The APAS Independence is an in vitro diagnostic system comprised of an instrument for automated imaging of agar plates and a software analysis module for the following uses:

The APAS Independence, when using its IC MRSA Chromogenic BD Analysis Module, automates culture plate imaging and interpretation to detect the presence of colonies with colors suggestive of methicillin-resistant Staphylococcus aureus (MRSA) growth on Beckton Dickinson BBL™ CHROMagar™ MRSA II agar that has been inoculated with anterior nares swabs and incubated at 36°C ± 1°C for 24 hours. The APAS Independence, when using its IC MRSA Chromogenic BD Analysis Module, provides an aid in routine screening for colonization with MRSA. It provides one of two screening results: Presumptive MRSA or Negative. All culture plates that are identified as Presumptive MRSA by the APAS Independence, when using the IC MRSA Chromogenic BD Analysis Module require review by a trained microbiologist.
The APAS Independence, when using its IC MRSA Chromogenic TFS/S Analysis Module, automates culture plate imaging and interpretation to detect the presence of colonies with colors suggestive of methicillin-resistant Staphylococus aureus (MRSA) growth on Thermo-Fisher Spectra™ MRSA agar that has been inoculated with anterior nares swabs and incubated at 36°C ± 1°C for 24 hours. The APAS Independence, when using its IC MRSA Chromogenic TFS/S Analysis Module, provides an aid in routine screening for colonization with MRSA. It provides one of three screening results: Presumptive MRSA, Presumptive non-MRSA, or Negative. All culture plates that are identified as Presumptive MRSA or Presumptive non-MRSA by the APAS Independence, when using the IC MRSA Chromogenic TFS/S Analysis Module, require review by a trained microbiologist.

Device Description

APAS Independence is a device designed to be used in a microbiology laboratory to automate the initial screening of specimens for the presence of growth on culture plates. It is an in vitro diagnostic device and has no direct contact with patients.

The APAS Independence consists of an automated plate handling mechanism to move culture plates through the instrument, an imaging station to capture images of culture plates, and software for image analysis (e.g., determination of growth) and presentation of reports.

The APAS Independence is intended to be installed with multiple software (analysis) modules, each of which will provide an assessment of growth for a specific clinical indication. More than one analysis module may be developed for the same indication to allow APAS to assess growth on culture plates from multiple agar manufacturers sold for the same indications.

This submission includes two MRSA analysis modules that have been developed for the same indication, which is to be used in a microbiology laboratory to automate the initial screening for the presence of presumptive methicillin-resistant Staphylococcus aureus (MRSA) growth on culture plates. It is indicated for the screening of MRSA colonization from swabs, where a specimen is collected from the anterior nares by non-invasive sampling techniques and plated onto specified chromogenic MRSA agars. No quantification of growth is required.

APAS Independence with IC MRSA Chromogenic BD Analysis Module is designed to interpret growth on BBL™ CHROMagar™ MRSA II agar from Becton Dickinson, and APAS Independence with IC MRSA Chromogenic TFS/S Analysis Module is designed to interpret growth on Spectra™ MRSA agar from Thermo Fisher Scientific (Remel).

AI/ML Overview

Here's a breakdown of the acceptance criteria and study findings for the APAS Independence with MRSA Analysis Modules, based on the provided document:

1. Table of Acceptance Criteria and Reported Device Performance

The document defines acceptance for "Presumptive MRSA growth" based on agreement with a reference panel. The distinction between a 2-designation and 3-designation rule set is also tied to specific performance metrics.

Performance Metric	Acceptance Criteria (BD Analysis Module)	Reported Performance (BD Analysis Module)	Acceptance Criteria (TFS/S Analysis Module)	Reported Performance (TFS/S Analysis Module)
Agreement for "Presumptive MRSA growth" in digital image quality study (Microbiologist Image vs Plate-in-Hand)	>95%	95.9% (Table 5-6)	<95% (justifies 3-designation)	93.5% (Table 5-6)
Agreement for "Presumptive MRSA growth" against Australian clinical study reference panel	>98%	100.0% (Table 5-20)	>98%	99.2% (Table 5-23)
Agreement for "Presumptive MRSA growth" against US clinical study reference panel	>98%	99.7% (Table 5-21)	>98%	99.5% (Table 5-24)
Agreement for "Presumptive MRSA growth" between Australian and US microbiologist panel results	>95%	99.2% (Table 5-26)	<95% (justifies 3-designation)	90.6% (Table 5-27)
Accuracy - Trueness (MRSA colony detection)	95%	99.3% (Table 5-7)	95%	99.5% (Table 5-8)
Analytical Sensitivity - LoD of Colony Size (MRSA colony detection) for smallest MRSA colony	>95% detection rate	95.1% for 0.82mm (wild strain), 97.7% for 0.91mm (ATCC) (Table 5-11)	>95% detection rate	98.0% for 0.63mm (wild strain), 97.7% (implied for 0.54mm ATCC) (Table 5-12)
Analytical Sensitivity - Detection of MRSA in Mixtures (Presence of MRSA)	≥95%	100.0% (Table 5-13)	≥95%	100.0% (Table 5-14)

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

BD Analysis Module & TFS/S Analysis Module (Clinical Study):
- Total Samples: 1590 enrolled.
- BD Analyzed: 1573 (1118 non-simulated, 395 simulated MRSA-positive, 60 simulated negative MRSA).
- TFS/S Analyzed: 1580 (1122 non-simulated, 398 simulated MRSA-positive, 60 simulated negative MRSA).
- Data Provenance: A single site in Australia collected left-over specimens from standard-of-care screening. Simulated samples were also used to supplement the study, incorporating unique MRSA strains for global representation, including the United States. This indicates a mix of prospective (clinical) and engineered (simulated) data.
Digital Image Quality Study (Reproducibility & Equivalency):
- BD Media: 263 plates for "No growth", 82 for "Presumptive non-MRSA", 55 for "Presumptive MRSA" (Reproducibility); 263, 77, 60 respectively for "Microbiologist Image vs Plate-in-Hand" (Equivalency).
- TFS/S Media: 196 plates for "No growth", 103 for "Presumptive non-MRSA", 101 for "Presumptive MRSA" (Reproducibility); 194, 101, 105 respectively for "Microbiologist Image vs Plate-in-Hand" (Equivalency).
- Data Provenance: Not explicitly stated, but likely laboratory-generated images and physical plates used by microbiologists during the study.
Accuracy - Trueness Study:
- BD Analysis Module: 1106 colonies evaluated (798 MRSA, 308 Non-MRSA).
- TFS/S Analysis Module: 1320 colonies evaluated (776 MRSA, 544 Non-MRSA).
- Data Provenance: Laboratory-produced pure cultures of MRSA and non-MRSA organisms.
Accuracy - Precision Study:
- Sample Size: For each organism (MRSA wild strain, MRSA ATCC 43300, S. haemolyticus wild strains 1 & 2), 3 dilutions were used, with each diluted sample inoculated in triplicate. Five replicate images of each plate were taken at 3 different orientations on 3 different APAS Independence instruments. For each organism/dilution/instrument combination, there are 45 images * (e.g. MRSA Wild Strain 1, dilution 1 on Instrument 1 has 45 images).
- Data Provenance: Laboratory-produced cultures.
Analytical Sensitivity - Limit of Detection of Colony Size:
- Sample Size: Two MRSA strains (one ATCC, one wild). Six replicate plates prepared for each organism, with images taken at 1-hour intervals until colonies were approx. 2mm. Multiple isolated colonies digitally labeled for size measurement.
- Data Provenance: Laboratory-produced cultures.
Analytical Specificity - Limit of Blank:
- Sample Size: 96 plates (3 applicators x 4 media x 4 labels x 2 marks).
- Data Provenance: Laboratory-prepared plates with no growth.
Analytical Specificity - Interference with detection of MRSA:
- Sample Size: 48 plates per organism (3 applicators x 2 media x 4 labels x 2 marks) for MRSA and for S. haemolyticus heavy growth.
- Data Provenance: Laboratory-prepared cultures with known interfering substances/conditions.

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

Clinical Study (IVD Studies) & Analytical Sensitivity - Detection of MRSA in Mixtures:
- Number of Experts: Two reference panels, each consisting of 3 clinical microbiologists.
- Qualifications: "Clinical microbiologists." Specific years of experience or board certifications are not explicitly stated in the document.
Digital Image Quality Study (Reproducibility & Equivalency):
- Number of Experts: 3 microbiologists.
- Qualifications: "Microbiologists." Specific years of experience or board certifications are not explicitly stated.
Accuracy - Trueness Study:
- Number of Experts: One microbiologist for digitally labeling isolated colonies.
- Qualifications: "Microbiologist." Specific years of experience or board certifications are not explicitly stated.

4. Adjudication Method for the Test Set

Clinical Study (IVD Studies) & Analytical Sensitivity - Detection of MRSA in Mixtures:
- Adjudication Method (Reference Panels): Majority vote (likely 3+0 or 2+1, meaning at least 2 out of 3 agreed) from the respective panel of 3 independent microbiologists. This established the "truth state."
Digital Image Quality Study (Reproducibility):
- Adjudication Method: Single panel result (i.e. majority vote) for each image among the three microbiologists.
Digital Image Quality Study (Equivalency):
- Adjudication Method: The plate-in-hand interpretation was considered the "truth state."
Accuracy - Trueness Study:
- Adjudication Method: Ground truth for individual colonies was established by digital labeling by a microbiologist.

5. If a Multi Reader Multi Case (MRMC) Comparative Effectiveness Study was done

Yes, in part. The clinical studies (IVD studies) for both analysis modules involved multiple readers (the 3 microbiologists in each of the two panels) and multiple cases (the clinical and simulated samples) to establish the reference standard against which the APAS device was compared.
Effect Size of Human Readers Improve with AI vs. without AI assistance:
- The study design was a standalone performance evaluation of the AI without human assistance, compared to a human consensus reference. It did not evaluate the comparative effectiveness of human readers with AI vs. without AI assistance. Therefore, there is no reported effect size for how much human readers improve with AI assistance from this document. The device instead functions as an aid in routine screening, flagging plates that require review by a trained microbiologist.

