SlideShare a Scribd company logo
1 of 61
Molecular diagnostics in the future: 
How will it look like and what are the 
challenges! 
Bert Niesters 
Department of Medical Microbiology 
Division of Clinical of Virology 
University Medical Center Groningen 
The Netherlands
Point of Impact: 
From Classical PCR to Point-of-Care Systems. 
Division of Clinical Virology
Division of Clinical Virology 
Disclosures 
• Executive board member of QCMD. 
• Commercial developments on FlowG MiddleWare solutions. 
• Assessor for the Dutch Council of Accreditation. 
• Editor-in-Chief of Journal of Clinical Virology. 
• Advisory board Stratec on AURORA VigiLant.
Division of Clinical Virology 
What I will present 
• Introduction 
• How we are interlinked, networks, cross-border 
• Facts on molecular diagnostics 
• The diagnostic triangle 
• The €hr concept 
• The Extended Diagnostic Triangle 
• The AID-Stewardship Portfolio
Division of Clinical Virology
Division of Clinical Virology
Division of Clinical Virology 
What is the UMCG? 
The UMCG is a tertiary referral hospital providing care for both adults 
and children and has a large Solid Organ Transplant program. 
The large proportion of immune-compromised patients require isolation 
from patients with respiratory illness.
Division of Clinical Virology 
Introduction 
• The Influenza season of 2012-2013 was characterized by co-circulation 
of two Influenza A types. 
– H1N1 2009pdm09 
– H3N2 
• Due to the circulation of two Influenza viruses Influenza A-positive 
patients had to be admitted into single rooms. 
• A large number of different respiratory viruses were circulating 
during a long (5 months) period of time, with RSV and influenza 
viruses being present simultaneously.
Number of viruses identified 
Division of Clinical Virology 
December 2012-April 2013 
300 
200 
100 
0 
December 
January 
February 
March 
April 
Influenza A 
Influenza B 
hMPV 
RSV 
Adeno 
Boca 
Corona 
Rhino 
Parainfl 
A total of 1259 respiratory samples were tested
Typing results of Influenza A positives 
Division of Clinical Virology 
0 20 40 60 
December 
January 
February 
March 
April 
H3N2 
H1N1pdm09 
NT 
166 patients had Influenza A 
• 59 had H1N1pdm09 
• 104 had H3N2 
• 3 NT
Isolation regiment of patients admitted 
Division of Clinical Virology 
with a respiratory illness 
? 
Neg 
Infl 
A 
Other 
virus 
No 
isolation 
Geno-type? 
H1N1 
Care in cohort 
H3N2 
isolation 
H1N1 H1N1 H1N1 
H3N2 H3N2 H3N2 
Care in cohort
The Challenges 
• In our setting, the validation of BINAX Now influenza test 
resulted in a negative outcome. Too insensitive. Did not pass the 
validation process. 
• Request for data on more viruses that circulated simultaneously. 
• Samples from patients received at the end of the day, on Friday 
Division of Clinical Virology 
(after 16.00 hr) and in the weekend, had a long TAT. 
• Lack of isolation rooms.
Patient Referral Network in 
the Netherlands 
Donker et al. Math Biol 2012 
Prof Grundmann, UMCG 
University Hospitals 
Regional Centers 
Local Hospital
Connectivity between regional centers 
Labmicta, Enschede 
Izore, Leeuwarden UMCG 
Isala, Zwolle 
LvI 
Apeldoorn 
UMCG 
Regional Center 
Satellite 
Dr. Donker, Prof. Grundmann, UMCG 
(does not cross borders)
Intra-Hospital travel of potentially 
exposed patients 
KPNEU, esbl+ outbreak, UMCG 09-2012 
Day-by-day patient transfer 
Start: 29.5.2012 
<10 
<50 
>50 
Mariano Ciccolini, 
MMB, UMCG
How patients are moved within UMCG 
Division of Clinical Virology 
Data analysed with UCINET 6 
www.medicalmicrobiology.eu
Ems-Dollart Region
HealthCare Network EDR 
-Patient transfer 2011 
- 5 healthcare clusters 
- Regional network building 
Dr. Rocker, Dr. Pulz (NLGA) & Dr. Ciccolini (UMCG)
From TypeNed to RegioType to UMCG 
Nosocomial Infections 
 Percentage of nosocomial infections in UMCG 
 12% for influenza A virus, 19% for influenza B virus 
 22-24% for rhinovirus and enterovirus 68 
 Around 50% for norovirus 
 Consequence is Infection Control 
 Focusing on patients 
 Less focusing on visitors 
 Sequence a select number of target viruses ASAP 
 Norovirus, rhinovirus 
Division of Clinical Virology
Division of Clinical Virology
The Facts on Molecular Diagnostics 
• Molecular diagnostics is an integrated, solid and important part 
Division of Clinical Virology 
within our diagnostic laboratory. 
• Investments over the years have been high, both equipment, 
reagents and consumables. 
• Equipment from different diagnostic companies. 
• Patient diagnostics, treatment and safety is important within our 
work. A short TAT time has impact on the use of antibiotics. 
• Limited availability of Point-of-Care (Impact) technologies.
Division ooff CClliinniiccaall VViirroollooggyy
Overview (virology) 
High throughput 
Sample in-result out 
Commercial 
Blood screening 
Commercial 
STD 
Commercial 
HPV 
Medium to low throughput In-house or LDT 
“Everything” 
Commercial 
Limited portfolio 
No sample in - result 
out 
Point-of-Care 
Point-of-Impact 
Commercial 
Short TAT 
Influenza virus 
Norovirus 
Respiratory 
viruses 
Sample in - result 
out 
Division of Clinical Virology
Alternatives for the LDT (in-house) PCR 
Point-of-Care/Point-of-Impact (respiratory targets) 
Cepheid GeneXpert Flu 
(too insensitive). Detects not 
enough clinical relevant respiratory 
targets. 
BioFire FilmArray Respiratory 
assay. 
1 Sample per instrument. Broad 
panel. 
GenMark NexGen Respiratory Panel 
(Should be as sensitive as previous 
eSensor technology) 
Division of Clinical Virology
‘QA & QC’ within the Microbiology Laboratory 
Certification 
Accreditation 
New method Establish 
Performance 
Perform 
Clinical tests 
ISO15189:2012 
Characterised 
Quality 
reagents 
Verify method 
Validate 
Performance 
Method 
Equivalence 
Quality 
Improvements 
Report Results 
Implement 
method 
Assay 
Verification 
Assay 
Validation 
Assay 
Implementation 
Method 
Maintenance 
Quality 
Management 
System 
EQA 
(PT) 
Internal 
QC 
Internal 
QA 
Division of Clinical Virology
Division of Clinical Virology 
QCMD proficiency testing 
Stock dilution series 
Coronavirus NL63 
Influenza A H1pdm09 
Influenza H3 
Influenza B 
Parainfluenza virus 1 
RSV A 
RSV B 
Panels 
Adenovirus 
Influenza virus 
Parainfluenza virus 
Rhinovirus 
RSV 
Compared eSensor technology with our LDT assays 
Compare FilmArray with our LDT assays
Conclusions FilmArray eSensor Technology 
• FilmArray RP (Ct <31) is more sensitive than INF 
and RSV BinaxNOW (Ct < 21 en <24) 
• Detects 98% of the positive patient samples with Ct values < 31. 
Missed a rhinovirus positive sample 
• Specificity of the validated targets is 100%, with an 
exception for Rhinovirus 98.5% 
Division of Clinical Virology
Conclusions GenMark Technology 
