Predicate Devices

Reference Devices

Not Found

AI/ML (Artificial Intelligence / Machine Learning)

No
The device description focuses on automated real-time PCR technology and does not mention AI or ML.

Therapeutic

No
The device is described as a qualitative in vitro diagnostic test designed for the detection and differentiation of specific gene sequences associated with carbapenem-non-susceptibility. It is intended as an aid to infection control for monitoring the spread of carbapenem-non-susceptible bacteria and is not intended to guide or monitor treatment.

Diagnostic

Yes

The "Intended Use / Indications for Use" section explicitly states, "The Xpert® Carba-R Assay... is a qualitative in vitro diagnostic test designed for the detection and differentiation..." and later, "The Xpert Carba-R Assay is intended as an aid to infection of carbapenem-non- susceptible bacteria that colonize patients in healthcare settings." These statements clearly indicate its purpose in assisting in the diagnosis of infection.

SaMD (Software as a Medical Device)

No

The device description explicitly states it is an "in vitro diagnostic test" that utilizes "automated real-time polymerase chain reaction (PCR)" and is performed on "GeneXpert® Instrument Systems" using "single-use, disposable cartridges." This involves significant hardware components and chemical reagents, not just software.

IVD (In Vitro Diagnostic)

Yes, this device is an IVD (In Vitro Diagnostic).

Here's why:

Explicitly Stated in Intended Use: The very first sentence of the "Intended Use / Indications for Use" section clearly states: "The Xpert® Carba-R Assay... is a qualitative in vitro diagnostic test..."
Explicitly Stated in Device Description: The first sentence of the "Device Description" section also states: "The Xpert Carba-R Assay is an automated real-time polymerase chain reaction (PCR) in vitro diagnostic test..."
Purpose: The device is designed to detect specific gene sequences in biological samples (rectal swabs and pure colonies) to aid in the identification of carbapenem-non-susceptible bacteria. This is a classic function of an in vitro diagnostic device, which is used to examine specimens from the human body to provide information for the diagnosis, treatment, or prevention of disease.
Sample Types: It uses biological samples (rectal swabs and pure colonies).
Methodology: It utilizes real-time PCR, a common technique in in vitro diagnostics for detecting genetic material.
Intended Use Context: It is intended as an aid to infection control in healthcare settings, which aligns with the use of IVDs to manage and monitor health conditions.

PCCP (Predetermined Change Control Plan) Authorized

N/A

Overview

Intended Use / Indications for Use

The Xpert® Carba-R Assay, performed on the GeneXpert® Instrument Systems, is a qualitative in vitro diagnostic test designed for the detection and differentiation of the blaker, blaNDM, blayIM, blackA-48, and blanny gene sequences associated with carbapenem-non-susceptibility. The test utilizes automated real-time polymerase chain reaction (PCR),

The Xpert Carba-R Assay is intended as an aid to infection of carbapenem-non- susceptible bacteria that colonize patients in healthcare settings. The Xpert Carba-R Assay is not intended to guide or monitor treatmannon-susceptible bacterial infections. A negative Xpert Carba-R Assay result does not preclude the presence of other resistance mechanisms.

The Xpert Carba-R Assay is for use with the following sample types:

Rectal Swab Specimens

The assay is performed on rectal swab specimens at risk for intestinal colonization with carbapenem-non-susceptible bacteria. Concomitant cultures are necessary to reanisms for epidemiological typing, antimicrobial susceptibility testing, and for further confirmatory bacterial identification.

Pure Colonies

The assay is performed on carbapenen-non-susceptible pure colonies of Enterobacter baumanni, or Pseudomonas aeruginosa, when grown on blood agar or MacConkey agar. For testing pure colonies, the Xpert Carba-R Assay should be used in conjunction with other laboratory tests including phenotypic antimicrobial susceptibility testing.

Product codes (comma separated list FDA assigned to the subject device)

POC, OOI

Device Description

The Xpert Carba-R Assay is an automated real-time polymerase chain reaction (PCR) in vitro diagnostic test for qualitative detection of the blaxpc, blaym, blaoxa-a8, and blamp gene sequences from rectal swab specimens. The Xpert Carba-R Assay is intended as an aid for infection control for monitoring the spread of carbapenem-nonsusceptible organisms in healthcare settings.

The Xpert Carba-R Assay is performed on the Cepheid GeneXpert® Instrument Systems (GeneXpert Dx, GeneXpert Infinity-48, GeneXpert Infinity-48s, and GeneXpert Infinity-80 systems). The GeneXpert Instrument System platform automates sample preparation. amplification and real-time detection.

The GeneXpert Instrument Systems require the use of single-use, disposable cartridges (the Xpert Carba-R cartridges) that hold the PCR reagents and host the PCR process. Because the cartridges are self-contained and specimens never come into contact with working parts of the instrument modules, cross-contamination between samples is minimized.

The Xpert Carba-R Assay cartridges contain reagents for the detection of blakec, blanDM, blaym, blaox 8-8, and blance gene sequences. A Sample Processing Control (SPC) and a Probe Check Control (PCC) are controls utilized by the GeneXpert Instrument System platform. The SPC is present to control for adequate processing of the target bacteria and to monitor the presence of inhibitors in the real-time PCR reaction to reduce the possibility of false negative results. The PCC verifies reagent rehydration, real-time PCR tube filling in the cartridge, probe integrity, and dye stability.

The single-use, multi-chambered fluidic cartridges are designed to complete sample preparation and real-time PCR for the detection of the blaker, blanny, blaoxA-48. and blank gene sequences from rectal swab specimens in approximately 50 minutes. The GeneXpert Instrument Systems, comprised of the GeneXpert Dx Systems and the GeneXpert Infinity Systems, have 1 to 80 randomly accessible modules, depending upon the instrument, that are each capable of performing separate sample processing and realtime PCR and RT- PCR tests. Each module contains a syringe drive for dispensing fluids (i.e., the syringe drive activates the plunger that works in concert with the rotary valve in the cartridge to move fluids between chambers), an ultrasonic horn for lysing cells or spores, and a proprietary I-CORE® thermocycler for performing real-time PCR and RT-PCR and detection.

Rectal swab specimens are placed into a sample reagent. The sample is transferred to the sample chamber of the disposable fluidic cartridge (the Xpert Carba-R cartridge). The user initiates a test from the system user interface and places the cartridge into the GeneXpert instrument platform, which performs hands-off real-time, multiplex PCR for detection of the blaker, blaypy, blaym, blaoxy-48, and blane gene sequences. The results are automatically generated at the end of the process in a report that can be viewed and printed.

Mentions image processing

Not Found

Mentions AI, DNN, or ML

Not Found

Input Imaging Modality

Not Found

Anatomical Site

Rectal Swab Specimens

Indicated Patient Age Range

Not Found

Intended User / Care Setting

Operators in CLIA Moderate or High Complexity labs
healthcare settings

Description of the training set, sample size, data source, and annotation protocol

Not Found

Description of the test set, sample size, data source, and annotation protocol

Clinical Performance:

Sample Size: 802 prospective rectal swab specimens initially enrolled, 785 eligible, 755 included in final dataset. 432 contrived specimens in rectal swab matrix.
Data Source: Paired rectal swab specimens prospectively collected from subjects hospitalized or in long-term care facilities across five geographically diverse sites (three in the United States and two in Europe). Contrived specimens were prepared due to low prevalence.
Annotation Protocol:
- One rectal swab used for Xpert Carba-R Assay testing.
- Second rectal swab inoculated into MacConkey enrichment broth for reference method testing.
- Reference culture laboratory determined the presence of carbapenem non-susceptible organisms by culturing MacConkey enrichment broth, screening on MacConkey agar plates with meropenem disk, and confirming non-susceptibility on isolated colonies using disk diffusion (CLSI M02) and CLSI M100.
- DNA extracted from carbapenem non-susceptible isolates was purified, quantified, and amplified using primers specific to all 5 target genes (amplified regions included more bases than Xpert Carba-R Assay). Production of appropriate size amplification product confirmed on Agilent 2100 Bioanalyzer.
- If Bioanalyzer bands corresponded to expected amplicon size, amplicon sent to an independent laboratory for reference bi-directional sequencing analysis (validated for the five targets).
- If no bands, reference method result considered negative for the five target genes.
- For discordant results (Xpert Carba-R positive, reference culture negative), discordant analysis performed using bi-directional sequencing on DNA extracted directly from MacConkey enrichment broth.

Reproducibility Study:

Sample Size: Two panels of 11 samples, prepared in pooled negative rectal swab matrix. Each panel tested in replicates of four per day over six testing days (11 samples x 2 replicates x 2 times/day x 6 days x 2 operators x 3 sites). Total of 144 tests per sample type across all sites.
Data Source: Pooled negative human rectal swab matrix spiked with carbapenemase-producing organisms at "Mod Pos" (moderate positive) and "Low Pos" (low positive, approximately 3x LoD) concentrations for IMP, VIM, NDM, KPC, and OXA-48. Negative control samples also included.
Annotation Protocol: Three lots of Xpert Carba-R Assay cartridges used at each of the three testing sites. Two operators at each site performed the assay according to the Xpert Carba-R Assay procedure. Results were recorded as detected/not detected, and fluorescence signals (Ct values) were collected.