6. If a Standalone (i.e., algorithm only without human-in-the-loop performance) was done

Yes, a standalone performance evaluation was largely conducted. The core performance objective was to compare the APAS-generated result (algorithm-only) against the reference panel of microbiologists. The study determined the agreement of the APAS final designation with the consensus of human experts.
The "Indications for Use" explicitly state: "All culture plates that are identified as Presumptive MRSA by the APAS Independence... require review by a trained microbiologist." This indicates that the device operates as a screening/triage tool, and positive APAS results are not considered final without human review.

7. The Type of Ground Truth Used

Expert Consensus (Microbiologist Panel): For the clinical studies (IVD) and some analytical studies (e.g., Detection of MRSA in Mixtures), the ground truth was established by the majority vote of two independent panels of 3 clinical microbiologists interpreting digital images.
Plate-in-Hand Interpretation: For the "Equivalency of Plate-in-Hand vs. Plate Image" component of the digital image quality study, the plate-in-hand interpretation by a microbiologist was considered the truth state.
Microbiologist Digital Labeling: For the "Accuracy - Trueness" and "Analytical Sensitivity - Limit of Detection of Colony Size" studies, the ground truth at the colony level was established by a microbiologist digitally labeling colonies.
Expected Outcome (Laboratory-Controlled): For "Precision" and "Analytical Specificity" studies, the "expected outcome" (presence/absence of presumptive MRSA/growth) derived from controlled laboratory preparations served as the ground truth.

8. The Sample Size for the Training Set

The document does not explicitly state the sample size for the training set used to develop the APAS analysis modules. The provided data focuses entirely on the validation/test sets.

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

The document does not explicitly describe how the ground truth for the training set was established. It concentrates on the methodologies for the performance evaluation and validation data.

Summary

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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.

October 28, 2021

Clever Culture Systems Julie Winson Regulatory Affairs Manager Seestrasse 204a Bach. CH-8806 Switzerland

Re: K200839

Trade/Device Name: APAS Independence with IC Chromogenic MRSA BD Analysis Module; APAS Independence with IC Chromogenic MRSA TFS/S Analysis Module Regulation Number: 21 CFR 866.2190 Regulation Name: Automated Image Assessment System For Microbial Colonies On Solid Culture Media Regulatory Class: Class II Product Code: QQY Dated: March 27, 2020 Received: March 31, 2020

Dear Julie Winson:

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 statutes and regulations administered by other Federal agencies. You must comply with all the Act's

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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 (OS) 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 mediation-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,

Ribhi Shawar, Ph.D. (ABMM) Chief. General Bacteriology and Antimicrobial Susceptibility 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

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Indications for Use

510(k) Number (if known) K200839

Device Name

APAS Independence with IC MRSA Chromogenic BD Analysis Module APAS Independence with IC MRSA Chromogenic TFS/S Analysis Module

Indications for Use (Describe)

The APAS Independence is an in vitro diagnostic system comprised of an instrument for automated imaging of agar plates and a software analysis module for the following uses:

The APAS Independence, when using its IC MRSA Chromogenic BD Analysis Module, automates culture plate imaging and interpretation to detect the presence of colonies with colors suggestive of methicillin-resistant Staphylococcus aureus (MRSA) growth on Beckton Dickson BBL™ CHROMagar™ MRSA II agar that has been inoculated with anterior nares swabs and incubated at 36°C ± 1°C for 24 hours. The APAS Independence, when using its IC MRSA Chromogenic BD Analysis Module, provides an aid in routine screening for colonization with MRSA. It provides one of two screening results: Presumptive MRSA or Negative. All culture plates that are identified as Presumptive MRSA by the APAS Independence, when using the IC MRSA Chromogenic BD Analysis Module require review by a trained microbiologist.
The APAS Independence, when using its IC MRSA Chromogenic TFS/S Analysis Module, automates culture plate imaging and interpretation to detect the presence of colonies with colors suggestive of methicillin-resistant Staphylococus aureus (MRSA) growth on Thermo-Fisher Spectra™ MRSA agar that has been inoculated with anterior nares swabs and incubated at 36°C ± 1°C for 24 hours. The APAS Independence, when using its IC MRSA Chromogenic TFS/S Analysis Module, provides an aid in routine screening for colonization with MRSA. It provides one of three screening results: Presumptive MRSA, Presumptive non-MRSA, or Negative. All culture plates that are identified as Presumptive MRSA or Presumptive non-MRSA by the APAS Independence, when using the IC MRSA Chromogenic TFS/S Analysis Module, require review by a trained microbiologist.

Type of Use (Select one or both, as applicable)
☑ Prescription Use (Part 21 CFR 801 Subpart D)	☐ Over-The-Counter Use (21 CFR 801 Subpart C)

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Image /page/3/Picture/0 description: The image contains the logo for Clever Culture Systems. The logo consists of a red icon resembling interconnected nodes, followed by the text "CLEVER CULTURE SYSTEMS" in a bold, sans-serif font. To the right of the logo, the text "Traditional 510(k) APAS Independence with MRSA Analysis Module" is displayed, indicating the company's focus on traditional medical device clearance pathways and its expertise in automated plate assessment systems for MRSA analysis.

5.510(k) Summary

5.1 Submitter

Clever Culture Systems AG Seestrasse 204a, CH-8806 Bach, Switzerland

Contact person: Julie Winson

Telephone +61 88 2771555

e-mail: Julie.Winson@cleverculturesystems.com

Date prepared: 19 October 2021

5.2 Device

The information presented in this 510(k) premarket notification submission is for two devices, as follows:

Name of Devices	APAS Independence with IC MRSA Chromogenic BD Analysis ModuleAPAS Independence with IC MRSA Chromogenic TFS/S Analysis Module
Model Numbers	AI-16001 - APAS Independence instrumentAI-16053 - IC MRSA Chromogenic BD Analysis ModuleAI-16057 - IC MRSA Chromogenic TFS/S Analysis Module
Common or Usual Name	(Both Devices)APAS Independence with MRSA Analysis Module
Classification Name:	Automated image assessment system for microbial colonies on solid culture media (21 CFR 866.2190).
Regulatory Class:	II (special controls).
Product Code	QQY

5.3 Predicate Device

The predicate device is APAS Independence with Urine Analysis Module, K183648.

This predicate has not been subject to a design related recall.

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5.4 Device Description

Table 5-1. shows reported final plate designation and relationship to plate interpretation result for each module. respectively.

Chromogenic AgarResult	Chromogenic AgarDescription	IC Chromogenic Analysis Modules
		BD Analysis ModuleResult	TFS/S AnalysisModule Result
Presumptive MRSAGrowth	Colonies or growthsuggestive of MRSA	Presumptive MRSA	Presumptive MRSA
Presumptive non-MRSAGrowth	Colonies or growth notsuggestive of MRSA	Negative	Presumptive non-MRSA
No Growth	No colonies or growth	Negative	Negative

Table 5-1: APAS final designation

Both modules provide a triaqing step within the workflow of a microbiology laboratory. Each module takes two key inputs (agar plate images and flags) and computes a final plate designation so that the plate can be efficiently and appropriately routed to the next step in the laboratory workflow.

For APAS Independence with IC MRSA Chromogenic BD Analysis Module, the final designation will be either Presumptive MRSA or Negative.

. Presumptive MRSA designation indicates that the culture plate was determined to contain colored colonies which are suspected to be MRSA. Investigation and confirmation by a microbiologist are required.
. Negative designation indicates that the culture plate was determined to not contain colored colonies indicative of MRSA. No further investigations will be required.

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Figure 5-1 provides an illustration of the expected workflow after the IC MRSA Chromogenic BD Analysis Module has produced a screening result.

Figure 5-1: Typical workflow of APAS Independence with IC MRSA Chromogenic BD analysis module

Image /page/5/Figure/3 description: This image is a flowchart describing a laboratory process. The process starts with an incubated sample on media, which then goes through APAS. From APAS, the sample can either be presumptive MRSA or negative. If the sample is presumptive MRSA, it goes through laboratory protocols for confirmation, and then it is reported to LIS. If the sample is negative, no further work is needed, and it is reported to LIS, but a flag is set to indicate that the sample is negative.

When APAS Independence with IC MRSA Chromogenic BD analysis module completes the analysis of each plate, the APAS-generated result is sent to the LIS. In the case of a Negative designation which does not require any further work, the final laboratory report can be issued according to standard reporting protocols without any investigation. Any Presumptive MRSA designations, however, will require investigation according to laboratory protocols for confirmation.

For APAS Independence with IC MRSA Chromogenic TFS/S Analysis Module the final designation will be either Presumptive MRSA, Presumptive non-MRSA, or Negative.

. Presumptive MRSA designation indicates that the culture is likely to contain colored colonies which are suspected to be MRSA. Investigation and confirmation by a microbiologist are required.
. Presumptive non-MRSA designation indicates that the culture is likely to contain growth of organisms not typically suspected to be MRSA. Review is required by a microbiologist.
Negative designation indicates that no growth is present on the plate. No further . investigations will be required.

Figure 5-2 provides an illustration of the expected workflow after the IC MRSA Chromogenic TFS/S Analysis Module has produced a screening result.

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Image /page/6/Picture/0 description: The image features the logo of Clever Culture Systems on the left. To the right of the logo is the text "CLEVER CULTURE SYSTEMS" in bold font. Below this text is the phrase "Traditional 510(k) APAS Independence with MRSA Analysis Module". The text is horizontally aligned.

Image /page/6/Figure/1 description: The image is titled "Figure 5-2: Typical workflow of APAS Independence with IC MRSA Chromogenic TFS/S analysis module". The image is a figure that describes the typical workflow of APAS Independence. The figure includes IC MRSA Chromogenic TFS/S analysis module.

Image /page/6/Figure/2 description: This image is a flowchart describing a laboratory process. The process starts with an incubated sample on media, which then goes through APAS. From APAS, there are three possible outcomes: Presumptive MRSA, Presumptive non-MRSA, and Negative. The Presumptive MRSA outcome leads to following laboratory protocols for confirmation, while the Presumptive non-MRSA outcome leads to laboratory assessment, and the Negative outcome leads to no further work needed. Both the laboratory assessment and the follow laboratory protocols for confirmation outcomes lead to reporting to LIS.