• GenMark eSensor Technology (Ct <35-37) is more sensitive than 
Influenza and RSV BinaxNOW (Ct < 21 en <24). Similar sensitivity 
compared to LDT. 
• Initial results also indicate an improved sensitivity compared to 
BioFire FilmArray. 
• We have not yet validated all parameters. 
• A challenge for Proficiency Testing as well as for QCMD as a 
Proficiency Provider, is how to develop proficiency panels for multiplex 
system according to the ISO15189:2012 guidelines. 
Division of Clinical Virology
Performance of FilmArray versus LDT 
FilmArray RP 
Influenza A H1 
Influenza A H3 
Influenza A H1pdm09 
Influenza B 
Human Metapneumovirus 
RSV 
Adenovirus 
Bocavirus 
Coronavirus HKU1 
Coronavirus NL63 
Coronavirus 229 E 
Coronavirus OC43 
Rhinovirus/enterovirus 
Parainfluenza 1 
Parainfluenza 2 
Parainfluenza 3 
Parainfluenza 4 
Routine LDT PCR 
Influenza A 
Influenza B 
Human Metapneumovirus 
RSV 
Adenovirus 
Bocavirus 
Coronavirus NL63 
Coronavirus 229 E 
Coronavirus OC43 
Rhinovirus/enterovirus 
Parainfluenza 1 
Parainfluenza 2 
Parainfluenza 3 
Parainfluenza 4 
FilmArray RP (Ct <31-33) is more sensitive than 
Influenza and RSV BinaxNOW (Ct < 21 en <24). 
Division of Clinical Virology 
Influenza A H1 
Influenza A H3 
Influenza A H1pdm09 
Influenza A N1 
Influenza A N2 
Negative or positive result 
Turnaround time 1.5 hours after 
the sample arrived in the laboratory 
Negative or positive result 
Turnaround time 1.25 days 
Influenza A with genotype 
Turnaround time 2 days
Division of Clinical Virology 
The Diagnostic Triangle 
Time to Result 
TAT 
Diagnostics 
Quality 
LI 
S
Division of Clinical Virology 
Dear Dr. Riezebos, FilmArray 2 detected Influenza A, 
Influenza A/H1 in sample E2013100465
Division of Clinical Virology
Division of Clinical Virology 
Norovirus II.4.Sydney
Division of Clinical Virology 
Norovirus II.4.2009
Is this affordable point-of-care? 
Division ooff CClliinniiccaall VViirroollooggyy 
IQuum 
The lab in a tube technology 
GeneXpert Infinity System Biocartis platform 
FilmArray, bioMerieux GenMark Dx 
Luminex Aries
Division of Clinical Virology 
The € hour concept 
(comparable with kWhr) 
• Time-to-result or turn-around-time (TAT) for critical 
care is important. 
• Time-to-result for decision making is important. 
• Start or stop treatment 
• Isolation of patient or not 
• Cohorting of patients 
(e.g. Influenza H1 infected patients in one room) 
• Combine time-to-result with costs of assay.
Division of Clinical Virology 
The € hour concept 
(comparable with kWhr) 
• Calculate the costs of stay in hospital and/or isolation 
of a patient 
• Assay 30 € but TAT is 24 hr: total 720 €hr (Plus 1 
extra costs of bed). 
• Assay 100 € but TAT is 3 hr: total 300 €hr. 
• Cost –and earning- of bed (estimated between 
€1700 and €3200/day) 
• (example critical care at Friday late afternoon). 
• Calculate the costs for getting a hospital acquired 
infection. 
• We have to work more intensively with economists and 
mathematicians!
Modeling infection and transmission 
fHA due to delay and 
background 
transmission 
Model based on Rhinovirus data 
Model predicted impact of infection control (IC) on hospital acquired 
infections (fHA); the red circle represents UMCG data (74% under 
IC, 24% fHA).
Model predicted number of hospital acquired cases for five 
different infection control scenarios 
Rhinovirus as model 
Division of Clinical Virology
Nursing 
department 
Division of Clinical Virology 
The Ideal World 
Total turnaround time: ~3h 
Patient with respiratory 
ilness (or, Influenza like 
Ilness, ILI) 
Molecular 
diagnostic test 
application 
Sampling and 
sending to the 
laboratory 
Technician; 
Medical 
virologist 
Interpretation 
of test results 
Diagnosis ; 
Positioning; 
Treatment plan 
Nurse; 
Co-assistent 
Admission; 
Treatment 
Turnaround time : ~1 .5h 
Emergency Department 
Department of Medical Microbiology 
Technician 
Performing a 
Laboratory test 
(Clinical virology ) 
Turnaround time : ~1.5h 
Physician 
Increase of 288% in viral respiratoire diagnostics.
Respiratory season 2012-2013 
0 20 40 60 
Division of Clinical Virology 
300 
200 
100 
0 
December 
January 
February 
March 
April 
Influenza A 
Influenza B 
hMPV 
RSV 
Adeno 
Boca 
Corona 
Rhino 
Parainfl 
? 
Neg 
Infl 
A 
Other 
virus 
No 
isolation 
Geno-type? 
H1N1 
December 
January 
February 
March 
April 
Care in cohort 
H3N2 
isolation 
H1N1H1N1H1N1 
H3N2H3N2H3N2 
Care in cohort 
H3N2 
H1N1pdm09 
NT
The Extended Diagnostic Triangle 
Division of Clinical Virology 
Infection Control 
TAT 
Cost or €hr 
Quality 
Diagnostics 
Treatment 
LI 
S
The AID-Stewardship Portfolio 
Division of Clinical Virology 
• The Antibiotic/Antimicrobial Stewardship 
• The Infection Control Stewardship 
• The Diagnostic Stewardship 
• (Giving Antibiotics without Diagnostics should also be 
financially compensated to the laboratory) 
(For management, the Financial Stewardship portfolio)
E-health 
Current focus UMC’s 
Cure (and care) 
Patient oriented 
Based on Apple HealthKit 
Division of Clinical Virology 
(Near) Future 
Prevention 
Society oriented
The AID-Stewardship Portfolio 
• The Antibiotic/Antimicrobial Stewardship 
• The Infection Control Stewardship 
• The Diagnostic Stewardship 
Determine and communicate the value of molecular 
diagnostics! 
– Take the lead (use of POC/POI; E-health) 
– Cost effectiveness 
– Awareness (communicate) 
Division of Clinical Virology
Cost Effectiveness of AID-Stewardship 
Cost Benefit 
Division of Clinical Virology
Burden of infectious diseases 
• Nosocomial infections (HAI) 
• and Antibiotic resistance 
• (MRSA, VRE, ESBL et al.) 
• Pneumococci 
• HIV/AIDS 
• Viral Hepatitis 
• Pandemic flu 
• Diarrhea (v.a. Norovirus, 
Camplylobacter) 
• Emerging infections / Zoonosen 
(z.B. EHEC, MERS, H5N1) 
CDC-report 2005 ECDC-report 2009
The silver generation
Ageing Society
Division of Clinical Virology 
Improved Infectious Diseases Diagnostics • CID 2013:57 (Suppl 3) • S139
Division of Clinical Virology 
Who detects MERS in POC?
Division of Clinical Virology
Division of Clinical Virology
Division of Clinical Virology
“The only limitation is your imagination”.
Division of Clinical Virology 
Take home message 
• Increase in availability of Point-of-Care/Impact 
technologies. 
• Important is good sensitivity, however, less of a problem 
within the season. eSensor technology very promising. 
• Not all POC/POI assays detect all relevant targets. 
• Costs versus benefits. The €hr concept. 
• Consider the AID stewardship concept. 
• Value of a negative result is also very important!
Network-based Infection Control
Awareness 
Division of Clinical Virology
Division of Clinical Virology 
More info: 
www.FlowG.nl 
www.MedicalMicrobiology.eu
Division of Clinical Virology