Summary of Performance Studies (study type, sample size, AUC, MRMC, standalone performance, key results)

Non-Clinical Studies:

Analytical Sensitivity (Limit of Detection - LoD):
- Study Type: Analytical study to determine the lowest concentration of target cells (CFU/swab) that can be reproducibly distinguished from negative samples with 95% confidence.
- Sample Size: Replicates of 20 evaluated at a minimum of five different concentrations over four days for each of ten carbapenemase-producing organisms. LoD verification by testing 10 replicates from two independent dilutions of each bacterium at each estimated LoD.
- Key Results: Claimed LoD for IMP-1 Acinetobacter baumannii: 174 CFU/swab; IMP-1 Klebsiella pneumoniae: 306 CFU/swab; VIM-1 Klebsiella pneumoniae: 305 CFU/swab; VIM-4 Escherichia coli: 815 CFU/swab; NDM-1 Klebsiella pneumoniae ATCC BAA-2146: 251 CFU/swab; NDM Klebsiella pneumoniae: 74 CFU/swab; KPC-3 Klebsiella pneumoniae NCTC 13438: 373 CFU/swab; KPC Enterobacter cloacae: 779 CFU/swab; OXA-48 Enterobacter cloacae: 154 CFU/swab; OXA-48 Escherichia coli: 104 CFU/swab. Verification showed 19/20 or 20/20 positives for all tested levels.
Analytical Reactivity (Inclusivity):
- Study Type: Analytical study to evaluate reactivity with a panel of bacterial strains.
- Sample Size: 72 well-characterized bacterial strains (11 blaKPC, 11 blaVIM, 13 blaNDM, 8 blaOXA-48, 5 blaNDM/blaOXA-181, 6 blaOXA-181, 17 blaIMP, and one blaKPC/blaVIM). All tested in triplicate.
- Key Results: Xpert Carba-R Assay target genes were detected in 69 of 72 carbapenemase-producing bacterial strains. IMP-4 detected only at higher concentration. IMP-13, IMP-7, and IMP-14 were not detected by the assay (IMP-7 and IMP-14 not predicted by in silico, IMP-13 predicted but not detected).
Analytical Specificity (Cross-reactivity):
- Study Type: Analytical study to evaluate cross-reactivity with various bacterial isolates, commensals, and human cells.
- Sample Size: 62 carbapenem-susceptible bacterial strains, 24 commensal bacterial strains and other enteric microorganisms, and human cells. Viruses tested separately. Organisms tested in triplicate.
- Key Results: None of the 94 potentially cross-reactive organisms and nucleic acids tested were detected. Analytical specificity was 100%.
Competitive Interference:
- Study Type: Analytical study to test potential interference from high titers of one carbapenemase-producing organism on the detection of another at low titer.
- Sample Size: Replicates of eight for various combinations.
- Key Results: An inhibitory effect was observed for IMP, VIM, and OXA-48 when a low concentration was combined with a high concentration of one or two other targets. No inhibitory effect was observed at 4x LoD in the presence of clinically relevant co-infections.
Potentially Interfering Substances:
- Study Type: Analytical study to evaluate the effect of 24 potentially interfering substances.
- Sample Size: Eight replicate positive samples (mix of five carbapenemase-producing organisms at ~3x LoD) and eight replicate negative samples per substance. Controls run without interfering substances.
- Key Results: 22 substances did not interfere. Interference observed with barium sulfate at >0.1% w/v and Pepto-Bismol at >0.01% w/v. Fecal fat at 0.25% w/v caused delayed Ct values for VIM target, but no false negatives.
Carry-Over Contamination:
- Study Type: Analytical study to demonstrate prevention of carry-over contamination.
- Sample Size: 25 pairs of a negative sample following a very high positive sample, repeated on two GeneXpert modules (total 102 tests).
- Key Results: All 50 positive samples correctly reported all Xpert Carba-R targets as DETECTED. All 52 negative samples correctly reported all Xpert Carba-R targets as NOT DETECTED.

Clinical Studies:

Clinical Performance (Prospective Specimens):
- Study Type: Multi-site investigational study to determine performance characteristics of the Xpert Carba-R Assay with rectal swab specimens.
- Sample Size: 755 prospective rectal swab specimens.
- Key Results:
  - PPA for blaKPC, blaNDM, blaVIM, and blaOXA-48 ranged from 60.0% to 100%.
  - NPA for blaKPC, blaNDM, blaVIM, and blaOXA-48 ranged from 98.6% to 99.9%.
  - IMP: PPA N/A (0 TP), NPA 99.9% (99.3-100.0)
  - VIM: PPA 60.0% (31.3-83.2), NPA 98.9% (97.9-99.5)
  - NDM: PPA 100.0% (64.6-100.0), NPA 99.6% (98.8-99.9)
  - KPC: PPA 100.0% (88.3-100.0), NPA 99.2% (98.2-99.6)
  - OXA-48: PPA 96.7% (83.3-99.4), NPA 98.6% (97.5-99.2)
Clinical Performance (Contrived Specimens):
- Study Type: Study using contrived specimens.
- Sample Size: 432 contrived specimens.
- Key Results:
  - IMP: PPA 95.0% (87.8-98.0), NPA 100.0% (98.9-100.0)
  - VIM: PPA 98.8% (93.4-99.8), NPA 100.0% (98.9-100.0)
  - NDM: PPA 100.0% (95.4-100.0), NPA 100.0% (98.9-100.0)
  - KPC: PPA 100.0% (95.4-100.0), NPA 100.0% (98.9-100.0)
  - OXA-48: PPA 98.8% (93.3-99.8), NPA 100.0% (98.9-100.0)
Reproducibility Study:
- Study Type: Multi-site reproducibility study.
- Sample Size: 2 panels of 11 samples, tested in replicates of four per day over six testing days by two operators at three sites.
- Key Results:
  - IMP Low Pos: 86.1% Total Agreement (124/144)
  - NDM Low Pos: 95.1% Total Agreement (137/144)
  - KPC Low Pos: 96.5% Total Agreement (139/144)
  - OXA-48 Low Pos: 97.2% Total Agreement (140/144)
  - All other samples (Neg, Mod Pos for IMP, VIM, NDM, KPC, OXA-48) showed 100% Total Agreement.
  - Low %CVs for Ct values indicating good reproducibility.

Key Metrics (Sensitivity, Specificity, PPV, NPV, etc.)

Prospective Specimen Results (Xpert Carba-R Performance vs. Reference Culture + Sequencing):

IMP: PPA: N/A, NPA: 99.9% (99.3-100.0)
VIM: PPA: 60.0% (31.3-83.2), NPA: 98.9% (97.9-99.5)
NDM: PPA: 100.0% (64.6-100.0), NPA: 99.6% (98.8-99.9)
KPC: PPA: 100.0% (88.3-100.0), NPA: 99.2% (98.2-99.6)
OXA-48: PPA: 96.7% (83.3-99.4), NPA: 98.6% (97.5-99.2)

Contrived Specimen Results (Xpert Carba-R Performance vs. Reference Method):

IMP: PPA: 95.0% (87.8-98.0), NPA: 100.0% (98.9-100.0)
VIM: PPA: 98.8% (93.4-99.8), NPA: 100.0% (98.9-100.0)
NDM: PPA: 100.0% (95.4-100.0), NPA: 100.0% (98.9-100.0)
KPC: PPA: 100.0% (95.4-100.0), NPA: 100.0% (98.9-100.0)
OXA-48: PPA: 98.8% (93.3-99.8), NPA: 100.0% (98.9-100.0)

Analytical Specificity (Cross-reactivity): 100%

Predicate Device(s): If the device was cleared using the 510(k) pathway, identify the Predicate Device(s) K/DEN number used to claim substantial equivalence and list them here in a comma separated list exactly as they appear in the text. List the primary predicate first in the list.

K152614

Reference Device(s): Identify the Reference Device(s) K/DEN number and list them here in a comma separated list exactly as they appear in the text.

Not Found

Predetermined Change Control Plan (PCCP) - All Relevant Information for the subject device only (e.g. presence / absence, what scope was granted / cleared under the PCCP, any restrictions, etc).

Not Found

Regulation Number and Section

§ 866.1640 Antimicrobial susceptibility test powder.

(a)
Identification. An antimicrobial susceptibility test powder is a device that consists of an antimicrobial drug powder packaged in vials in specified amounts and intended for use in clinical laboratories for determining in vitro susceptibility of bacterial pathogens to these therapeutic agents. Test results are used to determine the antimicrobial agent of choice in the treatment of bacterial diseases.(b)
Classification. Class II (performance standards).

Summary

0

Image /page/0/Picture/1 description: The image is a seal for the Department of Health & Human Services - USA. The seal is circular with the text "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" around the perimeter. In the center of the seal is a stylized image of three faces in profile, stacked on top of each other.

Public Health Service

Food and Drug Administration 10903 New Hampshire Avenue Document Control Center - WO66-G609 Silver Spring, MD 20993-0002

June 29, 2016

CEPHEID JIM KELLY, Ph.D. EXECUTIVE DIRECTOR, REGULATORY AFFAIRS 904 CARIBBEAN DRIVE SUNNYVALE CA 94089-1189

Re: K160901

Trade/Device Name: Xpert® Carba-R Assay Regulation Number: 21 CFR 866.1640 Regulation Name: Antimicrobial susceptibility test powder Regulatory Class: II Product Code: POC, OOI Dated: March 31, 2016 Received: April 1, 2016

Dear Dr. Kelly:

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

1

If you desire specific advice for your device on our labeling regulations (21 CFR Parts 801 and 809), please contact the Division of Industry and Consumer Education at its toll-free number (800) 638 2041 or (301) 796-7100 or at its Internet address

http://www.fda.gov/MedicalDevices/Resourcesfor You/Industry/default.htm. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21 CFR 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 Industry and Consumer Education 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,

Ribhi Shawar -S

For Uwe Scherf, M.Sc., Ph.D. Director Division of Microbiology Devices Office of In Vitro Diagnostics and Radiological Health Center for Devices and Radiological Health

Enclosure

2

510(k) Number (if known) K160901

Device Name

Xpert Carba-R

Indications for Use (Describe)

The Xpert® Carba-R Assay, performed on the GeneXpert® Instrument Systems, is a qualitative in vitro diagnostic test designed for the detection and differentiation of the blaker, blaNDM, blayIM, blackA-48, and blanny gene sequences associated with carbapenem-non-susceptibility. The test utilizes automated real-time polymerase chain reaction (PCR),

The Xpert Carba-R Assay is intended as an aid to infection of carbapenem-non- susceptible bacteria that colonize patients in healthcare settings. The Xpert Carba-R Assay is not intended to guide or monitor treatmannon-susceptible bacterial infections. A negative Xpert Carba-R Assay result does not preclude the presence of other resistance mechanisms.

