(307 days)
The ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test is an in vitro, rapid, lateral flow test, also known as a lateral flow immunochromatographic assay, intended for the qualitative detection of Streptococus pneumoniae and Legionella pneumophila antigens in urine specimens with symptoms of pneumonia. The assay is intended to aid in diagnosis of S. pneumoniae and L. pneumophila serogroup 1 infections. The assay is further intended to aid in the diagnosis of S. pneumoniae infection of S. pneumoniae antigen in cerebrospinal fluid (CSF). Results from the ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test should be interpreted in conjunction with the patient's clinical evaluation and other diagnostic methods.
ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test is a rapid lateral flow test for qualitative detection of S. pneumoniae in human urine and CSF samples and L. pneumophila (primarily serogroup 1) antigens in human urine samples. The test is effective in presumptive diagnosis of pneumococcal pneumonia caused by S. pneumoniae or Legionella pneumonia (Legionnaires' disease) caused by L. pneumophila, in conjunction with culture and other methods. Correct and early treatment is vital for the prognosis of both diseases and therefore quick methods to confirm both diseases in the initial phase are very important in order to initiate the proper antibiotic treatment as soon as possible.
This document describes the validation of the ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test, an in vitro lateral flow immunochromatographic assay.
1. Acceptance Criteria and Reported Device Performance
The acceptance criteria for the device are implicitly demonstrated by the reported sensitivities and specificities, and positive/negative percent agreements achieving certain levels across various studies (retrospective, prospective, analytical). While explicit numerical acceptance criteria are not stated in a dedicated table, the consistently high performance metrics across both S. pneumoniae and L. pneumophila detection in urine and CSF demonstrate the device's acceptable performance.
Here's a summary of the reported device performance, which serves as evidence of meeting implicit acceptance criteria:
Table 1: Summary of ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test Performance
| Parameter | Target Analyte | Sample Type | Study Type | Performance (ImmuView) | 95% Confidence Interval | Comparator Performance (if applicable) |
|---|---|---|---|---|---|---|
| Sensitivity (vs. Culture) | S. pneumoniae (Urine) | Urine | Retrospective | 78% (78/100) | (69.0-85.0%) / (67-85%) | 80% (76/95) |
| L. pneumophila (Urine) | Urine | Retrospective | 87.8% (86/98) | (79.8-92.9%) | ||
| L. pneumophila Sg 1 (U.S.) | Urine | Retrospective | 97.7% (42/43) | (88-100%) | 100% (43/43) | |
| L. pneumophila Sg 1 (Europe) | Urine | Retrospective | 80.0% (44/55) | (68-88%) | 66.7% (36/54) | |
| Specificity (vs. Culture) | S. pneumoniae (Urine) | Urine | Retrospective | 98.1% (217/221) | (95.4-99.3%) / (95-99%) | 97.8% (218/223) |
| L. pneumophila (Urine) | Urine | Retrospective | 99.6% (239/240) | (97.4-100.0%) | ||
| L. pneumophila (U.S.) | Urine | Retrospective | 100% (19/19) | (83-100%) | 100% (19/19) | |
| L. pneumophila (Europe) | Urine | Retrospective | 99.5% (220/221) | (97-100%) | 99.6% (223/224) | |
| Positive Percent Agreement | S. pneumoniae (Urine) | Urine | Prospective | 96.0% (72/75) | (88.9%-98.6%) | - |
| Negative Percent Agreement | S. pneumoniae (Urine) | Urine | Prospective | 97.4% (225/231) | (94.5%-98.8%) | - |
| Positive Percent Agreement | L. pneumophila SG1 (Urine) | Urine | Prospective | 100.0% (3/3) | (43.9%-100%) | - |
| Negative Percent Agreement | L. pneumophila SG1 (Urine) | Urine | Prospective | 100.0% (303/303) | (98.8%-100%) | - |
| Sensitivity (vs. Culture) | S. pneumoniae (CSF) | CSF | Clinical Study | 92.9% (13/14) | (68.5%-98.7%) | - |
| Specificity (vs. Culture) | S. pneumoniae (CSF) | CSF | Clinical Study | 96.0% (162/169) | (91.7%-98.0%) | - |
| Positive Percent Agreement | S. pneumoniae (Spiked CSF) | CSF | Spiked Study | 100% (50/50) | (92.9%-100%) | 100% (50/50) (Comparator) |
| Negative Percent Agreement | S. pneumoniae (Negative CSF) | CSF | Spiked Study | 100% (10/10) | (72.2%-100%) | 100% (10/10) (Comparator) |
| Reproducibility | Various positive/negative samples | Urine/CSF | Reproducibility | 99.6% (1068/1072 correct results) | - | - |
| Limit of Detection (LOD) | S. pneumoniae antigen | Urine | Analytical | 62.5 pg/mL | - | - |
| L. pneumophila SG1 (Philadelphia) antigen | Urine | Analytical | 25 ng/mL (0.025 µg/mL) | - | - | |
| S. pneumoniae (whole cell) | Urine | Analytical | 10^5^ CFU/mL | - | - | |
| L. pneumophila SG1 (whole cell) | Urine | Analytical | 10^4^ CFU/mL | - | - | |
| S. pneumoniae (whole cell) | CSF | Analytical | 10^3^ CFU/mL | - | - |
2. Sample Sizes and Data Provenance
-
Retrospective Study (Urine Samples):
- S. pneumoniae: 100 culture-positive urine samples (48 from Sweden, 52 from Denmark, all from blood culture positive patients). 221 known negative urine samples.
