The B. anthracis Real-Time PCR Assay is an in vitro diagnostic test for the qualitative detection of plasmid and chromosomal DNA sequences from B. anthracis. The assay can be used to test human respiratory samples, whole blood, serum, plasma, swabs from lesions, CSF, pleural fluid, and bacterial culture isolates from individuals suspected of having anthrax.

Results generated from direct specimen testing are presumptive for the identification of B. anthracis. Results generated from culture isolate testing should be used in conjunction with other conventional methods for identification of Bacillus anthracis isolates as part of the LRN Bacillus anthracis Testing Algorithm. The diagnosis of anthrax infection must be made based on history, signs, symptoms, exposure likelihood, and other laboratory evidences in addition to the identification of B. anthracis from cultures or detection directly in clinical specimens.

Use is limited to Laboratory Response Network (LRN) designated laboratories.

The B. anthracis Real-time PCR Assay is also intended for environmental specimen testing for biothreat detection and response. FDA has not evaluated claims related to the use of this assay on environmental specimens.

Device Description

The B. anthracis Real-time PCR Assay uses a fluorogenic probe, consisting of an oligonucleotide with a reporter dye (FAM) attached to the 5' end and a quencher dye (BHQ1) attached at or near the 3' end. The probe anneals to a specific target sequence located between the forward and reverse primers. During the extension phase of the PCR cycle, the 5′ nuclease activity of Tag polymerase degrades the probe causing the reporter dye to separate from the quencher dye and a fluorescent signal is generated. With each cycle, additional reporter dye molecules are cleaved from their respective probes and the fluorescence intensity is monitored during the PCR. The Tag polymerase used in this assay is inactive at room temperature. It must be activated by incubation at 95°C, which also minimizes the production of nonspecific amplification products.

Each extracted DNA sample is tested with three B. anthracis primer and probe sets run as individual reactions. The primer and probe sets target genes encoding virulence factors as well as conserved regions of DNA from the B. anthracis chromosome. All three primer and probe sets must be positive for the overall result of the B. anthracis Real-time PCR Assay to be interpreted as positive. Any result that is positive for some, but not all three target regions, is still considered equivocal and follow-up laboratory investigation should be performed per the LRN Bacillus anthracis Testing Algorithm.

AI/ML Overview

Here's an analysis of the acceptance criteria and study information for the B. anthracis Real-time PCR Assay, based on the provided 510(k) summary:

1. Acceptance Criteria and Reported Device Performance

The provided document does not explicitly state quantitative acceptance criteria (e.g., sensitivity, specificity thresholds with confidence intervals) for the B. anthracis Real-time PCR Assay. However, the performance characteristics were established by demonstrating its ability to differentiate B. anthracis from other Bacillus species. The document details the types of studies conducted to establish performance but does not provide specific numerical outcomes.

Acceptance Criteria Category	Reported Device Performance
Limit of Detection (LoD)	Determined through in-house and multicenter sensitivity studies. (Specific numerical LoD not provided in this summary.)
Analytical Sensitivity	Inquiries regarding performance characteristics should be directed to the Centers for Disease Control and Prevention. (Specific numerical sensitivity not provided in this summary.)
Analytical Specificity	Demonstrated by evaluating the BA3 marker in a historical collection of Bacillus sp. isolates and by testing known B. cereus and other bacterial isolates. (Specific numerical specificity not provided in this summary.)
Clinical Performance	Established through three evaluations: a) Evaluation of the BA3 marker to identify B. anthracis in a historical collection of Bacillus sp. isolates. b) Testing of known B. cereus isolates using the B. anthracis Real-time PCR Assay. c) Testing of known bacterial isolates using the B. anthracis Real-time PCR Assay. Repeatability in clinical matrices was determined through a multicenter study. Specific numerical results are not provided in this summary.

2. Sample Size Used for the Test Set and Data Provenance

The document does not explicitly state the specific sample sizes used for the test sets in each of the clinical performance evaluations (historical collection of Bacillus sp. isolates, known B. cereus isolates, known bacterial isolates).

Data Provenance: The studies utilized "a historical collection of Bacillus sp. isolates," "known B. cereus isolates," and "known bacterial isolates." The direct country of origin for these specific collections is not mentioned, but the submitting organization is the Centers for Disease Control and Prevention (CDC) in the USA, suggesting the data is likely from the USA or samples curated by the CDC. The studies appear to be retrospective as they involve testing historical and known isolate collections.

3. Number of Experts Used to Establish the Ground Truth for the Test Set and Their Qualifications

The document does not specify the "number of experts" or their "qualifications" involved in establishing the ground truth for the test set.