The Xpert Carba-R Assay is for use with the following sample types:

Rectal Swab Specimens

The assay is performed on rectal swab specimens at risk for intestinal colonization with carbapenem-non-susceptible bacteria. Concomitant cultures are necessary to reanisms for epidemiological typing, antimicrobial susceptibility testing, and for further confirmatory bacterial identification.

Pure Colonies

The assay is performed on carbapenen-non-susceptible pure colonies of Enterobacter baumanni, or Pseudomonas aeruginosa, when grown on blood agar or MacConkey agar. For testing pure colonies, the Xpert Carba-R Assay should be used in conjunction with other laboratory tests including phenotypic antimicrobial susceptibility testing.

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

X Prescription Use (Part 21 CFR 801 Subpart D)

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

CONTINUE ON A SEPARATE PAGE IF NEEDED.

This section applies only to requirements of the Paperwork Reduction Act of 1995.

DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL ADDRESS BELOW.

The burden time for this collection of information is estimated to average 79 hours per response, including the time to review instructions, search existing data sources, gather and maintain the data needed and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden, to:

Department of Health and Human Services Food and Drug Administration Office of Chief Information Officer Paperwork Reduction Act (PRA) Staff PRAStaff(@fda.hhs.gov

"An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB number."

3

510(k) Summary

Product code:

Classification

Advisory Panel

Prescription Use

Predicate Device

Assay:

As required by 21 CFR Section 807.92(c).

| Submitted by: | Cepheid
904 Caribbean Drive
Sunnyvale, CA 90489
Phone number: (847) 228-3299
Fax number: (847) 890-6589 |
|----------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Contact: | Scott A. Campbell, PhD, MBA |
| Date of Preparation: | June 28, 2016 |
| Device: | |
| Trade name: | Xpert ® Carba-R |
| Common name: | Xpert Carba-R Assay |
| Type of Test: | Qualitative nucleic acid amplification test of the bla KPC , bla NDM ,
bla VIM , bla OXA-48 , and bla IMP gene sequences associated with
carbapenem-non-susceptibility in gram-negative bacteria
obtained from rectal swab specimens |
| Classification: | II |
| Regulation number: | 866.1640 |
| Classification name: | Antimicrobial susceptibility test powder |

POC, OOI

Yes

Microbiology (83)

[510(k) #K152614]

Cepheid Xpert ® Carba-R

4

Device Description:

The Xpert Carba-R Assay is an automated real-time polymerase chain reaction (PCR) in vitro diagnostic test for qualitative detection of the blaxpc, blaym, blaoxa-a8, and blamp gene sequences from rectal swab specimens. The Xpert Carba-R Assay is intended as an aid for infection control for monitoring the spread of carbapenem-nonsusceptible organisms in healthcare settings.

The Xpert Carba-R Assay is performed on the Cepheid GeneXpert® Instrument Systems (GeneXpert Dx, GeneXpert Infinity-48, GeneXpert Infinity-48s, and GeneXpert Infinity-80 systems). The GeneXpert Instrument System platform automates sample preparation. amplification and real-time detection.

The GeneXpert Instrument Systems require the use of single-use, disposable cartridges (the Xpert Carba-R cartridges) that hold the PCR reagents and host the PCR process. Because the cartridges are self-contained and specimens never come into contact with working parts of the instrument modules, cross-contamination between samples is minimized.

The Xpert Carba-R Assay cartridges contain reagents for the detection of blakec, blanDM, blaym, blaox 8-8, and blance gene sequences. A Sample Processing Control (SPC) and a Probe Check Control (PCC) are controls utilized by the GeneXpert Instrument System platform. The SPC is present to control for adequate processing of the target bacteria and to monitor the presence of inhibitors in the real-time PCR reaction to reduce the possibility of false negative results. The PCC verifies reagent rehydration, real-time PCR tube filling in the cartridge, probe integrity, and dye stability.

The single-use, multi-chambered fluidic cartridges are designed to complete sample preparation and real-time PCR for the detection of the blaker, blanny, blaoxA-48. and blank gene sequences from rectal swab specimens in approximately 50 minutes. The GeneXpert Instrument Systems, comprised of the GeneXpert Dx Systems and the GeneXpert Infinity Systems, have 1 to 80 randomly accessible modules, depending upon the instrument, that are each capable of performing separate sample processing and realtime PCR and RT- PCR tests. Each module contains a syringe drive for dispensing fluids (i.e., the syringe drive activates the plunger that works in concert with the rotary valve in the cartridge to move fluids between chambers), an ultrasonic horn for lysing cells or spores, and a proprietary I-CORE® thermocycler for performing real-time PCR and RT-PCR and detection.

Rectal swab specimens are placed into a sample reagent. The sample is transferred to the sample chamber of the disposable fluidic cartridge (the Xpert Carba-R cartridge). The user initiates a test from the system user interface and places the cartridge into the GeneXpert instrument platform, which performs hands-off real-time, multiplex PCR for detection of the blaker, blaypy, blaym, blaoxy-48, and blane gene sequences. The results are automatically generated at the end of the process in a report that can be viewed and printed.

5

Device Intended Use:

The Xpert® Carba-R Assay, performed on the GeneXpert® Instrument Systems, is a qualitative in vitro diagnostic test designed for the detection and differentiation of the blakpc, blaNDM, blaoxA-48, and blamp gene sequences associated with carbapenem-non-susceptibility. The test utilizes automated real-time polymerase chain reaction (PCR).

The Xpert Carba-R Assay is intended as an aid to infection control in the detection of carbapenem-non-susceptible bacteria that colonize patients in healthcare settings. The Xpert Carba-R Assay is not intended to guide or monitor treatment for carbapenem-nonsusceptible bacterial infections. A negative Xpert Carba-R Assay result does not preclude the presence of other resistance mechanisms.

The Xpert Carba R-Assay is for use with the following sample types:

Rectal Swab Specimens

The assay is performed on rectal swab specimens from patients at risk for intestinal colonization with carbapenem-non-susceptible bacteria. Concomitant cultures are necessary to recover organisms for epidemiological typing, antimicrobial susceptibility testing, and for further confirmatory bacterial identification.

Pure Colonies

The assay is performed on carbapenem-non-susceptible pure colonies of Enterobacteriaceae, Acinetobacter baumannii, or Pseudomonas aeruginosa, when grown on blood agar or MacConkey agar. For testing pure colonies, the Xpert Carba-R Assay should be used in conjunction with other laboratory tests including phenotypic antimicrobial susceptibility testing.

Substantial Equivalence:

The Cepheid Xpert Carba-R Assay is substantially equivalent to the Xpert® Carba-R Assay, 510(k) #K152614. Both assays utilize the same GeneXpert cartridge and detect target gene sequences (blakec, blandM, blavM, blaoxA-48, and blamp) using real-time PCR amplification and fluorogenic target-specific hybridization detection. The performance of the Xpert Carba-R Assay for an expanded indication was determined in a multi-site clinical study in which the performance of the Xpert Carba-R Assay was evaluated relative to culture and reference DNA sequence analysis. The results of the study demonstrated that the performance of the Xpert Carba-R Assay is substantially equivalent to the predicate device. Please refer to K152614 for information on the performance of the Xpert Carba-R Assay with pure colonies of carbapenem nonsusceptible Enterobacteriaceae, Acinetobacter baumannii, and Pseudomonas aeruginosa.

Table 5-1 shows the similarities and differences between the Xpert Carba-R Assay and the predicate device.

6

Table 5-1: Comparison of Similarities and Differences of the Xpert Carba-R Assay with the Predicate Device

Similarities
Item	Device	Predicate Device
	Cepheid Xpert Carba-R Assay	Cepheid Xpert Carba-R Assay
K152614
General Intended Use	The Xpert® Carba-R Assay, performed
on the GeneXpert® Instrument Systems,
is a qualitative in vitro diagnostic test
designed for the detection and
differentiation of the blaKPC ,
blaNDM , blaVIM , blaOXA-48 , and
blaIMP gene sequences associated with
carbapenem-non-susceptibility. The
test utilizes automated real-time
polymerase chain reaction (PCR).

The Xpert Carba-R Assay is intended as
an aid to infection control in the
detection of carbapenem-non-susceptible
bacteria that colonize patients in
healthcare settings. The Xpert Carba-R Assay is not intended to guide or
monitor treatment for carbapenem-
non-susceptible bacterial infections. A
negative Xpert Carba-R Assay result
does not preclude the presence of other
resistance mechanisms.

The Xpert Carba-R Assay is for use with
the following sample types:
Rectal Swab Specimens

The assay is performed on rectal swab
specimens from patients at risk for
intestinal colonization with carbapenem-
non-susceptible bacteria. Concomitant
cultures are necessary to recover
organisms for epidemiological typing,
antimicrobial susceptibility testing, and
for further confirmatory bacterial
identification.

Pure Colonies

The assay is performed on carbapenem-
non-susceptible pure colonies of
Enterobacteriaceae , Acinetobacter
baumannii , or Pseudomonas aeruginosa ,
when grown on blood agar or
MacConkey agar. For testing pure
colonies, the Xpert Carba-R Assay
should be used in conjunction with other | The Xpert® Carba-R Assay, performed
on the GeneXpert® Instrument Systems,
is a qualitative in vitro diagnostic test for
the detection and differentiation of the
blaKPC , blaNDM , blaVIM , blaOXA -
48, and blaIMP gene sequences
associated with carbapenem-non-
susceptible pure colonies of
Enterobacteriaceae , Acinetobacter
baumannii , or Pseudomonas
aeruginosa grown on blood agar or
MacConkey agar. The test utilizes
automated real-time polymerase chain
reaction (PCR).