More Related Content

What's hot

Automation in microbiology, changing concept and defeating challenges
Automation in microbiology, changing concept and defeating challengesAutomation in microbiology, changing concept and defeating challenges
Automation in microbiology, changing concept and defeating challengesAyman Allam
 
Vitek 2 compac tpptx
Vitek 2 compac tpptxVitek 2 compac tpptx
Vitek 2 compac tpptxabeer-babeker
 
Automated methods in the microbiology lab
Automated methods in the microbiology labAutomated methods in the microbiology lab
Automated methods in the microbiology labFaris K
 
MOLECULAR TOOLS IN DIAGNOSIS AND CHARACTERIZATION OF INFECTIOUS DISEASES
MOLECULAR TOOLS IN  DIAGNOSIS AND CHARACTERIZATION OF INFECTIOUS DISEASES MOLECULAR TOOLS IN  DIAGNOSIS AND CHARACTERIZATION OF INFECTIOUS DISEASES
MOLECULAR TOOLS IN DIAGNOSIS AND CHARACTERIZATION OF INFECTIOUS DISEASES tawheedshafi
 
Quality Assurance in Clinical Microbiology
Quality Assurance in Clinical MicrobiologyQuality Assurance in Clinical Microbiology
Quality Assurance in Clinical MicrobiologySantosh Kumar Yadav
 
Fluorescence- Activated Cell Sorter (FACS)
Fluorescence- Activated Cell Sorter (FACS)Fluorescence- Activated Cell Sorter (FACS)
Fluorescence- Activated Cell Sorter (FACS)Nidhi Parikh
 
Clinical microbiology
Clinical microbiologyClinical microbiology
Clinical microbiologyNursing Path
 
MALDI - TOF MS: Where Mass Spectrometry Meets Microbiology
MALDI - TOF MS: Where Mass Spectrometry Meets MicrobiologyMALDI - TOF MS: Where Mass Spectrometry Meets Microbiology
MALDI - TOF MS: Where Mass Spectrometry Meets MicrobiologyICAR-CIFE
 
Tissue culture and virology (cpe, plaque assay)
Tissue culture and virology (cpe, plaque assay)Tissue culture and virology (cpe, plaque assay)
Tissue culture and virology (cpe, plaque assay)Noman-Hafeez khosa
 
Lecture 2 diagnostic molecular microbiology bls
Lecture 2 diagnostic molecular microbiology blsLecture 2 diagnostic molecular microbiology bls
Lecture 2 diagnostic molecular microbiology blsBruno Mmassy
 
Nanopore for dna sequencing by shreya
Nanopore for dna sequencing by shreyaNanopore for dna sequencing by shreya
Nanopore for dna sequencing by shreyaShreya Modi
 

What's hot (20)

Automation in microbiology, changing concept and defeating challenges
Automation in microbiology, changing concept and defeating challengesAutomation in microbiology, changing concept and defeating challenges
Automation in microbiology, changing concept and defeating challenges
 
Vitek 2 compac tpptx
Vitek 2 compac tpptxVitek 2 compac tpptx
Vitek 2 compac tpptx
 
Automated methods in the microbiology lab
Automated methods in the microbiology labAutomated methods in the microbiology lab
Automated methods in the microbiology lab
 
NEWER TECHNOLOGIES DIAGNOSTIC MICROBIOLOGY
NEWER TECHNOLOGIES DIAGNOSTIC MICROBIOLOGYNEWER TECHNOLOGIES DIAGNOSTIC MICROBIOLOGY
NEWER TECHNOLOGIES DIAGNOSTIC MICROBIOLOGY
 
MOLECULAR TOOLS IN DIAGNOSIS AND CHARACTERIZATION OF INFECTIOUS DISEASES
MOLECULAR TOOLS IN  DIAGNOSIS AND CHARACTERIZATION OF INFECTIOUS DISEASES MOLECULAR TOOLS IN  DIAGNOSIS AND CHARACTERIZATION OF INFECTIOUS DISEASES
MOLECULAR TOOLS IN DIAGNOSIS AND CHARACTERIZATION OF INFECTIOUS DISEASES
 
Quality Assurance in Clinical Microbiology
Quality Assurance in Clinical MicrobiologyQuality Assurance in Clinical Microbiology
Quality Assurance in Clinical Microbiology
 
Flow cytometry
Flow cytometryFlow cytometry
Flow cytometry
 
Fluorescence- Activated Cell Sorter (FACS)
Fluorescence- Activated Cell Sorter (FACS)Fluorescence- Activated Cell Sorter (FACS)
Fluorescence- Activated Cell Sorter (FACS)
 
Clinical microbiology
Clinical microbiologyClinical microbiology
Clinical microbiology
 
Bio terrorism
Bio terrorismBio terrorism
Bio terrorism
 
Flow cytometry
Flow cytometry Flow cytometry
Flow cytometry
 
LABORATORY SAFETY WORKING WITH TUBERCULOSIS
LABORATORY  SAFETY WORKING WITH TUBERCULOSIS LABORATORY  SAFETY WORKING WITH TUBERCULOSIS
LABORATORY SAFETY WORKING WITH TUBERCULOSIS
 
MALDI - TOF MS: Where Mass Spectrometry Meets Microbiology
MALDI - TOF MS: Where Mass Spectrometry Meets MicrobiologyMALDI - TOF MS: Where Mass Spectrometry Meets Microbiology
MALDI - TOF MS: Where Mass Spectrometry Meets Microbiology
 
Molecular biology
Molecular biologyMolecular biology
Molecular biology
 
Vitek MS Brochure
Vitek MS BrochureVitek MS Brochure
Vitek MS Brochure
 
Flow cytometry
Flow cytometryFlow cytometry
Flow cytometry
 
Tissue culture and virology (cpe, plaque assay)
Tissue culture and virology (cpe, plaque assay)Tissue culture and virology (cpe, plaque assay)
Tissue culture and virology (cpe, plaque assay)
 
Lecture 2 diagnostic molecular microbiology bls
Lecture 2 diagnostic molecular microbiology blsLecture 2 diagnostic molecular microbiology bls
Lecture 2 diagnostic molecular microbiology bls
 
Epsilometer Test
Epsilometer TestEpsilometer Test
Epsilometer Test
 
Nanopore for dna sequencing by shreya
Nanopore for dna sequencing by shreyaNanopore for dna sequencing by shreya
Nanopore for dna sequencing by shreya
 

Similar to Molecular diagnostics in the future July 14 - Prof. Bert Niesters

Multiplex Arrays for POC infection detention
Multiplex Arrays for POC infection detentionMultiplex Arrays for POC infection detention
Multiplex Arrays for POC infection detentionScott Buckler
 
Sepsis and antibiotic guidance in neurology wards
Sepsis and antibiotic guidance in neurology wardsSepsis and antibiotic guidance in neurology wards
Sepsis and antibiotic guidance in neurology wardsDivya Shilpa
 
Covid 19- consideration in Dental Practice
Covid 19- consideration in Dental PracticeCovid 19- consideration in Dental Practice
Covid 19- consideration in Dental PracticeRiya Shah
 
Considerations for Diagnostic COVID-19 Tests in the 4 Medical Testing Centre ...
Considerations for Diagnostic COVID-19 Tests in the 4 Medical Testing Centre ...Considerations for Diagnostic COVID-19 Tests in the 4 Medical Testing Centre ...
Considerations for Diagnostic COVID-19 Tests in the 4 Medical Testing Centre ...semualkaira
 
Role of ct chest in covid management
Role of ct chest in covid managementRole of ct chest in covid management
Role of ct chest in covid managementDrVeereshDhanni
 
Using POCT for Influenza
Using POCT for InfluenzaUsing POCT for Influenza
Using POCT for InfluenzaScott Buckler
 
Role of infection control in patient safety [compatibility mode]
Role of infection control in patient safety [compatibility mode]Role of infection control in patient safety [compatibility mode]
Role of infection control in patient safety [compatibility mode]drnahla
 