4. Adjudication Method for the Test Set

The document does not describe an adjudication method (such as 2+1 or 3+1) for the test set.

5. Multi-Reader Multi-Case (MRMC) Comparative Effectiveness Study

A Multi-Reader Multi-Case (MRMC) comparative effectiveness study comparing human readers with and without AI assistance was not done. This device is an in vitro diagnostic test (a PCR assay), not an AI-assisted diagnostic tool that would typically involve human readers interpreting results.

6. Standalone Performance Study (Algorithm Only Without Human-in-the-Loop Performance)

Yes, a standalone performance study was done. The B. anthracis Real-time PCR Assay is an automated PCR-based diagnostic test. Its performance characteristics (Limit of Detection, Analytical Sensitivity, Analytical Specificity, and Clinical Performance) were established by evaluating the assay's ability to detect B. anthracis DNA in various samples. This represents the intrinsic performance of the diagnostic algorithm/assay itself, without direct human interpretation of raw data beyond reading the assay's output.

7. Type of Ground Truth Used

The ground truth for the clinical performance evaluations was established using a "battery of tests performed by the CDC, including the gamma phage lysis, conventional culture, microbiological, and biochemical testing." This indicates the use of expert consensus based on established microbiological and biochemical methods as the reference standard.

8. Sample Size for the Training Set

The document does not specify a "training set" or its sample size. As a PCR assay, its development typically involves primer and probe design and optimization, which isn't usually framed in terms of a "training set" in the same way machine learning models are. The performance characteristics were established using "in-house and multicenter sensitivity studies" and evaluations on historical and known bacterial isolate collections.

9. How the Ground Truth for the Training Set Was Established

Since the concept of a "training set" in the context of machine learning isn't directly applicable here, the method of establishing ground truth for development/optimization wasn't explicitly stated. However, similar to the test set, it would logically involve established microbiological and molecular techniques to confirm the identity of B. anthracis and other Bacillus species used during the assay's development and validation.

Summary

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510(k) Summary

This summary of 510(k) substantial equivalence information is being submitted in accordance with the requirements of 21 CFR 807.92.

Assigned 510(k)number:	K140426
Submitted by:	Centers for Disease Control and Prevention1600 Clifton Road NEAtlanta, GA 30333
Contact Person:	CDR Yon Yu, Pharm.D.Associate Director for Regulatory AffairsOffice of the DirectorNational Center for Emerging and Zoonotic Infectious DiseasesCenters for Disease Control and Prevention(Registration number: 1050190)1600 Clifton Road, NE, MS C-18Atlanta, GA 30333(404) 639-3046 (office)(404) 639-1275 (fax)Fkb8@cdc.gov
Date prepared:	February 14, 2014
Device trade name:	B. anthracis Real-time PCR Assay
Classification nameand regulation:	In vitro diagnostic device for Bacillus spp.detection; 21 CFR 866.3045
Product Code:	NHT
Class:	II
Panel:	Microbiology (83)
Predicatedevice(s):	JBAIDS Anthrax Detection System(K051713, K071188) November 18, 2005

Background

Anthrax is a zoonotic disease caused by B. anthracis that is transmissible to humans through handling or consumption of contaminated animal products. Infection can also occur through inhalation of B. anthracis spores from contaminated animal products such as wool or hides. Infection caused by human-to-human contact has been reported only rarely, and only via the cutaneous route (Versalovic, 2011). There have been 3 major presentations of anthrax in humans: cutaneous, ingestion, and inhalation. In cases of

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cutaneous anthrax, patients typically present with a painless blister or skin ulcer with a black area in the center. Inhalation anthrax is typically associated with cold or flu-like symptoms, cough, chest discomfort, shortness of breath, fatigue, and muscle aches. Symptoms of gastrointestinal anthrax typically include nausea, loss of appetite, bloody diarrhea, fever and severe stomach pain.

Prior to the development of the LRN B. anthracis Real-time PCR Assay, identification of B. anthracis was determined by using phenotypic differences between B. anthracis and the rest of the B. cereus group. (i.e. lack of motility and hemolysis, susceptibility to penicillin, colony morphology, susceptibility to lysis by gamma phage) (Hoffmaster, 2002). However, these methods require growth of the microorganism and can take at least 24 hours incubation to obtain a result. Due to the prevalence of B. anthracis in the environment, and its past use as a biological weapon, it has long been an organism of concern. The use of B. anthracis in the bioterrorism attacks of 2001 resulting in cases of inhalation and cutaneous anthrax increased public health concern and reinforced the worry that it would be used in the same way again. For these reasons, there was a need for rapid testing to aid in the identification of B. anthracis. The Laboratory Response Network (LRN) is part of a national bioterrorism preparedness initiative and one of the major goals of this initiative is the development and validation of rapid and specific assays for agents likely to be used in a bioterrorism event. Accordingly, scientists at the Centers for Disease Control and Prevention have developed several real-time PCR based assays to detect B. anthracis and other potential agents of bioterrorism in an effort to meet the need for rapid detection.