7

The Xpert Carba-R Assay has the same general intended use as the predicate device and has the same technological characteristics as the predicate device. The differences between the Xpert Carba-R Assay and the predicate device do not raise questions of safety and effectiveness. The clinical study demonstrates that the Xpert Carba-R Assay is acceptable for its intended use with inexperienced laboratory users and is substantially equivalent to the predicate device described above.

8

Non-Clinical Studies:

Analytical Sensitivity (Limit of Detection)

The analytical sensitivity or Limit of Detection (LoD) of the Xpert Carba-R Assay was assessed using carbapenemase-producing organisms seeded into pooled negative human rectal swab matrix. The LoD was determined for two carbapenemase-producing bacteria for each gene analyte.i.e., the genes encoding KPC, NDM, VIM, OXA-48, and IMP. Bacteria were titered by plate counts and spiked onto clean swabs. Swabs were placed into pooled negative rectal swab matrix and replicates of 20 were evaluated at a minimum of five different concentrations over four days. The LoD for each of the ten carbapenemaseproducing organisms was estimated by probit analysis. The LoD is defined as the lowest concentration of target cells (CFU/swab) that can be reproducibly distinguished from negative samples with 95% confidence. The study was performed with two different lots of Xpert Carba-R reagents and the claimed LoD is the higher of the two determinations. The estimated LoDs were verified by preparing and testing 10 replicates from two independent dilutions of each bacterium at each estimated LoD.

The claimed LoD for each pair of carbapenemase-producing organism in rectal swab matrix are shown in Table 5-2.

| Target Gene and Organism | LoD Estimates (Probit)
CFU /swab | | LoD
Claim
CFU/swab | Estimated
LoD
In Sample
Reagent
CFU/mL | Verification
(Positives/20) |
|----------------------------------------------|-------------------------------------|-------|--------------------------|----------------------------------------------------|--------------------------------|
| | Lot 1 | Lot 2 | | | |
| IMP-1 Acinetobacter baumannii | 174 | 141 | 174 | 35 | 20/20 |
| IMP-1 Klebsiella pneumoniae | 303 | 306 | 306 | 61 | 20/20 |
| VIM-1 Klebsiella pneumoniae | 247 | 305 | 305 | 61 | 20/20 |
| VIM-4 Escherichia coli | 815 | 468 | 815 | 163 | 20/20 |
| NDM-1 Klebsiella pneumoniae ATCC
BAA-2146 | 117 | 251 | 251 | 50 | 20/20 |
| NDM Klebsiella pneumoniae | 74 | 57 | 74 | 15 | 19/20 |
| KPC-3 Klebsiella pneumoniae NCTC
13438 | 373 | 292 | 373 | 75 | 20/20 |
| KPC Enterobacter cloacae | 779 | 537 | 779 | 156 | 20/20 |
| OXA-48 Enterobacter cloacae | 154 | 109 | 154 | 31 | 20/20 |
| OXA-48 Escherichia coli | 104 | 99 | 104 | 21 | 20/20 |

Table 5-2. LoD Estimates and Verification for Organisms Harboring Carbapenemase Genes using the Xpert Carba-R Assay in Rectal Swab Matrix

Analytical Reactivity (Inclusivity)

The analytical reactivity of the Xpert Carba-R Assay with rectal swab matrix was evaluated by testing a panel of 72 samples. This panel consisted of 11 blakec (KPC), 11 blavin (VIM), 13 blaNDM (NDM), 8 blaoxa-48 (OXA-48), 5 blands(blaoxA-18) (NDM/OXA-181), 6 blaoxa-181(OXA-181), 17 blang (IMP), and one blakec/blayM (KPC/VIM) well-characterized

9

bacterial strains. The strains tested in rectal swab matrix and their test concentrations are presented in Table 5-3.

For testing in rectal swab matrix, organisms were seeded into pooled negative rectal swab matrix. All bacterial strains were tested in triplicate at approximately 3x LoD for each specimen type. Xpert Carba-R Assay target genes were detected in 69 of 72 carbapenemase-producing bacterial strains although IMP-4 was detected only using a higher concentration (Table 5-3). Xpert Carba-R Assay target DNA sequences were not detected in three bacterial strains as shown in Table 5-3. In one of the three bacterial strains, the IMP-13 gene was not detected by the assay, although it was predicted to be detected by in silico analysis. In two of the other three bacterial strains, the IMP-7 and IMP-14 genes were not predicted to be detected by in silico analysis and were not detected by the assay. See Limitations in the package insert.

The variants detected, and predictions for detecting other subtypes of each resistance gene based on in silico analysis, are presented in Table 5-4.

| Strain ID | Organism | Resistance
Marker with
variant
information | Concentration
Tested in
Rectal Swab
Matrix
(CFU/mL) |
|---------------|-------------------------|-----------------------------------------------------|-----------------------------------------------------------------|
| NCTC 13438 | Klebsiella pneumoniae | KPC-3 | 153 |
| 31551 | Klebsiella pneumoniae | KPC-4 | 50 |
| ATCC BAA-1705 | Klebsiella pneumoniae | KPC-2 | 130 |
| PA-Col | Pseudomonas aeruginosa | KPC-2 | 250 |
| KBM18 | Enterobacter aerogenes | KPC-2 | 250 |
| BM9 | Klebsiella pneumoniae | KPC-3 | 330 |
| PA3 | Klebsiella pneumoniae | KPC-2 | 100 |
| CGNC | Serratia marcescens | KPC-2 | 300 |
| CFVL | Enterobacter cloacae | KPC-2 | 160 |
| COL | Escherichia coli | KPC-2 | 147 |
| GR-04/KP-69 | Klebsiella pneumoniae | KPC-2, VIM | 80 |
| 164-3 | Klebsiella oxytoca | KPC | 70 |
| NCTC 13437 | Pseudomonas aeruginosa | VIM-10 | 500 |
| NCTC 13439 | Klebsiella pneumoniae | VIM-1 | 130 |
| NCTC 13440 | Klebsiella pneumoniae | VIM-1 | 70 |
| 758 | Pseudomonas aeruginosa | VIM | 250 |
| PA-87 | Klebsiella pneumoniae | VIM | 200 |
| B92A | Pseudomonas aeruginosa | VIM | 2000 |
| Col1 | Pseudomonas aeruginosa | VIM-2 | 500 |
| BM19 | Serratia marcescens | VIM-2 | 250 |
| KOW7 | Escherichia coli | VIM-4 | 250 |
| DIH | Klebsiella pneumoniae | VIM-19 | 250 |
| MSH2014-3 | Enterobacter cloacae | VIM | 500 |
| NCTC 13443 | Klebsiella pneumoniae | NDM-1 | 80 |
| Strain ID | Organism | Resistance
Marker with
variant
information | Concentration
Tested in
Rectal Swab
Matrix
(CFU/mL) |
| ATCC BAA-2146 | Klebsiella pneumoniae | NDM-1 | 80 |
| 34262 | Klebsiella pneumoniae | NDM | 80 |
| GEN | Acinetobacter baumannii | NDM-1 | 130 |
| 3047 | Enterobacter cloacae | NDM-1 | 70 |
| 7892 | Proteus mirabilis | NDM-1 | 30 |
| CAN | Salmonella spp. | NDM-1 | 70 |
| EGY | Acinetobacter baumannii | NDM-2 | 40 |
| I5 | Escherichia coli | NDM-4 | 30 |
| 405 | Escherichia coli | NDM-5 | 30 |
| CF-ABE | Citrobacter freundii | NDM | 30 |
| 73999 | Pseudomonas aeruginosa | NDM | 50 |
| 39365 | Providencia rettgeri | NDM-1 | 70 |
| NCTC 13442 | Klebsiella pneumoniae | OXA-48 | 40 |
| OM11 | Klebsiella pneumoniae | OXA-48 | 60 |
| 501 | Enterobacter cloacae | OXA-48 | 80 |
| DUW | Klebsiella pneumoniae | OXA-48 | 120 |
| OM22 | Escherichia coli | OXA-48 | 80 |
| BOU | Enterobacter cloacae | OXA-48 | 80 |
| TUR | Enterobacter cloacae | OXA-48 | 120 |
| 11670 | Escherichia coli | OXA-48 | 100 |
| 166643 | Klebsiella pneumoniae | OXA-181 | 20 |
| 42194 | Klebsiella pneumoniae | OXA-181 | 20 |
| MSH2014-64 | Klebsiella pneumoniae | OXA-181 | 280 |
| MSH2014-72 | Escherichia coli | OXA-181 | 100 |
| 74 | Escherichia coli | OXA-181 | 100 |
| CDC0051 | Klebsiella ozaenae a | OXA-181 | 250 |
| B108A | Klebsiella pneumoniae | NDM, OXA-181 | 10 |
| C10192-DISCS | Enterobacter aerogenes | NDM, OXA-181 | 10 |
| KP-OMA3 | Klebsiella pneumoniae | NDM, OXA-181 | 60 |
| 1300920 | Klebsiella pneumoniae | NDM, OXA-181 | 15 |
| MSH2014-69 | Klebsiella pneumoniae | NDM, OXA-181 | 20 |
| NCTC 13476 | Escherichia coli | IMP-1 | 250 |
| 695 | Acinetobacter baumannii | IMP-1 | 1720 |
| 2340 | Enterobacter cloacae | IMP-1 | 250 |
| IMPBMI | Klebsiella pneumoniae | IMP-1 | 100 |
| Yonsei 1 | Acinetobacter baumannii | IMP-1 | 1000 |
| Yonsei_2 | Acinetobacter baumannii | IMP-1 | 500 |
| 6852 | Klebsiella pneumoniae | IMP-1 | 100 |
| MKAM | Pseudomonas aeruginosa | IMP-1 | 500 |
| 70450-1 | Pseudomonas aeruginosa | IMP-1 | 250 |
| 3994 | Pseudomonas spp. | IMP-10 | 250 |
| Strain ID | Organism | Resistance
Marker with
variant
information | Concentration
Tested in
Rectal Swab
Matrix
(CFU/mL) |
| CDC0161 | Enterobacter aerogenesa | IMP-4 | 5.00E+04 |
| 5344 | Pseudomonas aeruginosa | IMP-2 | 60 |
| 3985 | Pseudomonas aeruginosa | IMP-11 | 2000 |
| 4032 | Pseudomonas aeruginosa | IMP-6 | 80 |
| 3424 | Pseudomonas aeruginosa | IMP-7b, c | 1.00E+06 |
| 32443 | Klebsiella pneumoniae | IMP-13c | 1.00E+06 |
| 92 | Pseudomonas aeruginosa | IMP-14b, c | 1.00E+06 |

