Predicate Devices

Reference Devices

Not Found

AI/ML (Artificial Intelligence / Machine Learning)

No
The summary describes a real-time PCR assay performed on an automated instrument system. The technology described is standard molecular diagnostics and does not mention any AI or ML components for data analysis or interpretation.

Therapeutic

No

This device is an in vitro diagnostic test designed to detect gene sequences associated with carbapenem-non-susceptibility, aiding in infection control and guiding therapeutic strategies. It does not directly treat or prevent a disease.

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 "The Xpert Carba-R Assay is intended as an aid to infection of carbapenem-non-susceptible bacteria that colonize patients in healthcare settings." The "Device Description" also refers to it as an "in vitro diagnostic test".

SaMD (Software as a Medical Device)

No

The device is an in vitro diagnostic test that utilizes a physical instrument system (GeneXpert) and disposable cartridges containing reagents to perform real-time PCR. While software is involved in controlling the instrument and analyzing results, the core functionality relies on hardware and chemical components.

IVD (In Vitro Diagnostic)

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

Here's why:

Explicitly Stated: The "Intended Use / Indications for Use" section clearly states: "The Xpert® Carba-R Assay, performed on the GeneXpert® Instrument Systems, is a qualitative in vitro diagnostic test..."
Device Description: The "Device Description" section also refers to it as an "in vitro diagnostic test".
Purpose: The device is designed to detect and differentiate gene sequences associated with carbapenem-non-susceptibility in patient samples (pure colonies, rectal and perirectal swabs). This is a diagnostic purpose performed outside of the body.
Sample Types: It uses biological samples (pure colonies, rectal/perirectal swabs) which are characteristic of IVD tests.
Intended Use: The intended use is to aid in infection control and potentially guide therapeutic strategies, which are clinical applications of diagnostic information.

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 blakes, blaypy, blaxx -8, and blang 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. 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:

Pure Colonies
The assay is performed on carbapentible 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.

The identification of a blawy, blayin metallo-beta-lactamase gene (i.e., the genes that encode the INP, NDM, and VIM metallo-beta-lactamases, respectively) may be used as an aid to clinicians in determining appropriate therapeutic strategies for patients with known or suspected carbapenem-non- susceptible bacterial infections.

Rectal and Perirectal 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.

The Xpert Carba-R Assay, when performed on rectal and perirectal swab specimens, is not intended to guide or monitor treatment for carbapenem-non-susceptible bacterial infections or to determine infection from carbapenem-nonsusceptible bacteria.

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

POC, PMY, 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 blakpo, blaymy, blavny, blaoxa-as, and blamp gene sequences from rectal or perirectal swab specimens or isolates of pure cultures of carbapenem-non-susceptibility gram-negative bacteria. The Xpert Carba-R Assay is intended as an aid for infection control for monitoring the spread of carbapenem-non-susceptible 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 blaxpy blayDM blaym, blacks, and blamp 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 blakpc, blaNDM, blagxA-48 and blamp gene sequences from rectal or perirectal swab specimens or isolates of pure cultures of carbapenem-non- susceptibility gram-negative bacteria 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 real-time 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 or perirectal swab specimens or bacterial isolates from culture 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 blakers, blayDM blaym, blacks, and blamp 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 and Perirectal

Indicated Patient Age Range

Not Found

Intended User / Care Setting

Operators in CLIA Moderate or High Complexity labs

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 -Perirectal Swab Specimens
A total of 963 prospective perirectal swab specimens were initially enrolled in this clinical study, of which 947 were eligible for inclusion. From the 947 eligible specimens, 924 specimens were included in the final dataset after exclusions based on protocol deviations (including 10 Stenotrophomonas maltophilia, one Pseudomonas putida and one Pseudomonas stutzeri organisms that were excluded due to their intrinsic resistance to the carbapenems tested).
Performance characteristics of the Xpert Carba-R Assay perirectal 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/bidirectional DNA sequence analysis.
Five geographically diverse sites prospectively collected paired perirectal swab specimens from subjects who were hospitalized or in a long-term care facility. Highly soiled perirectal swab specimens, according to the directions in Section 9 of package insert (Sample Preparation and Storage) were excluded from the study.

Contrived Specimen Results Obtained with the Xpert Carba-R Assay in Comparison to the Reference Method
A total of 432 contrived specimens prepared in perirectal 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).

Perirectal Swab and Rectal Swab Equivalence Study
A total of 207 specimens were initially enrolled in this clinical study, all of which were eligible for inclusion. Of the 207 eligible specimens were included in the final dataset used for the analyses. Six swab specimens (4 perirectal swab specimens and 2 rectal swab specimens) were excluded due to indeterminate results from the Xpert Carba-R Assay.
To demonstrate equivalence of perirectal swab specimens and rectal swab specimens, a study was conducted at one site enrolling fresh prospectively collected rectal and perirectal swab specimens from consented subjects who were hospitalized in-patients.
Paired swab sets provided in the Cepheid Specimen Collection Device were used to collect specimens from each subject. One paired swab set was used to collect the perirectal swab specimen and a second paired swab set was used to collect the rectal swab specimen. The perirectal swab specimen was collected first followed by the rectal swab specimen from the same subject. One swab from each paired swab set was used for Xpert Carba-R Assay testing. The second swab from each paired swab set was used for culture and susceptibility testing when either or both the perirectal or rectal swab specimen(s) were positive for one or more target(s) by the Xpert Carba-R Assay. No culture was performed if perirectal and rectal swab specimens were both negative by the Xpert assay.
Bi-directional DNA sequencing was performed on DNA extracted from isolated colonies that manifested carbapenem-non-susceptibility by the CLSI disk diffusion method or from MacConkey broth with meropenem disk if the culture result was negative and the Xpert Carba-R Assay result was positive.