New technologies in point-of-care nucleic acid tests
New technologies in point-of-care nucleic acid testsNew technologies in point-of-care nucleic acid tests
New technologies in point-of-care nucleic acid testsPaolo Dametto
 
Journal club on Hydrcortisone for Severe Community acquired pneumonia
Journal club on Hydrcortisone for Severe Community acquired pneumoniaJournal club on Hydrcortisone for Severe Community acquired pneumonia
Journal club on Hydrcortisone for Severe Community acquired pneumoniaWondwosenMulatu
 
ARGHA KAMAL BANERJEE OIST
ARGHA KAMAL BANERJEE OISTARGHA KAMAL BANERJEE OIST
ARGHA KAMAL BANERJEE OISTArnim Banerjee
 
Diagnostic stewardship in respiratory viral infections multipronged approa...
Diagnostic stewardship  in respiratory viral infections   multipronged approa...Diagnostic stewardship  in respiratory viral infections   multipronged approa...
Diagnostic stewardship in respiratory viral infections multipronged approa...SOMESHWARAN R
 
Hospital Acquired Infection-Management, Prevention-Control & Awareness
Hospital Acquired Infection-Management, Prevention-Control & AwarenessHospital Acquired Infection-Management, Prevention-Control & Awareness
Hospital Acquired Infection-Management, Prevention-Control & AwarenessDr. Priyanka Wandhe
 
Clinical features,diagnosis and treatment of tuberculosis
Clinical features,diagnosis and treatment of tuberculosisClinical features,diagnosis and treatment of tuberculosis
Clinical features,diagnosis and treatment of tuberculosisdocpiash
 
ArticleCritique_Presentation
ArticleCritique_PresentationArticleCritique_Presentation
ArticleCritique_PresentationSwarali Tadwalkar
 

Similar to Molecular diagnostics in the future July 14 - Prof. Bert Niesters (20)

Multiplex Arrays for POC infection detention
Multiplex Arrays for POC infection detentionMultiplex Arrays for POC infection detention
Multiplex Arrays for POC infection detention
 
Sepsis and antibiotic guidance in neurology wards
Sepsis and antibiotic guidance in neurology wardsSepsis and antibiotic guidance in neurology wards
Sepsis and antibiotic guidance in neurology wards
 
Covid 19- consideration in Dental Practice
Covid 19- consideration in Dental PracticeCovid 19- consideration in Dental Practice
Covid 19- consideration in Dental Practice
 
1645 ainsworth
1645 ainsworth1645 ainsworth
1645 ainsworth
 
1645 ainsworth
1645 ainsworth1645 ainsworth
1645 ainsworth
 
Diagnosis of COVID-19
Diagnosis of COVID-19Diagnosis of COVID-19
Diagnosis of COVID-19
 
Considerations for Diagnostic COVID-19 Tests in the 4 Medical Testing Centre ...
Considerations for Diagnostic COVID-19 Tests in the 4 Medical Testing Centre ...Considerations for Diagnostic COVID-19 Tests in the 4 Medical Testing Centre ...
Considerations for Diagnostic COVID-19 Tests in the 4 Medical Testing Centre ...
 
Role of ct chest in covid management
Role of ct chest in covid managementRole of ct chest in covid management
Role of ct chest in covid management
 
Nat testing
Nat testingNat testing
Nat testing
 
Using POCT for Influenza
Using POCT for InfluenzaUsing POCT for Influenza
Using POCT for Influenza
 
Rossen eccmid2015v1.5
Rossen eccmid2015v1.5Rossen eccmid2015v1.5
Rossen eccmid2015v1.5
 
Role of infection control in patient safety [compatibility mode]
Role of infection control in patient safety [compatibility mode]Role of infection control in patient safety [compatibility mode]
Role of infection control in patient safety [compatibility mode]
 
New technologies in point-of-care nucleic acid tests
New technologies in point-of-care nucleic acid testsNew technologies in point-of-care nucleic acid tests
New technologies in point-of-care nucleic acid tests
 
Journal club on Hydrcortisone for Severe Community acquired pneumonia
Journal club on Hydrcortisone for Severe Community acquired pneumoniaJournal club on Hydrcortisone for Severe Community acquired pneumonia
Journal club on Hydrcortisone for Severe Community acquired pneumonia
 
ARGHA KAMAL BANERJEE OIST
ARGHA KAMAL BANERJEE OISTARGHA KAMAL BANERJEE OIST
ARGHA KAMAL BANERJEE OIST
 
Swine influenza
Swine influenzaSwine influenza
Swine influenza
 
Diagnostic stewardship in respiratory viral infections multipronged approa...
Diagnostic stewardship  in respiratory viral infections   multipronged approa...Diagnostic stewardship  in respiratory viral infections   multipronged approa...
Diagnostic stewardship in respiratory viral infections multipronged approa...
 
Hospital Acquired Infection-Management, Prevention-Control & Awareness
Hospital Acquired Infection-Management, Prevention-Control & AwarenessHospital Acquired Infection-Management, Prevention-Control & Awareness
Hospital Acquired Infection-Management, Prevention-Control & Awareness
 
Clinical features,diagnosis and treatment of tuberculosis
Clinical features,diagnosis and treatment of tuberculosisClinical features,diagnosis and treatment of tuberculosis
Clinical features,diagnosis and treatment of tuberculosis
 
ArticleCritique_Presentation
ArticleCritique_PresentationArticleCritique_Presentation
ArticleCritique_Presentation
 

More from WAidid

Designing vaccines for specific populations and germs - Slides by Professor E...
Designing vaccines for specific populations and germs - Slides by Professor E...Designing vaccines for specific populations and germs - Slides by Professor E...
Designing vaccines for specific populations and germs - Slides by Professor E...WAidid
 
Influenza vaccination and prevention of antimicrobial resistance - Slides by ...
Influenza vaccination and prevention of antimicrobial resistance - Slides by ...Influenza vaccination and prevention of antimicrobial resistance - Slides by ...
Influenza vaccination and prevention of antimicrobial resistance - Slides by ...WAidid
 
POINT-of-IMPACT testing. A European perspective - Bert Niesters
POINT-of-IMPACT testing. A European perspective - Bert NiestersPOINT-of-IMPACT testing. A European perspective - Bert Niesters
POINT-of-IMPACT testing. A European perspective - Bert NiestersWAidid
 
Measles and its prevention - Slideset by professor Edwards
Measles and its prevention - Slideset by professor EdwardsMeasles and its prevention - Slideset by professor Edwards
Measles and its prevention - Slideset by professor EdwardsWAidid
 
Is the use of antibiotics necessary in the treatment of diarrhoea?
Is the use of antibiotics necessary in the treatment of diarrhoea?Is the use of antibiotics necessary in the treatment of diarrhoea?
Is the use of antibiotics necessary in the treatment of diarrhoea?WAidid
 
Are we running out of antibiotics? - Slideset by Professor Esposito
Are we running out of antibiotics? - Slideset by Professor EspositoAre we running out of antibiotics? - Slideset by Professor Esposito
Are we running out of antibiotics? - Slideset by Professor EspositoWAidid
 
Mandatory vaccinations: the italian experience - Slideset by Professor Esposito
Mandatory vaccinations: the italian experience - Slideset by Professor EspositoMandatory vaccinations: the italian experience - Slideset by Professor Esposito
Mandatory vaccinations: the italian experience - Slideset by Professor EspositoWAidid
 
Efficacy differences between PCV10 and PCV13 - Slideset by Professors Esposit...
Efficacy differences between PCV10 and PCV13 - Slideset by Professors Esposit...Efficacy differences between PCV10 and PCV13 - Slideset by Professors Esposit...
Efficacy differences between PCV10 and PCV13 - Slideset by Professors Esposit...WAidid
 