- L. pneumophila: 98 culture-confirmed urine samples (55 from Europe, 43 from the United States (US), these 43 were previously determined positive in a urinary antigen test). 240 known negative urine samples.
- Data Provenance: Retrospective, samples from Europe (Sweden, Denmark) and the United States.
-
Prospective Study (Urine Samples):
- Total Samples: 306 freshly collected urine samples (with 92 having to be frozen before testing due to practicalities).
- Data Provenance: Prospective, collected from two sites in Spain and Denmark. These were from "all comers" at risk of community-acquired pneumonia.
-
Clinical Study (CSF Samples):
- S. pneumoniae: 14 culture-positive CSF specimens (9 from US labs, 5 from European labs). 169 known negative CSF samples (113 from US labs, 56 from European labs).
- Data Provenance: Retrospective/Clinical, samples from US and Europe.
-
Spiked CSF Testing:
- S. pneumoniae: 50 human CSF samples spiked at the LOD. 10 additional unspiked negative CSF samples.
-
Analytical Studies (Cross-Reactivity, LOD, Interfering Substances, Strain Reactivity): Sample sizes vary by test and are described in the relevant sections (e.g., 143 samples for cross-reactivity with spiked bacteria/viruses in urine, 47 interfering agents tested).
3. Number of Experts and Qualifications for Ground Truth
The document does not explicitly state the number of experts or their specific qualifications (e.g., "radiologist with 10 years of experience") used to establish the ground truth. However, the ground truth for clinical studies (both retrospective and prospective) is defined as culture-confirmed results for S. pneumoniae and L. pneumophila infections, and "known negative" samples based on culture.
For the CSF study, patients were "suspected of meningitis," and the ground truth was also culture-confirmed S. pneumoniae.
Given that these are in vitro diagnostic tests, the "experts" in establishing ground truth would primarily be laboratory personnel performing culture confirmation, which is the gold standard for defining infection status.
4. Adjudication Method
The document does not describe any specific adjudication method (e.g., 2+1, 3+1 concensus) for establishing the ground truth for the test sets. The ground truth appears to be based on culture results, which typically do not require adjudication by multiple human interpreters in the same way imaging studies might.
For the reproducibility study, the reading and interpretation of the panels were performed visually by operators. Errors in reading (e.g., operator interpreted S. pneumoniae Band result as negative even though band was present) are mentioned, indicating potential for individual variability, but a formal adjudication process for disagreements is not explicitly stated beyond what happens when "invalid" results occur.
5. Multi-Reader Multi-Case (MRMC) Comparative Effectiveness Study
No multi-reader, multi-case (MRMC) comparative effectiveness study was performed or described. This device is an in vitro diagnostic (IVD) lateral flow assay, which is primarily a standalone test designed to provide a direct result, not an AI-assisted diagnostic tool for human readers. Therefore, there is no discussion of how human readers' performance might improve with AI assistance.
6. Standalone Performance
Yes, extensive standalone performance testing was done. The entire study described focuses on the "algorithm only" (i.e., the ImmuView test's intrinsic performance) without human-in-the-loop assistance for interpretation. The results in the tables for sensitivity, specificity, and agreement are all measures of the device's standalone performance against established ground truth (culture or comparator tests).
7. Type of Ground Truth Used
The primary type of ground truth used was culture confirmation for S. pneumoniae and L. pneumophila from urine and CSF samples.
- Urine Retrospective Study: Culture-positive urine samples (blood culture positive for S. pneumoniae, culture confirmed for L. pneumophila) and known negative (culture confirmed negative) urine samples.
- CSF Clinical Study: Culture-positive CSF specimens.
- Prospective Study: Comparison with other lateral flow urine antigen tests (Comparator) was used, implying the Comparator's results served as an indirect ground truth or reference in this specific study, although the retrospective studies relied on culture.
- Analytical Studies: Ground truth was based on known concentrations of purified antigens (pg/mL, ng/mL) or specific colony-forming units (CFU/mL) for LOD and strain reactivity, and known substances/organisms for cross-reactivity and interfering substances.
8. Sample Size for Training Set
The document does not explicitly mention a "training set" in the context of an algorithm or AI development. This product is a lateral flow immunoassay, a biochemical test, not a machine learning algorithm that undergoes a training phase. Therefore, the concept of a "training set" as it pertains to AI/ML models is not applicable here. The samples described were used for validation and performance evaluation.
9. How Ground Truth for Training Set Was Established
As explained under point 8, the product is a lateral flow immunoassay, not an AI/ML model. Therefore, there is no "training set" in the computational sense, and thus no ground truth establishment specific to a training set for an algorithm. All samples were used for validation and performance assessment, with ground truth established primarily by culture confirmation as described in point 7.
{0}------------------------------------------------
Image /page/0/Picture/0 description: The image contains the logo of the U.S. Food and Drug Administration (FDA). On the left is the Department of Health & Human Services logo. To the right of that is the FDA logo, which is a blue square with the letters "FDA" in white. To the right of the blue square is the text "U.S. FOOD & DRUG ADMINISTRATION" in blue.