When APAS Independence with IC MRSA Chromogenic TFS/S analysis module completes the analysis of each plate, the APAS-generated result is sent to the LIS. In the case of a Negative designation, which does not require any further work, the final laboratory report can be issued according to standard reporting protocols without any investigation. Any Presumptive MRSA or Presumptive non-MRSA designation, however, will require investigation according to laboratory protocols for confirmation prior to a laboratory report being issued.

Figure 5-3 shows a photograph of the instrument from the front. It shows the input area on the left, the imaging area in the middle and the output area on the right. The user controls the instrument via the screen at the top middle of the instrument.

Image /page/6/Picture/5 description: The image shows a laboratory instrument called APAS Independence. The instrument is white and gray and has a touch screen on the front. There are several containers on the right side of the instrument, and a drawer on the left side. The instrument is sitting on a black base.

Figure 5-3: APAS Independence

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5.5 Intended Use

The APAS Independence is an in vitro diagnostic system comprised of an instrument and software analysis module(s) for specific indications that are used to automate imaging and interpretation of microbial colonies on plates of solid culture media.

5.6 Indications for Use

The indication for use for APAS Independence, when using one of the MRSA analysis modules included in this application, is one of the following:

APAS Independence with IC MRSA Chromogenic BD Analysis Module 5.6.1

The APAS Independence is an in vitro diagnostic system comprised of an instrument for automated imaging of agar plates and a software analysis module for the following use:

The APAS Independence, when using its IC MRSA Chromogenic BD analysis module, automates culture plate imaging and interpretation to detect the presence of colonies with colors suggestive of methicillin-resistant Staphylococcus aureus (MRSA) growth on Beckton Dickson BBL ™ CHROMagar™ MRSA II agar that has been inoculated with anterior nares swabs and incubated at 36°C ± 1°C for 24 hours.

The APAS Independence, when using its IC MRSA Chromogenic BD analysis module, provides an aid in routine screening for colonization with MRSA. It provides one of two screening results: Presumptive MRSA or Negative. All culture plates that are identified as Presumptive MRSA by the APAS Independence, when using the IC MRSA Chromogenic BD analysis module require review by a trained microbiologist.

5.6.2 APAS Independence with IC MRSA Chromogenic TFS/S Analysis Module

The APAS Independence is an in vitro diagnostic system comprised of an instrument for automated imaging of agar plates and a software analysis module for the following use:

The APAS Independence, when using its IC MRSA Chromogenic TFS/S analysis module, automates culture plate imaging and interpretation to detect the presence of colonies with colors suggestive of methicillin-resistant Staphylococcus aureus (MRSA) growth on Thermo-Fisher Spectra™ MRSA agar that has been inoculated with anterior nares swabs and incubated at 36°C ± 1°C for 24 hours.

The APAS Independence, when using its IC MRSA Chromogenic TFS/S analysis module, provides an aid in routine screening for colonization with MRSA. It provides one of three screening results: Presumptive MRSA, Presumptive non-MRSA, or Negative. All culture plates that are identified as Presumptive MRSA or Presumptive non-MRSA by the APAS Independence, when using the IC MRSA Chromogenic TFS/S analysis module, require review by a trained microbiologist.

5.6.3 Predicate device APAS Independence with Urine Analysis Module

The indication for use of the predicate device, which is the APAS Independence with Urine Analysis Module, is as follows:

The APAS Independence is an in vitro diagnostic system comprised of an instrument for automated imaging of agar culture plates and a software analysis module for the following use:

The APAS Independence, when usinq its urine analysis module, automates urine culture plate imaging and interpretation to detect the presence of microbial growth on sheep blood and MacConkey agar culture plates that are inoculated with a 1uL sample volume. The

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APAS Independence, when using its urine analysis module, provides a semi-quantitative assessment of colony counts that are used as an aid in the diagnosis of urinary tract infection. All urine culture plates that are identified as positive for growth by the APAS Independence, when using its urine analysis module, must be reviewed by a trained microbiologist.

The difference in indications for use reflects the different therapeutic screening purposes supported by APAS. Neither the predicate urine analysis module nor either of the MRSA analysis modules provide a final diagnostic result; for each module, a positive screening result is confirmed by a microbiologist.

The same questions of safety and effectiveness for all analysis modules are addressed by fulfilling the requirements of the Special Controls for automated image assessment systems for microbial colonies on solid culture media.

5.7 Comparison of Technological Characteristics with the Predicate Device

The nominated predicate device is the APAS Independence with Urine Analysis Module which was cleared via application K183648.

APAS Independence when using both MRSA analysis modules included in this submission uses the same technology and methods to provide an interpretation of growth from anterior nares swabs taken by non-invasive techniques and cultured for screening for specific indications.

Both devices have been developed by Clever Culture Systems (CCS). Table 5-2 provides a side-byside comparison of the main components of APAS Independence as used in the predicate and the two new devices, showing that no changes were necessary to accommodate the two new modules.

Component	Predicate Device	Subject Devices
Hardware	APAS Independence with Urine Analysis Module (K183648)	APAS Independence with IC MRSA Chromogenic BD Analysis ModuleAndAPAS Independence with IC MRSA Chromogenic TFS/S Analysis Module
	Imaging Station	Light Emitting Diode (LED) illumination of culture plates and image capture using a Charge Coupled Device (CCD) camera	Same
	Plate Handling Mechanism	An automated system that accepts input carriers of multiple plates, moves plates through the instrument and sorts them to output carriers and stacks based on the analysis result.Accurately positions the plate for imaging	Same
Software	APAS Controller PC	Controls image capture, analysis, report generation and result storage	Same

Table 5-2: Comparison of Main Components Between Predicate and Subject Device

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Image /page/9/Picture/0 description: The image shows the logo for Clever Culture Systems. The logo consists of a red circle with a white molecular structure inside, followed by the text "CLEVER CULTURE" in bold black letters above the text "SYSTEMS" in bold black letters. The logo is simple and modern, and it is likely used to represent a company that is involved in science or technology.

Traditional 510(k) APAS Independence with MRSA Analysis Module

Component	Predicate Device	Subject Devices
	APAS Independence with UrineAnalysis Module (K183648)	APAS Independence with IC MRSAChromogenic BD Analysis ModuleAndAPAS Independence with IC MRSAChromogenic TFS/S AnalysisModule
	InstrumentController PC	User interface for operation of the APASIndependence.Oversight of plate movements	Same
	AnalysisModule	Installed on the APAS Controller PC toprovide the configuration andinstructions for image capture andanalysis	Same
	LaboratoryInformationSystem (LIS)Interface	Analysis result for each plate sent to theLIS.Sample ID details retrieved from theLIS.	Same
	LaboratoryNetworkInteractions	Interfaces with an external LIS.Optionally interfaces with NTP, LDAP,DNS and DHCP servers.	Same
QC	QualificationTools	Color Check Tool: - Multicolored disk forchecking and correcting color of thesystem optics.System Check Tool: - A pair of diskswith small dots replicating colonies forchecking overall system functionalityand associated software	Same

Table 5-3 and Table 5-4 provide a side-by-side comparison of the main characteristics of the Analysis Modules used in the predicate and subject devices. The differences do not raise different questions about safety and effectiveness, which are addressed by determining analytical performance and clinical performance.

Table 5-3: Comparison of Characteristics Between Predicate and Subject Analysis Modules
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Characteristic	Predicate Device	Subject Device
Intended Use	The APAS Independence is an in vitrodiagnostic system comprised of aninstrument and software analysismodule(s) for specific indications thatare used to automate imaging andinterpretation of microbial colonies onplates of solid culture media.	Same
Target population	All patients	Same
Anatomical site	Biological samples taken by non-invasive techniques	Same
Sample Type	Urine samples	Anterior nares swab samples
Where used	Microbiology laboratory	Same

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Characteristic	Predicate Device	Subject Device
Media used	Urine analysis module uses media manufactured by Remel, USA:Trypticase Soy Agar with 5% sheep blood, Product Code R01202A MacConkey Agar with crystal violet, Product Code R01552A	IC MRSA Chromogenic BD analysis module uses media manufactured by Beckton DickinsonBBLTM CHROMagarTM MRSA II, Product Codes 215228 (20pk) and 215229 (120pk) IC MRSA Chromogenic TFS/S analysis module uses media manufactured by Thermo Fisher Scientific SpectraTM MRSA, Product Codes R01821(A) (10pk) and R01822(A) (100pk)

Table 5-4: Comparison of Indications for Use Between Predicate and Subject Analysis Modules

Predicate Urine Analysis	IC MRSA Chromogenic BD	IC MRSA Chromogenic TF/S
Module	analysis module	analysis module
The APAS Independence is an in	The APAS Independence is an in	The APAS Independence is an in
vitro diagnostic system comprised	vitro diagnostic system comprised	vitro diagnostic system comprised
of an instrument for automated	of an instrument for automated	of an instrument for automated
imaging of agar culture plates and	imaging of agar plates and a	imaging of agar plates and a
a software analysis module for the	software analysis module for the	software analysis module for the
following use:	following use:	following use:
The APAS Independence, when	The APAS Independence, when	The APAS Independence, when
using its urine analysis module,	using its IC MRSA Chromogenic BD	using its IC MRSA Chromogenic
automates urine culture plate	analysis module, automates	TFS/S analysis module, automates
imaging and interpretation to	culture plate imaging and	culture plate imaging and
detect the presence or absence of	interpretation to detect the	interpretation to detect the
microbial growth on sheep blood	presence or absence of colonies	presence or absence of colonies
and MacConkey agar culture	with colors suggestive of	with colors suggestive of
plates that are inoculated with a	methicillin-resistant	methicillin-resistant
1µL sample volume.	Staphylococcus aureus (MRSA)	Staphylococcus aureus (MRSA)
The APAS Independence, when	growth on Beckton Dickson BBL™	growth on Thermo-Fisher
using its urine analysis module,	CHROMagar™ MRSA II agar that	Spectra™ MRSA agar that has
provides a semi-quantitative	has been inoculated with anterior	been inoculated with anterior
assessment of colony counts that	nares swabs and incubated at	nares swabs and incubated at
are used as an aid in the diagnosis	36°C ± 1°C for 24 hours.	36°C ± 1°C for 24 hours.
of urinary tract infection. All urine	The APAS Independence, when	The APAS Independence, when
culture plates that are identifiedas positive for growth by the APASIndependence, when using itsurine analysis module, must bereviewed by a trainedmicrobiologist.	using its IC MRSA Chromogenic BDanalysis module, provides an aid inroutine screening for colonizationwith MRSA. It provides one of twoscreening results: PresumptiveMRSA or Negative. All cultureplates that are identified asPresumptive MRSA by the APASIndependence, when using the ICMRSA Chromogenic BD analysismodule require review by a trainedmicrobiologist.	using its IC MRSA ChromogenicTFS/S analysis module, providesan aid in routine screening forcolonization with MRSA. Itprovides one of three screeningresults: Presumptive MRSA,Presumptive non-MRSA, orNegative. All culture plates thatare identified as PresumptiveMRSA or Presumptive non-MRSAby the APAS Independence, whenusing the IC MRSA ChromogenicTFS/S analysis module, requirereview by a trained microbiologist.