Efficacy and safety of immunomodulators in pediatric age - Slideset by Profes...
Efficacy and safety of immunomodulators in pediatric age - Slideset by Profes...Efficacy and safety of immunomodulators in pediatric age - Slideset by Profes...
Efficacy and safety of immunomodulators in pediatric age - Slideset by Profes...WAidid
 
The importance of pertussis booster vaccine doses throughout life - Slideset ...
The importance of pertussis booster vaccine doses throughout life - Slideset ...The importance of pertussis booster vaccine doses throughout life - Slideset ...
The importance of pertussis booster vaccine doses throughout life - Slideset ...WAidid
 
Vaccination in immunosuppressed adults - Slideset by professor Katie Flanagan
Vaccination in immunosuppressed adults - Slideset by professor Katie FlanaganVaccination in immunosuppressed adults - Slideset by professor Katie Flanagan
Vaccination in immunosuppressed adults - Slideset by professor Katie FlanaganWAidid
 
Potential advantages of booster containing PCV regimen - Professor Shabir Madhi
Potential advantages of booster containing PCV regimen - Professor Shabir MadhiPotential advantages of booster containing PCV regimen - Professor Shabir Madhi
Potential advantages of booster containing PCV regimen - Professor Shabir MadhiWAidid
 
Considerations against the new shorter MDR-TB regimen - Prof. G. B. Migliori
Considerations against the new shorter MDR-TB regimen - Prof. G. B. MiglioriConsiderations against the new shorter MDR-TB regimen - Prof. G. B. Migliori
Considerations against the new shorter MDR-TB regimen - Prof. G. B. MiglioriWAidid
 
Group 5 drugs in the treatment of multidrug-resistant tuberculosis - Slideset...
Group 5 drugs in the treatment of multidrug-resistant tuberculosis - Slideset...Group 5 drugs in the treatment of multidrug-resistant tuberculosis - Slideset...
Group 5 drugs in the treatment of multidrug-resistant tuberculosis - Slideset...WAidid
 
Lymphogranuloma venereum - Professor Ivan Hung
Lymphogranuloma venereum - Professor Ivan HungLymphogranuloma venereum - Professor Ivan Hung
Lymphogranuloma venereum - Professor Ivan HungWAidid
 
Bacterial and bacterial-like sepsis in children - Susanna Esposito
Bacterial and bacterial-like sepsis in children - Susanna Esposito   Bacterial and bacterial-like sepsis in children - Susanna Esposito
Bacterial and bacterial-like sepsis in children - Susanna Esposito WAidid
 
Guidelines on the management of cystic fibrosis in the adult - Professor Fran...
Guidelines on the management of cystic fibrosis in the adult - Professor Fran...Guidelines on the management of cystic fibrosis in the adult - Professor Fran...
Guidelines on the management of cystic fibrosis in the adult - Professor Fran...WAidid
 
Katie Flanagan - Malaria vaccines current status and challenges
Katie Flanagan - Malaria vaccines current status and challengesKatie Flanagan - Malaria vaccines current status and challenges
Katie Flanagan - Malaria vaccines current status and challengesWAidid
 
New perspectives in the treatment of multidrug-resistant tuberculosis - Profe...
New perspectives in the treatment of multidrug-resistant tuberculosis - Profe...New perspectives in the treatment of multidrug-resistant tuberculosis - Profe...
New perspectives in the treatment of multidrug-resistant tuberculosis - Profe...WAidid
 
Indicators of acute otitis media severity - Prof. Tal Marom
Indicators of acute otitis media severity - Prof. Tal MaromIndicators of acute otitis media severity - Prof. Tal Marom
Indicators of acute otitis media severity - Prof. Tal MaromWAidid
 

More from WAidid (20)

Designing vaccines for specific populations and germs - Slides by Professor E...
Designing vaccines for specific populations and germs - Slides by Professor E...Designing vaccines for specific populations and germs - Slides by Professor E...
Designing vaccines for specific populations and germs - Slides by Professor E...
 
Influenza vaccination and prevention of antimicrobial resistance - Slides by ...
Influenza vaccination and prevention of antimicrobial resistance - Slides by ...Influenza vaccination and prevention of antimicrobial resistance - Slides by ...
Influenza vaccination and prevention of antimicrobial resistance - Slides by ...
 
POINT-of-IMPACT testing. A European perspective - Bert Niesters
POINT-of-IMPACT testing. A European perspective - Bert NiestersPOINT-of-IMPACT testing. A European perspective - Bert Niesters
POINT-of-IMPACT testing. A European perspective - Bert Niesters
 
Measles and its prevention - Slideset by professor Edwards
Measles and its prevention - Slideset by professor EdwardsMeasles and its prevention - Slideset by professor Edwards
Measles and its prevention - Slideset by professor Edwards
 
Is the use of antibiotics necessary in the treatment of diarrhoea?
Is the use of antibiotics necessary in the treatment of diarrhoea?Is the use of antibiotics necessary in the treatment of diarrhoea?
Is the use of antibiotics necessary in the treatment of diarrhoea?
 
Are we running out of antibiotics? - Slideset by Professor Esposito
Are we running out of antibiotics? - Slideset by Professor EspositoAre we running out of antibiotics? - Slideset by Professor Esposito
Are we running out of antibiotics? - Slideset by Professor Esposito
 
Mandatory vaccinations: the italian experience - Slideset by Professor Esposito
Mandatory vaccinations: the italian experience - Slideset by Professor EspositoMandatory vaccinations: the italian experience - Slideset by Professor Esposito
Mandatory vaccinations: the italian experience - Slideset by Professor Esposito
 
Efficacy differences between PCV10 and PCV13 - Slideset by Professors Esposit...
Efficacy differences between PCV10 and PCV13 - Slideset by Professors Esposit...Efficacy differences between PCV10 and PCV13 - Slideset by Professors Esposit...
Efficacy differences between PCV10 and PCV13 - Slideset by Professors Esposit...
 
Efficacy and safety of immunomodulators in pediatric age - Slideset by Profes...
Efficacy and safety of immunomodulators in pediatric age - Slideset by Profes...Efficacy and safety of immunomodulators in pediatric age - Slideset by Profes...
Efficacy and safety of immunomodulators in pediatric age - Slideset by Profes...
 
The importance of pertussis booster vaccine doses throughout life - Slideset ...
The importance of pertussis booster vaccine doses throughout life - Slideset ...The importance of pertussis booster vaccine doses throughout life - Slideset ...
The importance of pertussis booster vaccine doses throughout life - Slideset ...
 
Vaccination in immunosuppressed adults - Slideset by professor Katie Flanagan
Vaccination in immunosuppressed adults - Slideset by professor Katie FlanaganVaccination in immunosuppressed adults - Slideset by professor Katie Flanagan
Vaccination in immunosuppressed adults - Slideset by professor Katie Flanagan
 
Potential advantages of booster containing PCV regimen - Professor Shabir Madhi
Potential advantages of booster containing PCV regimen - Professor Shabir MadhiPotential advantages of booster containing PCV regimen - Professor Shabir Madhi
Potential advantages of booster containing PCV regimen - Professor Shabir Madhi
 
Considerations against the new shorter MDR-TB regimen - Prof. G. B. Migliori
Considerations against the new shorter MDR-TB regimen - Prof. G. B. MiglioriConsiderations against the new shorter MDR-TB regimen - Prof. G. B. Migliori
Considerations against the new shorter MDR-TB regimen - Prof. G. B. Migliori
 
Group 5 drugs in the treatment of multidrug-resistant tuberculosis - Slideset...
Group 5 drugs in the treatment of multidrug-resistant tuberculosis - Slideset...Group 5 drugs in the treatment of multidrug-resistant tuberculosis - Slideset...
Group 5 drugs in the treatment of multidrug-resistant tuberculosis - Slideset...
 
