Near patient molecular diagnostics test for infections

摘要 目前，还没有FDA批准的用于尿路感染（UTI）病原体鉴定的基于分子的测试， 抗菌药物敏感性测试，以取代'金标准'的试纸尿液分析和尿液培养。所有病原体 鉴定试验仍然依赖于来自尿培养的临床分离物，与Koch发展的假设基本上没有变化 在世纪作为鉴定病原体的一般准则。然而，随着时间的推移， 这些病原体中抗生素耐药性的逐步出现。数据来自疾病控制中心和 预防（CDC）国家医疗保健安全网络（NHSN）指出，70%的病原体分离自 医院获得性感染（HAI）现在对至少两种主要类别的抗生素具有耐药性。最近的事态发展 多药耐药（MDR）病原体的分子诊断检测可以提供一个敏感、特异和实时的 支持主动监测驱动的感染控制干预措施的解决方案，但这些基于PCR的检测只能 在简单的样本基质上进行，如拭子或阳性血液培养基（血液与肉汤比例为1：10）。没有 基于分子的方法是由FDA批准的，可以直接在尿液或全血样本上进行测试。 这项商业化准备试点（CRP）赠款的目标是加速 来自我们的NIAID SBIR R44 AI 088756项目“快速诊断的集成诊断系统”的程序结果 抗菌药物敏感性试验（AST）"。我们建议在制定监管战略方面提供技术援助， 成本效益的制造，以及后期的研究和开发活动的独立复制的关键 研究符合FDA要求和ISO 13485标准。我们NIAID先进技术的目标 SBIR项目是开发和验证RAST（快速抗菌药物敏感性测试），一个集成的，紧凑的 一种诊断系统，使临床医生能够通过基于证据的抗生素选择指导护理点（POC）， 治疗急性细菌感染。我们的第一个紧凑的自动化系统能够快速病原体识别（ID） 和AST直接从患者的样本与循证信息开始患者特异性抗菌治疗。 预计在2016年2月即将到来的ISO 13485监督认证审核后获得CE标志。然而，在这方面， FDA的批准受到以下因素的阻碍：（1）FDA没有批准用于尿路感染的基于分子的等同试验 (UTI)，（2）常规试纸尿液分析测试的低成本，以及（3）缺乏通过多个 临床可行性研究。 我们将通过以下目标克服这些障碍： 技术援助 目的1：通过外部重新分类请求获得II类器械的基于风险的分类 在18个月内获得NSF International（国际认证组织）的监管援助 目标2：降低商品销售成本，即检测盒低于3美元，外部制造系统低于5000美元 发展援助 后期研究和开发活动 目标3：进行多中心临床性能研究，并证明>95%的临床 敏感性/特异性和>95%敏感性分类一致性 在本研究中，我们重点根据联邦法规21 CFR 866.2660验证快速UTI诊断器械 （微生物区分和鉴定装置），21 CFR 866.1640（抗菌药物敏感性试验粉末）， 和21 CFR 866.1645（全自动、短期孵育周期抗菌药物敏感性测试系统）。FDA的 这种系统的产品代码是“JSS”和“LON”。监管策略将在目标1（监管）中最终确定， 目标3（临床研究）中的临床方案和多中心临床性能研究的准备，将使用 在目标2（制造）中优化的具有成本效益的系统和耗材。

ABSTRACT Currently, there are no FDA cleared molecular-based tests for urinary tract infection (UTI) pathogen identification and antimicrobial susceptibility testing to replace the 'gold standard' of dipstick urinalysis and urine culturing. All pathogen identification tests still rely on clinical isolates from urine cultures, largely unchanged from Koch's postulates developed in the 19th century as general guidelines to identify pathogens. What has changed over time, however, is the dramatic and progressive emergence of antibiotic resistance among these pathogens. Data from the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) indicate that 70% of the pathogens isolated from hospital-acquired infections (HAIs) now are resistant to at least 2 major classes of antibiotics. Recent developments in molecular diagnostic testing for multidrug resistant (MDR) pathogens can provide a sensitive, specific, and real-time solution to support active surveillance-driven infection control interventions, but these PCR-based tests can only be performed on simple specimen matrices such as swabs or positive blood culture media (1:10 blood-to-broth ratio). No molecular-based method is cleared by the FDA to test directly on urine or whole blood samples. The goal of this Commercialization Readiness Pilot (CRP) Grant is to accelerate the commercialization effort of the program outcome from our NIAID SBIR R44AI088756 project titled “An Integrated Diagnostic System for Rapid Antimicrobial Susceptibility Testing (AST)”. We propose technical assistance on regulatory strategy development and cost-effective manufacturing, as well as later stage research and development activities on independent replication of key studies in compliance with FDA requirements and ISO 13485 standards. The goal of our NIAID Advanced Technology SBIR project is to develop and validate RAST (rapid antimicrobial susceptibility testing), an integrated and compact diagnostic system that enables clinicians direct point-of-care (POC) with an evidence-based selection of antibiotics for treatment of acute bacterial infections. Our first compact automated system is capable of rapid pathogen identification (ID) and AST directly from patient's samples with evidenced-based information to start patient-specific antimicrobial treatment. It is expected to obtain a CE Mark after the coming ISO 13485 surveillance certification audit in February 2016. However, the FDA clearance is hindered by: (1) no molecular-based predicate test cleared by the FDA for urinary tract infections (UTI), (2) the low cost of conventional dipstick urinalysis tests, and (3) the lack of fresh urine specimens through a multi- site clinical feasibility study. We will overcome these hurdles through the following aims: TECHNICAL ASSISTANCE Aim 1: Obtain a risk-based classification of the Class II device through a de novo request with external regulatory assistance from NSF International (an international certification organization) in 18 months Aim 2: Reduce the cost of goods sold of <$3 for cartridge and <$5k for system with external manufacturing development assistance LATE STAGE RESEARCH AND DEVELOPMENT ACTIVITIES Aim 3: Conduct a multi-center clinical performance study and demonstrate >95% clinical sensitivity/specificity and >95% susceptibility categorical agreement In this study, we focus on validating the rapid UTI diagnostic device according to federal regulations 21 CFR 866.2660 (microorganism differentiation and identification device), 21 CFR 866.1640 (antimicrobial susceptibility test powder), and 21 CFR 866.1645 (fully automated, short-term incubation cycle antimicrobial susceptibility testing system). The FDA product codes for such systems are “JSS” and “LON.” The regulatory strategy will be finalized in Aim 1 (Regulatory) for preparation of the clinical protocol and multicenter clinical performance study in Aim 3 (Clinical study) that will utilize the cost-effective system and consumables optimized in Aim 2 (Manufacturing).