March 5, 2020
SSI Diagnostica A/S % Christopher Bentsen Regulatory and Clinicals Consultant Bentsen Regulatory and Clinicals Consulting LLC 25803 NE 9th Street Redmond, Washington 98074
Re: K191184
Trade/Device Name: ImmuView S pneumoniae and L pneumophila Urinary Antigen Test Regulation Number: 21 CFR 866.3300 Regulation Name: Haemophilus Spp. Serological Reagents Regulatory Class: Class II Product Code: MJH, GTZ Dated: June 3, 2019 Received: June 10, 2019
Dear Christopher Bentsen:
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. Although this letter refers to your product as a device, please be aware that some cleared products may instead be combination products. The 510(k) Premarket Notification Database located at https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm identifies combination product submissions. 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
{1}------------------------------------------------
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) for devices or postmarketing safety reporting (21 CFR 4, Subpart B) for combination products (see https://www.fda.gov/combination-products/guidance-regulatory-information/postmarketing-safety-reportingcombination-products); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820) for devices or current good manufacturing practices (21 CFR 4, Subpart A) for combination products; and, if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.
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 https://www.fda.gov/medical-device-safety/medical-device-reportingmdr-how-report-medical-device-problems.
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/device-advice-comprehensive-regulatory-assistance) and CDRH Learn (https://www.fda.gov/training-and-continuing-education/cdrh-learn). 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 (https://www.fda.gov/medical-device-advice-comprehensive-regulatoryassistance/contact-us-division-industry-and-consumer-education-dice) for more information or contact DICE by email (DICE@fda.hhs.gov) or phone (1-800-638-2041 or 301-796-7100).
Sincerely,
Kristian Roth, Ph.D. Chief Bacterial Multiplex and Medical Counter Measures Branch Division of Microbiology Devices OHT7: Office of In Vitro Diagnostics and Radiological Health Office of Product Evaluation and Quality Center for Devices and Radiological Health
Enclosure
{2}------------------------------------------------
Indications for Use
510(k) Number (if known) K191184
Device Name
ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test
Indications for Use (Describe)
Intended use
The ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test is an in vitro, rapid, lateral flow test, also known as a lateral flow immunochromatographic assay, intended for the qualitative detection of Streptococus pneumoniae and Legionella pneumophila antigens in urine specimens with symptoms of pneumonia. The assay is intended to aid in diagnosis of S. pneumoniae and L. pneumophila serogroup 1 infections. The assay is further intended to aid in the diagnosis of S. pneumoniae infection of S. pneumoniae antigen in cerebrospinal fluid (CSF). Results from the ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test should be interpreted in conjunction with the patient's clinical evaluation and other diagnostic methods.
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) # | K191184 | 510(k) SUMMARY | Date of Preparation: March 4, 2020 |
|---|---|---|---|
| Submitter: | Christopher Bentsen, M.S., RAC, FRAPS; Bentsen Regulatory and Clinicals Consulting LLC. | ||
| Submitters Address: | Gig Harbor, Washington 98332 | ||
| Submitters Number: | (206) 910-1974 | ||
| Sponsor: | SSI Diagnostica A/S (SSID) | ||
| Contact: | Dr. Pernille Landsbo Elverdal, VP R&D | ||
| Contact Number: | 0045 4111 2731 | ||
| Device Name: | ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test | ||
| Common Name: | Urinary Antigen Test, Streptococcus pneumoniae and Legionella pneumophila serogroup 1 | ||
| Classification: | Streptococcus spp and Legionella spp serological reagents21 CFR 866.3740 and 866.3300 | ||
| Product Codes: | GTZ and MJH | ||
| Predicate Devices: | BinaxNOW® Streptococcus pneumoniae (K012521) and BinaxNOW® Legionella (K982238) |
Panel:
Microbiology
Intended Use:
The ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test is an in vitro, rapid, lateral flow test, also known as a lateral flow immunochromatographic assay, intended for the qualitative detection of Streptocccus pneumoniae and Legionella pneumophila antigens in urine specimens from patients with symptoms of pneumonia. The assay is intended to aid in diagnosis of S. pneumoniae and L. pneumophila serogroup 1 infections. The assay is further intended to aid in the diagnosis of S. pneumoniae infection of S. pneumoniae antigen in cerebrospinal fluid (CSF). Results from the ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test should be interpreted in conjunction with the patient's clinical evaluation and other diagnostic methods.
Indication(s) for use:
Same as Intended Use
Special conditions for use statement(s):
This device is for in vitro diagnostic use only. It is for prescription use only and to be used only by clinical laboratory professionals.
Special instrument requirements:
N/A
{4}------------------------------------------------
Device Description:
ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test is a rapid lateral flow test for qualitative detection of S. pneumoniae in human urine and CSF samples and L. pneumophila (primarily serogroup 1) antigens in human urine samples. The test is effective in presumptive diagnosis of pneumococcal pneumonia caused by S. pneumoniae or Legionella pneumonia (Legionnaires' disease) caused by L. pneumophila, in conjunction with culture and other methods. Correct and early treatment is vital for the prognosis of both diseases and therefore quick methods to confirm both diseases in the initial phase are very important in order to initiate the proper antibiotic treatment as soon as possible.