Reproducibility Study
The reproducibility of the Xpert Carba-R Assay was evaluated using of a panel of 11 samples, prepared in pooled negative perirectal 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).

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

Clinical Performance -Perirectal Swab Specimens
When tested with prospective perirectal swab specimens, the Xpert Carba-R Assay demonstrated a PPA of 100% for the three assay targets (blayDM, blagge and blaoxA-48) relative to the reference method. The NPA for the blakpc, blaNDM, blaoxA-48, and blaIMP gene sequences ranged from 99.6% to 100% relative to the reference method (Table 8-11).
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.

Contrived Specimen Results Obtained with the Xpert Carba-R Assay in Comparison to the Reference Method
When tested with contrived specimens, the Xpert Carba-R Assay demonstrated a PPA and NPA of 100% for the blakpc, blaNDM, blayM, blagxA-48, and blaIMP gene sequences was 100% relative to the reference method (Table 8-14).

Perirectal Swab and Rectal Swab Equivalence Study
The performance (PPA and NPA) of the Xpert Carba-R Assay using perirectal swab specimens was determined relative to the results of the Xpert Carba-R Assay using rectal swab specimens from the same subject. The PPA and NPA estimates are shown in Table 8-15. Relative to the Xpert Carba-R Assay rectal swab specimen result, the perirectal swab specimens demonstrated an overall PPA and NPA of 94.7% (95%CI: 75.4-99.1) and 97.8% (95%CI: 94.5-99.1), respectively.

Reproducibility Study
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 8-17. Refer to Table 8-16 for reproducibility results.

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

Clinical Performance -Perirectal Swab Specimens
PPA of 100% for the three assay targets (blayDM, blagge and blaoxA-48)
NPA for the blakpc, blaNDM, blaoxA-48, and blaIMP gene sequences ranged from 99.6% to 100%

Contrived Specimen Results Obtained with the Xpert Carba-R Assay in Comparison to the Reference Method
PPA and NPA of 100% for the blakpc, blaNDM, blayM, blagxA-48, and blaIMP gene sequences.

Perirectal Swab and Rectal Swab Equivalence Study
Overall PPA and NPA of 94.7% (95%CI: 75.4-99.1) and 97.8% (95%CI: 94.5-99.1), respectively.

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.

K160901

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/0 description: The image contains the logos of the Department of Health & Human Services and the Food and Drug Administration (FDA). The Department of Health & Human Services logo is on the left, and the FDA logo is on the right. The FDA logo is a blue square with the letters "FDA" in white, followed by the words "U.S. FOOD & DRUG ADMINISTRATION" in blue.

January 9, 2018

Cepheid Jim Kelly Executive Director, Regulatory Affairs 904 Caribbean Drive Sunnyvale, California 94089

Re: K173263

Trade/Device Name: Xpert Carba-R Regulation Number: 21 CFR 866.1640 Regulation Name: Antimicrobial susceptibility test powder Regulatory Class: Class II Product Code: POC, PMY, OOI Dated: October 10, 2017 Received: October 12, 2017

Dear Jim 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 Part 801 and Part 809); medical device 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

K173263

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.

For comprehensive regulatory information about medical devices and radiation-emitting products, including information about labeling regulations, please see Device Advice (https://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/) and CDRH Learn (http://www.fda.gov/Training/CDRHLearn). Additionally, you may contact the Division of Industry and Consumer Education (DICE) to ask a question about a specific regulatory topic. See the DICE website (http://www.fda.gov/DICE) for more information or contact DICE by email (DICE@fda.hhs.gov) or phone (1-800-638-2041 or 301-796-7100).

Sincerely,

Ribhi Shawar -S

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

Indications for Use

510(k) Number (if known) K173263

Device Name

Xpert Carba-R Assay

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 blakes, blaypy, blaxx -8, and blang 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. 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:

Pure Colonies

The assay is performed on carbapentible 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.

The identification of a blawy, blayin metallo-beta-lactamase gene (i.e., the genes that encode the INP, NDM, and VIM metallo-beta-lactamases, respectively) may be used as an aid to clinicians in determining appropriate therapeutic strategies for patients with known or suspected carbapenem-non- susceptible bacterial infections.

Rectal and Perirectal 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.

The Xpert Carba-R Assay, when performed on rectal and perirectal swab specimens, is not intended to guide or monitor treatment for carbapenem-non-susceptible bacterial infections or to determine infection from carbapenem-nonsusceptible bacteria.