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5.8 Performance Data

This section addresses the software verification and validation conducted for each MRSA analysis module, and the performance requirements specified as Special Controls for a device of this type, which require that pre-market notification submissions include:

1. detailed documentation of the analytical studies performed to characterize device performance to support the intended use, as appropriate.
1. detailed documentation from clinical studies performed on a population that is consistent with the intended use population.
- a) The clinical studies must establish the device performance based on comparison to results obtained by an acceptable reference method, as appropriate.
- b) The clinical study documentation must include the study protocol with a predefined statistical analysis plan and the final report documenting support for the Indications for Use and the results of the statistical analysis, as appropriate.

5.8.1 Analysis Module Software Verification and Validation

Software verification and validation testing were conducted, and documentation was provided as recommended by FDA's Guidance for Industry and Staff, Guidance for the Content of Premarket Submissions for Software Contained in Medical Devices. The software for this device was considered as a "moderate" level of concern as a malfunction of, or latent design flaw in the software could lead to an erroneous diagnosis or a delay in delivery of appropriate medical care that would likely lead to a Minor injury to the patient. See Section 16 for additional details.

Digital Image Quality, Digital Image Interpretation 5.8.2

When conducting clinical studies and some analytical performance studies, the reference result against which APAS performance was compared was generated by microbiologists interpreting growth on digital images of plates (plate image) rather than from the physical plate (plate-in-hand). Studies were conducted to determine:

a) If the interpretation of the digital imaqe of the same plate is reproducible across microbiologists, as this is the method used to generate performance data in support of the current 510(k) application.
b) Whether the plate-in-hand interpretation and plate image interpretation of the same plate are equivalent across microbiologists to determine if a microbiologist can equivalently interpret presumptive MRSA on the plate and the digital image, as this provide confidence that the diqital image interpretation is a true representation of the agar plate interpretation.

5.8.2.1 Point (a) Reproducibility of plate image interpretations

The reproducibility of plate image interpretations was assessed by comparing the individual assessments of plate images by three microbiologists with a single panel result (i.e., majority vote) for each image. Table 5-5 shows the percent agreement of the three microbiologists with the panel result for detection of presumptive MRSA, presumptive non-MRSA, and no growth on each of the BD BBL and TFS Spectra media.

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		Percent Agreement
		No growth	Presumptive non-MRSA	Presumptive MRSA
BD	Microbiologist 1	98.9% (260/263)	97.6% (80/82)	100.0% (55/55)
	Microbiologist 2	100.0% (263/263)	97.6% (80/82)	100.0% (55/55)
	Microbiologist 3	95.4% (251/263)	100.0% (82/82)	100.0% (55/55)
	Combined	98.1% (774/789)	98.4% (242/246)	100.0% (165/165)
TFS/S	Microbiologist 1	98.0% (192/196)	95.1% (98/103)	98.0% (99/101)
	Microbiologist 2	100.0% (196/196)	93.2% (96/103)	97.0% (98/101)
	Microbiologist 3	99.0% (194/196)	97.1% (100/103)	98.0% (99/101)
	Combined	99.0% (582/588)	95.1% (294/309)	97.7% (296/303)

Table 5-5: Microbiologist agreement with panel result

Table 5-5 shows that for BD media, when interpreting growth from digital images, microbiologists agree with the panel 100% of the time for detection of presumptive MRSA, over 97% of the time for presumptive non-MRSA, and over 95% of the time for no growth. Combining (averaging) these results yields 100%, 98.4% and 98.1%, respectively. These results support the use of digital images by a panel of microbiologists to establish a reference result against which the APAS result can be compared.

Table 5-5 shows that for TFS/S media, when interpreting growth from digital images, microbiologists agree with the panel more than 97% of the time for detection of presumptive MRSA, 93% of the time for presumptive non-MRSA, and 98% of the time for no growth. Combining (averaging) these results yields 97.7%, 95.1% and 99.0%, respectively. These results support the use of digital images by a panel of microbiologists to establish a reference result against which the APAS result can be compared.

5.8.2.2 Point (b) Equivalency of Plate-in-Hand vs. Plate Image

The equivalency of plate-in-hand vs. plate image measurements were assessed by measuring the percent of time a microbiologist's interpretations of the plate and image were in agreement for presumptive MRSA and applying an acceptance criterion of 95% for the combined result. In this comparison, the plate-in-hand interpretation is considered to be the truth state.

		Percent Agreement Microbiologist Image vs Plate-in-Hand
		No growth	Presumptive Non-MRSA	Presumptive MRSA
BD	Microbiologist 1	95.8% (252/263)	89.6% (69/77)	91.7% (55/60)
	Microbiologist 2	98.1% (264/269)	98.7% (74/75)	98.2% (55/56)
	Microbiologist 3	95.4% (250/262)	97.6% (82/84)	98.1% (53/54)
	Combined	96.5% (766/794)	95.3% (225/236)	95.9% (163/170)
TFS/S	Microbiologist 1	93.8% (182/194)	87.1% (88/101)	92.4% (97/105)
	Microbiologist 2	96.0% (193/201)	90.8% (89/98)	92.1% (93/101)
	Microbiologist 3	94.2% (180/191)	86.8% (92/106)	96.1% (99/103)
	Combined	94.7% (555/586)	88.2% (269/305)	93.5% (289/309)

Table 5-6: Microbiologist Image vs. Plate-in-hand agreement

Table 5-6 shows that on average, microbiologists interpret the plate image equivalent to the plate-inhand using the BD media >95% of the time for each result designation. Presumptive MRSA

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agreement is >95%, supporting the use of a 2-designation approach (Presumptive MRSA and Negative) with this media.

Table 5-6 shows that on average, microbiologists interpret the plate image equivalent to the plate-inhand using the TFS media <95% of the time for each result designation. Presumptive MRSA agreement is <95%, supporting the use of a 3-designation approach (Presumptive MRSA, Presumptive non-MRSA and Negative) with this media.

5.8.3 Quality Control Test Results

During the IVD and analytical performance studies, quality control tests were conducted using the methods described in the APAS Independence User Manual. Daily instrument checks were conducted for Colour Check and System Check using the tools provided with the instrument and both tests passed on all testing days.

In addition, biological quality control testing was performed using specially prepared positive QC plates as described in the user manuals for each of the analysis modules. These QC plates were prepared from a 0.5 McFarland suspension in saline of S. aureus MRSA ATCC 43300 which was serially diluted with sterile saline to make a suspension containing approximately 105 cells per ml and then inoculated onto BBL™ CHROMagar™ MRSA II plates and Spectra™ MRSA plates using a 10 µL loop for quadrant streaking. The plates were incubated at 36°C ±1°C for 24 hours.

A positive OC was performed for each instrument used per experiment for each day of the IVD study and analytical studies. APAS produced the expected presumptive positive MRSA result in all cases.

Analytical Performance Studies 5.8.4

5.8.4.1 Accuracy - Trueness

This study tested the ability of APAS to correctly detect colonies of MRSA and non-MRSA.

A range of methicillin-resistant Staphylococcus aureus and other non-MRSA organisms that may grow on the media, were used to produce 0.5 McFarland suspensions of pure cultures. These were serially diluted in sterile saline to create suspensions which, when streaked, produced either light or confluent growth. The plates were incubated at 36°C ± 1°C for 24 hours then imaged using APAS. Across the set of images produced for each of the organisms plated, at least 100 isolated colonies were digitally labelled by a microbiologist as displaying the distinctive morphology associated with colonies of MRSA or non-MRSA on the specific agar, where non-MRSA means colonies which will grow on the media but do not react with the chromogen. The APAS result for each colony was compared with the result by the microbiologist.

Table 5-7 shows that APAS with IC MRSA Chromogenic BD analysis module was able to correctly detect the typical morphology associated with MRSA 99.3 % of the time.

		Microbiologist Assigned
All colonies combined		MRSA Colony	Non-MRSA Colony	Total
APAS Assigned	Presumptive MRSAColony	793	23	816
	Presumptive Non-MRSAColony	3	208	211
	Colony Not Detected	2	77	79
	Total	798	308	1106

Table 5-7: Trueness - IC MRSA Chromogenic BD

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Traditional 510(k) APAS Independence with MRSA Analysis Module

	All colonies combined	Microbiologist Assigned
		MRSA Colony	Non-MRSA Colony	Total
Agreement	By colony morphology	99.4%	67.5%
	All colony morphologies	90.5%

Table 5-8 shows that APAS with IC MRSA Chromogenic TFS/S analysis module was able to correctly detect the typical morphology associated with MRSA 99.5% of the time.

Table 5-8: Trueness - IC MRSA Chromogenic TFS/S
-------------------------------------------------	--

	All colonies combined	Microbiologist Assigned
		MRSA Colony	Non-MRSA Colony	Total
APASAssigned	Presumptive MRSA Colony	772	262	1034
	Presumptive Non-MRSAColony	2	226	228
	Colony Not Detected	2	56	58
	Total	776	544	1320
Agreement	By colony morphology	99.5%	41.5%
	All colony morphologies	75.6%

The measured performance of both modules met the performance target of 95%.