Table 5-3. Analytical Reactivity of the Xpert Carba-R Assay in Rectal Swab Matrix

10

11

a. These organisms were not tested as bacterial isolates.

b. IMP-7 and IMP-14 genes (Pseudomonas aeruginosa) were not detected by the assay and were not predicted to be detected by in silico analysis (see Limitations).

c. IMP-13 gene (Klebsiella pneumoniae): although predicted to be detected by in silico analysis, the IMP-13 gene was not detected by the assay (see Limitations).

	Table 5-4. Summary of Variants Detected by Wet Testing or Predicted to be Detected
Based on In Silico Analysis
Marker
(or Traditional Subgroup)	No. of
Samples	Wet testing		Not tested but predicted to be detected based on
in silico analysis
KPC	12	KPC-2, 3, 4	--	KPC-5, 6, 7, 8, 9, 10, 11, 12, 13,
14, 15, 16
NDM	18	NDM-1, 2, 4, 5	--	NDM-3, 6, 7, 8, 9
VIM	12	VIM-1, 2, 4, 10, 19	--	VIM-5, 6, 7, 8, 9, 11, 12, 13, 14,
15, 16, 17, 18, 20, 23, 24, 25,
26, 27, 28, 29, 30, 31, 32, 33,
34, 35, 36, 37, 38
OXA-48	19	OXA-48,
181(OXA-48
variant)	--	OXA-162, 163, 204, 232, 244,
245, 247
IMP	17	IMP-1 (9
strains), IMP-
2, 4, 6, 10, 11	IMP-7a, 13b,
14a	IMP-3, 8, 9, 13b, 19, 20, 21, 22,
24, 25, 27, 28, 30, 31, 33, 37,
40, 42

a. IMP-7 and IMP-14 genes (Pseudomonas aeruginosa) were not detected by the assay and were not predicted to be detected by in silico analysis (see Limitations).

b. IMP-13 gene (Klebsiella pneumoniae) was tested: although predicted to be detected by in silico analysis, the IMP-13 gene was not detected by the assay (see Limitations).

Analytical Specificity (Cross-reactivity)

The analytical specificity of the Xpert Carba-R Assay was evaluated for bacterial isolates, organisms seeded into rectal swab matrix. For all three specimen types, a panel of 62 wellcharacterized bacterial strains of carbapenem-susceptible bacteria with carbapenem non-susceptibility due to genes or mechanisms other than the Xpert Carba-R target genes (Table 5-5 and Table 5-6) and 24 commensal bacterial strains and other enteric

12

microorganisms were also evaluated in the study (Table 5-7). Human cells were also tested in rectal swab matrix (Table 5-8). Resistance mechanisms were determined by individual PCR assays, DNA sequence analysis, or Check-Points array version CT102.

For rectal swab matrix samples, 62 strains were tested at concentrations >1 x 10° CFU/mL with the exception of Peptostreptococcus anaerobius that was tested at 5 x10° CFU/mL. Viruses were tested at >1 x 10 TCID50/mL or greater than 2.5 x107 RNA copies/mL. A bladder cell line (human genomic DNA) was tested at 1 x 10 cells/mL. Organisms were diluted into pooled negative rectal swab matrix and tested in triplicate. None of the 94 potentially cross-reactive organisms and nucleic acids tested was detected with the Xpert Carba-R Assay.

The Xpert Carba-R Assay did not cross react with any of the organisms tested (Table 5-6, Table 5-7, and Table 5-8). The analytical specificity of the assay was 100%.

	T TOTAL DECORD POLOTY OF COLUMNITY TOT SCIENCE TO PARTY LETTER POST
		Ertapenem Imipenem Meropenem
Susceptible	19	30	24
Intermediate	0	ನಿ	4
Resistant	43	24	34

Table 5-5. Number of Carbapenem-susceptible and Non-susceptible Organisms for each Antibiotic

| Organism Mechanisms susceptibility (S/I/R)ª | |---------------------- | | Escherichia coli like); TEM | Klebsiella pneumoniae | Enterobacter aerogenes TEM | Citrobacter freundii | Enterobacter cloacae | Klebsiella pneumoniae | Klebsiella pneumoniae | Escherichia coli | Escherichia coli | Enterobacter cloacae | Serratia marcescens | Morganella morganii | Proteus mirabilis | Salmonella spp. | Organism Mechanisms susceptibility (S/I/R)a | | | Shigella flexnerii | Enterobacter cloacae | Klebsiella pneumoniae | Klebsiella pneumoniae like); SHV | Klebsiella pneumoniae like); SHV; TEM | Klebsiella pneumoniae TEM-1 | Klebsiella pneumoniae | Klebsiella pneumoniae | Klebsiella pneumoniae | Klebsiella pneumoniae | Klebsiella pneumoniae | Klebsiella pneumoniae | Enterobacter cloacae TEM | Enterobacter aerogenes | Enterobacter aerogenes | Escherichia coli | Enterobacter aerogenes | Klebsiella pneumoniae +240K) | Klebsiella pneumoniae +240K) | Enterobacter cloacae | Enterobacter amnigenus | Klebsiella pneumoniae 240K) | Klebsiella pneumoniae like); SHV (WT+238S);
TEM | R | Enterobacter cloacae | Klebsiella pneumoniae | Escherichia coli | Providencia stuartii | Enterobacter cloacae | Organism Mechanisms susceptibility (S/I/R)ª | | | Escherichia coli like); TEM | Klebsiella pneumoniae like); SHV | Klebsiella pneumoniae like); SHV | Enterobacter cloacae | Escherichia coli | Enterobacter cloacae | Enterobacter cloacae | Klebsiella pneumoniae SHV; TEM. | Klebsiella pneumoniae SHV | Klebsiella pneumoniae SHV | Pseudomonas aeruginosa | Serratia marcescens | Serratia marcescens | Serratia marcescens | Serratia marcescens | Serratia marcescens | Serratia marcescens | Serratia marcescens | Enterobacter cloacae
group | CDC0132 | IMI | Enterobacter cloacae
complex | CDC0164 | IMI | Strain ID | Confirmed Resistance
| Carbapenem
| |
-----------|------------|----------------------------------------------------|---------------------------------------|------|------|
| | | ETPa | IMPa | MEMª |
| NCTC 13441 | CTX-M (-1, -type 15
| S | S | S |
| NCTC 13465 | CTX-M (25) | S | S | S |
| 810 | OmpC/OmpF deficient;
| R | R | R |
| 1698 | TEM (WT+164S) | S | S | S |
| 5557 | AmpC (ACT/MIR) | R | R | R |
| kpn5 | CTX-M-2 | R | S | R |
| kpn12 | TEM; SHV; CTX-M | R | R | R |
| ecol | TEM; CTX-M-2 | R | R | R |
| eco2 | CTX-M (2); TEM | R | S | S |
| corl | CTX-M (2); TEM | R | R | R |
| hpp21 | CTX-M (2); TEM | S | S | S |
| fer29 | CTX-M (2); TEM | S | R | S |
| gut25 | CTX-M (2); TEM | S | R | S |
| 3209 | CTX-M (2); TEM | S | S | S |
| Strain ID | Confirmed Resistance
| Carbapenem
| |
| | | ETPa | IMPa | MEMa |
| 3331 | CTX-M (2); TEM | S | S | S |
| PA_3 | AmpC; CTX-M-15; TEM | S | S | S |
| 32189 | SHV | S | S | S |
| 32443 | CTX-M (1, -type 15
| S | S | S |
| 32598 | CTX-M (-1, -type 15
| R | I | R |
| 33560 | CTX-M (15); SHV-11;
| S | S | S |
| 33603 | SHV-2 | R | I | R |
| 33617 | SHV-27 | S | S | S |
| 33643 | SHV (-5, -55); TEM | S | S | S |
| 34430 | SHV; TEM; CTX-M-15 | S | S | S |
| 34680 | TEM; CTX-M-2 | R | S | R |
| 34732 | CTX-M (15); SHV; TEM | R | S | S |
| PA_174 | GX-/Culture+; SHV;
| S | S | S |
| STU 645 | SHV (WT+238S+240K) | R | S | R |
| STU 669 | SHV (WT+238S+240K) | R | R | R |
| C3015 | AmpC (CMY II); TEM | R | R | R |
| RI_100 | AmpC (DHA); SHV | R | R | R |
| B4A | SHV (WT + 238S
| R | R | R |
| B13A | SHV (WT + 238S
| R | S | S |
| RI_474 | AmpC (ACT/MIR) | R | I | I |
| B71 | AmpC (ACT/MIR) | R | R | R |
| DD82A | SHV (WT + 238S +
| R | S | R |
| B100 | CTX-M (-1, type-15
| S | R |
| 135B | TEM | S | S | S |
| B157 | SHV; TEM | R | R | R |
| T2914280 | CTX-M (-1, -15); TEM | R | S | R |
| DD188 | TEM (104K + 164S) | R | I | I |
| DD189 | AmpC (ACT/MIR) | R | S | S |
| Strain ID | Confirmed Resistance
| Carbapenem
| |
| | | ETPª | IMPª | MEMª |
| B198B | CTX-M (-1, type -15
| R | S | R |
| T3019989-1 | CTX-M (-1, type-15
| R | I | R |
| T3019989-2 | CTX-M (-1, type-15
| R | S | R |
| ENC-THAI14 | VEB-1, TEM | S | S | S |
| CB154006 | CTX-M (9); TEM | R | I | I |
| S35766 | AmpC(ACT/MIR) | S | S | S |
| X1856910 | AmpC (ACT/MIR); TEM | R | I | I |
| W3758164 | CTX-M (-1, -15 like);
| R | I | R |
| X2135758 | CTX-M (-1, -15 like);
| R | S | S |
| W3809535 | CTX-M (-1, -15 like);
| R | R | R |
| CDC0064 | SPM | R | R | R |
| CDC0099 | SME | R | R | R |
| CDC0121 | SME | R | R | R |
| CDC0122 | SME | R | R | R |
| CDC0123 | SME | R | R | R |
| CDC0124 | SME | R | R | R |
| CDC0130 | SME | R | R | R |
| CDC0131 | SME | R | R | R |
| R | R | R |
| R | R | R |