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)

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3

8.0 510(k) Summary

As required by 21 CFR Section 807.92(c).

| Submitted by: | Cepheid
904 Caribbean Drive
Sunnyvale, CA 90489
Phone number: (408) 745-4183
Fax number: (408) 744-1479 |
|--------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Contact: | Jim Kelly, Ph.D. |
| Date of Preparation: | January 04, 2018 |
| Device: | |
| Trade name: | Xpert® Carba-R |
| Common name: | Xpert Carba-R Assay |
| Type of Test: | Qualitative nucleic acid amplification test of the blaKPC
blaNDM, blaVIM, blaOXA-48, and blaIMP gene sequences
associated with carbapenem-non-susceptibility in gram-
negative bacteria obtained from rectal swab specimens,
perirectal swab specimens, and bacterial isolates |
| Classification:
Regulation number:
Classification name:
Product code: | II
866.1640
Antimicrobial susceptibility test powder
POC, OOI |
| Classification
Advisory Panel | Microbiology (83) |
| Prescription Use | Yes |
| Predicate Device
Assay: | Cepheid Xpert® Carba-R
[510(k) #K160901] |

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 blakpo, blaymy, blavny, blaoxa-as, and blamp gene sequences from rectal or perirectal swab specimens or isolates of pure cultures of carbapenem-non-susceptibility gram-negative bacteria. The Xpert Carba-R Assay is intended as an aid for infection control for monitoring the spread of carbapenem-non-susceptible 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 blaxpy blayDM blaym, blacks, and blandp 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 blakpc, blaNDM, blagxA-48 and blamp gene sequences from rectal or perirectal swab specimens or isolates of pure cultures of carbapenem-non- susceptibility gram-negative bacteria 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 real-time 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 or perirectal swab specimens or bacterial isolates from culture 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 blakers, blayDM blaym, blacks, and blamp 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 blaker, blaNDM, blaoxs-48, and blaMp gene sequences associated with carbapenemnon-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. 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:

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.

The identification of a blanp, blaNDM, or blaviM metallo-beta-lactamase gene (i.e., the genes that encode the IMP, NDM, and VIM metallo-beta-lactamases, respectively) may be used as an aid to clinicians in determining appropriate therapeutic strategies for patients with known or suspected carbapenem-non- susceptible bacterial infections.

Rectal and Perirectal Swab Specimens

The assay is performed on rectal and perirectal 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.

The Xpert Carba-R Assay, when performed on rectal and perirectal swab specimens, is not intended to guide or monitor treatment for carbapenem-non-susceptible bacterial infections or to determine infection from carbapenem-non-susceptible bacteria.

Substantial Equivalence:

The Cepheid Xpert Carba-R Assay is substantially equivalent to the Xpert® Carba-R Assay, 510(k) #K160901. Both assays utilize the same GeneXpert cartridge and detect target gene sequences 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 and in a second separate clinical study using rectal and perirectal swab specimens to demonstrate the equivalency of both sample types. 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 K160901 for information on the

6

performance of the Xpert Carba-R Assay with rectal swab specimens.

Table 8-1 shows the similarities and differences between the Xpert Carba-R Assay and the predicate device.

Similarities
Item	Device	Predicate Device
	Cepheid Xpert Carba-R Assay	Cepheid Xpert Carba-R Assay
K160901
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. A
negative Xpert Carba-R Assay result
does not preclude the presence of other
resistance mechanisms.	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:

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.

The identification of a blaIMP blaNDM
or blaVIM metallo-beta-lactamase gene
(i.e., the genes that encode the IMP,
NDM, and VIM metallo-beta- | The Xpert Carba R-Assay is for use with
the following sample types:

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. |
| Similarities | | |
| Item | Device | Predicate Device |
| | Cepheid Xpert Carba-R Assay | Cepheid Xpert Carba-R Assay
K160901 |
| | as an aid to clinicians in determining
appropriate therapeutic strategies for
patients with known or suspected
carbapenem-non- susceptible bacterial
infections. | |
| | Rectal and Perirectal Swab Specimens
The assay is performed on rectal and
perirectal 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.
The Xpert Carba-R Assay, when
performed on rectal and perirectal swab
specimens, is not intended to guide or
monitor treatment for carbapenem-non-
susceptible bacterial infections or to
determine infection from carbapenem-
non-susceptible bacteria. | 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. |
| Type of test | Same | Qualitative |
| Technological
Principles | Same | Fully-automated nucleic acid
amplification (DNA); real-time
PCR |
| Test Cartridge | Same | Disposable single-use, multi-chambered
fluidic cartridge |
| Probes | Same | TaqMan® Probes |
| Controls | Same | Internal sample processing
control (SPC) and probe
check control (PCC)
External controls available |
| Instrument System | Same | GeneXpert Instrument System
(includes GeneXpert Dx, Infinity-48,
Infinity-48s, and Infinity-80) |
| Time to obtain test
results | Same | Approximately 50 minutes to results |
| Interpretation of test
results | Same | Diagnostic software of the GeneXpert
Instrument System |
| Similarities | | |
| Item | Device | Predicate Device |
| Laboratory Users | Same | Operators in CLIA Moderate or High
Complexity labs |
| Differences | | |
| Item | New Device | Predicate Device |
| Sample Types | Bacterial isolates from culture, rectal
swab and perirectal swab specimens | Bacterial isolates from culture and
rectal swab specimens |
| | Cepheid Xpert Carba-R Assay | Cepheid Xpert Carba-R Assay
K160901 |

Table 8-1: Comparison of Similarities and Differences of the Xpert Carba-R Assay with the Predicate Device

7

8

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.