Substantial Equivalence Information:
-
- Predicate device names(s): BinaxNOW" Streptococcus pneumoniae Card and BinaxNOW" Legionella pneumophila Card
{5}------------------------------------------------
Table 1 Comparison with predicate:
| Description | ImmuView S. pneumoniae andL. pneumophila UrinaryAntigen Test | BinaxNOW® Streptococcuspneumoniae and BinaxNOW®Legionella Antigen Cards | |
|---|---|---|---|
| Test Format | Rapidimmunochromatographiclateral flow test | Rapid immunochromatographiccard tests | |
| Quantitative/Quantitative | Qualitative | Qualitative | |
| Test Antigen | Streptococcus pneumoniaeand Legionella pneumophilaserogroup 1 | Streptococcus pneumoniae orLegionella pneumophilaserogroup 1 | |
| Specimen Types | Human CSF and human urine | Human CSF and human urine | |
| Reagents/Components | Test StripsTest TubesSample Running BufferNegative ControlPositive ControlPlastic transfer pipettesTweezerCardboard test tube holder | Test CardsReagent APositive Control SwabNegative Control SwabSwabs | |
| Antibody Sources | |||
| Test Card | Rabbit Polyclonal antibodies | Rabbit Polyclonal antibodies | |
| Conjugate | Rabbit Polyclonal antibodies | Rabbit Polyclonal antibodies | |
| Sample Preparation | |||
| Unpreserved andpreserved urine | Add 3 (120 ul) drops of urineor add 10 ul of CSF to a testtubeAdd 2 (90 ul) drops of samplerunning diluentMix wellAdd test strip with arrowdown | 1. Dip swab into the urine sampleand then insert swab into thebottom hole of the Test Card.2. Add 2 drops of Reagent A tothe bottom hole for LegionellaCard and 3 drops for S.pneumoniae Card. | |
| Testing Time | Approximately 15 minutes | Approximately 15 minutes | |
| Equipment | |||
| General LaboratoryEquipment | Urine collection containerTimerVortex or mix by swirlingDisposable gloves | Urine collection containerTimerSwab packDisposable gloves | |
| Reading Method | Visual | Visual | |
| Results Interpretation | |||
| Visual Read | Negative: A single purple/grayControl line in the top of thestrip.Positive: For both S. pn. and L.pn. S-1 will show a pink/redline and a blue line.For S. pn. will show a pink/redline.For L. pn. S-1 will show a blueline | Negative: Single pink to purplecolored Control line visible in tophalf of the windowPositive: Two pink to purple lines | |
| Invalid: No line at the Control line position and if there is adot instead of a test line.Also, if gray lines appear.Follow IFU instructions | Invalid: No line at the Control line position or no lines at the Control and Sample line positions. | Test |
{6}------------------------------------------------
{7}------------------------------------------------
Principle:
ImmuView® S. pneumoniae and L. pneumophila Urinary Antigen Test is a rapid lateral flow test for detection of S. pneumoniae and L. pneumophila using the same test.
Clinical Sensitivity and Specificity for Urine Samples (Retrospective study)
To determine the sensitivity of the ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test, 100 frozen urine samples from patients originally determined to be infected with S. pneumoniae were tested. All 100 urine samples came from Europe, and all were from blood culture positive patients; Fortyeight (48) samples were from Sweden3 and fifty-two (52) samples were from Denmark.
To determine the sensitivity of the ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test, 98 stored frozen urine samples from patients with a culture confirmed Legionella infection were tested. A total of 55 urine samples came from Europe. The remaining 43 urine samples came from the United States (U.S.), and these were also determined to be previously positive in a urinary antigen test.
The clinical specificity of the ImmuView S. pneumoniae and L. pneumophila test lines was obtained by testing known negative (culture confirmed negative) urine samples collected from 3 sites, one in the U.S. and two in Europe.
| S. pneumoniae culture verified vs. ImmuView | ||
|---|---|---|
| Culture positive | Culture negative | |
| ImmuView pos | 78 | 4 |
| ImmuView neg | 22 | 217 |
| Total | 100 | 221 |
| ImmuView Sensitivity | 78% | 95%CI (69.0-85.0%) |
| ImmuView Specificity | 98.1% | 95%CI (95.4-99.3%) |
| L. pneumophila culture verified vs. ImmuView | ||
| Culture positive | Culture negative | |
| ImmuView pos | 86 | 1 |
| ImmuView neg | 12 | 239 |
| Total | 98 | 240 |
| ImmuView Sensitivity | 87.8% | 95%CI (79.8-92.9%) |
Table 1
{8}------------------------------------------------
Table 3
| ImmuView | Comparator | |
|---|---|---|
| Sensitivity (Urine) Based on culture vs comparator | ||
| S. pneumoniae(Blood culture only) | 78% (78/100)(CI 67-85%) | 80% (76/95a)(CI 71-87%) |
| L. pneumophila Sg 1(U.S.) | 97.7% (42/43)(CI 88-100%) | 100% (43/43)(CI 92-100%) |
| L. pneumophila Sg 1(Europe) | 80.0% (44/55)(CI 68-88%) | 66.7% (36/54b)(CI 53-78%) |
| Specificity (Urine) Based on culture vs comparator | ||
| S. pneumoniae(Europe) | 98.2% (217/221c)(CI 95-99%) | 97.8% (218/223)(CI 95-99%) |
| L. pneumophila(U.S.) | 100% (19/19)(CI 83-100%) | 100% (19/19)(CI 83-100%) |
| L. pneumophila(Europe) | 99.5% (220/221d)(CI 97-100%) | 99.6% (223/224)(CI 98-100%) |
ª 5 samples were QNS for testing, º 1 sample was QNS for testing, º 3 samples were QNS for testing, º 3 samples were QNS for testing
S. pneumoniae sensitivity (Europe) increased to 81/100 or 81% for ImmuView S. pneumoniae and L. pneumophila urinary antigen test compared with comparator that after boiling had 76/95 or 80%. L. pneumophila sensitivity (Europe) changed to 41/55 or 74.6% for ImmuView and remained 36/54 or 66.7% for the comparator. The specificity (Europe) increased to 98.6% (218/221) and 100% (221/221) for S. pneumoniae and L. pneumophila respectively after boiling when using ImmuView. The comparator did not change after boiling. L. pneumophila sensitivity (U.S.) increased to 43/43 or 100% (95%Cl 91.8-100%) in the ImmuView Test for L. pneumophila after boiling2-2. L. pneumophila specificity (U.S.) did not change after boiling for either test.