Table 5-6. Cross-reactivity Panel

13

14

a. S//R = Susceptible/Intermediate/Resistant, ETP = Ertapenem, IMP = Imipenem, MEM = Meropenem

| Strain ID | Organism | Concentration Tested
(CFU/mL unless otherwise
specified) |
|-------------|------------------------|----------------------------------------------------------------|
| ATCC 25922 | Escherichia coli | 2.67E+06 |
| ATCC 29212 | Enterococcus faecalis | 3.15E+06 |
| ATCC 700603 | Klebsiella pneumoniae | 5.20E+06 |
| ATCC 35218 | Escherichia coli | 2.47E+06 |
| ATCC 25923 | Staphylococcus aureus | 4.53E+06 |
| ATCC 27853 | Pseudomonas aeruginosa | 3.17E+06 |

15

| Strain ID | Organism | Concentration Tested
(CFU/mL unless otherwise
specified) |
|---------------------------|-------------------------------|----------------------------------------------------------------|
| ATCC 9689 | Clostridium difficile | 1.80E+07 |
| ATCC 700621 | Enterobacter cloacae | 8.95E+06 |
| ATCC 9756 | Enterococcus faecium | 6.54E+06 |
| ATCC 13182 | Klebsiella oxytoca | 4.76E+06 |
| ATCC BAA-747 | Acinetobacter baumannii | 2.27E+06 |
| ATCC 33128 | Citrobacter freundii | 2.01E+06 |
| ATCC 49948 | Morganella morganii | 8.19E+06 |
| ATCC 51331 | Stenotrophomonas maltophilia | 3.15E+06 |
| ATCC 27028 | Citrobacter koseri | 5.05E+06 |
| ATCC 49809 | Providencia stuartii | 3.01E+06 |
| ATCC 49037 | Peptostreptococcus anaerobius | 5.00E+05 |
| CCUG 29780 / ATCC 12401 | Streptococcus agalactiae | 5.21E+06 |
| ATCC 15703 | Bifidobacterium adolescentis | 1.10E+08 |
| ATCC 51697 | Enterobacter aerogenes | 3.19E+06 |
| ATCC 43071 | Proteus mirabilis | 1.78E+06 |
| CCUG 34787 | Acinetobacter spp. | 2.40E+06 |
| CCUG 418 | Citrobacter freundii | 2.95E+06 |
| CCUG 33629 | Corynebacterium diphtheriae | 4.48E+06 |
| CCUG 17874 | Helicobacter pylori | 1.61E+06 |
| CCUG 33548 | Listeria monocytogenes | 4.77E+06 |
| CCUG 6325 | Providencia alcalifaciens | 4.91E+06 |
| CCUG 43594 / ATCC 33560 | Campylobacter jejuni | 3.27E+06 |
| MRVP/ZeptoMetrix | Adenovirus B Type 7A/NY | 1.40E+05 TCID50/mL |
| MRVP/ZeptoMetrix | Enterovirus Type 71/NY | 4.40E+05 TCID50/mL |
| Clinical Sample - Cepheid | Norovirus GII | 2.5 x 107 RNA copies/mL |

				Table 5-8. Cell Line Representing Human Genomic DNA
--	--	--	--	------------------------------------------------------

Organism Name	Source
Bladder Cell Carcinoma
(hgDNA)	ATCC HTB-4

Competitive Interference

A competitive interference study was performed to test whether a high titer of one or more carbapenemase-producing organisms would interfere with the detection of a second target carbapenemase-producing organism that was present at a low titer. High titered samples were formulated at concentrations of 5 x 106 CFU/swab and low titered targets were formulated at approximately 2x LoD for the respective strain in rectal swab matrix. One carbapenemase-producing bacterial strain for each gene analyte, i.e., the genes encoding

16

KPC, NDM, VIM, OXA-48, and IMP, was used in this study. Each carbapenemaseproducing bacterial strain type was tested at low titers in conjunction with a high titer of each of the other one or two carbapenemase-producing bacterial strain types (Table 5-9). Samples were tested in replicates of eight. An inhibitory effect was observed for three of the five targets (IMP, VIM, and OXA-48) when a low concentration of each target was present in combination with a high concentration of one or two other targets for samples tested in rectal swab matrix. The three targets (IMP, VIM, and OXA-48) were tested at a higher concentration (4x LoD) in combination with a high concentration of one of two other targets for samples in rectal swab matrix. No inhibitory effect was observed for the three targets (IMP, VIM and OXA-48) at 4x LoD in the presence of clinically relevant co-infections for the Xpert Carba-R Assay. The competitive inhibitory effect on the Carba-R targets (IMP, VIM and OXA-48) is addressed in Section 15, Limitations in the package insert.

Table 5-9. Combinations of Carbapenemase-producing Bacteria Tested with the
Xpert Carba-R Assay

Combination
High KPC/High NDM/Low VIM
High KPC/High NDM/Low OXA
High KPC/High NDM/Low IMP
High VIM/High OXA/Low KPC
High VIM/High OXA/Low NDM
High VIM/High OXA/Low IMP
High IMP/Low KPC
High IMP/Low NDM
High IMP/Low VIM
High IMP/Low OXA
High OXA/Low VIM
High VIM/Low OXA
High KPC/Low NDM
Negative

Potentially Interfering Substances

The performance of the Xpert Carba-R Assay was evaluated with 24 potentially interfering substances that may be present in rectal swab specimens. Potentially interfering substances (IS) solutions were prepared and tested at concentrations specified in Table 5-10. Positive and negative samples were included in this study. Positive samples consisted of a mix of five carbapenemase-producing organisms harboring KPC, NDM, VIM, IMP-1 and OXA-48 gene sequences seeded into pooled negative rectal swab matrix at approximately 3x LoD. Eight replicate positive samples were tested per substance. Negative samples consisted of pooled negative rectal swab matrix not seeded with carbapenemase-producing organisms. Eight replicate negative samples were tested per substance to determine the effect on the

17

performance of the sample processing control (SPC). Controls consisted of positive and negative samples with no interfering substances added. The effect of each potentially interfering substance on positive and negative replicates was evaluated by comparing target cycle threshold (Ct) values generated in the presence of the substance to Ct values from controls lacking the substance. The positive and negative replicate samples for 22 potentially interfering substances were correctly identified using the Xpert Carba-R Assay. Interference with the Xpert Carba-R Assay may be observed with barium sulfate at > 0.1% w/v and Pepto-Bismol at > 0.01% w/v in tests with rectal swab matrix samples. See Limitations in the package insert. Rectal swab matrix samples, positive for a mix of five carbapenemase-producing organisms harboring KPC, NDM, VIM, IMP-1 and OXA-48 gene sequences that were tested with fecal fat at 0.25% w/v, did not yield any false negative results, however, delayed cycle threshold values were observed for the VIM target. This potential interference from the presence of 0.25% w/v fecal fat is provided in the Limitations section of the package insert.