Device description

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is still considered equivocal and follow-up laboratory investigation should be performed per the LRN Bacillus anthracis Testing Algorithm.

Intended Use

The B. anthracis Real-time PCR Assay is an in vitro diagnostic test for the qualitative detection of plasmid and chromosomal DNA sequences from B. anthracis. The assay can be used to test human respiratory samples, whole blood, serum, plasma, swabs from lesions, CSF, pleural fluid, and bacterial culture isolates from individuals suspected of having anthrax.

Use is limited to Laboratory Response Network (LRN) designated laboratories.

Device comparison

As previously mentioned, there are several culture based methods used for identification of B. anthracis. While they are reliable methods, they do not offer a fast result since a pure culture of the microorqanism must first be isolated, then set up with each test (gamma phage, morphology, motility, penicillin resistance, etc.). Each of these tests requires approximately 24 hours incubation before they can be interpreted. There is a currently marketed device that uses similar nucleic acid amplification and fluorescent probe detection technology called the JBAIDS Anthrax Detection System (Idaho Technology, Inc., 510(k) #K051713). The following table summarizes the similarities and differences between the two devices.

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Device(Owner)	B. anthracis Real-time PCR Assay(Centers for Disease Control andPrevention)	JBAIDS Anthrax DetectionSystem (Idaho Technology, Inc.)
Similarities
IntendedUse	The B. anthracis Real-time PCR Assayis an in vitro diagnostic test for thequalitative detection of plasmid andchromosomal DNA sequences from B.anthracis . The assay can be used totest human respiratory samples, wholeblood, serum, plasma, swabs fromlesions, CSF, pleural fluid, andbacterial culture isolates fromindividuals suspected of havinganthrax.Results generated from directspecimen testing are presumptive forthe identification of B. anthracis .Results generated from culture isolatetesting should be used in conjunctionwith other conventional methods foridentification of Bacillus anthracisisolates as part of the LRN Bacillusanthracis Testing Algorithm. Thediagnosis of anthrax infection must bemade based on history, signs,symptoms, exposure likelihood, andother laboratory evidences in additionto the identification of B. anthracisfrom cultures or detection directly inclinical specimens.	The JBAIDS Anthrax DetectionSystem is a real-timepolymerase chain reaction (PCR)test system intended for thequalitative in vitro diagnostic(IVD) detection of target DNAsequences on the pXO1 plasmid(Target 1) and the pXO2 plasmid(Target 2) from Bacillusanthracis . The system can beused to test human whole bloodcollected in sodium citrate fromindividuals suspected of havinganthrax, positive blood cultures,and cultured organisms grown onblood agar plates. The JBAIDSAnthrax Target 2 assay is usedas a supplementary test onlyafter a positive result with theTarget 1 Assay.The JBAIDS Anthrax Target 1and Target 2 Assays are run onthe JBAIDS instrument using theDiagnostic Wizard.Results are for the presumptiveidentification of B. anthracis , inconjunction with culture andother laboratory tests. Thefollowing considerations alsoapply:
	Use is limited to LaboratoryResponse Network (LRN)designated laboratories.The B. anthracis Real-time PCRAssay is also intended forenvironmental specimen testing forbiothreat detection and response.FDA has not evaluated claims relatedto the use of this assay onenvironmental specimens.	The diagnosis of anthraxinfection must be madebased on history, signs,symptoms, exposurelikelihood, otherlaboratory evidence, inaddition to theidentification of pXO1 andpXO2 targets either fromcultures or from directblood specimens. The assays have not beenevaluated with blood fromindividuals without clinicalsigns or symptoms who

ﺍﯾﻦ ﻣﯿﻼﺩﯼ ﺍﺯ ﻣﺮﮐﺰ ﺩﺭ ﺍﺳﺖ ﻣﯽ ﺍﺳﺖ. ﺍﯾﻦ ﻣﺮﮐﺰ ﺍﯾﻦ ﻣﯽ ﺍﺳﺖ.

. ...