{9}------------------------------------------------
Positive and Negative Percent Agreement for urine samples
(Prospective study)
In a prospective study three-hundred-six (306) prospective collected urine samples from two different sites (Spain and Denmark) were tested with both the ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test and the Comparator tests. Fresh* urine samples were from patients (all comers) at risk of having community acquired pneumonia. The results were compared with other lateral flow urine antigen tests (Comparator).
| ableT4 |
|---|
| ---------------- |
| Prospective samples positive agreement S. pneumoniae | |||
|---|---|---|---|
| ImmuView | Comparator positive | Comparator negative | Total |
| Positive | 72 | 6 | 78 |
| Negative | 3 | 225 | 228 |
| Total | 75 | 231 | 306 |
| Positive percent agreement | 96.0% | 95% CI (88.9%-98.6%) | |
| Negative percent agreement | 97.4% | 95% CI (94.5%-98.8%) | |
| Prospective samples positive agreement L. pneumophila SG1 | |||
| ImmuView | Comparator positive | Comparator negative | Total |
| Positive | 3 | 0 | 3 |
| Negative | 0 | 303 | 303 |
| Total | 3 | 303 | 306 |
| Positive percent agreement | 100.0% | 95% CI (43.9%-100%) | |
| Negative percent agreement | 100.0% | 95% CI (98.8%-100%) |
- Of the 306 samples, a total of 92 had to be frozen before testing could be performed.
The positive agreement for S. pneumoniae was 72/75 or 96% (88.9-98.6%). The negative agreement for S. pneumoniae was 226/232 or 97.4% (94.5-98.8). The positive agreement for L. pneumophila was 3/3 or 100% (43.9-100%). Negative agreement for L. pneumophila was 304/304 or 100% (98.8-100%).
After boiling22 the positive and negative agreement for S. pneumoniae and L. pneumophila remained the same.
{10}------------------------------------------------
Analytical Studies - Urine
Specificity (Cross-Reactivity)
To determine the analytical specificity of the ImmuView S. pneumoniae and L. pneumophila Urinary Antigen test for cross-reactivity with urines spiked with whole cell bacteria and different inactivated viruses (N=143). The whole cell bacterial panel was tested in a 107 CFU/mL diluted from a stock solution. The Viral panel had a concentration of 105 TCID50/mL. The panel was also tested in negative urine.
| Organisms tested for interference | |
|---|---|
| Acinetobacter ssp.(4) | Lactobacillus sp. |
| Bacillus subtilis | Listeria monocytogenes |
| Bordetella pertussis | Morganella morganii |
| Moraxella catarrhalis | Moraxella osloensis |
| Candida albicans (4) | Mycoplasma genitalium |
| Citrobacter freundii | Neisseria gonorrhoeae (3) |
| Cornyebacterium sp. | Neisseria lactamica |
| Cornyebacterium uralyticum | Neisseria meningitidis |
| Enterobacter cloacae (3) | Neisseria polysaccharea |
| Escherichia coli (10) | Proteus mirabilis (2) |
| Enterococcus faecalis (7) | Proteus vulgaris |
| Enterococcus faecium | Pseudomonas aeruginosa (4) |
| Enterococcus durans | Pseudomonas stutzeri |
| Gardnerella vaginalis | Pseudomonas spp. (2) |
| Haemophilus Influenzae type a-f and non-caps (11) | Salmonella bredeney |
| Haemophilus paraInfluenzae | Salmonella Thompson |
| Adenovirus 2, | Salmonella typhimurium |
| Chlamydophila pneumoniae (2) | Serratia marcescens |
| Chlamydia trachomatis | Staphylococcus epidermidis |
| Cytomegalovirus | Salmonella glostrup |
| Enterovirus D68 | Streptococcus mutans (2) |
| Herpes Simplex 1,2 | Streptococcus parasanguis |
| Influenzae A (H1N1 and H3N2) virus | Streptococcus sanguinis |
| Influenzae B Virus | Streptococcus aureus (6) |
| ParaInfluenzae virus 1,2,3 (3) | Streptococcus epidermidis (5) |
| Respiratory Syncytial Virus A | Streptococcus saprophyticus (3) |
| Klebsiella oxytoca (2) | Stenotrophomonas maltophilia |
| Klebsiella pneumoniae (3) | Streptococcus gr. A, B, C, F, L and G (16) |
| Lactobacillus catenaforme | Streptococcus mitis |
| Lactobacillus rhamnosus |
Table 5
All of the above bacterial isolates were negative when using ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test. The only potential cross-reactivity was 1 of 3 isolates of E. cloaced which was positive for L. pneumophila. This was confirmed on re-testing of that one isolate.