Non-Clinical Studies:

Analytical Sensitivity (Limit of Detection) -Perirectal Swabs

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 perirectal 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 perirectal 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 carbapenemase-producing 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 perirectal swab matrix are shown in Table 8-2.

9

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	90	118	118	24	19/20
IMP-1 Klebsiella pneumoniae	269	635	635	127	20/20
VIM-1 Klebsiella pneumoniae	901	514	901	180	20/20
VIM-4 Escherichia coli	446	403	446	89	20/20
NDM-1 Klebsiella pneumoniae ATCC BAA-2146	133	113	133	27	20/20
NDM Klebsiella pneumoniae	56	54	56	11	20/20
KPC-3 Klebsiella pneumoniae NCTC 13438	358	292	358	72	20/20
KPC Enterobacter cloacae	1259	1303	1303	261	20/20
OXA-48 Enterobacter cloacae	223	166	223	45	20/20
OXA-48 Escherichia coli	126	137	137	27	20/20

Table 8-2: LoD Estimates and Verification for Organisms Harboring anenemase Genes using the Xpert Carba-R Assay in Perirectal Swah Matriy

Analytical Reactivity (Inclusivity)

The analytical reactivity of the Xpert Carba-R Assay with perirectal swab matrices was evaluated by testing a panel of 72 samples. This panel consisted of 11 blakec (KPC), 11 blavm (VIM), 8 blaoxa-48 (OXA-48), 5 blayDM/blaoxA-181 (NDM/OXA-181), 6 blaoxA-181(OXA-181), 17 blamp (IMP), and one blaxpc/blavIM (KPC/VIM) well-characterized bacterial strains. The strains tested in perirectal swab matrix and their test concentrations are presented in Table 8-3.

For testing in perirectal swab matrix, organisms were seeded into pooled negative perirectal swab matrix. All bacterial strains were tested in triplicate at approximately 3X LoD. Xpert Carba-R Assay target genes were detected in 69 of 72 carbapenemaseproducing bacterial strains although IMP-4 was detected only using a higher concentration (Table 8-3). Xpert Carba-R Assay target DNA sequences were not detected in three bacterial strains as shown in Table 8-3. 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 8-4.

10

Strain ID	Organism	Resistance Marker with Variant Information	Concentration Tested in Perirectal 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
Coll	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
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
15	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
Strain ID	Organism	Resistance
Marker with
Variant
Information	Concentration
Tested in
Perirectal Swab
Matrix
(CFU/mL)
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
CDC0161	Enterobacter aerogenes a	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 8-3: Analytical Reactivity of the Xpert Carba-R Assay in Perirectal Swab Matrix

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).

12

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).

| Marker

(or Traditional Subgroup)	No. of Samples	Wet testing		Not tested but predicted to be detected Based on In Silico Analysis
		Type(s) Detected	Type(s) not Detected
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

Table 8-4: Summary of Variants Detected by Wet Testing or Predicted to be
Detected Based on In Silico Analysis

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 organisms seeded into perirectal swab matrix. A panel of 62 well-characterized bacterial strains of carbapenem-susceptible bacteria or bacteria with carbapenem non-susceptibility due to genes or mechanisms other than the Xpert Carba-R target genes (Table 8-5 and Table 8-6) and 24 commensal bacterial strains and other enteric microorganisms were also evaluated in the study (Table 8-7). Human cells were also tested in perirectal swab matrix (Table 8-8). Resistance mechanisms were determined by individual PCR assays, DNA sequence analysis, or Check-Points array version CT102.

For perirectal swab matrix samples, 62 strains were tested at concentrations >1 x 100 CFU/mL with the exception of Peptostreptococcus anaerobius that was tested at 5 x105 CFU/mL. Viruses were tested at >1 x 105 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 perirectal 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 8-5, Table 8-6, and Table 8-7). The analytical specificity of the assay was 100%.

13

each Allubloutic
	Ertapenem	Imipenem
Meropenem
Susceptible	19	30	24
Intermediate		8	ਪ
Resistant	43	24	34

Table 8-5: Number of Carbapenem-susceptible and Non-susceptible Organisms for each Antibiotic