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・・

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Principle of Operation	Nucleic acid amplification and fluorescent probe detection
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were presumed exposed and who subsequently developed anthrax (inhalation or other forms of the disease), or from individuals with any form of anthrax (inhalational, cutaneous, or gastrointestinal).
The level of plasmid targets that would be present in blood from individuals with early systemic infection is unknown.
The definitive identification of B. anthracis from colony growth, liquid blood culture growth, or from blood specimens requires additional testing and confirmation procedures in consultation with public health or other authorities for whom reports are required.
The safety and effectiveness of other types of tests or sample types (not identified as "For in vitro diagnostic use") have not been established.

Nucleic acid amplification and fluorescent probe detection
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

제

사용 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 14 - 1

ﺮ ﻣﺤﻤﺪ ﺍﻟﻤﻮﺿﻮﻉ ﺍﻟﻤﺴﺎﺣﺔ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪﺓ ﺍﻟﻤﺘﺤﺪ

ર-ર

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Differences
Sample Types	Swabs from lesions and vesicular material Whole blood (EDTA or sodium citrate) Serum/Plasma Respiratory specimens (transtracheal aspirates, bronchial lavage, and sputum) Cerebrospinal fluid Pleural fluid Bacterial culture isolates Environmental samples collected for investigational or surveillance use	Whole blood (sodium citrate)
Instrumentation	Applied Biosystems 7500 Fast Dx Real-Time PCR System and Cepheid SmartCycler I or II Instruments with native software	JBAIDS integrated thermocycler and fluorimeter with Diagnostic Wizard software
Targets	B. anthracis virulence plasmids and chromosomal region DNA	B. anthracis virulence plasmids

Establishment of Performance Characteristics

Inquiries regarding performance characteristics for the B. anthracis Real-time PCR Assay should be directed to the Centers for Disease Control and Prevention.

Limit of Detection (LoD)

The limit of detection for the B. anthracis Real-time PCR Assay was determined through in-house and multicenter sensitivity studies.

Analytical Sensitivity and Specificity

Inquiries regarding performance characteristics for the B. anthracis Real-time PCR Assay should be directed to the Centers for Disease Control and Prevention.

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Clinical Performance

Clinical performance of the B. anthracis Real-time PCR Assay was established through three evaluations: a) Evaluation of the BA3 marker to identify B. anthracis in a historical collection of Bacillus sp. isolates; b) Testing of known B. cereus isolates using the B. anthracis Real-time PCR Assay; c) Testing of known bacterial isolates using the B. anthracis Real-time PCR Assay. All three data sets compared the performance of the B. anthracis Real-time PCR Assay to a battery of tests performed by the CDC, including the gamma phage lysis, conventional culture, microbiological, and biochemical testing.

Repeatability in clinical matrices was determined through a multicenter study.

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Image /page/7/Picture/0 description: The image shows the logo for the U.S. Department of Health & Human Services. The logo consists of a stylized depiction of an eagle or bird-like figure with outstretched wings. The text "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" is arranged in a circular fashion around the bird-like figure.

DEPARTMENT OF HEALTH & HUMAN SERVICES

Public Health Service

May 22, 2014

Food and Drug Administration 10903 New Hampshire Avenue Document Control Center - WO66-G60 Silver Spring, MD 20993-0002

CENTERS FOR DISEASE CONTROL AND PREVENTION YON YU ASSOCIATE DIRECTOR FOR REGULATORY AFFAIRS LABORATORY PREPAREDNESS AND RESPONSE BRANCH NCEZID/DPEI 1600 CLIFTON RD. NE, MS C-18 ATLANTA, GA 30333 USA

Re: K140426

Trade/Device Name: B. anthracis Real-Time PCR Assay Regulation Number: 21 CFR 866.3045 Regulation Name: In vitro Diagnostic Devices for Bacillus spp. Detection Regulatory Class: II Product Code: NHT Dated: February 14, 2014 Received: February 25, 2014

Dear Ms. Yu:

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food. Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Parts 801 and 809); medical device reporting (reporting of medical device-related adverse events) (21 CFR 803); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the

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Page 2-Ms. Yu

electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

If you desire specific advice for your device on our labeling regulations (21 CFR Parts 801 and 809), please contact the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number (800) 638 2041 or (301) 796-7100 or at its Internet address http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to

http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm for the CDRH's Office of Surveillance and Biometrics/Division of Postmarket Surveillance.

You may obtain other general information on your responsibilities under the Act from the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number (800) 638-2041 or (301) 796-7100 or at its Internet address http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm.