5.8.4.2 Accuracy - Precision

The reproducibility of plate interpretation performed by the APAS when installed with each module was evaluated on different instruments over multiple runs. The test determined:

. Repeatability of interpretation within an instrument when the same plate is presented to the imaging system at the same angle and at different angles, and
. Reproducibility of interpretations across instruments.

Testing was performed using 3 dilutions of two strains of MRSA, (one isolated from the wild and one ATCC strain), and 3 dilutions of two strains of Staphylococcus haemolyticus, both of which were isolated from the wild and which will grow on BD and Spectra media but do not react with the chromogen. The dilutions were chosen to produce plates with mainly confluent growth (dilution 1), partially confluent growth (dilution 2) and only isolated colonies (dilution 3), respectively, when 10µL of each dilution is plated using the quadrant streak method. Each dilution was inoculated in triplicate and the plates incubated at 35℃ ± 2℃ for 24 hours. Five replicate images of each plate were taken at 3 different orientations (0°, 120° and 270°) on 3 different APAS Independence instruments.

The results tables report the agreement of the APAS-generated interpretation with the expected outcome (presence or absence of presumptive MRSA (Color) and Growth), along with the agreement across instruments, expressed as a percent. Confidence intervals are calculated for the measure of reproducibility across instruments.

Table 5-9 provides the results for IC MRSA Chromogenic BD Analysis Module and Table 5-10 provides the results for IC MRSA Chromoqenic TFS/S Analysis Module. The results demonstrate reproducibility of APAS-qenerated results with multiple plate orientations and across multiple instruments.

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Image /page/15/Picture/0 description: The image contains the logo for Clever Culture Systems. The logo consists of a red circular icon with a white molecular-like structure inside. To the right of the icon are the words "CLEVER CULTURE" stacked on top of "SYSTEMS" in a bold, sans-serif font. The text is black.

Traditional 510(k) APAS Independence with MRSA Analysis Module

Organism	Dilution	Percent Agreement
			Instrument 1		Instrument 2		Instrument 3	Combined
		Growth1	Color2	Growth1	Color2	Growth1	Color2	Growth1(95% CI)	Color2(95% CI)
MRSA -Wild Strain 1	1	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0% (135/135)97.2%-100.0%	100.0% (135/135)97.2%-100.0%
	2	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0% (135/135)97.2%-100.0%	100.0% (135/135)97.2%-100.0%
	3	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0% (135/135)97.2%-100.0%	100.0% (135/135)97.2%-100.0%
MRSA -ATCC 43300	1	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0% (135/135)97.2%-100.0%	100.0% (135/135)97.2%-100.0%
	2	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0% (135/135)97.2%-100.0%	100.0% (135/135)97.2%-100.0%
	3	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0% (135/135)97.2%-100.0%	100.0% (135/135)97.2%-100.0%
Saline(negative control)		100.0%(45/45)	100.0%(45/45)	97.8%(44/45)	100.0%(45/45)	95.6%(43/45)	100.0%(45/45)	97.8% (132/135)93.7%-99.2%	100.0% (135/135)97.2%-100.0%
S. haemolyticus -Wild Strain 1	1	100.0%(45/45)	80.0%(36/45)	100.0%(45/45)	93.3%(42/45)	100.0%(45/45)	75.6%(34/45)	100.0% (135/135)97.2%-100.0%	83.0% (112/135)75.7%-88.4%
	2	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	97.8%(44/45)	100.0% (135/135)97.2%-100.0%	99.3% (134/135)95.9%-99.9%
	3	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	93.3%(42/45)	100.0% (135/135)97.2%-100.0%	97.8% (132/135)93.7%-99.2%
S. haemolyticusWild Strain 2	1	100.0%(45/45)	80.0%(36/45)	100.0%(45/45)	75.6%(34/45)	100.0%(45/45)	55.6%(25/45)	100.0% (135/135)97.2%-100.0%	70.4% (95/135)62.2%-77.4%
	2	100.0%(45/45)	97.8%(44/45)	100.0%(45/45)	88.9%(40/45)	100.0%(45/45)	82.2%(37/45)	100.0% (135/135)97.2%-100.0%	89.6% (121/135)83.3%-93.7%
	3	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	95.6%(43/45)	100.0% (135/135)97.2%-100.0%	98.5% (133/135)94.8%-99.6%
Organism	Dilution	Percent Agreement
		Instrument 1	Instrument 2	Instrument 3	Combined
		Growth¹	Color²	Growth¹	Color²	Growth¹	Color²	Growth¹ (95% CI)	Color² (95% CI)
MRSA -Wild Strain 2	1	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0% (135/135)97.2%-100.0%	100.0% (135/135)97.2%-100.0%
	2	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0% (135/135)97.2%-100.0%	100.0% (135/135)97.2%-100.0%
	3	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0% (135/135)97.2%-100.0%	100.0% (135/135)97.2%-100.0%
MRSA -ATCC 43300	1	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0% (135/135)97.2%-100.0%	100.0% (135/135)97.2%-100.0%
	2	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0% (135/135)97.2%-100.0%	100.0% (135/135)97.2%-100.0%
	3	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0% (135/135)97.2%-100.0%	100.0% (135/135)97.2%-100.0%
Saline(negative control)	0	66.7%(30/45)	100.0%(45/45)	66.7%(30/45)	100.0%(45/45)	68.9%(31/45)	100.0%(45/45)	67.4% (91/135)59.1%-74.7%	100.0% (135/135)97.2%-100.0%
S. haemolyticus -Wild Strain 1	1	100.0%(45/45)	75.6%(34/45)	100.0%(45/45)	93.3%(42/45)	100.0%(45/45)	95.6%(43/45)	100.0% (135/135)97.2%-100.0%	88.1% (119/135)81.6%-92.6%
	2	100.0%(45/45)	97.8%(44/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	84.4%(38/45)	100.0% (135/135)97.2%-100.0%	94.1% (127/135)88.7%-97.0%
	3	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0% (135/135)97.2%-100.0%	100.0% (135/135)97.2%-100.0%
S. haemolyticus -Wild Strain 2	1	100.0%(45/45)	82.2%(37/45)	100.0%(45/45)	80.0%(36/45)	100.0%(45/45)	82.2%(37/45)	100.0% (135/135)97.2%-100.0%	81.5% (110/135)74.1%-87.1%
	2	100.0%(45/45)	95.6%(43/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	91.1%(41/45)	100.0% (135/135)97.2%-100.0%	95.6% (129/135)90.6%-97.9%
Organism	Dilution	Percent Agreement
		Instrument 1	Instrument 2	Instrument 3	Combined
		Growth1	Color2	Growth1	Color2	Growth1	Color2	Growth1 (95% CI)	Color2 (95% CI)
	3	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0%(45/45)	100.0% (135/135)97.2%-100.0%	100.0% (135/135)97.2%-100.0%

Table 5-9: Precision (Repeatability and Reproducibility) IC MRSA Chromogenic BD

¹ Value calculated by dividing the number of images with (i.e. growth or no growth detected) by the total number of images

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² Value calculated by dividing the number of inal the expected color (i.e. at least one color detected) by the total number of images

CI: confidence interval; LB: lower bound of the 95% CI; UB: upper bound of the 95% CI

Table 5-10: Precision (Repeatability and Reproducibility) IC MRSA Chromogenic TFS/S

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Traditional 510(k) APAS Independence with MRSA Analysis Module

¹ Value calculated by dividing the number of images with (i.e. growth or no growth detected) by the total number of images

² Value calculated by dividing the number of ine expected color (i.e. at least one colored colony or no color detected) by the total number of inages

CI: confidence interval; LB: lower bound of the 95% CI; UB: upper bound of the 95% CI

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5.8.4.3 Analytical Sensitivity - Limit of Detection of Colony Size

A study was conducted to determine the smallest colony size that can be reproducibly detected as presumptive MRSA 95% of the time. The study was conducted using 2 strains of MRSA, one ATCC strain and one wild strain.

Five 10-fold dilutions of a 0.5 McFarland suspension were prepared of each organism and the fifth dilution (approximately 102 CFU/mL) was further diluted 1:2. 100μL of the final dilution was spread onto 6 replicate plates and incubated at 36°C ± 1°C until pinpoint colonies were detected. The plates were then imaged and returned to the incubator at 1-hour intervals until the colonies on the plate were approximately 2mm in diameter.

Selecting from the images at each timepoint, the operator digitally labelled multiple isolated colonies to measure the colony diameter. The image of each plate was then analysed to generate the corresponding APAS result. The smallest colony diameter that was successfully detected for growth and color by APAS >95% of the time was identified as the smallest colony size for each organism (bolded result).

Results of the study demonstrated that the smallest MRSA colony size that can be detected 95% of the time by APAS is 0.82 mm for MRSA wild strain and 0.91 mm for MRSA ATCC 43300 using the BD module (Table 5-11) and 0.63 mm for MRSA wild strain and 0.54 mm for MRSA ATCC 43300 using the TFS/S module (Table 5-12).

Colony Size (Diameter)		Detection Rate¹
Pixels	Extrapolatedmm	MRSA Wild Strain	MRSA ATCC 43300
1-3	0.09-0.27	0.0% (0/399)	0.4% (1/264)
4-5	0.36-0.45	1.5% (4/258)	1.7% (3/175)
6	0.54	5.2% (7/135)	9.7% (9/93)
7	0.63	18.6% (21/113)	22.8% (18/79)
8	0.72	72.5% (66/91)	42.9% (36/84)
9	0.82	95.1% (117/123)	67.6% (50/74)
10	0.91	98.0% (147/150)	97.7% (84/86)
11	1.00	100.0% (130/130)	99.0% (95/96)
12	1.09	100.0% (156/156)	100.0% (90/90)

Table 5-11: LoD of Colony Size - IC MRSA Chromogenic BD

1 Value calculated by dividing the number of presumptive MRSA colonies detected by APAS by the total number of colonies located by a microbiologist.