| Organism Mechanisms susceptibility (S/I/R)a | |---------------------- | | Escherichia coli | Klebsiella pneumoniae | Enterobacter aerogenes | Citrobacter freundii | Enterobacter cloacae | Klebsiella pneumoniae | Klebsiella pneumoniae | Escherichia coli | Escherichia coli | Enterobacter cloacae | Serratia marcescens | Morganella morganii | Proteus mirabilis | Salmonella spp. | Shigella flexnerii | Enterobacter cloacae | Klebsiella pneumoniae | Klebsiella pneumoniae | Klebsiella pneumoniae TEM | R | Klebsiella pneumoniae | Klebsiella pneumoniae | Klebsiella pneumoniae | Klebsiella pneumoniae | susceptibility (S/I/R)a | Organism | Klebsiella pneumoniae | Klebsiella pneumoniae | Klebsiella pneumoniae | Enterobacter cloacae | Enterobacter aerogenes | Enterobacter aerogenes | Escherichia coli | Enterobacter aerogenes | Klebsiella pneumoniae | Klebsiella pneumoniae | Enterobacter cloacae | Enterobacter amnigenus | Klebsiella pneumoniae | Klebsiella pneumoniae (WT+238S); TEM | R | Enterobacter cloacae | Klebsiella pneumoniae | Escherichia coli | Providencia stuartii | Enterobacter cloacae | Escherichia coli | Klebsiella pneumoniae | Klebsiella pneumoniae | Enterobacter cloacae | Escherichia coli | Enterobacter cloacae | Enterobacter cloacae | Klebsiella pneumoniae | Klebsiella pneumoniae | Klebsiella pneumoniae | Pseudomonas aeruginosa | Organism Mechanisms susceptibility (S/I/R)a | | | Serratia marcescens | Serratia marcescens | Serratia marcescens | Serratia marcescens | Serratia marcescens | Serratia marcescens | Serratia marcescens | Enterobacter cloacae
group | CDC0132 | Enterobacter cloacae
complex | CDC0164 | Strain ID | Confirmed Resistance
| Carbapenem
| |
-----------|----------------------|-------------------------------------------------|---------------------------------------|------|------|
| | | ETPa | IMPa | MEMa |
| NCTC 13441 | CTX-M (-1, -type 15 like); TEM | S | S | S |
| NCTC 13465 | CTX-M (25) | S | S | S |
| 810 | OmpC/OmpF deficient; TEM | 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 |
| eco1 | 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 |
| 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 like); SHV | S | S | S |
| 32598 | CTX-M (-1, -type 15 like); SHV;
| I | R |
| 33560 | CTX-M (15); SHV-11; TEM-1 | S | S | S |
| 33603 | SHV-2 | R | I | R |
| 33617 | SHV-27 | S | S | S |
| 33643 | SHV (-5, -55); TEM | S | S | S |
| Confirmed Resistance | Carbapenem
| | | |
| Strain ID | Mechanisms | ETPa | IMPa | MEMa |
| 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; TEM | 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 +240K) | R | R | R |
| B13A | SHV (WT + 238S +240K) | R | S | S |
| RI_474 | AmpC (ACT/MIR) | R | I | I |
| B71 | AmpC (ACT/MIR) | R | R | R |
| DD82A | SHV (WT + 238S + 240K) | R | S | R |
| B100 | CTX-M (-1, type-15 like); SHV
| 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 |
| B198B | CTX-M (-1, type -15 like); TEM | R | S | R |
| T3019989-1 | CTX-M (-1, type-15 like); SHV | R | I | R |
| T3019989-2 | CTX-M (-1, type-15 like); SHV | 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); SHV; TEM. | R | I | R |
| X2135758 | CTX-M (-1, -15 like); SHV | R | S | S |
| W3809535 | CTX-M (-1, -15 like); SHV | R | R | R |
| CDC0064 | SPM | R | R | R |
| Strain ID | Confirmed Resistance
| Carbapenem
| |
| | | ETPa | IMPa | MEMa |
| 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 |
| IMI | R | R | R |
| IMI | R | R | R |

Table 8-6: Cross-reactivity Panel

Xpert Carba-R 510(k)

14

15

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 |
| ATCC 9689 | Clostridium difficilea | 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 anaerobiusa | 5.00E+05 |
| CCUG 29780 / ATCC 12401 | Streptococcus agalactiae | 5.21E+06 |
| ATCC 15703 | Bifidobacterium adolescentisa | 1.10E+08 |
| ATCC 51697 | Enterobacter aerogenes | 3.19E+06 |

Table 8-7: Cross-reactivity Panel (Commensal and Other Enteric Microorganisms)

16

| Strain ID | Organism | Concentration Tested
(CFU/mL unless otherwise
specified) |
|---------------------------|-----------------------------|----------------------------------------------------------------|
| 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 jejunia | 3.27E+06 |
| MRVP/ZeptoMetrix | Adenovirus B Type 7A/NYa | 1.40E+05 TCID50/mL |
| MRVP/ZeptoMetrix | Enterovirus Type 71/NYa | 4.40E+05 TCID50/mL |
| Clinical Sample - Cepheid | Norovirus GIIa | 2.5 x 107 RNA copies/mL |

a. These organisms were tested in perirectal swab matrix only.

Table 8-8: 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 titer samples were formulated at concentrations of 5 x 10° CFU/swab and low titer targets were formulated at approximately 2X LoD for the respective strain in perirectal swab matrix. One carbapenemase-producing bacterial strain for each gene analyte, i.e., the genes encoding KPC, NDM, VIM, OXA-48, and IMP, was used in this study. Each carbapenemase-producing 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 8-9). Samples were tested in replicates of eight.

An inhibitory effect was observed for two of the five targets (NDM and IMP) 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 perirectal swab matrix. The two targets (NDM and IMP) were tested at a higher concentration (4X LoD) in combination with a high concentration of one or two other targets for samples in perirectal swab matrix. No inhibitory effect was observed for the two targets (NDM and IMP) 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 (NDM, IMP, VIM and OXA-48) is addressed in the Limitations section in the package insert.