Lymphogranuloma venereum - Professor Ivan Hung
Lymphogranuloma venereum - Professor Ivan HungLymphogranuloma venereum - Professor Ivan Hung
Lymphogranuloma venereum - Professor Ivan Hung
 
Bacterial and bacterial-like sepsis in children - Susanna Esposito
Bacterial and bacterial-like sepsis in children - Susanna Esposito   Bacterial and bacterial-like sepsis in children - Susanna Esposito
Bacterial and bacterial-like sepsis in children - Susanna Esposito
 
Guidelines on the management of cystic fibrosis in the adult - Professor Fran...
Guidelines on the management of cystic fibrosis in the adult - Professor Fran...Guidelines on the management of cystic fibrosis in the adult - Professor Fran...
Guidelines on the management of cystic fibrosis in the adult - Professor Fran...
 
Katie Flanagan - Malaria vaccines current status and challenges
Katie Flanagan - Malaria vaccines current status and challengesKatie Flanagan - Malaria vaccines current status and challenges
Katie Flanagan - Malaria vaccines current status and challenges
 
New perspectives in the treatment of multidrug-resistant tuberculosis - Profe...
New perspectives in the treatment of multidrug-resistant tuberculosis - Profe...New perspectives in the treatment of multidrug-resistant tuberculosis - Profe...
New perspectives in the treatment of multidrug-resistant tuberculosis - Profe...
 
Indicators of acute otitis media severity - Prof. Tal Marom
Indicators of acute otitis media severity - Prof. Tal MaromIndicators of acute otitis media severity - Prof. Tal Marom
Indicators of acute otitis media severity - Prof. Tal Marom
 

Recently uploaded

call girls in green park DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in green park  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in green park  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in green park DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️saminamagar
 
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service LucknowVIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknownarwatsonia7
 
Pharmaceutical Marketting: Unit-5, Pricing
Pharmaceutical Marketting: Unit-5, PricingPharmaceutical Marketting: Unit-5, Pricing
Pharmaceutical Marketting: Unit-5, PricingArunagarwal328757
 
call girls in Connaught Place DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...call girls in Connaught Place  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...saminamagar
 
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort ServiceCollege Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort ServiceNehru place Escorts
 
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking ModelsMumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Modelssonalikaur4
 
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
Call Girls Thane Just Call 9910780858 Get High Class Call Girls Service
Call Girls Thane Just Call 9910780858 Get High Class Call Girls ServiceCall Girls Thane Just Call 9910780858 Get High Class Call Girls Service
Call Girls Thane Just Call 9910780858 Get High Class Call Girls Servicesonalikaur4
 
Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbersBook Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbersnarwatsonia7
 
Report Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptxReport Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptxbkling
 
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any TimeCall Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Timevijaych2041
 
Case Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptxCase Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptxNiranjan Chavan
 
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call NowKolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call NowNehru place Escorts
 
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️saminamagar
 
97111 47426 Call Girls In Delhi MUNIRKAA
97111 47426 Call Girls In Delhi MUNIRKAA97111 47426 Call Girls In Delhi MUNIRKAA
97111 47426 Call Girls In Delhi MUNIRKAAjennyeacort
 
Statistical modeling in pharmaceutical research and development.
Statistical modeling in pharmaceutical research and development.Statistical modeling in pharmaceutical research and development.
Statistical modeling in pharmaceutical research and development.ANJALI
 
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...narwatsonia7
 
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi NcrDelhi Call Girls
 
Hemostasis Physiology and Clinical correlations by Dr Faiza.pdf
Hemostasis Physiology and Clinical correlations by Dr Faiza.pdfHemostasis Physiology and Clinical correlations by Dr Faiza.pdf
Hemostasis Physiology and Clinical correlations by Dr Faiza.pdfMedicoseAcademics
 
Glomerular Filtration and determinants of glomerular filtration .pptx
Glomerular Filtration and  determinants of glomerular filtration .pptxGlomerular Filtration and  determinants of glomerular filtration .pptx
Glomerular Filtration and determinants of glomerular filtration .pptxDr.Nusrat Tariq
 

Recently uploaded (20)

call girls in green park DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in green park  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in green park  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in green park DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
 
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service LucknowVIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
 
Pharmaceutical Marketting: Unit-5, Pricing
Pharmaceutical Marketting: Unit-5, PricingPharmaceutical Marketting: Unit-5, Pricing
Pharmaceutical Marketting: Unit-5, Pricing
 
call girls in Connaught Place DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...call girls in Connaught Place  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
 
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort ServiceCollege Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
 
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking ModelsMumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
 
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
 
Call Girls Thane Just Call 9910780858 Get High Class Call Girls Service
Call Girls Thane Just Call 9910780858 Get High Class Call Girls ServiceCall Girls Thane Just Call 9910780858 Get High Class Call Girls Service
Call Girls Thane Just Call 9910780858 Get High Class Call Girls Service
 
Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbersBook Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
 
Report Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptxReport Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptx
 
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any TimeCall Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Time
 
Case Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptxCase Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptx
 
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call NowKolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
 
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
 
97111 47426 Call Girls In Delhi MUNIRKAA
97111 47426 Call Girls In Delhi MUNIRKAA97111 47426 Call Girls In Delhi MUNIRKAA
97111 47426 Call Girls In Delhi MUNIRKAA
 
Statistical modeling in pharmaceutical research and development.
Statistical modeling in pharmaceutical research and development.Statistical modeling in pharmaceutical research and development.
Statistical modeling in pharmaceutical research and development.
 
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
 
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
 
Hemostasis Physiology and Clinical correlations by Dr Faiza.pdf
Hemostasis Physiology and Clinical correlations by Dr Faiza.pdfHemostasis Physiology and Clinical correlations by Dr Faiza.pdf
Hemostasis Physiology and Clinical correlations by Dr Faiza.pdf
 
Glomerular Filtration and determinants of glomerular filtration .pptx
Glomerular Filtration and  determinants of glomerular filtration .pptxGlomerular Filtration and  determinants of glomerular filtration .pptx
Glomerular Filtration and determinants of glomerular filtration .pptx
 