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Colony Size (Diameter)		Detection Rate1
Pixels	Extrapolatedmm	MRSA Wild Strain 1	MRSA ATCC 43300
1-3	0.09-0.27	0.0% (0/285)	1.8% (3/163)
4-5	0.36-0.45	7.6% (12/159)	43.0% (98/228)
6	0.54	70.8% (63/89)	97.7% (129/132)
7	0.63	98.0% (145/148)	100.0% (100/100)
8	0.72	99.5% (197/198)	100.0% (71/71)
9	0.82	100.0% (167/167)	100.0% (43/43)
10	0.91	100.0% (103/103)	100.0% (12/12)
11	1.00	100.0% (21/21)	100.0% (2/2)

Table 5-12: LoD of Colony Size - IC MRSA Chromogenic TFS/S

1 Value calculated by dividing the number of presumptive MRSA colonies detected by APAS by the total number of colonies located by a microbiologist.

5.8.4.4 Analytical Sensitivity - Detection of MRSA in Mixtures

This test evaluated the ability of APAS to detect small amounts (1-100 colonies) and large amounts (>100 colonies) of MRSA when in the presence of other growth (>100 white colonies) after incubation for 24 hours.

Five, 10-fold dilutions of a 0.5 McFarland suspension were prepared with two strains of MRSA, one strain of S. haemolyticus, and one strain of S. warneri, all of which had been isolated from the wild. A 1:1 mixture and a 1:10 mixture of MRSA with a non-MRSA orqanism were prepared for two different combinations of MRSA and non-MRSA. The plates were incubated at 36℃ ± 1℃ for 24 hours. The images were read and interpreted by APAS and by 3 microbiologists, each of whom recorded the presence or absence of MRSA colonies on the plate. The majority vote was taken as the truth state against which the APAS result was compared.

The results for APAS Independence with IC Chromogenic MRSA BD Analysis Module are shown in Table 5-13 and show that APAS correctly identifies the presence of MRSA colonies ≥95% of the time at 24 hours.

The results for APAS Independence with IC Chromogenic MRSA TFS/S Analysis Module are shown in Table 5-14. and show that APAS correctly identifies the presence of MRSA colonies ≥95% of the time at 24 hours.

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OrganismsPlated	MixtureRatios	CFU		Agreement1
		MRSA	Other	Presence orabsenceof MRSA	Presence orabsenceof Growth
MRSA (Strain 1)S. haemolyticus	1:1	>100	>100	100.0% (5/5)	100.0% (5/5)
	1:100	1-100	>100	100.0% (5/5)	100.0% (5/5)
MRSA (Strain 2)S. warneri	1:1	>100	>100	100.0% (5/5)	100.0% (5/5)
	1:100	1-100	>100	100.0% (5/5)	100.0% (5/5)

Table 5-13: Detection of MRSA in Mixtures - IC MRSA Chromogenic BD

1 Agreement between majority panel microbiologist result (i.e., truth state) and APAS result.

Table 5-14: Detection of MRSA in Mixtures - IC MRSA Chromogenic TFS/S

Organisms Plated	Mixture Ratios	CFU		Agreement1
		MRSA	Other	Presence or absence of MRSA	Presence or absence of Growth
MRSA (Strain 1)S. haemolyticus(Strain 2)	1:1	>100	>100	100.0% (5/5)	100.0% (5/5)
	1:100	1-100	>100	100.0% (5/5)	100.0% (5/5)
MRSA (Strain 2)S. warneri	1:1	>100	>100	100.0% (5/5)	100.0% (5/5)
	1:100	1-100	>100	100.0% (5/5)	100.0% (5/5)

1 Agreement between majority panel microbiologist result (i.e., truth state) and APAS result.

5.8.4.5 Analytical Specificity - Limit of Blank

This test examined the ability of APAS to correctly identify when there is no growth present on the agar, and therefore determine the likelihood of false positives caused by known interferences.

A test matrix of plates with no growth were prepared using 3 different applicators (flocked swab, cotton swab and 10μL loop) to inoculate plates using 3 different media (Stuart Transport, Amies Transport and saline) and no media (dry). The plates were labelled with one of 4 different labels applied to the base or side and were either marked with felt-tip pen or not. The test therefore consisted of a matrix of 96 plates (3 applicators x 4 media x 4 labels x 2 marks).

Table 5-15 shows that for APAS with IC MRSA Chromogenic BD, there was qood agreement that colored colonies indicative of MRSA were not present. The table also shows that growth may be detected, but that it was unlikely to be reported as presumptive MRSA.

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InterferenceMechanism	InterferenceVariable	Total number ofImages evaluated	Agreement thatno growth ispresent (%)1	Agreement that nocolored coloniesare present (%)2
Label Type	Paper, 1D, Base	24	83.3 (20/24)	100.0 (24/24)
Label Type	Paper, 2D, Base	24	79.2 (19/24)	95.8 (23/24)
Label Type	Plastic, 2D, Base	24	75.0 (18/24)	100.0 (24/24)
Label Type	Paper, 1D, Side	24	70.8 (17/24)	100.0 (24/24)
Applicator	Cotton swab	32	65.6 (21/32)	96.9 (31/32)
Applicator	Flocked swab	32	84.4 (27/32)	100.0 (32/32)
Applicator	10uL Loop	32	81.2 (26/32)	100.0 (32/32)
Transport Media	Amies Transport	24	91.7 (22/24)	100.0 (24/24)
Transport Media	Dry	24	75.0 (18/24)	100.0 (24/24)
Transport Media	Saline	24	87.5 (21/24)	100.0 (24/24)
Transport Media	Stuart Transport	24	54.2 (13/24)	95.8 (23/24)
Pen	Present	48	79.2 (38/48)	100.0 (48/48)
Pen	Absent	48	75.0 (36/48)	97.9 (47/48)

Table 5-15: Limit of Blank - IC MRSA Chromogenic BD

1 Value calculated by dividing the number of images with no detected growth by the total number of images

2 Value calculated by dividing the number of images with zero detected colored colonies by the total number of images

Table 5-16 shows that for APAS with IC MRSA Chromogenic TFS/S, there was good agreement that colored colonies indicative of MRSA were not present. The table also shows that growth may be detected, but that it was unlikely to be reported as presumptive MRSA.

Table 5-16: Limit of Blank - IC MRSA Chromogenic TFS/S

InterferenceMechanism	InterferenceVariable	Total number ofImages evaluated	Agreement thatno growth ispresent (%)1	Agreement that nocolored coloniesare present (%)2
Label Type	Paper, 1D, Base	24	58.3 (14/24)	100.0 (24/24)
	Paper, 2D, Base	24	66.7 (16/24)	100.0 (24/24)
	Plastic, 2D, Base	24	54.2 (13/24)	100.0 (24/24)
	Paper, 1D, Side	24	58.3 (14/24)	91.7 (22/24)
Applicator	Cotton swab	32	62.5 (20/32)	100.0 (32/32)
	Flocked swab	32	50.0 (16/32)	93.8 (30/32)
	10uL Loop	32	65.6 (21/32)	100.0 (32/32)
TransportMedia	Amies Transport	24	62.5 (15/24)	95.8 (23/24)
	Dry	24	70.8 (17/24)	100.0 (24/24)
	Saline	24	91.7 (22/24)	100.0 (24/24)
	Stuart Transport	24	12.5 (3/24)	95.8 (23/24)
Pen	Present	48	56.2 (27/48)	97.9 (47/48)
	Absent	48	62.5 (30/48)	97.9 (47/48)

1 Value calculated by dividing the number of images with no detected growth by the total number of images

2 Value calculated by dividing the number of images with zero detected colored colonies by the total number of images

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5.8.4.6 Analytical Specificity - Interference with detection of MRSA

This test evaluated the ability of APAS to correctly detect MRSA in the presence of known interferences and to determine if a heavy growth of non-MRSA is detected by APAS as MRSA, as heavy growth of some non-MRSA orqanisms may display a chromogen reaction.

Pure 0.5 McFarland suspensions of MRSA and S. haemolyticus (representing non-MRSA) were serially diluted to produce an inoculum for each organism which would produce predominantly isolated colonies of MRSA and heavy growth of S. haemolyticus when cultured.

A test matrix of plates per organism was quadrant streaked using 3 different applicators (flocked swab, cotton swab and 10μL loop) to inoculate plates using 2 different media (Stuart Transport and Amies Transport), The plates were labelled with one of 4 different labels applied to the base or side and were either marked with felt-tip pen or not. The test therefore consisted of 48 plates (3 applicators x 2 media x 4 labels x 2 marks) per organism. The inoculated plates were incubated at 36℃ ± 1℃ for 24 hours and then imaged.

The images were processed to generate the APAS report for each plate and then the reported presence or absence of MRSA and non-MRSA were compared with the expected result for growth and color, which was the presence of colored growth and no colored growth, respectively.

The results for APAS Independence with IC MRSA Chromogenic BD Analysis Module are shown in Table 5-17. These results show that the interference modes tested had minimal impact on the ability of APAS to detect the presence of MRSA. The results also show that when a heavy inoculum of S. haemolyticus is present, false positive detections as presumptive MRSA occurred in this interference study.

Organism	InterferenceMechanism	InterferenceVariable	Total number ofImagesevaluated	Agreement withExpected Growth¹(%)	Agreement withExpected Color²(%)
MRSA	Label Type	Paper, 1D,Base	12	100.0 (12/12)	100.0 (12/12)
		Paper, 2D,Base	12	100.0 (12/12)	100.0 (12/12)
		Plastic, 2D,Base	12	100.0 (12/12)	100.0 (12/12)
		Paper, 1D, Side	12	100.0 (12/12)	100.0 (12/12)
	Applicator	Cotton swab	16	100.0 (16/16)	100.0 (16/16)
		Flocked swab	16	100.0 (16/16)	100.0 (16/16)
		10uL Loop	16	100.0 (16/16)	100.0 (16/16)
	TransportMedia	AmiesTransport	24	100.0 (24/24)	100.0 (24/24)
		StuartTransport	24	100.0 (24/24)	100.0 (24/24)
	Pen	Present	24	100.0 (24/24)	100.0 (24/24)
		Absent	24	100.0 (24/24)	100.0 (24/24)
S.haemolyticus (heavygrowth)	Label Type	Paper, 1D,Base	12	100.0 (12/12)	41.7 (5/12)
		Paper, 2D,Base	12	100.0 (12/12)	16.7 (2/12)
		Plastic, 2D,Base	12	100.0 (12/12)	50.0 (6/12)
		Paper, 1D, Side	12	100.0 (12/12)	100.0 (12/12)

Table 5-17: Analytical Specificity - Interference - IC MRSA Chromogenic BD

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Image /page/23/Picture/0 description: The image shows the logo for Clever Culture Systems. The logo consists of a red circle with a white molecular structure inside, followed by the words "CLEVER CULTURE" in bold, black letters on one line, and the word "SYSTEMS" in bold, black letters on the line below. The logo is simple and modern, and the use of red and black gives it a strong and professional look.

