New Molecular Diagnostic Assays for Solana Performance Assessment, Workflow Analysis, and Clinical Utility

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1 New Molecular Diagnostic Assays for Solana Performance Assessment, Workflow Analysis, and Clinical Utility Gerald A. Capraro, Ph.D., D(ABMM) Director, Clinical Microbiology Carolinas Pathology Group Atrium Health Charlotte, North Carolina ECCMID Quidel Workshop April 23, 2018

2 Atrium Health (formerly Carolinas HealthCare System)

3 Microbiology Scope of Service Core Microbiology Laboratory 11 Acute Care Hospitals Levine Cancer Institute Levine Children s Hospital 6 Free-standing Emergency Departments 21 Skilled Nursing Facilities 2,978 providers in 938 medical practices Reference Lab for non-system hospitals in the region Full Service Laboratory (24/7/365) Bacteriology Mycobacteriology Mycology Virology Molecular Micro: C. difficile, positive blood cultures Minimal Parasitology: EIA, WORM, INSECT Teaching: Med Tech students, Peds ID residents/msiv, Pharmacy residents Frequent site for method comparison and workflow studies TEST Annual Volume Urine Cultures 300,000 GAS Cultures 82,000 Exudate/Wound Cultures 31,000 Respiratory Cultures 29,000 GBS Screens 21,000 Positive Blood Cultures 17,000 Sterile Fluid Cultures 16,000 Stool Cultures 14,000 C. difficile Testing 14,000 Fungal Cultures 13,000 Anaerobic Cultures 10,000 Virology Cultures 9,000 AFB Cultures 7,000 Parasitology Testing 6,000 MRSA Screens 4,000

4 Microbiology Testing Schedule TEST 1 st SHIFT 2 nd SHIFT 3 rd SHIFT Hood Processing X X X Processing of Positive Blood Cultures X X X Gram Stains X X X Cdiff EIA X X X Respiratory Bench X Anaerobe Bench X Blood Bench X X Virology X AFB X Mycology X Urine Bench X X Exudate Bench X X Fungal Smears X X Stool Bench X Cdiff PCR X AFB Processing X X AFB Smears X X Fecal Lactoferrin X X Rotavirus Antigen X X Trichomonas Antigen X X Giardia/Cryptosporidium EIA X X

5 Microbiology Staffing We staff 24/7 and modify based on volume demand Technologists per shift per day of the week: Shift M T W F Sat Sun 1 st nd rd

6 Molecular Testing Faster TAT & accurate detection Increased sensitivity leads to superior detection Decrease length of stay Stop unnecessary ordering of additional tests Improved sensitivity and specificity plays an important role in antimicrobial stewardship

7 Quidel molecular Solana Real-time isothermal platform Helicase Dependent Amplification (HDA) technology, fluorescent probe based detection Amplification and detection occur simultaneously No sample extraction High throughput, 12 results in less than 1 hour Minimal hands on time LIS Interface and data management capabilities Virena Solana bench top instrument a mere 9.4 x 9.4 x 5.9

8 Quidel molecular Solana

9 Helicase-Dependent Amplification Uses two sequence specific primers A helicase enzyme separates the strands of DNA/RNA Strands are copied by the polymerase Detection mediated by probes bound to a fluorophore and a quencher

10 Clostridioides difficile (Lawson et al. 2016) Gram positive, anaerobic, spore-forming bacillus virulence factors include toxins, endospores Normal habitat GI Tract Clinical Relevance infectious diarrhea, antibiotic-associated pseudomembranous colitis causes >250K cases per year of diarrheal disease, at a cost of > $1 billion recovered from 3 5% of healthy people hospital-acquired CDAD is of major concern to hospital administrators Laboratory Diagnosis formerly toxigenic culture, cytotoxin-neutralization assay, EIA currently detection of GDH and Toxin A/B Treatment based on new guidelines from IDSA/SHEA and dependent upon initial or recurrent disease

11 Clostridioides difficile Two-step algorithm for Cdiff testing No repeat testing within 7 days GDH/Toxin A/B Assay +/+ +/- -/- True Positive CDI present Isolate/treat as indicated Reflex to Molecular Assay tcd gene test True Negative CDI not present No isolation/treatment indicated POSITIVE Regard as CDI-positive NEGATIVE Regard as CDI-negative

12 Clostridioides difficile (Based on McDonald et al. 2018)

13 Solana Cdiff Workflow Maximum of 12 samples per run Average hands-on time: 1 minute, 33 seconds of setup time per sample 14 seconds of instrument time per sample

14 Solana Cdiff Workflow

15 Solana Workflow 200 liquid stools Cdiff assay 200 Carrot Broth GBS assay Timings collected for 10 independent runs (each assay) Determined average hands-on and instrument time per sample Hands-On Time Instrument Time Specimens Per Run Run Time (min) Theoretical Specimens Per 8h Shift Cdiff 1:23 0: GBS 1:33 0:

16 Solana Cdiff Performance We tested a total of 200 GDH-positive/Toxin-negative specimens Compared Solana Cdiff to BD Max, with Lyra for confirmation of discordant specimens Solana Cdiff BD Max/Lyra POS NEG POS NEG 6 84 Sensitivity: 95% Specificity: 99% PPV: 99% NPV: 93%

17 Respiratory Virus Testing Solutions Influenza antigen testing has poor performance Sofia back to pre-2009 performance levels Molecular testing allows for better performance, faster TAT Molecular syndromic panels offer comprehensive testing Is the cost of such testing justified for all patients??? Current approach: full molecular panel available for inpatients and immunocompromised respiratory viral DFA available for outpatients Solana provides a unique mini-panel that could be used for outpatient testing for: Influenza A Influenza B Respiratory Syncytial Virus (Human Metapneumovirus)

18 Solana Mini RVP Process Solana Flu alongside RSV + hmpv in same run Same operating temperature This includes using the same specimen and same lysed sample, and then splitting to two tests Flu A+B in one reaction and RSV+hMPV in a second reaction 1 specimen and 2 Solana tests can provide 4 respiratory results

19 Summary Molecular testing is replacing conventional culture-based methods for pathogen detection Solana is a simple, sample-to-answer molecular assay that can be tailored to laboratory s workflow to aid in the diagnosis of CDI Solana allows for small batch processing of specimens and multiple runs in a single shift Solana shows excellent performance, fast TAT, and workflow efficiency for a variety of diagnostic analytes, including: Cdiff Flu A/B, RSV, hmpv GBS

20 Questions?

21 Solana GBS Performance We tested a total of 200 specimens from positive and negative Carrot Broth Compared Solana GBS to conventional culture Solana GBS Carrot Broth/Culture POS NEG POS 51 4 NEG Picked up 15 additional positives from negative Carrot Broth (would have saved ~24 hours in TAT) Sensitivity: 98.1% Specificity: 97.3% PPV: 92.7% NPV: 99.3% Percent Agreement: 97.5% GBS Prevalence: 26%

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