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|
Para-Amino Salicyclic Acid |
|
|
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|
|
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|
Molecular Results Worksheet for Culture:
Drug |
Resistant |
Susceptible |
No Result |
Not Done |
Rifampin |
|
|
|
|
Isoniazid |
|
|
|
|
Pyrazinamide |
|
|
|
|
Ethambutol |
|
|
|
|
Streptomycin |
|
|
|
|
Ethionamide |
|
|
|
|
Rifabutin |
|
|
|
|
Amikacin |
|
|
|
|
Kanamycin |
|
|
|
|
Capreomycin |
|
|
|
|
Ciprofloxacin |
|
|
|
|
Levofloxacin |
|
|
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|
Ofloxacin |
|
|
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Moxifloxacin |
|
|
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|
Cycloserine |
|
|
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|
Para-Amino Salicyclic Acid |
|
|
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|
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)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Yakrus, Mitchell (CDC/OID/NCHHSTP) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-29 |