17

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

Table 8-9: Combinations of Carbapenemase-producing Bacteria Tested with the Xpert Carba-R Assav

Potentially Interfering Substances

The performance of the Xpert Carba-R Assay was evaluated with 24 potentially interfering substances that may be present in perirectal swab specimens. Potentially interfering substances (IS) solutions were prepared and tested at concentrations specified in

18

Table 8-10. Positive and negative samples were included in this study. Positive samples consisted of a mix of five carbapemase-producing organisms harboring KPC, NDM, VIM, IMP-1 and OXA-48 gene sequences seeded into pooled negative perirectal swab matrix at approximately 3X LoD. Eight replicate positive samples were tested per substance. Negative samples consisted of pooled negative perirectal swab matrix not seeded with carbapenemase-producing organisms. Eight replicate negative samples were tested per substance to determine the effect on the 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 > 0.025% w/v in tests with perirectal swab matrix samples. See Limitations in the package insert.

19

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
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

	Table 8-10: Potentially Interfering Substances Tested

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.

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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 perirectal 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 perirectal 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 -Perirectal Swab Specimens

Performance characteristics of the Xpert Carba-R Assay perirectal 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/bidirectional DNA sequence analysis.

Five geographically diverse sites prospectively collected paired perirectal swab specimens from subjects who were hospitalized or in a long-term care facility. Highly soiled perirectal swab specimens, according to the directions in Section 9 of package insert (Sample Preparation and Storage) 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.

One swab of the pair was used for Xpert Carba-R Assay testing. The second swab was inoculated into MacConkey enrichment broth and used for reference method testing. A reference culture laboratory determined the presence of carbapenem non-susceptible organisms by culturing the MacConkey enrichment broth from each of the specimens. The MacConkey 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 gram-negative bacteria around the meropenem disk, confirmation of carbapenem non-susceptibility 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 carbapem non-susceptible isolates was purified, quantified, and amplified using primers specific to all five 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).

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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 963 prospective perirectal swab specimens were initially enrolled in this clinical study, of which 947 were eligible for inclusion. From the 947 eligible specimens, 924 specimens were included in the final dataset after exclusions based on protocol deviations (including 10 Stenotrophomonas maltophilia, one Pseudomonas putida and one Pseudomonas stutzeri organisms that were excluded due to their intrinsic resistance to the carbapenems tested).

When tested with prospective perirectal swab specimens, the Xpert Carba-R Assay demonstrated a PPA of 100% for the three assay targets (blayDM, blagge and blaoxA-48) relative to the reference method. The NPA for the blakpc, blaNDM, blaoxA-48, and blaIMP gene sequences ranged from 99.6% to 100% relative to the reference method (Table 8-11).

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 8-11.

Specimen Type	Target	N	TP	FP	TN	FN	PPA	NPA
							(95% CI)	(95% CI)
Perirectalc	IMP	924	0	0	924	0	N/A	100%
(99.6-100)
	VIM	924	0	0	924	0	N/A	100%
(99.6-100)
	NDM	924	1	0	923	0	100%
(20.7-100)	100%
(99.6-100)
	KPC	924	2	4a	918	0	100%
(34.2-100)	99.6%
(98.9-99.8)
	OXA-48	924	1	1b	922	0	100%
(20.7-100)	99.9%
(99.4-100)

Table 8-11: Xpert Carba-R Performance vs. Reference Culture + Sequencing -Prospective Perirectal Specimens

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

a. Testing results by sequencing: 4 of 4 were KPC negative.

b. Testing results by sequencing: 1 of 1 was OXA-48 negative.

c. Of the 924 prospective perirectal swab specimens evaluated in the study, 891 specimens did not yield a culture isolate. From the remaining 33 specimens, 31 carbapenem-non-susceptible organisms were recovered by the Reference Culture in addition to two carbapenem susceptible organisms (Pseudomonas aeruginosa).

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Performance of the Xpert Carba-R Assay on the prospective perirectal specimens is shown in Table 8-12 by species. Only organisms for which at least one positive specimen was collected are included in Table 8-12.

| Speciesa | Target | N | TP | FP | TN | FN | PPA
(95% CI) | NPA
(95% CI) |
|-----------------------------------|--------|---|----|----|----|----|---------------------|--------------------|
| Enterobacter
aerogenes | IMP | 1 | 0 | 0 | 1 | 0 | NA | 100%
(20.7-100) |
| | VIM | 1 | 0 | 0 | 1 | 0 | NA | 100%
(20.7-100) |
| | NDM | 1 | 0 | 0 | 1 | 0 | NA | 100%
(20.7-100) |
| | KPC | 1 | 1 | 0 | 0 | 0 | 100%
(20.7-100) | NA |
| | OXA-48 | 1 | 0 | 0 | 1 | 0 | NA | 100%
(20.7-100) |
| Klebsiella
pneumoniae | IMP | 3 | 0 | 0 | 3 | 0 | NA | 100%
(43.9-100) |
| | VIM | 3 | 0 | 0 | 3 | 0 | NA | 100%
(43.9-100) |
| | NDM | 3 | 1 | 0 | 2 | 0 | 100%
(20.7-100) | 100%
(34.2-100) |
| | KPC | 3 | 1 | 0 | 2 | 0 | 100%
(20.7-100) | 100%
(34.2-100) |
| | OXA-48 | 3 | 1 | 0 | 2 | 1 | 96.2%
(20.7-100) | 100%
(34.2-100) |

Table 8-12. Xpert Carba-R Performance vs. Reference Culture + Sequencing by Organism type - Prospective Perirectal Snecimens

a. Acinetobacter baumannii (1), and Pseudomonas aeruginosa (28) were recovered but did not contain target sequences by the Reference Method.