Sincerely yours,

Sally A. Hojvat, M. Sc., Ph.D. Director Division of Microbiology Devices Office of In Vitro Diagnostics and Radiological I-lealth Center for Devices and Radiological Health

Enclosure

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Indications for Use

K140426

Device Name

B. anthracis Real-Time PCR Assay Indications for Use (Describe)

Results generated from direct specimentive for the identification of B. anthracis. Results generated from culture isolate testing should be used in conventional methods for identification of Bacillus anthracis isolates as part of the LRN Bacillus anthracis Testing Algorithm. The diagnosis of anthrax infection must be made based on history, signs re likelihood, and other laboratory evidences, in addition to the identification of B. anthracis from cultures or detectly in clinical specimens.

Use is limited to Laboratory Response Network (LRN) designated laboratories.

The B. anthracis Real-time PCR Assay is also intended for environmental speciment testing for biothreat detection and response. FDA has not evaluated claims related to the use of this assay on environmental specimens.

Type of Use (Select one or both, as applicable)

2 Prescription Use (Part 21 CFR 801 Subpart D)

Over-The-Counter Use (21 CFR 801 Subpart C)

Form Approved: OMB No. 0910-0120

Expiration Date: January 31, 2017

See PRA Statement on last page.

PLEASE DO NOT WRITE BELOW THIS LINE - CONTINUE ON A SEPARATE PAGE IF NEEDED.

. : " … : : : FOR FDA USE ONLY

Concurrence of Center for Devices and Radiological Health (CDRH) (Signature)

John Hobson -S 2014.05.22 09:46:42 -04'00'

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Regulation Number and Section

§ 866.3045 In vitro diagnostic device for

Bacillus spp. detection.(a)
Identification. An in vitro diagnostic device forBacillus species (spp.) detection is a prescription device used to detect and differentiate amongBacillus spp. and presumptively identifyB. anthracis and otherBacillus spp. from cultured isolates or clinical specimens as an aid in the diagnosis of anthrax and other diseases caused byBacillus spp. This device may consist ofBacillus spp. antisera conjugated with a fluorescent dye (immunofluorescent reagents) used to presumptively identify bacillus-like organisms in clinical specimens; bacteriophage used for differentiatingB. anthracis from otherBacillus spp. based on susceptibility to lysis by the phage; or antigens used to identify antibodies toB. anthracis (anti-toxin and anti-capsular) in serum. Bacillus infections include anthrax (cutaneous, inhalational, or gastrointestinal) caused byB. anthracis, and gastrointestinal disease and non-gastrointestinal infections caused byB. cereus. (b)
Classification. Class II (special controls). The special controls are set forth in FDA's special controls guideline document entitled “In Vitro Diagnostic Devices forBacillus spp. Detection; Class II Special Controls Guideline for Industry and Food and Drug Administration Staff.” For availability of the guideline document, see § 866.1(e).(c)
Restriction on Distribution. The distribution of these devices is limited to laboratories that follow public health guidelines that address appropriate biosafety conditions, interpretation of test results, and coordination of findings with public health authorities.(d)
Restriction on Use. The use of this device is restricted to prescription use and must comply with the following:(1) The device must be in the possession of:
(i)(A) A person, or his agents or employees, regularly and lawfully engaged in the manufacture, transportation, storage, or wholesale or retail distribution of such device; or
(B) A practitioner, such as a physician, licensed by law to use or order the use of such device; and
(ii) The device must be sold only to or on the prescription or other order of such practitioner for use in the course of his professional practice.
(2) The label of the device shall bear the statement “Caution: Federal law restricts this device to sale by or on the order of a ____”, the blank to be filled with the word “physician” or with the descriptive designation of any other practitioner licensed by the law of the State in which he practices to use or order the use of the device.
(3) Any labeling, as defined in section 201(m) of the Federal Food, Drug, and Cosmetic Act, whether or not it is on or within a package from which the device is to be dispensed, distributed by, or on behalf of the manufacturer, packer, or distributor of the device, that furnishes or purports to furnish information for use of the device contains adequate information for such use, including indications, effects, routes, methods, and frequency and duration of administration and any relevant hazards, contraindications, side effects, and precautions, under which practitioners licensed by law to employ the device can use the device safely and for the purposes for which it is intended, including all purposes for which it is advertised or represented. This information will not be required on so-called reminder-piece labeling which calls attention to the name of the device but does not include indications or other use information.
(4) All labeling, except labels and cartons, bearing information for use of the device also bears the date of the issuance or the date of the latest revision of such labeling.