Substance/Class	Active Ingredient	Concentration Tested
Non-steroidal anti-
inflammatory
medication	Naproxen	0.25% w/v
Imaging compound	Barium sulfate	0.25% and 0.1% w/v
Antibiotic (oral)	Cephalexin	0.25% w/v
Antibiotic (oral)	Ciprofloxacin	0.25% w/v
Condom with
spermicidal lubricant	Nonoxynol-9	1 condoma
Creams/ointment/
suppositories	Hydrocortisone	0.25% w/v
Laxative	Sennosides	0.25% w/v
Lipids	Stearic acid/Palmitic
acid/Cholesterol (fecal
fat)	0.25% w/v
Anti-diarrheal
medication	Loperamide
hydrochloride/bismuth
subsalicylate (Imodium)	0.25% w/v
Anti-diarrheal
medication	Loperamide
hydrochloride/bismuth
subsalicylate (Kaopectate)	0.25% w/v
Topical cream	K-Y Jelly	0.25% w/v
Antacids	Calcium
carbonate/aluminum
hydroxide/magnesium
hydroxide/simethicone
(Milk of Magnesia)	0.25% w/v
Enemas	Mineral oil	0.25% w/v
Antibiotic (topical)	Polymixin B/ Neomycin/
Bacitracin (Neosporin)	0.25% w/v
Anti-fungal/
anti-itch Vaginal	Nystatin	0.25% w/v
Antacid	Famotidine (Pepcid)	0.25% w/v

Table 5-10. Potentially Interfering Substances Tested

18

| Substance/Class | Active Ingredient | Concentration
Tested |
|-------------------------------------|------------------------------------------------------------------------|------------------------------------------|
| Anti-diarrheal
medication | Loperamide
hydrochloride/bismuth
subsalicylate
(Pepto-Bismol) | 0.25%, 0.1%, 0.05%,
0.025%, 0.01% w/v |
| Topical cream | Petroleum jelly | 0.25% w/v |
| Anti-hemorrhoid
creams/ointments | Phenylephrine
(Preparation H) | 0.25% w/v |
| Acid reducer; antacid | Oemprazole (Prilosec) | 0.25% w/v |
| Enemas | Saline-enema | 0.25% w/v |
| Antacid | Cimetidine (Tagamet) | 0.25% w/v |
| Anti-fungal/anti-itch
Vaginal | Benzocaine, resorcinol
(Vagisil) | 0.25% w/v |
| Moist towelettes | Benzalkonium chloride,
ethanol (Wet Ones) | 1 pieceb |

a. One condom added to 40 mL swab matrix.

b. One piece (5 inch x 7-1/2 inch) added to 40 mL swab matrix.

Carry-Over Contamination

A study was conducted to demonstrate that single-use, self-contained GeneXpert cartridges prevent carry-over contamination in negative samples run following very high positive samples. The study consisted of a negative sample processed in the same GeneXpert module immediately following a very high positive sample. The high positive sample is composed of inactivated E. coli cells containing a plasmid with an insert consisting of a synthetic oligonucleotide of the amplicon sequences from the five Xpert Carba-R target analyte genes (KPC, NDM, VIM, IMP and OXA-48 targets). Positive cells were diluted in pooled negative rectal swab matrix to a concentration of 1 x 10 CFU/mL. The testing scheme was repeated 25 times on two GeneXpert modules for a total of 102 tests (25 high positive samples per module and 26 negative samples per module) for the rectal swab matrix. All 50 positive samples correctly reported all Xpert Carba-R targets as DETECTED. All 52 negative samples correctly reported all Xpert Carba-R targets as NOT DETECTED.

Clinical Studies

Clinical Performance

Performance characteristics of the Xpert Carba-R Assay with rectal swab specimens were determined in a multi-site investigational study. The positive percent agreement (PPA) and negative percent agreement (NPA) of the Xpert Carba-R Assay was evaluated relative to a reference method of culture (MacConkey enrichment broth) and PCR/bi-directional DNA sequence analysis.

Five geographically diverse sites (three across the United States and two in Europe) prospectively collected paired rectal swab specimens from subjects who were hospitalized or in a long-term care facility. Highly soiled rectal swab specimens, were excluded from the study. Due to low prevalence of each of the Xpert Carba-R Assay target genes in the absence of an outbreak, contrived specimens were also included in the study.

19

One rectal swab of the pair was used for Xpert Carba-R Assay testing. The second rectal swab was inoculated into MacConkey enrichment broth and used for reference method testing. A reference culture laboratory determined the presence of carbapenem nonsusceptible organisms by culturing the MacConkey enrichment broth from each of the specimens. The MacConkev enrichment broth was screened for the presence of carbapenem-non-susceptible organisms initially by plating the broth on MacConkey agar plates with a meropenem disk. For specimens that exhibited growth of gramnegative bacteria around the meropenem disk, confirmation of carbapenem nonsusceptibility was determined on isolated colonies by using the disk diffusion method (per CLSI document M02) as well as CLSI document M100. DNA extracted from the carbapenem non-susceptible isolates was purified, quantified, and amplified using primers specific to all 5 target genes; amplified regions included more bases than the regions amplified by the Xpert Carba-R Assay. The production of the appropriate size amplification product was confirmed on Agilent 2100 Bioanalyzer (Agilent Technologies, Santa Clara, CA).

If bands shown on the Bioanalyzer corresponded to the expected size of the amplicon from any of the five target genes detected by the Xpert Carba-R Assay, the amplicon for the isolate was sent to an independent laboratory for reference bi-directional sequencing analysis, which was validated for detection of the five targets in the Xpert Carba-R Assay. If no bands were shown on the Bioanalyzer for any of the five target genes, the isolate was not sent for sequence analysis and the reference method result was considered negative for the five target genes.

Prospective Specimen Results Obtained with the Xpert Carba-R Assay in Comparison to the Reference Method

A total of 802 prospective rectal swab specimens were initially enrolled in this clinical study, of which 785 were eligible for inclusion. From the 785 eligible specimens. 755 specimens were included in the final dataset after exclusions based on protocol deviations (including 16 Stenotrophomonas maltophilia organisms that were excluded due to their intrinsic resistance to the carbapenems tested).

When tested with prospective rectal swab specimens, the Xpert Carba-R Assay demonstrated a PPA range from 60.0% to 100% for the four assay targets (blakec, blaNDM, blaym, and blaoxA-48) relative to the reference method (Table 5-11). The NPA for the blakpc, blann, blanx 4-48, and blansp gene sequences ranged from 98.6%-99.9% relative to the reference method (Table 5-11).

For specimens with discordant results (the Xpert Carba-R Assay was positive for a target gene but a carbapenem-non-susceptible organism was not isolated by reference culture), discordant analysis was performed using bi-directional sequencing on DNA extracted directly from the MacConkey enrichment broth. Discrepant testing results are footnoted in Table 5-11.

20

| Specimen
Type | Target | N | TP | FP | TN | FN | PPA%
(95 CI) | NPA%
(95 CI) |
|------------------|--------|-----|----|------|-----|----|------------------------|-----------------------|
| Prospectiveg | IMP | 755 | 0 | 1a | 754 | 0 | N/A | 99.9%
(99.3-100.0) |
| | VIM | 755 | 6 | 8b | 737 | 4 | 60.0%
(31.3-83.2) | 98.9%
(97.9-99.5) |
| | NDM | 755 | 7 | 3c | 745 | 0 | 100.0%
(64.6-100.0) | 99.6%
(98.8-99.9) |
| | KPC | 755 | 29 | 6d,e | 720 | 0 | 100.0%
(88.3-100.0) | 99.2%
(98.2-99.6) |
| | OXA-48 | 755 | 29 | 10f | 715 | 1 | 96.7%
(83.3-99.4) | 98.6%
(97.5-99.2) |

Table 5-11. Xpert Carba-R Performance vs. Reference Culture + Sequencing -Prospective Specimens

N = Number, TP = True Positive, FP = False Positive, TN = True Negative, FN = False Negative

a. 1 discordant specimen was confirmed as FP after discordant analysis.

b.2 of the 8 FPs were determined to be TPs after discordant analysis.

c. 1 of the 3 FPs was determined to be TP after discordant analysis.

d. 1of the 6 FPs was determined to be TP after discordant analysis.

e. Site reported that subject was on ertapenem during time of specimen collection.

f. 3 of the 10 FPs were determined to be TPs after discordant analysis.

g. Of the 755 prospective rectal swab specimens evaluated in the study, 636 specimens did not yield a culture isolate by Reference Culture. From the remaining 119 specimens, 112 carbapenem-non-susceptible organisms were recovered by Reference Culture in addition to 7 carbapenem susceptible organisms [Pseudomonas aeruginosa (5); Escherichia coli (1), and Enterobacter cloacae (1)].

Performance of the Xpert Carba-R Assay on the prospective specimens is shown in Table 5-12 by species. Only organisms for which at least one positive specimen was collected are included in Table 5-12.

| Speciesa | Target | N | TP | FP | TN | FN | PPA
(95% CI) | NPA
(95% CI) |
|-----------------------------|--------|----|----|----|----|----|----------------------|----------------------|
| Enterobacter cloacae | IMP | 4 | 0 | 0 | 4 | 0 | NA | 100%
(51.0-100.0) |
| | VIM | 4 | 1 | 0 | 3 | 0 | 100%
(20.7-100.0) | 100%
(43.9-100.0) |
| | NDM | 4 | 0 | 0 | 4 | 0 | NA | 100%
(51.0-100.0) |
| | KPC | 4 | 0 | 0 | 4 | 0 | NA | 100%
(51.0-100.0) |
| | OXA-48 | 4 | 1 | 0 | 3 | 0 | 100%
(20.7-100.0) | 100%
(43.9-100.0) |
| E. coli | IMP | 10 | 0 | 0 | 10 | 0 | NA | 100%
(72.3-100.0) |
| | VIM | 10 | 0 | 0 | 10 | 0 | NA | 100%
(72.3-100.0) |
| | NDM | 10 | 3 | 0 | 7 | 0 | 100%
(43.9-100.0) | 100%
(64.6-100.0) |
| | KPC | 10 | 2 | 0 | 8 | 0 | 100%
(34.2-100.0) | 100%
(64.6-100.0) |
| | OXA-48 | 10 | 3 | 0 | 7 | 0 | 100%
(43.9-100.0) | 100%
(64.6-100.0) |

Table 5-12. Xpert Carba-R Performance vs. Reference Culture + Sequencing by Organism type - Prospective Specimens