Multiple targets were detected by the Xpert Carba-R Assay in one prospective specimen. The details are provided in Table 8-13, along with the discrepant sequencing result.

Table 8-13. Prospective Perirectal 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 |
|----------|-----------------------------------------------|---------------------------------------------------|-----------------------------------------------------------------------------|
| g | NDM, OXA-48 | NDM, OXA-48 | NA |

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

A total of 432 contrived specimens prepared in perirectal 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).

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When tested with contrived specimens, the Xpert Carba-R Assay demonstrated a PPA and NPA of 100% for the blakpc, blaNDM, blayM, blagxA-48, and blaIMP gene sequences was 100% relative to the reference method (Table 8-14).

Specimens
Matrix	Target	N	TP	FP	TN	FN	PPA
(95% CI)	NPA
(95% CI)
Perirectal	IMP	432	80	0	352	0	100%
(95.4-100)	100%
(98.9-100)
	VIM	432	82	0	350	0	100%
(95.5-100)	100%
(98.9-100)
	NDM	432	80	0	352	0	100%
(95.4-100)	100%
(98.9-100)
	KPC	432	80	0	352	0	100%
(95.4-100)	100%
(98.9-100)
	OXA-48	432	80	0	352	0	100%
(95.4-100)	100%
(98.9-100)

Table 8-14. Xpert Carba-R Performance vs. Reference Method - Contrived Snecimens

Perirectal Swab and Rectal Swab Equivalence Study

To demonstrate equivalence of perirectal swab specimens and rectal swab specimens, a study was conducted at one site enrolling fresh prospectively collected rectal and perirectal swab specimens from consented subjects who were hospitalized in-patients.

Paired swab sets provided in the Cepheid Specimen Collection Device were used to collect specimens from each subject. One paired swab set was used to collect the perirectal swab specimen and a second paired swab set was used to collect the rectal swab specimen. The perirectal swab specimen was collected first followed by the rectal swab specimen from the same subject. One swab from each paired swab set was used for Xpert Carba-R Assay testing. The second swab from each paired swab set was used for culture and susceptibility testing when either or both the perirectal or rectal swab specimen(s) were positive for one or more target(s) by the Xpert Carba-R Assay. No culture was performed if perirectal and rectal swab specimens were both negative by the Xpert assay.

Bi-directional DNA sequencing was performed on DNA extracted from isolated colonies that manifested carbapenem-non-susceptibility by the CLSI disk diffusion method or from MacConkey broth with meropenem disk if the culture result was negative and the Xpert Carba-R Assay result was positive.

A total of 207 specimens were initially enrolled in this clinical study, all of which were eligible for inclusion. Of the 207 eligible specimens were included in the final dataset used for the analyses. Six swab specimens (4 perirectal swab specimens and 2 rectal swab specimens) were excluded due to indeterminate results from the Xpert Carba-R Assay.

Of the 201 specimens included in the data analyses, 92 (45.8%) were collected from female subjects and 109 (54.2%) from male subjects. Overall 45.8% (92/201) specimens were collected from subjects between 21 and 65 years of age and 54.2%

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(109/201) were from subjects >65 years of age.

The performance (PPA and NPA) of the Xpert Carba-R Assay using perirectal swab specimens was determined relative to the results of the Xpert Carba-R Assay using rectal swab specimens from the same subject. The PPA and NPA estimates are shown in

Table 8-15. Relative to the Xpert Carba-R Assay rectal swab specimen result, the perirectal swab specimens demonstrated an overall PPA and NPA of 94.7% (95%CI: 75.4-99.1) and 97.8% (95%CI: 94.5-99.1), respectively.

Table 8-15. Xpert Carba-R Assay – Perirectal Swab Specimens vs Rectal Swab
Specimens

Xpert Carba-R Assay – Rectal Swab Specimens
		Positive	Negative	Total
Xpert Carba-R Assay –
Perirectal Swab
Specimens	Pos	18a	4b	22
	Neg	1c	178	179
	Total	19	182	201
	PPA		94.7% (95%CI: 75.4-99.1)
	NPA		97.8% (95%CI: 94.5-99.1)

4 For one specimen, Xpert testing on the rectal swab was positive for KPC and OXA-48 and on the perirectal swab was positive for OXA-48 only. The specimen was culture negative for both rectal and perirectal swabs. Sequence results from the MacConkey broths were negative for the perirectal swab and OXA-48 positive for the rectal swab.

b 2 of 4 were culture positive for both rectal and perirectal swabs, sequence results from isolates were both OXA-48 positive, 1 of 4 was culture negative for both rectal and perirectal swabs, sequence result the rectal sequence result was not available due to isolate not saved, the perirectal isolate was interpreted as carbapenem susceptible and per protocol sequencing was not required.

Culture negative for both rectal and perirectal swabs, sequence results from MacConkey broths were both OXA-48 Positive.

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Reproducibility Study

Reproducibility of the Xpert Carba-R Assay was evaluated using of a panel of 11 samples, prepared in pooled negative perirectal 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 8-16.

