The Clinical Benefits of Rapid Multiplex PCR Testing Nick Sands - PowerPoint PPT Presentation

The Clinical Benefits of Rapid Multiplex PCR Testing Nick Sands Field Application Specialist Manager BioFire Diagnostics, LLC Nick.Sands@biofiredx.com

The System How the FilmArray Works

The System How the FilmArray Works

The System How the FilmArray Works Reagent Storage Chemical Circuit Board Sample 1 st Stage Extraction & Preparation Multiplex 2 nd Stage PCR PCR

The System How the FilmArray Works

The System How the FilmArray Works 2 nd Stage Multiplex PCR 1 st Stage Multiplex PCR Dilute 100x

The System How the FilmArray Works Automated Protocol Bladders inflate over blisters to move liquid Pistons open and close the channels Plungers deliver reagents Air Bladder Piston

The System How the FilmArray Works Results Analysis 102 individual 2 nd stage PCR wells Each well contains one reaction Melt curves generated for each well Presentation Title

Clinical Benefits: Gastrointestinal Panel (GI)

Gastrointestinal (GI) Panel Bacteria Parasites Campylobacter (jejuni, coli, and upsaliensis) Cryptosporidium Clostridium difficile (Toxin A/B) Cyclospora cayetanensis Plesiomonas shigelloides Entamoeba histolytica Salmonella Giardia lamblia Vibrio (parahaemolyticus, vulnificus, and cholerae) Vibrio cholerae Viruses Yersinia enterocolitica Adenovirus F 40/41 Diarrheagenic E. coli/Shigella Astrovirus Enteroaggregative E. coli (EAEC) Norovirus GI/GII Rotavirus A Enteropathogenic E. coli (EPEC) Sapovirus (I, II, IV, and V) Enterotoxigenic E. coli (ETEC) Shiga-like toxin-producing E. coli (STEC) E. coli O157 Shigella /Enteroinvasive E. coli (EIEC) FDA-cleared for the first time.

Gastrointestinal Infections: Mortality and Costs 211 – 375 million episodes of diarrheal illness occur in the United  States annually, resulting in: $6 billion 73,000,000 spent on 1,800,000 3,100 physician medical care and hospitalizations deaths consultations lost productivity Guerrant RL et al. Clin Infect Dis. 2001;32:331-351.

The Current State of GI Testing Traditional Stool Culture O&P Staining EIA DFA PCR e e Bacteria, Bacteria, Bacteria, Pathogens Bacteria Parasites Viruses, Parasites Viruses, Parasites Viruses, Parasites 3 – 5 days 1 1 – 7 days 2,3 5 – 6 hours 6 Time to Result <2 hours 4 30 mins 5 77% – 91% 7 50% – 90% 8,9a 75% – 95% 10 90% – 99% 9 Sensitivity up to 100% 11 61% – 78% 7 80% – 90% 9 83% – 98% 10 95% – 100% 9 Specificity up to 100% 11 DFA=direct fluorescent antibody; EIA=enzyme immunoassay; O&P=ova and parasite; PCR=polymerase chain reaction. a Sensitivity scores are affected by a number of variables, including the number and quality of samples tested, previous antibiotic administration, and the proficiency of laboratory technicians. 1. Cunningham SA et al. J Clin Microbiol. 2010;48:2929-2933. 2. Quest Diagnostics. www.Questdiagnostics.com/testcenter/BUOrderInfo.action? tc=6652&labCode=MET. Accessed February 7, 2014. 3. Children’s Hospitals and Clinics of Minnesota. Laboratory Service Manual. Ova and Parasite Examination, Stool. 2009. www.childrensmn.org/manuals/lab/microbioviral/033644.pdf. Accessed March 12, 2014. 4. Meridian Bioscience, Inc. www.meridianbioscience.com/disease-information/c-difficile/testing.aspx. Accessed February 13, 2014. 5. Meridian Bioscience, Inc. www.meridianbioscience.com/diagnostic-products/cryptosporidium-and-giardia/merifluor/merifluor-cryptosporidium-and-giardia.aspx. Accessed February 13, 2014. 6. Saunders NA. Lee MA. Real-Time PCR: Advanced Technologies and Applications. Horizon Scientific Press, 2013. 7. Altwegg M et al. Diagn Microbiol Infect Dis. 1996;24:121-124. 8. Kucik CJ et al. Am Fam Physician . 2004;69:1161-1168. 9. Black ER. Diagnostic Strategies for Common Medical Problems, ACP Press. 1999. 10. Surawicz CM et al. Am J Gastroenterol . 2013;108:478-498. 11. Verweij JJ et al. J Clin Microbiol. 2004;42:1220-1223.

Challenges in Diagnosing Gastrointestinal Infections  Limited clinical guidelines for the diagnosis and treatment of patients with suspected infectious diarrhea 1  Challenges associated with currently available testing methods 1-4 : Time-consuming Limited coverage Confounded by: Labor-intensive Overlapping symptomology Technically complex/ require specific expertise Need to order multiple tests specific for suspected organisms Low yield Unavailability of tests Lack sensitivity and for many organisms specificity 1. Guerrant RL et al. Clin Infect Dis. 2001;32:331-351. 2. Hatchette TF, Farina D. CMAJ. 2011;183:339-344. 3. Lalonde LF et al. Am J Trop Med Hyg . 2013;89:892-898. 4. Lee SD, Surawicz CM. MedGenMed . 2001;3:1-5.