21

| Speciesa | Target | N | TP | FP | TN | FN | PPA
(95% CI) | NPA
(95% CI) |
|----------------------------------|-----------------------------------|-----|----|----|----|----|----------------------|-----------------------|
| Klebsiella
oxytoca | IMP | 1 | 0 | 0 | 1 | 0 | NA | 100%
(20.7-100.0) |
| | VIM | 1 | 0 | 0 | 1 | 0 | NA | 100%
(20.7-100.0) |
| | NDM | 1 | 0 | 0 | 1 | 0 | NA | 100%
(20.7-100.0) |
| | KPC | 1 | 0 | 0 | 1 | 0 | NA | 100%
(20.7-100.0) |
| | OXA-48 | 1 | 1 | 0 | 0 | 0 | 100%
(20.7-100.0) | NA |
| Klebsiella
pneumoniae | IMP | 60 | 0 | 1 | 59 | 0 | NA | 98.3%
(94.0-100.0) |
| | VIM | 60 | 0 | 1 | 59 | 0 | NA | 98.3%
(94.0-100.0) |
| | NDM | 60 | 4 | 1 | 55 | 0 | 100%
(51.0-100.0) | 98.2%
(90.6-99.7) |
| | KPC | 60 | 27 | 1 | 32 | 0 | 100%
(87.5-100.0) | 97.0%
(89.6-100.0) |
| | OXA-48 | 60 | 24 | 3 | 32 | 1 | 96.0%
(80.5-99.3) | 91.4%
(77.6-97.0) |
| | Pseudomonas
aeruginosa | IMP | 30 | 0 | 0 | 30 | 0 | NA |
| VIM | | 30 | 5 | 0 | 21 | 4 | 55.6%
(26.7-81.1) | 100%
(84.5-100.0) |
| NDM | | 30 | 0 | 1 | 29 | 0 | NA | 96.7%
(83.3-99.4) |
| KPC | | 30 | 0 | 1 | 29 | 0 | NA | 96.7%
(83.3-99.4) |
| OXA-48 | | 30 | 0 | 0 | 30 | 0 | NA | 100%
(88.7-100.0) |

a. Acinetobacter baumannii (13) and Enterobacter amnigensus (1) were recovered but did not contain target sequences by the Reference Method.

Multiple targets were detected by the Xpert Carba-R Assay in eight prospective specimens. The details are provided in Table 5-13, along with the discrepant sequencing result.

Table 5-13. Prospective Specimens with Multiple Targets Detected
------------------------------------------------------------------	--	--	--	--	--

| Specimen | Targets Detected
by Xpert Carba-R
Assay | Targets
Detected by
Reference
Sequencing | Discrepant Testing
Results - Targets
Detected by
Reference
Sequencing |
|----------|-----------------------------------------------|---------------------------------------------------|-----------------------------------------------------------------------------------|
| 1 | KPC, OXA-48 | NEG | NEG |
| 2 | VIM, KPC | NEGa | NEGa |
| 3 | VIM, OXA-48 | OXA-48 | OXA-48 |
| 4 | KPC, OXA-48 | KPC | KPC, OXA-48 |
| 5 | NDM, OXA-48 | NDM | NDM, OXA-48 |
| 6 | VIM, NDM | NEGa | NEG |
| 7 | NDM, KPC | KPC | NDM, KPC |
| 8 | VIM, KPC | VIM | VIM, KPC |

a. An organism was not isolated from reference culture, therefore, reference sequencing was not performed.

22

Contrived Specimen Results Obtained with the Xpert Carba-R Assay in Comparison to the Reference Method

A total of 432 contrived specimens prepared in rectal swab matrix were also tested as part of the clinical study.

In addition to Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter baumannii groups tested in the contrived study, 5 other non-Enterobacteriaceae strains were also evaluated: Pseudomonas stutzeri (1), Pseudomonas oryzihabitans (1), Pseudomonas putida (2), and Empedobacter brevis (1).

When tested with contrived specimens, the Xpert Carba-R Assay demonstrated a PPA range from 95% to 100% across the assay targets (blakp., blandM. blagsA.48. and blamp). The NPA for the blakec, blaNDM, blaoxA-48, and blamp gene sequences was 100% relative to the reference method (Table 5-14).

Table 5-14. Xpert Carba-R Performance vs. Reference Method-Contrived Specimens

Contrived Specimens
Target	N	TP	FP	TN	FN	PPA%
(95 CI)	NPA%
(95 CI)
IMP	432	76	0	352	4	95.0%
(87.8-98.0)	100.0%
(98.9-100.0)
VIM	432	81	0	350	1	98.8%
(93.4-99.8)	100.0%
(98.9-100.0)
NDM	432	80	0	352	0	100.0%
(95.4-100.0)	100.0%
(98.9-100.0)
KPC	432	80	0	352	0	100.0%
(95.4-100.0)	100.0%
(98.9-100.0)
OXA-48	432	79	0	352	1	98.8%
(93.3-99.8)	100.0%
(98.9-100.0)

Reproducibility Study

Reproducibility of the Xpert Carba-R Assay was evaluated using two panels of 11 samples, prepared in pooled negative rectal swab matrix. Two operators at each of the three study sites tested one panel of 11 samples in replicates of four per day over six testing days (11 samples x 2 replicates x 2 times/day x 6 days x 2 operators x 3 sites). Three lots of Xpert Carba-R Assay cartridges were used at each of the 3 testing sites. The Xpert Carba-R Assay was performed according to the Xpert Carba-R Assay procedure. Results are summarized in Table 5-15.

23

| Sample | Matrixª | Site 1 | | | Site 2 | | | Site 3 | | | % Total
Agreement
by Sample |
|-------------------|---------|------------------|------------------|------------------|------------------|------------------|------------------|------------------|------------------|------------------|-----------------------------------|
| | | Op 1 | Op 2 | Site | Op 1 | Op 2 | Site | Op 1 | Op 2 | Site | |
| Neg | R | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(144/144) |
| IMP
Mod Pos | R | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(144/144) |
| IMP
Low Pos | R | 91.7%
(22/24) | 87.5%
(21/24) | 89.5%
(43/48) | 83.3%
(20/24) | 87.5%
(21/24) | 85.4%
(41/48) | 87.5%
(21/24) | 79.2%
(19/24) | 83.3%
(40/48) | 86.1%
(124/144) |
| VIM
Mod Pos | R | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(144/144) |
| VIM
Low Pos | R | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(144/144) |
| NDM
Mod Pos | R | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(144/144) |
| NDM
Low Pos | R | 91.7%
(22/24) | 95.8%
(23/24) | 93.8%
(45/48) | 95.8%
(23/24) | 95.8%
(23/24) | 95.8%
(46/48) | 100%
(24/24) | 91.7%
(22/24) | 95.8%
(46/48) | 95.1%
(137/144) |
| KPC
Mod Pos | R | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(144/144) |
| KPC
Low Pos | R | 95.8%
(23/24) | 100%
(24/24) | 97.9%
(47/48) | 100%
(24/24) | 91.7%
(22/24) | 95.8%
(46/48) | 95.8%
(23/24) | 95.8%
(23/24) | 95.8%
(46/48) | 96.5%
(139/144) |
| OXA-48
Mod Pos | R | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(24/24) | 100%
(24/24) | 100%
(48/48) | 100%
(144/144) |
| OXA-48
Low Pos | R | 95.8%
(23/24) | 100%
(24/24) | 97.9%
(47/48) | 95.8%
(23/24) | 100%
(24/24) | 97.9%
(47/48) | 91.7%
(22/24) | 100%
(24/24) | 95.8%
(46/48) | 97.2%
(140/144) |

Table 5-15. Summary of Reproducibility Results - % Agreement, Rectal Swab Matrix

a. R=rectal

The reproducibility of the Xpert Carba-R Assay was also evaluated in terms of the fluorescence signal expressed in Ct values for each target detected. The mean, standard deviation (SD), and coefficient of variation (CV) between-sites, between-lots, betweendays, between-operators, and within-assays for each panel member are presented in Table 5-16.

Between-Within-Between-Site Between-Lot Between-Day Total Assay Operator Assay Mean Nº Matrixª Channel Sample Ct CV CV CV CV CV CV (Analyte) SD SD SD SD SD SD (%) (%) (%) (%) (%) (%) 0.2 2.0 Neg R SPC 144 32.9 0.2 0.5 0.7 0.0 0.1 0.0 0 0.6 18 0.7 IMP Mod Pos 34.5 0.0 0.2 0.2 R IMP 144 0.0 0:5 0.0 0.1 0.7 2.0 0.7 2.1 0 IMP Low Pos R IMP 140 36.4 0.0 0.0 0.0 0.0 0.2 0.5 0.0 0 1.2 3.3 1.2 3.4 VIM Mod Pos VIM 144 31.0 0.5 R 0.0 0.0 0.3 0.9 0 0.0 0.2 0.5 1.6 0.6 1.9 VIM Low Pos R VIM 144 33.8 0.0 0.0 0.6 1.8 0.3 0.9 1.0 1.4 4.0 4.6 0.3 1.6 NDM Mod Pos 144 33.7 0.0 R NDM 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.6 1.7 0.6 1.7 NDM Low Pos R NDM 143 36.2 0.2 0.7 0.0 0.0 0.3 0.7 0.0 0.0 0.8 2.3 0.9 2.5 KPC Mod Pos R КРС 144 34.2 0.0 0.0 0.3 0.8 0.2 0.6 0.0 0.0 0.4 1.2 0.6 1.6 35.8 0.5 1.9 KPC Low Pos R КРС 141 0.0 0.0 1.5 0.0 0.0 0.3 0.9 0.7 0.9 2.6 OXA-48 Mod Pos R OXA-48 144 34.3 0.0 0.0 0.2 0.5 0.2 0.5 0.1 0.3 0.5 1.6 0.6 1.7 OXA-48 OXA-48 Low Pos R 143 36.1 0.0 0.0 0.0 0.0 0.2 0.6 0.0 0.0 0.8 2.3 0.9 2.4

Table 5-16. Summary of Reproducibility Data, Rectal Swab Matrix

a. R=rectal

b. Results with non-zero Ct values out of 144.

24

Conclusions

The results of the nonclinical analytical and clinical performance studies summarized above demonstrate that the Xpert Carba-R Assay is safe and effective for its intended use and is substantially equivalent to the predicate device.