Molecular diagnostics in the future July 14 - Prof. Bert Niesters

  • 1. Molecular diagnostics in the future: How will it look like and what are the challenges! Bert Niesters Department of Medical Microbiology Division of Clinical of Virology University Medical Center Groningen The Netherlands
  • 2. Point of Impact: From Classical PCR to Point-of-Care Systems. Division of Clinical Virology
  • 3. Division of Clinical Virology Disclosures • Executive board member of QCMD. • Commercial developments on FlowG MiddleWare solutions. • Assessor for the Dutch Council of Accreditation. • Editor-in-Chief of Journal of Clinical Virology. • Advisory board Stratec on AURORA VigiLant.
  • 4. Division of Clinical Virology What I will present • Introduction • How we are interlinked, networks, cross-border • Facts on molecular diagnostics • The diagnostic triangle • The €hr concept • The Extended Diagnostic Triangle • The AID-Stewardship Portfolio
  • 7. Division of Clinical Virology What is the UMCG? The UMCG is a tertiary referral hospital providing care for both adults and children and has a large Solid Organ Transplant program. The large proportion of immune-compromised patients require isolation from patients with respiratory illness.
  • 8. Division of Clinical Virology Introduction • The Influenza season of 2012-2013 was characterized by co-circulation of two Influenza A types. – H1N1 2009pdm09 – H3N2 • Due to the circulation of two Influenza viruses Influenza A-positive patients had to be admitted into single rooms. • A large number of different respiratory viruses were circulating during a long (5 months) period of time, with RSV and influenza viruses being present simultaneously.
  • 9. Number of viruses identified Division of Clinical Virology December 2012-April 2013 300 200 100 0 December January February March April Influenza A Influenza B hMPV RSV Adeno Boca Corona Rhino Parainfl A total of 1259 respiratory samples were tested
  • 10. Typing results of Influenza A positives Division of Clinical Virology 0 20 40 60 December January February March April H3N2 H1N1pdm09 NT 166 patients had Influenza A • 59 had H1N1pdm09 • 104 had H3N2 • 3 NT
  • 11. Isolation regiment of patients admitted Division of Clinical Virology with a respiratory illness ? Neg Infl A Other virus No isolation Geno-type? H1N1 Care in cohort H3N2 isolation H1N1 H1N1 H1N1 H3N2 H3N2 H3N2 Care in cohort
  • 12. The Challenges • In our setting, the validation of BINAX Now influenza test resulted in a negative outcome. Too insensitive. Did not pass the validation process. • Request for data on more viruses that circulated simultaneously. • Samples from patients received at the end of the day, on Friday Division of Clinical Virology (after 16.00 hr) and in the weekend, had a long TAT. • Lack of isolation rooms.
  • 13. Patient Referral Network in the Netherlands Donker et al. Math Biol 2012 Prof Grundmann, UMCG University Hospitals Regional Centers Local Hospital
  • 14. Connectivity between regional centers Labmicta, Enschede Izore, Leeuwarden UMCG Isala, Zwolle LvI Apeldoorn UMCG Regional Center Satellite Dr. Donker, Prof. Grundmann, UMCG (does not cross borders)
  • 15. Intra-Hospital travel of potentially exposed patients KPNEU, esbl+ outbreak, UMCG 09-2012 Day-by-day patient transfer Start: 29.5.2012 <10 <50 >50 Mariano Ciccolini, MMB, UMCG
  • 16. How patients are moved within UMCG Division of Clinical Virology Data analysed with UCINET 6 www.medicalmicrobiology.eu
  • 18. HealthCare Network EDR -Patient transfer 2011 - 5 healthcare clusters - Regional network building Dr. Rocker, Dr. Pulz (NLGA) & Dr. Ciccolini (UMCG)
  • 19. From TypeNed to RegioType to UMCG Nosocomial Infections  Percentage of nosocomial infections in UMCG  12% for influenza A virus, 19% for influenza B virus  22-24% for rhinovirus and enterovirus 68  Around 50% for norovirus  Consequence is Infection Control  Focusing on patients  Less focusing on visitors  Sequence a select number of target viruses ASAP  Norovirus, rhinovirus Division of Clinical Virology
  • 21. The Facts on Molecular Diagnostics • Molecular diagnostics is an integrated, solid and important part Division of Clinical Virology within our diagnostic laboratory. • Investments over the years have been high, both equipment, reagents and consumables. • Equipment from different diagnostic companies. • Patient diagnostics, treatment and safety is important within our work. A short TAT time has impact on the use of antibiotics. • Limited availability of Point-of-Care (Impact) technologies.
  • 22. Division ooff CClliinniiccaall VViirroollooggyy
  • 23. Overview (virology) High throughput Sample in-result out Commercial Blood screening Commercial STD Commercial HPV Medium to low throughput In-house or LDT “Everything” Commercial Limited portfolio No sample in - result out Point-of-Care Point-of-Impact Commercial Short TAT Influenza virus Norovirus Respiratory viruses Sample in - result out Division of Clinical Virology
  • 24. Alternatives for the LDT (in-house) PCR Point-of-Care/Point-of-Impact (respiratory targets) Cepheid GeneXpert Flu (too insensitive). Detects not enough clinical relevant respiratory targets. BioFire FilmArray Respiratory assay. 1 Sample per instrument. Broad panel. GenMark NexGen Respiratory Panel (Should be as sensitive as previous eSensor technology) Division of Clinical Virology
  • 25. ‘QA & QC’ within the Microbiology Laboratory Certification Accreditation New method Establish Performance Perform Clinical tests ISO15189:2012 Characterised Quality reagents Verify method Validate Performance Method Equivalence Quality Improvements Report Results Implement method Assay Verification Assay Validation Assay Implementation Method Maintenance Quality Management System EQA (PT) Internal QC Internal QA Division of Clinical Virology
  • 26. Division of Clinical Virology QCMD proficiency testing Stock dilution series Coronavirus NL63 Influenza A H1pdm09 Influenza H3 Influenza B Parainfluenza virus 1 RSV A RSV B Panels Adenovirus Influenza virus Parainfluenza virus Rhinovirus RSV Compared eSensor technology with our LDT assays Compare FilmArray with our LDT assays
  • 27. Conclusions FilmArray eSensor Technology • FilmArray RP (Ct <31) is more sensitive than INF and RSV BinaxNOW (Ct < 21 en <24) • Detects 98% of the positive patient samples with Ct values < 31. Missed a rhinovirus positive sample • Specificity of the validated targets is 100%, with an exception for Rhinovirus 98.5% Division of Clinical Virology
  • 28. Conclusions GenMark Technology • GenMark eSensor Technology (Ct <35-37) is more sensitive than Influenza and RSV BinaxNOW (Ct < 21 en <24). Similar sensitivity compared to LDT. • Initial results also indicate an improved sensitivity compared to BioFire FilmArray. • We have not yet validated all parameters. • A challenge for Proficiency Testing as well as for QCMD as a Proficiency Provider, is how to develop proficiency panels for multiplex system according to the ISO15189:2012 guidelines. Division of Clinical Virology
  • 29. Performance of FilmArray versus LDT FilmArray RP Influenza A H1 Influenza A H3 Influenza A H1pdm09 Influenza B Human Metapneumovirus RSV Adenovirus Bocavirus Coronavirus HKU1 Coronavirus NL63 Coronavirus 229 E Coronavirus OC43 Rhinovirus/enterovirus Parainfluenza 1 Parainfluenza 2 Parainfluenza 3 Parainfluenza 4 Routine LDT PCR Influenza A Influenza B Human Metapneumovirus RSV Adenovirus Bocavirus Coronavirus NL63 Coronavirus 229 E Coronavirus OC43 Rhinovirus/enterovirus Parainfluenza 1 Parainfluenza 2 Parainfluenza 3 Parainfluenza 4 FilmArray RP (Ct <31-33) is more sensitive than Influenza and RSV BinaxNOW (Ct < 21 en <24). Division of Clinical Virology Influenza A H1 Influenza A H3 Influenza A H1pdm09 Influenza A N1 Influenza A N2 Negative or positive result Turnaround time 1.5 hours after the sample arrived in the laboratory Negative or positive result Turnaround time 1.25 days Influenza A with genotype Turnaround time 2 days
  • 30. Division of Clinical Virology The Diagnostic Triangle Time to Result TAT Diagnostics Quality LI S
  • 31. Division of Clinical Virology Dear Dr. Riezebos, FilmArray 2 detected Influenza A, Influenza A/H1 in sample E2013100465
  • 32.
  • 34. Division of Clinical Virology Norovirus II.4.Sydney
  • 35. Division of Clinical Virology Norovirus II.4.2009
  • 36. Is this affordable point-of-care? Division ooff CClliinniiccaall VViirroollooggyy IQuum The lab in a tube technology GeneXpert Infinity System Biocartis platform FilmArray, bioMerieux GenMark Dx Luminex Aries
  • 37. Division of Clinical Virology The € hour concept (comparable with kWhr) • Time-to-result or turn-around-time (TAT) for critical care is important. • Time-to-result for decision making is important. • Start or stop treatment • Isolation of patient or not • Cohorting of patients (e.g. Influenza H1 infected patients in one room) • Combine time-to-result with costs of assay.
  • 38. Division of Clinical Virology The € hour concept (comparable with kWhr) • Calculate the costs of stay in hospital and/or isolation of a patient • Assay 30 € but TAT is 24 hr: total 720 €hr (Plus 1 extra costs of bed). • Assay 100 € but TAT is 3 hr: total 300 €hr. • Cost –and earning- of bed (estimated between €1700 and €3200/day) • (example critical care at Friday late afternoon). • Calculate the costs for getting a hospital acquired infection. • We have to work more intensively with economists and mathematicians!
  • 39. Modeling infection and transmission fHA due to delay and background transmission Model based on Rhinovirus data Model predicted impact of infection control (IC) on hospital acquired infections (fHA); the red circle represents UMCG data (74% under IC, 24% fHA).
  • 40. Model predicted number of hospital acquired cases for five different infection control scenarios Rhinovirus as model Division of Clinical Virology
  • 41. Nursing department Division of Clinical Virology The Ideal World Total turnaround time: ~3h Patient with respiratory ilness (or, Influenza like Ilness, ILI) Molecular diagnostic test application Sampling and sending to the laboratory Technician; Medical virologist Interpretation of test results Diagnosis ; Positioning; Treatment plan Nurse; Co-assistent Admission; Treatment Turnaround time : ~1 .5h Emergency Department Department of Medical Microbiology Technician Performing a Laboratory test (Clinical virology ) Turnaround time : ~1.5h Physician Increase of 288% in viral respiratoire diagnostics.
  • 42. Respiratory season 2012-2013 0 20 40 60 Division of Clinical Virology 300 200 100 0 December January February March April Influenza A Influenza B hMPV RSV Adeno Boca Corona Rhino Parainfl ? Neg Infl A Other virus No isolation Geno-type? H1N1 December January February March April Care in cohort H3N2 isolation H1N1H1N1H1N1 H3N2H3N2H3N2 Care in cohort H3N2 H1N1pdm09 NT
  • 43. The Extended Diagnostic Triangle Division of Clinical Virology Infection Control TAT Cost or €hr Quality Diagnostics Treatment LI S
  • 44. The AID-Stewardship Portfolio Division of Clinical Virology • The Antibiotic/Antimicrobial Stewardship • The Infection Control Stewardship • The Diagnostic Stewardship • (Giving Antibiotics without Diagnostics should also be financially compensated to the laboratory) (For management, the Financial Stewardship portfolio)
  • 45. E-health Current focus UMC’s Cure (and care) Patient oriented Based on Apple HealthKit Division of Clinical Virology (Near) Future Prevention Society oriented
  • 46. The AID-Stewardship Portfolio • The Antibiotic/Antimicrobial Stewardship • The Infection Control Stewardship • The Diagnostic Stewardship Determine and communicate the value of molecular diagnostics! – Take the lead (use of POC/POI; E-health) – Cost effectiveness – Awareness (communicate) Division of Clinical Virology
  • 47. Cost Effectiveness of AID-Stewardship Cost Benefit Division of Clinical Virology
  • 48. Burden of infectious diseases • Nosocomial infections (HAI) • and Antibiotic resistance • (MRSA, VRE, ESBL et al.) • Pneumococci • HIV/AIDS • Viral Hepatitis • Pandemic flu • Diarrhea (v.a. Norovirus, Camplylobacter) • Emerging infections / Zoonosen (z.B. EHEC, MERS, H5N1) CDC-report 2005 ECDC-report 2009
  • 51. Division of Clinical Virology Improved Infectious Diseases Diagnostics • CID 2013:57 (Suppl 3) • S139
  • 52. Division of Clinical Virology Who detects MERS in POC?
  • 56. “The only limitation is your imagination”.
  • 57. Division of Clinical Virology Take home message • Increase in availability of Point-of-Care/Impact technologies. • Important is good sensitivity, however, less of a problem within the season. eSensor technology very promising. • Not all POC/POI assays detect all relevant targets. • Costs versus benefits. The €hr concept. • Consider the AID stewardship concept. • Value of a negative result is also very important!
  • 59. Awareness Division of Clinical Virology
  • 60. Division of Clinical Virology More info: www.FlowG.nl www.MedicalMicrobiology.eu