Traditional 510(k) APAS Independence with MRSA Analysis Module

InterferenceMechanism	InterferenceVariable	Total number ofImagesevaluated	Agreement withExpected Growth1(%)	Agreement withExpected Color2(%)
Applicator	Cotton swab	16	100.0 (16/16)	43.8 (7/16)
	Flocked swab	16	100.0 (16/16)	50.0 (8/16)
	10uL Loop	16	100.0 (16/16)	62.5 (10/16)
TransportMedia	AmiesTransport	24	100.0 (24/24)	50.0 (12/24)
	StuartTransport	24	100.0 (24/24)	54.2 (13/24)
Pen	Present	24	100.0 (24/24)	50.0 (12/24)
	Absent	24	100.0 (24/24)	54.2 (13/24)

1 Value calculated by dividing the number of images with detected growth by the total number of images

² Value calculated by dividing the number of images where the detection or non-detection of colored colonies matches expectation, by the total number of images

The results for APAS Independence with IC MRSA Chromogenic TFS/S Analysis Module are shown in Table 5-18. These results show that the interference modes tested had minimal impact on the ability of APAS to detect the presence of MRSA. The results also show that the heavy growth of S. haemolyticus did not cause false detections of presumptive MRSA on this media.

		Table 5-18: Analytical Specificity - Interference - IC MRSA Chromogenic TFS/S
--	--	-------------------------------------------------------------------------------	--

Organism	InterferenceMechanism	InterferenceVariable	Total number ofImagesevaluated	Agreement withExpected Growth¹(%)	Agreement withExpected Color²(%)
MRSA	Label Type	Paper, 1D, Base	12	100.0 (12/12)	100.0 (12/12)
		Paper, 2D, Base	12	100.0 (12/12)	100.0 (12/12)
		Plastic, 2D, Base	12	100.0 (12/12)	100.0 (12/12)
		Paper, 1D, Side	12	100.0 (12/12)	100.0 (12/12)
	Applicator	Cotton swab	16	100.0 (16/16)	100.0 (16/16)
		Flocked swab	16	100.0 (16/16)	100.0 (16/16)
		10uL Loop	16	100.0 (16/16)	100.0 (16/16)
	TransportMedia	AmiesTransport	24	100.0 (24/24)	100.0 (24/24)
		StuartTransport	24	100.0 (24/24)	100.0 (24/24)
	Pen	Present	24	100.0 (24/24)	100.0 (24/24)
		Absent	24	100.0 (24/24)	100.0 (24/24)
S.haemolyticus (heavygrowth)	Label Type	Paper, 1D, Base	12	100.0 (12/12)	100.0 (12/12)
		Paper, 2D, Base	12	100.0 (12/12)	100.0 (12/12)
		Plastic, 2D, Base	12	100.0 (12/12)	100.0 (12/12)
		Paper, 1D, Side	12	100.0 (12/12)	91.7 (11/12)
	Applicator	Cotton swab	16	100.0 (16/16)	93.8 (15/16)
		Flocked swab	16	100.0 (16/16)	100.0 (16/16)
		10uL Loop	16	100.0 (16/16)	100.0 (16/16)

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Image /page/24/Picture/0 description: The image contains the logo for Clever Culture Systems. On the left is a red circle with a white abstract design inside. To the right of the circle are the words "CLEVER CULTURE" in bold, black letters on the top line, and "SYSTEMS" in bold, black letters on the bottom line.

Traditional 510(k) APAS Independence with MRSA Analysis Module

Organism	InterferenceMechanism	InterferenceVariable	Total number ofImagesevaluated	Agreement withExpected Growth1(%)	Agreement withExpected Color2(%)
	TransportMedia	AmiesTransport	24	100.0 (24/24)	100.0 (24/24)
		StuartTransport	24	100.0 (24/24)	95.8 (23/24)
Pen		Present	24	100.0 (24/24)	95.8 (23/24)
		Absent	24	100.0 (24/24)	100.0 (24/24)

1 Value calculated by dividing the number of images with detected growth by the total number of images

2 Value calculated by dividing the number of images where the detection or non-detection of colored colonies matches expectation, by the total number of images

IVD Studies 5.8.5

The clinical performance of each analysis module was assessed in a prospective study, where the performance of APAS with each analysis module was evaluated separately aqainst two reference panels of 3 clinical microbiologists interpreting growth from the same APAS-generated digital image.

Device	Agar	Growth interpreted by;
APAS Independence with IC MRSAChromogenic BD Analysis Module	BBL CHROMagar MRSA IIFrom Becton Dickinson	APAS and Reference Panel
APAS Independence with IC MRSAChromogenic TFS/S AnalysisModule	Spectra™ MRSAFrom Thermo Fisher Scientific (Remel)	APAS and Reference Panel

Left-over specimens from standard of care screening culture for colonization with MRSA were collected and inoculated onto chromogenic agar plates at a single site in Australia. The plates were then incubated and imaged with the APAS.

The APAS result for each image was compared against each of two reference results; one panel was located in the USA and the other in Australia. Each reference result was achieved using the majority result from the respective panel of 3 independent microbiologists.

Due to the low positivity rate for MRSA detection in the study population, simulated samples were prepared to supplement the study. The simulated swab samples were spiked with known MRSA and non-MRSA organisms. The use of simulated samples allowed the inclusion of unique strains of MRSA that provided global representation of the most common MRSA clades, including those found in the United States.

The total number of both clinical and simulated samples included in the final analysis for the IC MRSA Chromogenic BD Analysis Module (BD) and IC MRSA Chromogenic TFS/S Analysis Module (TFS/S) from the 1590 enrolled samples is shown in Table 5-19, stratified by the proportions of clinical and simulated samples.

Type	Samples recruited / included	Plates Imaged (BD)	Plates imaged (TFS/S)
PCR- MRSA Negative	1100	1093	1097
PCR- MRSA Positive	25	25	25
Simulated Negative	60	60	60
Simulated Positive	405	395	398
Total	1590	1573	1580

Table 5-19: Number of samples per specimen category

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Each specimen and simulated sample were inoculated onto a culture plate and incubated for 24 hours at 36±1ºC prior to analysis by APAS Independence and by the reference panels.

Performance was assessed by comparing the final interpretation of digital plate images established by the microbiologists (reference method) with the corresponding interpretation by APAS. The primary performance objective was positive percent agreement of presumptive MRSA growth.

Results - IC MRSA Chromogenic BD 5.8.5.1

Of the 1590 samples enrolled in the study, 13 were excluded due to defects in the agar and thus 1573 were analyzed, being 1118 non-simulated samples, 395 simulated MRSA-positive samples and 60 simulated negative MRSA samples. The study results are shown in Table 5-21 and Table 5-22.

Table 5-20: APAS Performance against Australian Reference Panel - IC MRSA Chromogenic BD

		AU Panel Result
		PresumptiveMRSA	Presumptivenon-MRSA	Negative	Total
APAS Result	Presumptive MRSA	393	30	3	426
	Presumptive non-MRSA	0	226	156	382
	Negative	0	11	754	765
	Total	393	267	913	1573
Presumptive MRSAAgreement	100.0% (393/393: 95% CI 99.0% - 100.0%)
Presumptive Non-MRSAAgreement	84.6% (226/267: 95% CI 79.8% - 88.5%)
Negative Agreement	82.6% (754/913: 95% CI 80.0% - 84.9%)

Table 5-21: APAS Performance against US Reference Panel - IC MRSA Chromogenic BD

		US Panel Result
		Presumptive MRSA	Presumptive non-MRSA	Negative	Total
APAS Result	Presumptive MRSA	390	33	3	426
	Presumptive non-MRSA	1	226	155	382
	Negative	0	10	755	765
	Total	391	269	913	1573
Presumptive MRSA Agreement	99.7% (390/391: 95% CI 98.6% - 100.0%)
Presumptive Non-MRSA Agreement	84.0% (226/269: 95% CI 79.2% - 87.9%)
Negative Agreement	82.7% (755/913: 95% CI 80.1% - 85.0%)

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Panel	Population	Statistic	Cases	Correct	Estimate	Lower95% CI	Upper95% CI
US	All	PPA1	391	390	99.7%	98.6%	100.0%
	All	NPA2	1182	1146	97.0%	95.8%	97.8%
	Simulated	PPA	358	358	100.0%	98.9%	100.0%
	Simulated	NPA	97	79	81.4%	72.6%	87.9%
	Non-simulated	PPA	33	32	97.0%	84.7%	99.5%
	Non-simulated	NPA	1085	1067	98.3%	97.4%	98.9%
AU	All	PPA	393	393	100.0%	99.0%	100.0%
	All	NPA	1180	1147	97.2%	96.1%	98.0%
	Simulated	PPA	359	359	100.0%	98.9%	100.0%
	Simulated	NPA	96	79	82.3%	73.5%	88.6%
	Non-simulated	PPA	34	34	100.0%	89.8%	100.0%
	Non-simulated	NPA	1084	1068	98.5%	97.6%	99.1%

Table 5-22. Presumptive MRSA agreement results stratified by sample type – IC MRSA Chromogenic BD

1 Positive percent agreement with the panel that presumptive MRSA is present

2Negative percent agreement. APAS agreement with the panel that presumptive MRSA is absent

5.8.5.2 Results - IC MRSA Chromogenic TFS/S

Of the 1590 samples enrolled in the study, 10 were excluded due to defects in the agar so that a total of 1580 was analyzed, being 1122 non-simulated samples, 398 simulated MRSA-positive samples and 60 simulated negative MRSA samples.