A total of 19 Urinary tract infection from patients were tested. Previously culture results had shown that eight (8) of them were infected with Escherichia coli, five (5) with Staphylococcus, aureus, five (5) with Streptococcus agalactiae gr. B and one (1) with Candida albicans. None showed any cross reactions with the ImmuView test.
{11}------------------------------------------------
Sensitivity (Limit of detection (LOD))
The limit of detection (LOD) for the ImmuView S. pneumoniae and L. pneumophila urinary antigen test is 62.5 pg/mL for purified S. pneumoniae CWPS antigen (native). For LPS specific for L. pneumophila SG1 (Philadelphia) the LOD is 25 ng/mL. Whole cell S. pneumoniae bacteria can be detected at an LOD at 105 CFU/mL and L. pneumophila SG1 (Philadelphia) has a LOD at 104 CFU/mL. Boiling or urine preservatives did not change these results.
Table 6
| Stock solution | LOD |
|---|---|
| S. pneumoniae antigen | 62.5 pg/mL |
| L. pneumophila SG 1 (Philadelphia) antigen | 0.025 µg/mL |
| L. pneumophila SG 1 (Bellingham) antigen | 0.5 µg/mL |
| S. pneumoniae (serotype 1) | 105 CFU/mL |
| L. pneumophila SG1 (Philadelphia) | 104 CFU/mL |
| L. pneumophila SG 1 (Bellingham) | 105 CFU/mL |
Strain Reactivity
lsolates from different S. pneumoniae serotypes were also positive tested with the ImmuView assay including serotype three (3), five (5), and thirty-seven (37). Different species of L. pneumophila were also found to be positive using the assay. Within serogroup one (1) these includes Philadelphia, Knoxville, OLDA/Oxford, Allentown/France, and Benidorm-Strain Lens. In additional studies have found other Legionella serogroups to be positive such as serogroup 3, 6, 8, 10 and 12.
| Streptococcus pneumoniae in urine | ||||
|---|---|---|---|---|
| Subgroup | Antigen Concentration(µg/mL) | Whole Organism Concentration(CFU/mL) | ||
| type 1 | ND* | 104 | ||
| type 3 | 0.001 | 104 | ||
| type 5 | 0.010 | 105 | ||
| type 37 | 0.0001 | ND* | ||
| Legionella pneumophila in urine | ||||
| Subgroup | Pontiac/Non-Pontiac | Species | Concentration(µg/mL) | Concentration(CFU/mL) |
| SG1 | Pontiac | Knoxville | 0.100 | 105 |
| SG1 | Pontiac | Allentown/France | 0.005 | ND* |
| SG1 | Pontiac | Benidorm | ND | 104 |
| SG1 | Pontiac | Philadelphia | 0.010 | 104 |
| SG1 | Non-Pontiac | OLDA/Oxford | 0.001 | ND |
| SG1 | Non-Pontiac | Camperdown | 0.315 | ND |
| SG1 | Non-Pontiac | Heysham | 1.250 | ND |
{12}------------------------------------------------
| SG3 | 250 | ND | |
|---|---|---|---|
| SG6 | 250 | ND | |
| SG8 | 250 | ND | |
| SG10 | 250 | ND | |
| SG12 | 7.8 | ND |
*ND=Not done
{13}------------------------------------------------
Interfering Substances
ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test were tested with forty-seven (47) interfering agents at different concentrations in urine samples.
Table 8
| Agent | Concentration | Agent | Concentration |
|---|---|---|---|
| Acetaminophen | 0.1mg/mL | Leucocytes | >250 cells/µL |
| Acetylsalicylic acid | 0.1mg/mL | Miconazole | 5% |
| Amantadine | 0.03mg/mL | Mix (pH, whole blood, protein and glucose) (H) | |
| Amoxicillin | 0.075mg/mL | Mix (pH, whole blood, protein and glucose) (M) | |
| Amphotericin B | 0.22mg/mL | Mix (pH, whole blood, protein and glucose) (L) | |
| Antihistamine | 0.22mg/mL | Mucin | 0.086mg/mL |
| Ascorbic acid (C-Vitamin) | 1mg/mL | Oseltamivir (Tamiflu) | 0.03mg/mL |
| Augmentin (Amoxicillin Clavulanate) | 0.22mg/mL | Oxalic acid | 0.01% |
| Azithromycin | 0.012mg/mL | pH (acidic) | 4 |
| Beet root | 20% | pH (neutral) | 7 |
| Beet root | 1.17% | pH (basic) | 9 |
| Beet root | 0.01% | Plasma | 90% |
| Bilirubin | 0.2mg/mL | Plasma | 50% |
| Bromhexin/cough drops/couch syrup | 0.22mg/mL | Plasma | 10% |
| Caffeine | 15mg/mL | Prednisone | 0.22mg/mL |
| Chlorophyll | 0.11mg/mL | Protein (albumin) (H) | 10mg/mL |
| Chlorophyll | 0.04mg/mL | Protein (albumin) (M) | 5mg/mL |
| Chlorophyll | 0.01mg/mL | Protein (albumin) (L) | 0.6mg/mL |
| Ciprofloxacin | 0.22mg/mL | Pyridium | 1mg/mL |
| Decongestant | 0.22mg/mL | Rifampicin | 0.09mg/mL |
| Corticosterone (Corticosteroids) | 0.015mg/mL | Spinach | 1% |
| Erythromycin | 0.067mg/mL | Tobacco purified | 0.4mg/mL |
| Glucose (H) | 20mg/mL | Triglycerides | 4mg/mL |
| Glucose (M) | 10mg/mL | Urea | 20mg/mL |
| Glucose (L) | 3mg/mL | Vaginal contraceptive gel | 5% |
| Hemoglobin | 5mg/mL | Vancomycin | 0.1mg/mL |
| Human albumin | 35mg/mL | Water-based personal lubricant | 5% |
| Human red blood cells 10% | 10% | White blood cells | 10% |
| Washed pooled cells | |||
| Ibuprofen | 0.1mg/mL | Whole blood | 10% |
| Itraconazole | 0.22mg/mL | Whole blood | 15% |
High concentration of plasma in urine may result in gray test lines. Additionally, basic (pH≥9) conditions in urine can give false positive S. pneumoniae lines. Water-based personal lubricant might result in false positive or gray L. pneumophila lines, however, this outcome seems dose-related.