Matrix
Sample		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		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		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		95.8%
(23/24)	91.7%
(22/24)	93.8%
(45/48)	100%
(24/24)	100%
(24/24)	100%
(48/48)	100%
(24/24)	91.7%
(22/24)	95.8%
(46/48)	96.5%
(139/144)
VIM
Mod Pos		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		100%
(24/24)	91.7%
(22/24)	95.8%
(46/48)	91.7%
(22/24)	91.7%
(22/24)	91.7%
(44/48)	95.8%
(23/24)	83.3%
(20/24)	89.6%
(43/48)	92.4%
(133/144)
NDM
Mod Pos		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		100%
(24/24)	100%
(24/24)	100%
(48/48)	100%
(24/24)	100%
(24/24)	100%
(48/48)	87.5%
(21/24)	100%
(24/24)	93.8%
(45/48)	97.9%
(141/144)
KPC
Mod Pos		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		91.7%
(22/24)	91.7%
(22/24)	91.7%
(44/48)	91.7%
(22/24)	95.8%
(23/24)	93.8%
(45/48)	100%
(24/24)	91.7%
(22/24)	95.8%
(46/48)	93.8%
(135/144)
OXA-48
Mod Pos		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		87.5%
(21/24)	87.5%
(21/24)	87.5%
(42/48)	100%
(24/24)	95.8%
(23/24)	97.9%
(47/48)	95.8%
(23/24)	95.8%
(23/24)	95.8%
(46/48)	93.8%
(135/144)

Table 8-16: Summary of Reproducibility Results - % Agreement, Perirectal Swab
Matrix

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 8-17.

Table 8-17: Summary of Reproducibility Data for Perirectal Swab Matrix

| Sample | Assay
Channel
(Analyte) | Na | Mean
Ct | Between
Site | | Between
Lot | | Between
Day | | Between-
Operator | | Within-Assay | | Total | |
|----------------|-------------------------------|-----|------------|-----------------|-----------|----------------|-----------|----------------|-----------|----------------------|-----------|--------------|-----------|-------|-----------|
| | | | | SD | CV
(%) | SD | CV
(%) | SD | CV
(%) | SD | CV
(%) | SD | CV
(%) | SD | CV
(%) |
| Neg | SPC | 144 | 32.7 | 0.0 | 0.0 | 0.2 | 0.6 | 0.0 | 0.0 | 0.2 | 0.5 | 0.4 | 1.2 | 0.5 | 1.4 |
| IMP
Mod Pos | IMP | 144 | 33.7 | 0.0 | 0.0 | 0.1 | 0.2 | 0.0 | 0.0 | 0.2 | 0.5 | 0.5 | 1.5 | 0.5 | 1.6 |
| IMP
Low Pos | IMP | 142 | 36.0 | 0.2 | 0.5 | 0.0 | 0.0 | 0.1 | 0.3 | 0.2 | 0.5 | 0.8 | 2.1 | 0.8 | 2.3 |

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| Sample | Assay | | Mean | Between
Site | | Between
Lot | | Between
Day | | Between-
Operator | | Within-Assay | | Total | |
|-------------------|----------------------|-----|------|-----------------|-----------|----------------|-----------|----------------|-----------|----------------------|-----------|--------------|-----------|-------|-----------|
| | Channel
(Analyte) | Na | Ct | SD | CV
(%) | SD | CV
(%) | SD | CV
(%) | SD | CV
(%) | SD | CV
(%) | SD | CV
(%) |
| VIM
Mod Pos | VIM | 144 | 31.2 | 0.1 | 0.2 | 0.1 | 0.3 | 0.0 | 0.1 | 0.2 | 0.5 | 0.4 | 1.3 | 0.5 | 1.5 |
| VIM
Low Pos | VIM | 142 | 35.0 | 0.0 | 0.0 | 0.6 | 1.6 | 0.0 | 0.0 | 0.6 | 1.7 | 1.4 | 4.1 | 1.6 | 4.7 |
| NDM
Mod Pos | NDM | 144 | 33.2 | 0.0 | 0.0 | 0.0 | 0.0 | 0.2 | 0.5 | 0.2 | 0.5 | 0.4 | 1.2 | 0.5 | 1.4 |
| NDM
Low Pos | NDM | 143 | 35.7 | 0.2 | 0.5 | 0.0 | 0.0 | 0.2 | 0.6 | 0.0 | 0.0 | 0.9 | 2.4 | 0.9 | 2.5 |
| KPC
Mod Pos | KPC | 144 | 34.6 | 0.0 | 0.0 | 0.3 | 1.0 | 0.0 | 0.0 | 0.2 | 0.5 | 0.4 | 1.3 | 0.6 | 1.7 |
| KPC
Low Pos | KPC | 143 | 36.4 | 0.0 | 0.0 | 0.5 | 1.3 | 0.1 | 0.4 | 0.0 | 0.0 | 0.7 | 2.0 | 0.9 | 2.4 |
| OXA-48
Mod Pos | OXA-48 | 144 | 34.4 | 0.1 | 0.2 | 0.2 | 0.6 | 0.0 | 0.0 | 0.2 | 0.5 | 0.5 | 1.5 | 0.6 | 1.7 |
| OXA-48
Low Pos | OXA-48 | 144 | 36.4 | 0.0 | 0.0 | 0.0 | 0.0 | 0.4 | 1.2 | 0.0 | 0.0 | 1.0 | 2.7 | 1.1 | 2.9 |

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

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.