The study results are shown in Table 5-23 Table 5-24 and Table 5-25

Table 5-23: Performance against Australian Reference Panel - IC MRSA Chromogenic TFS/S

	AU Panel Result
		Presumptive MRSA	Presumptive non-MRSA	Negative	Total
APAS Result	Presumptive MRSA	476	69	1	546
	Presumptive non-MRSA	3	383	116	502
	Negative	1	5	526	532
	Total	480	457	643	1580
Presumptive MRSA Agreement		99.2% (476/480: 95% CI 97.9% - 99.7%)
Presumptive Non-MRSA Agreement		83.8% (383/457: 95% CI 80.2% - 86.9%)
Negative Agreement		81.8% (526/643: 95% CI 78.6% - 84.6%)

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			US Panel Result
			PresumptiveMRSA	Presumptivenon-MRSA	Negative	Total
APAS Result	Presumptive MRSA	434	110	2	546
	Presumptive non-MRSA	1	369	132	502
	Negative	1	4	527	532
Total		436	483	661	158
Presumptive MRSAAgreement		99.5% (434/436: 95% CI 98.3% - 99.9%)
Presumptive Non-MRSAAgreement		76.4% (369/483: 95% CI 72.4% - 80.0%)
Negative Agreement		79.7% (527/661; 95% CI 76.5% - 82.6%)

Table 5-24: Performance against US Reference Panel - IC MRSA Chromogenic TFS/S

Table 5-25: Presumptive MRSA agreement stratified by sample type for MRSA performance – IC MRSA Chromogenic TFS/S

Panel	Population	Statistic	Cases	Correct	Estimate	Lower 95% CI	Upper 95% CI
All	All	PPA1	436	434	99.5%	98.3%	99.9%
	All	NPA2	1144	1032	90.2%	88.4%	91.8%
US	Simulated	PPA	362	362	100.0%	98.9%	100.0%
		NPA	96	88	91.7%	84.4%	95.7%
US	Non-simulated	PPA	74	72	97.3%	90.7%	99.3%
		NPA	1048	944	90.1%	88.1%	91.7%
AU	All	PPA	479	475	99.2%	97.9%	99.7%
	All	NPA	1101	1030	93.6%	91.9%	94.9%
AU	Simulated	PPA	362	362	100.0%	98.9%	100.0%
		NPA	96	88	91.7%	84.4%	95.7%
AU	Non-simulated	PPA	117	113	96.6%	91.5%	98.7%
		NPA	1005	942	93.7%	92.1%	95.1%

1 Positive percent agreement with the panel that presumptive MRSA is present 2Negative percent agreement. APAS agreement with the panel that presumptive MRSA is absent

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5.8.5.3 Agreement between the Australian and US reference panels

An analysis of the results from the Australian and US panels of microbiologists was performed to determine the extent of agreement in interpretation of the same digital images. This data is presented in Table 5-26 and Table 5-27 where the AU panel result is treated as being the truth.

		AU Microbiologist panel
		MRSA Growth	Non-MRSA Growth	No growth	Total
US Microbiologist panel	MRSA Growth	390	1	0	391
	Non-MRSA Growth	3	253	13	269
	No growth	0	13	900	913
	Total	393	267	913	1573
Agreement - PresumptiveMRSA	99.2% (390/393: 95% CI 97.8% - 99.7%)
Agreement - PresumptiveNon-MRSA	94.8% (253/267: 95% CI 91.4% - 96.9%)
Agreement - No growth	98.6% (900/913: 95% CI 97.6% - 99.2%)

Table 5-26: Aqreement of US panel with Australian panel - images of BD plates

Table 5-27: Agreement of US panel with Australian panel - images of TFS plates

		AU Microbiologist
		MRSA Growth	Non-MRSA Growth	No growth	Total
US Microbiologist	MRSA Growth	435	1	0	436
	Non-MRSA Growth	45	432	6	483
	No growth	0	24	637	661
	Total	480	457	643	1580
Agreement - PresumptiveMRSA	90.6% (435/480: 95% CI 87.7% - 92.9%)
Agreement - PresumptiveNon-MRSA	94.5% (432/457: 95% CI 92.0% - 96.3%)
Agreement - No growth	99.1% (637/643: 95% CI 98.0% - 99.6%)

The tables show that the US panel had 99.8% agreement with the Australian panel for presumptive MRSA when interpreting images of BD plates and 90.6% agreement for images of TFS plates, indicating that the Australian panel reported more MRSA than the US panel.

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Image /page/29/Picture/0 description: The image features the logo for Clever Culture Systems, which includes a stylized red atom-like graphic to the left of the company name. To the right of the logo is the text "Traditional 510(k) APAS Independence with MRSA Analysis Module". The text describes the company's focus on traditional 510(k) APAS independence and its MRSA analysis module.

5.9 Conclusions

5.9.1 2 vs 3 Designation Rule Set

The overall performances for the BD MRSA and TFS/S MRSA analysis modules have been evaluated to determine the possible claims that could be supported and how performance issues could be mitigated. As a result, considering data and supportive metrics from other studies, it was concluded that either a two-designation rule set (i.e., presumptive MRSA growth and negative) or a threedesignation rule set (i.e., presumptive MRSA growth, presumptive non-MRSA growth, and negative) would be appropriate.

The overall performance of the BD MRSA analysis module for detection of presumptive MRSA growth (both in the analytical studies and clinical study) is acceptable to support a two-designation rule set (i.e., presumptive MRSA growth and negative). As such, only plates with "presumptive MRSA growth" require review by a microbiologist. The acceptability of the two-designation rule set is based on the following performance metrics:

95% agreement for "presumptive MRSA growth" (95.9%, Table 5-6) in the digital image ● quality study
98% agreement for "presumptive MRSA growth" in the Australian (100.0%, Table 5-20) and . US clinical studies (99.7%, Table 5-21)
95% agreement for "presumptive MRSA growth" when comparing the Australian and US . microbiologist panel results (99.2%, Table 5-26)

The overall performance of the TFS/S MRSA analysis modules for detection of presumptive MRSA growth (both in the analytical studies and clinical study) is acceptable to support a three-designation rule set (i.e., presumptive MRSA growth, presumptive non-MRSA growth, and negative). As such, all plates with growth ("presumptive MRSA growth" or "presumptive non-MRSA growth) require review by a microbiologist. The acceptability of the three-designation rule set is based on the following performance metrics:

<95% agreement for "presumptive MRSA growth" (93.5%, Table 5-6) in the digital image . quality study
98% agreement for "presumptive MRSA growth" in the Australian reference panel (99.2%, . Table 5-23) and US clinical studies (99.5%, Table 5-24)
. <95% agreement for "presumptive MRSA growth" when comparing the Australian and US microbiologist panel results (90.6%, Table 5-27)

Substantial Equivalence 5.9.2

Both APAS Independence with IC MRSA Chromogenic BD Analysis Module and APAS Independence with IC MRSA Chromogenic TFS/S Analysis Module have equivalent safety and effectiveness to the predicate device, APAS Independence with Urine Analysis Module (K183648) because:

. They have the same intended use.
The technological characteristics are very similar.
The differences in technological characteristics do not raise different questions about safety . and effectiveness.
. The same questions of safety and effectiveness are addressed by fulfilling the requirements of the Special Controls for automated image assessment systems for microbial colonies on solid culture media.
The safety and effectiveness of the MRSA modules compared with the urine module has been ● assured by applying the same 98% Positive Percent Agreement target for the decision point where a microbiologist review is required. For urine analysis and IC MRSA Chromogenic

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Image /page/30/Picture/0 description: The image shows the logo for Clever Culture Systems, which includes a red circular icon with a white design inside. Next to the icon, the text "CLEVER CULTURE SYSTEMS" is written in bold, black letters. Below the logo is the text "Traditional 510(k) APAS Independence with MRSA Analysis Module".

TFS/S, the decision is whether growth is present on the agar. For IC MRSA Chromogenic BD, the decision is whether chromogen activation is detected, indicating a presumptive MRSA result.

Regulation Number and Section

§ 866.2190 Automated image assessment system for microbial colonies on solid culture media.

(a)
Identification. An automated image assessment system for microbial colonies on solid culture media is a system that is intended to assess the presence or absence of microbial colonies on solid microbiological culture medium, and to interpret their number, and phenotypic and morphologic characteristics through analysis of two dimensional digital images as an aid in diagnosis of infectious disease.(b)
Classification. Class II (special controls). The special controls for this device are:(1) Premarket notification submissions must include a detailed description of the device, including the technology employed, components and software modules, as well as a detailed explanation of the result algorithms and any expert rules that are used to assess colony characteristics and enumerate colonies from image capture through end result.
(2) Premarket notification submissions must include detailed documentation of the analytical studies performed to characterize device performance to support the intended use, as appropriate.
(3) Premarket notification submissions must include detailed documentation from clinical studies performed on a population that is consistent with the intended use population.
(i) The clinical studies must establish the device performance based on comparison to results obtained by an acceptable reference method, as appropriate.
(ii) The clinical study documentation must include the study protocol with a predefined statistical analysis plan and the final report documenting support for the Indications for Use and the results of the statistical analysis, as appropriate.
(4) Premarket notification submissions must include detailed documentation for device software, including but not limited to software applications and hardware based components that incorporate software, and any decision-making thresholds used to generate results for the device. If a part of a Total Laboratory Automation System, the premarket notification submission must include detailed documentation addressing the instrument and software system integration.
(5) Premarket notification submissions must include detailed documentation of appropriate instructions for use regarding the intended user's device quality control procedures for the instrument system and components, as appropriate.
(6) The 21 CFR 809.10 compliant device labeling must include:
(i) Detailed user instructions to mitigate the risk of failure to operate the instrument correctly.
(ii) A detailed explanation of the interpretation of results and limitations regarding the need for review of culture plates by a qualified microbiologist, as appropriate.
(iii) A summary of performance data obtained from the analytical studies used to support device performance, as appropriate.
(iv) A summary of performance data obtained from clinical studies performed on a population that is consistent with the intended use population, as appropriate.
(7) Under 21 CFR 820.30 compliant design control, device manufacturers must, as appropriate:
(i) Conduct human factors/usability validation testing with the final version of the labeling and related materials to adequately mitigate the risk of failure to operate the instrument correctly.
(ii) Document a device training program that will be offered to the end user to adequately mitigate the risk of failure to operate the instrument correctly.