{14}------------------------------------------------
Clinical sensitivity and specificity - CSF
The sensitivity of the S. pneumoniae test line was obtained by testing leftover CSF specimens from patients suspected of meningitis, as well as spiked CSF and negative CSF table 10 below.
Table 9
| ImmuView | S.pn. Culture positive | S.pn. Culture negative |
|---|---|---|
| S.pn. Positive | 13 | 7 |
| S.pn. Negative | 1 | 162 |
| Total | 14 | 169 |
| sensitivity | 92.9% (13/14) | 95% CI (68.5%-98.7%) |
| specificity | 96.0% (162/169) | 95% CI (91.7%-98.0%) |
U.S.A Laboratory testing
Of the samples tested at the two U.S. labs, 9 were known positive for S. pneumoniae meningitis. Onehundred-thirteen (113) were negative human CSF samples were blinded, and the testing of the ImmuView Test was performed by three operators on different days to prevent test bias.
European Laboratory testing
Of the samples tested within Europe, 5 were known to be positive for S. pneumoniae. Of the total samples, 56 were negative CSF samples were blinded and the testing with the ImmuView Test was performed by one operator on different
days to prevent test bias.
The sensitivity of ImmuView L. pneumophila test line was not validated in this study, Legionella do not usually cause meningitis.
Spiked CSF testing
Additional human CSF samples were spiked at the LOD with S. pneumoniae (N=50) and an additional unspiked negative CSF samples (N=10) were tested with the Immuview test and the comparator test. The sensitivity for the both the ImmuView test and the comparator test was 50/50 (100%) and the additional negative CSF samples used for blinding of the testing were negative 10/10 (100%) in both the ImmuView test and the comparator test.
| 60 real human CSF samples 50 spiked with S. pneumoniae | |||
|---|---|---|---|
| ImmuView | Comparator | ||
| S.pn. Positive | S.pn. Negative | Total | |
| S.pn. Positive | 50 | 0 | 50 |
| S. pn. Negative | 0 | 10 | 10 |
| Positive percentagreement | 100% | 95% CI (92.9%-100%) | |
| Negative percentagreement | 100% | 95% CI (72.2%-100%) |
{15}------------------------------------------------
Analytical Studies - CSF
Specificity (Cross-Reactivity)
ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test were tested with a panel of 24 potential cross-reacting agents. No cross-reactions were detected for the S. pneumoniae or the L. pneumophila test lines.
Table 11
| Organisms not affecting test performance in CSF | |
|---|---|
| E. coli (5) | Neisseria meningitidis Gr. B, D and W135 (3) |
| Haemophilus influenza type a-f and non-caps (7) | Staphylococcus aureus |
| Listeria monocytogenes | Streptococcus Gr A |
| Measles | Streptococcus agalactiae (GBS) sg la, Ib, II, III (4) |
| Streptococcus mitis |
Sensitivity (Limit of detection (LOD)) in CSF
ImmuView S. pneumoniae and L. pneumophila analytical sensitivity was determined by limit of detection. Two different operators performed the dilutions and the testing. The dilutions were made with whole cell bacteria spiked in human CSF.
| CSF | LoD |
|---|---|
| S. pneumoniae | 103 CFU/mL |
{16}------------------------------------------------
Interference agents
ImmuView S. pneumoniae and L. pneumophila Urinary Antigen Test were tested with forty-seven (47) interfering agents at different concentrations in artificial CSF either negative or spiked with either CWPS or S. pneumoniae 107 CFU/mL.
Table 13
| Agent in CSF | Concentration | Agent | Concentration |
|---|---|---|---|
| Whole S. pneumoniae (Type 1) | Negative Artificial CSF | ||
| Glucose (H) | 1mg/mL | Glucose (H) | 1mg/mL |
| Glucose (M) | 0.5mg/mL | Glucose (M) | 0.5mg/mL |
| Glucose (L) | 0.1mg/mL | Glucose (L) | 0.1mg/mL |
| Red blood cells (H) | 15% | Red blood cells (H) | 15% |
| Red blood cells(M) | 10% | Red blood cells(M) | 10% |
| Red blood cells (L) | 5% | Red blood cells (L) | 5% |
| Protein (H) | 60mg/mL | Protein (H) | 60mg/mL |
| Protein (M) | 30mg/mL | Protein (M) | 30mg/mL |
| Protein (L) | 10mg/mL | Protein (L) | 10mg/mL |
| White blood cells | 10.6x106/mL | White blood cells | 10.6x106/mL |
| White blood cells | 5.3x106/mL | White blood cells | 5.3x106/mL |
| White blood cells | 2.7x106/mL | White blood cells | 2.7x106/mL |
| White blood cells | 1.8x106/mL | White blood cells | 1.8x106/mL |
| White blood cells | 0.9x106/mL | White blood cells | 0.9x106/mL |
| Bilirubin | |||
| Antigen | Bilirubin | ||
| Bilirubin | 15% | Bilirubin | |
| Bilirubin | 10% | Plasma | |
| Bilirubin | 5% | Plasma | |
| Plasma | 15% | Plasma | |
| Plasma | 10% | ||
| Plasma | 5% |
Red blood cells may give false positive shadows on the S. pneumoniae line due to excessive red color. The other agents in the panel did not interfere with the test.