Editor's Notes

  1. 3 QCMD panels INFHT11H1N1pdm09 H1 en H3N2 tot Ct &amp;lt;32H7N7 kon niet getypeerd worden INFRNA11Core Panel1 Eq Ct 33 &amp;gt;Ct 33 m.u.v InfB ct 36 RSV11RSV A en BCt &amp;lt;36geen onderscheid tussEN RSV A en B
  2. De FilmArray RP detecteert gevoeliger dan de influenza en RSV BinaxNOW sneltesten. Deze testen detecteren positieve monsters respectievelijk bij Ct ≤ 21 en ≤ 24 (bijlage 5 en 6). De FilmArray RP is een kwalitatieve test die een positief of negatief resultaat geeft. De FilmArray RP detecteert 98% van de patiëntenmaterialen met Ct ≤ 31 en is daarmee minder gevoelig dan de in-house PCR. De adenovirus detectie is hierin niet meegenomen. Slechts 20% van het geteste positieve adenovirus patiëntenmateriaal werd positief bevonden in de FilmArray RP. Loeffelholz, M.J. et al 2011 heeft een sensitiviteit van de FilmArray RP voor het adenovirus gemeten van 54,5% met een panel van 192 samples (bijlage 7). De specificiteit van de gevalideerde targets is 100%, uitgezonderd het rhinovirus (98,5%). Loeffelholz, M.J. et al 2011 heeft een specificiteit van 85,1% van de FilmArray RP voor het rhinovirus gemeten met een panel van 192 samples (1). Rand, K.H., et al 2011 heeft echter een specificiteit van 100% van de FilmArray RP voor het rhinovirus gemeten met een panel van 200 samples (bijlage 8).
  3. De FilmArray RP detecteert gevoeliger dan de influenza en RSV BinaxNOW sneltesten. Deze testen detecteren positieve monsters respectievelijk bij Ct ≤ 21 en ≤ 24 (bijlage 5 en 6). De FilmArray RP is een kwalitatieve test die een positief of negatief resultaat geeft. De FilmArray RP detecteert 98% van de patiëntenmaterialen met Ct ≤ 31 en is daarmee minder gevoelig dan de in-house PCR. De adenovirus detectie is hierin niet meegenomen. Slechts 20% van het geteste positieve adenovirus patiëntenmateriaal werd positief bevonden in de FilmArray RP. Loeffelholz, M.J. et al 2011 heeft een sensitiviteit van de FilmArray RP voor het adenovirus gemeten van 54,5% met een panel van 192 samples (bijlage 7). De specificiteit van de gevalideerde targets is 100%, uitgezonderd het rhinovirus (98,5%). Loeffelholz, M.J. et al 2011 heeft een specificiteit van 85,1% van de FilmArray RP voor het rhinovirus gemeten met een panel van 192 samples (1). Rand, K.H., et al 2011 heeft echter een specificiteit van 100% van de FilmArray RP voor het rhinovirus gemeten met een panel van 200 samples (bijlage 8).
  4. Model predicted impact of infection control (IC) on hospital acquired infections (fHA); the red circle represents UMCG data (74% under IC, 24% fHA). No infection control in place doubles the amount of hospital acquired cases. If all infected patients are under infection control, hospital acquired infections can occur due to delay in implementation of IC measures and background transmission.
  5. Figure 4. Model predicted number of hospital acquired cases for five different infection control scenarios as depicted in the method section of the paper (blue boxes). The contribution of patient-to-patient transmission (red boxes) and background transmission (green boxes) for the given number of hospital acquired cases is also given. No IC = no baseline infection control policies + no HRV specific measures Early = baseline infection control policies + no HRV specific measures Late = baseline infection control policies + HRV specific measures limited to specific wards and only when Ct value&amp;lt; 30 All = baseline infection control policies + HRV specific measures for all HRV positive patients
  6. Als uitstapje naar toekomstig denken, van cure en care naar prevention, overigens gestimuleerd door zorgverzekeraars.
  7. POCT Point of Care tests POIT point of impact tests
  8. Concrete cijfers of effecten van een nw beleid nog niet altijd bekend, maar prototyping (in de vorm van een business case oid) is van belang om ‘ergens’ te komen.