Consequences of Misdiagnosis and Mistreatment of GI Infections Potential outcomes of incorrect diagnosis and treatment Worsened Postinfectious Unnecessary Antibiotic illness 1 sequelae 1,2 side effects 3,4 resistance 3,5 Early diagnosis facilitates timely and appropriate therapeutic interventions that can alleviate symptoms and prevent secondary transmission 1 1. Guerrant RL et al. Clin Infect Dis. 2001;32:331-351. 2. Connor BA, Riddle MS. J Travel Med. 2013;20:303-312. 3. CDC. Antibiotic Resistance Threats in the United States. www.cdc.gov/drugresistance/threat-report-2013/pdf/ ar-threats-2013-508.pdf. Accessed February 10, 2014. 4. Owens RC, Ambrose PG. Clin Infect Dis. 2005;41:S144-S157. 5. WHO. Antimicrobial Resistance Global Report on Surveillance. www.who.int/drugresistance/documents/surveillancereport/en. Accessed June 6, 2014.

Potential Patient and Provider Benefits  Rapid diagnosis of the causative agent of GI infections and appropriate treatment decisions can improve patient outcomes and decrease healthcare costs 1,2 Provider Patient Fast results 3 Provides more Shortened illness 1 comprehensive Comprehensive testing 4 Shorter hospital visits 2 coverage 3 Informs improved Reduced morbidity 1 Accurate quality of care 2 pathogen Prevents secondary identification 3 Guides appropriate transmission 1 follow-up 3 1. Guerrant RL et al. Clin Infect Dis . 2001;32:334-351. 2. Nanosphere. Enteric Pathogens Test. www.nanosphere.us/products/enteric-pathogens-test. Accessed February 10, 2014. 3. FilmArray GI [Instruction Booklet]. Salt Lake City, UT: BioFire Diagnostics, LLC. 4. Buss SN et al. J Clin Microbiol . 2013;51:3909.

Clinical Benefits: Blood Culture Identification Panel (BCID)

Blood Culture Identification (BCID) Panel Gram+ Bacteria Gram- Bacteria Yeast Enterococcus Acinetobacter baumannii Candida albicans Listeria monocytogenes Haemophilus influenzae Candida glabrata Staphylococcus Neisseria meningitidis Candida krusei S. aureus Pseudomonas aeruginosa Candida parapsilosis Streptococcus Enterobacteriaceae Candida tropicalis S. agalactiae Enterobacter cloacae complex S. pyogenes Escherichia coli S. pneumoniae Klebsiella oxytoca Klebsiella pneumoniae Antibiotic Resistance Proteus mecA – methicillin resistant Serratia marcescens van A/B – vancomycin resistant KPC – carbapenem resistant FDA-cleared for the first time.

The Current State of Blood Culture Testing Blood Blood Gram Antimicrobial Draw Culture Positive Stain Pathogen ID Standard Testing Susceptibility Testing 12 – 72 h 24 – 72 h 5 min Definitive identification of a pathogen can take 24 to 72 hours through traditional culture methods. This delay can lead to inadequate or overly broad antimicrobial therapy and result in therapy-related complications, antimicrobial resistance, and increases in patient morbidity, mortality, and costs. Blaschke AJ. Diagn Microbiol Infect Dis . 2012;74(4):349-355. 19

Unmet Needs in Treating Sepsis In 58% 58% , therapy was delayed A retrospective cohort analysis of 760 patients 31% received 31% with severe sepsis 1 inappropriate antibiotic treatment 42% had 42% resistance to the antibiotic administered Patients who progress to septic shock have a 7.6% 7.6% increase in mortality every y hour r while not on appropriate therapy. 2 1. Shorr AF et al. Crit Care Med . 2011;39(1):46-51. 2. Kumar A et al. Crit Care Med . 2006;34(6):1589-1596.

Septicemia: Mortality and Costs • Septicemia remains a leading cause of death in both adults and infants in the United States, and is the leading cause of death in noncardiac ICUs 1,2 Sepsis 2 Mortality 2 $24.3 billion 2 >1.1 million cases >40% annual cost annually ICU=intensive care unit. 1. Heron M. Nat Vit Stat Rep. 2012;60:1-95. 2. Moore LJ, Moore FA. Surg Clin North Am. 2012;92(6):1425-1443.

A Fast Diagnosis Can Ensure Timely Treatment, Which May Reduce Mortality Mortality Rate of Sepsis, Severe Sepsis, and Septic Shock 1 70 Mortality rate (%) 61% 60 50 42% 40 26% 30 20 10 0 Infection/sepsis Severe sepsis Septic shock Timely treatment is essential to prevent the progression of sepsis to septic shock and reduce mortality 1-3 1. Alberti C et al, for the European Sepsis Study Group. Am J Respir Crit Care Med . 2005;171(5):461-468. 2. Shorr AF et al. Crit Care Med . 2011;39(1):46-51. 3. Moore LJ et al. Surg Clin North Am . 2012;92(6):1425-1443.

Clinical Benefits: Respiratory Panel (RP)