{17}------------------------------------------------
Reproducibility study
The ImmuView S. pneumoniae and L. pneumophila Urinary Antigen test demonstrated excellent overall reproducibility with 1,068 correct results out of 1,072 test results (99.6%), when tested with 10 members of real positive S. pneumoniae or L. pneumophila urine samples and negative urine samples; and artificial CSF positive spiked with S. pneumoniae isolates as well as negative artificial CSF samples. The ImmuView Positive Control and Negative Control were also tested as blinded/masked panel members. The testing was performed for 5 days with a different kit lot at each site, two in the U.S. and one in Europe.
| Description | Correct results | Agreement |
|---|---|---|
| S. pneumoniae , moderate positive urine | 90/90 Positive | 100.0% |
| S. pneumoniae , moderate positive CSF | 89/892 Positive | 100.0% |
| S. pneumoniae , low positive spiked in artificial CSF | 89/903 Positive | 98.9% |
| S. pneumoniae , low positive urine | 90/90 Positive | 100.0% |
| L. pneumophila , moderate positive urine 2A | 90/90 Positive | 100.0% |
| L. pneumophila , moderate positive urine 2B | 88/894 Positive | 98.9% |
| L. pneumophila , low positive urine 1A | 89/895 Positive | 100.0% |
| L. pneumophila , low positive urine 1B | 89/906 Positive | 98.9% |
| Negative pooled urine | 90/90 Negative | 100.0% |
| Negative artificial CSF | 90/90 Negative | 100.0% |
| ImmuView Pos Control | 89/907 Positive | 98.9% |
| ImmuView Neg Control | 85/858 Negative | 100.0% |
| Summary | 1068/1072 Correct | 99.6% |
Table 14
A total of 3 different lots were tested. Each site, using two operators (A and B) performed a total of 360 reproducibility tests and a grand total of 1,072 reproducibility results out of 1,080 tests in the study using 6 operators. A total of 8 test results (0.7%) were determined to be invalid and were excluded and not re-tested. The panel members were blinded by changing of the panel members and identity daily. The reading and interpretation of the reproducibility panels was performed visually. There were no statistical differences in reproducibility by lot, by time or by operator.
{18}------------------------------------------------
-
The protocol was run five different days, each day each sample had a different code number.
-
Operator did not see a positive control band, so one sample was invalid as the package insert states that this is necessary before interpreting the result. The sample was not re-tested.
-
A visual L. pneumophila band was seen.
-
Operator interpreted band as S. pneumoniae positive instead of L. pneumophila positive. One sample was invalid due to dot (incomplete band) on the strip per the package insert and was not re-tested.
-
One sample was invalid due to an incomplete band in S. pneumoniae according to the pack insert.
-
No L. pneumophila band present.
-
Operator interpreted S. pneumoniae Band result as negative even though band was present.
-
Five samples excluded due to the presence of dots and incomplete bands. The samples were not retested.
{19}------------------------------------------------
References
- Rota MC, Fontana S, Montaño-Remacha C, et al. Legionnaires? disease pseudoepidemic due to 1. falsely positive urine antigen test results. J Clin Microbiol. 2014;52(6):2279-2280. doi:10.1128/JCM.00493-14
-
- Briones ML, Blanquer J, Ferrando D, Blasco ML, Gimeno C, Marín J. Assessment of analysis of urinary pneumococcal antigen by immunochromatography for etiologic diagnosis of community-acquired pneumonia in adults. Clin Vaccine Immunol. 2006;13(10):1092-1097. doi:10.1128/CVI.00090-06
-
- Athlin S, Iversen A, Özenci V. Comparison of the ImmuView and the BinaxNOW antigen tests in detection of Streptococcus pneumoniae and Legionella pneumophila in urine. Eur J Clin Microbiol Infect Dis. 2017;36(10):1933-1938. doi:10.1007/s10096-017-3016-6
§ 866.3300
Haemophilus spp. serological reagents.(a)
Identification. Haemophilus spp. serological reagents are devices that consist of antigens and antisera, including antisera conjugated with a fluorescent dye, that are used in serological tests to identifyHaemophilus spp. directly from clinical specimens or tissue culture isolates derived from clinical specimens. The identification aids in the diagnosis of diseases caused by bacteria belonging to the genusHaemophilus and provides epidemiological information on diseases cause by these microorganisms. Diseases most often caused byHaemophilus spp. include pneumonia, pharyngitis, sinusitis, vaginitis, chancroid venereal disease, and a contagious form of conjunctivitis (inflammation of eyelid membranes).(b)
Classification. Class II (special controls). The device is exempt from the premarket notification procedures in subpart E of part 807 of this chapter subject to § 866.9.