Predicate Devices

Reference Devices

Not Found

AI/ML (Artificial Intelligence / Machine Learning)

No
The description focuses on automated RT-PCR technology and standard data analysis for qualitative detection, with no mention of AI or ML algorithms for interpretation or processing.

Therapeutic

No
The device is an in vitro diagnostic test for detecting viral RNA, aiding in diagnosis, but it does not treat or cure any condition.

Diagnostic

Yes.
The "Intended Use / Indications for Use" section states that the test "aids in the diagnosis of COVID-19, influenza and/or RSV infections." The "Device Description" also explicitly calls it an "in vitro diagnostic test".

SaMD (Software as a Medical Device)

No

The device description clearly states that the Xpert Xpress CoV-2/Flu/RSV plus test is an automated in vitro diagnostic test performed on GeneXpert Instrument Systems, which consist of an instrument, computer, and preloaded software. It also mentions the use of single-use disposable cartridges containing reagents. This indicates the device is a system that includes hardware components (instrument, computer, cartridges) in addition to software.

IVD (In Vitro Diagnostic)

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

The "Device Description" explicitly states: "The Xpert Xpress CoV-2/Flw/RSV plus test is an automated in vitro diagnostic test for the simultaneous qualitative detection and differentiation of SARS-CoV-2, Flu A, Flu B, and RSV viral RNA..."

Furthermore, the "Intended Use / Indications for Use" describes the test as being performed on specimens collected from individuals to aid in the diagnosis of infections, which is a typical characteristic of an in vitro diagnostic device.

PCCP (Predetermined Change Control Plan) Authorized

N/A

Overview

Intended Use / Indications for Use

The Xpert Xpress CoV-2/Flu/RSV plus test, performed on the GeneXpert Infinity Systems, is an automated multiplexed real-time reverse transcriptase chain reaction (RT-PCR) test intended for use in viro qualitative detection and differentiation of severe acute respiratory syndrome coronavirus (SARS-CoV-2), influenza B, and/or respiratory syncytial virus (RSV) viral RNA in nasopharyngeal swab specimens collected from individuals with signs and symptoms of respiratory tract infection. Clinical signs and symptoms of respiratory tract infection due to SARS-CoV-2, influenza A, influenza B, and RSV can be similar.

The Xpert Xpress CoV-2/Flu/RSV plus is intended for use in the differential detection of SARS-CoV-2, influenza B and or RSV RNA and aids in the diagnosis of COVID-19, influenza and/or RSV infections if used in conjunction with other clinical and epidemiological information, and laboratory findings. SARS-CoV-2, influenza B, and RSV viral RNA are generally detectable in nasopharyngeal swab anterior nasal swab specimens during the acute phase of infection.

Positive results are indicative of the identified virus, but do not rule out bacterial infection or co-infection with other pathogens not detected by the test. The agent(s) detected by the Xpert Xpress COV-2/Flu/RSV plus test may not be the definite cause of disease.

Negative results do not preclude SARS-CoV-2, influenza B, and/or RSV infection. The results of this test should not be used as the sole basis for diagnosis, treatment, or other patient management decisions.

Product codes

QOF, OOI

Device Description

The Xpert Xpress CoV-2/Flw/RSV plus test is an automated in vitro diagnostic test for the simultaneous qualitative detection and differentiation of SARS-CoV-2, Flu A, Flu B, and RSV viral RNA in nasopharyngeal swab (NPS) and anterior nasal swab (NS) specimens collected from individuals showing signs and symptoms of respiratory viral infection.

The Xpert Xpress CoV-2/Flu/RSV plus test is performed on GeneXpert Instrument Systems (GeneXpert Dx, GeneXpert Infinity-48s and GeneXpert Infinity-80 systems), which consist of an instrument, computer, and preloaded software for running tests and viewing the results. The GeneXpert Instrument Systems automate and integrate sample preparation, nucleic acid extraction and amplification, and detection of the target sequences in simple or complex samples using real-time reverse transcription (RT)-polymerase chain reaction (PCR) and PCR assays. Depending on the instrument, the GeneXpert Instrument Systems can have from 1 and up to 80 randomly accessible modules, each capable of performing separate sample preparation and real-time RT-PCR and PCR tests. Each module contains a syringe drive for dispensing fluids (i.e., the syringe drive activates the plunger that works in concert with the rotary valve in the cartridge to move fluids between chambers), an ultrasonic horn for lysing cells or spores, and a proprietary I-CORE® thermocycler for performing real-time RT-PCR and PCR as well as detection. The systems require the use of single-use disposable cartridges that hold the RT-PCR reagents and host sample purification, nucleic acid amplification, and detection of the target sequences. Because the cartridges are selfcontained, cross-contamination between samples is minimized.

The Xpert Xpress CoV-2/Flu/RSV plus test includes reagents for the detection of SARS-CoV-2, Flu A. Flu B and RSV viral RNA from NPS and NS specimens. The primers and probes in the Xpert Xpress CoV-2/Flu/RSV plus test are designed to amplify and detect unique sequences in the genes that encode the following proteins: SARS-CoV-2 nucleocapsid (N), SARS-CoV-2 envelope (E), SARS-CoV-2 RNA-dependent RNA polymerase (RdRP), influenza A matrix (M), influenza A basic polymerase (PB2), influenza A acidic protein (PA), influenza B matrix (M), influenza B non-structural protein (NS), and the RSV A and RSV B nucleocapsid. A Sample Processing Control (SPC) and a Probe Check Control (PCC) are also included in the cartridge utilized by the GeneXpert instrument. The SPC is present to control for adequate processing of the sample and to monitor for the presence of potential inhibitor(s) in the RT-PCR reaction. The SPC also ensures that the RT-PCR reaction conditions (temperature and time) are appropriate for the amplification reaction and that the RT-PCR reagents are functional. The PCC verifies reagent rehydration, PCR tube filling, and confirms that all reaction components are present in the cartridge including monitoring for probe integrity and dye stability.

The Xpert Xpress CoV-2/Flu/RSV plus test is designed for use with NPS or NS specimens collected with nylon flocked swabs and placed into viral transport medium (VTM), Universal Transport Medium (UTM), or eNAT®. The ancillary specimen collection kits, swabs and transport media validated for use with the Xpert Xpress CoV-2/Flu/RSV plus test included:

. Nasopharyngeal Sample Collection Kit for Viruses

Copan UTM® 3C057N (Flexible Minitip Flocked Swab with UTM® Medium о without Beads)
Copan eNAT® Molecular Collection and Preservation Medium P/N O 6U074S01 (Flexible Minitip Flocked Swab with eNAT® Medium)
Becton Dickinson Universal Viral Transport Kit P/N 220531 (Flexible Minitip O Flocked Swab with UVT Medium)
Nasal Sample Collection Kit for Viruses .
- Copan UTM® 3C064N (Regular Flocked Swab with UTM® Medium without o Beads)
- Copan eNAT® Molecular Collection and Preservation Medium P/N O 6U073S01 (Regular Flocked Swab with eNAT® Medium)
Alternatively, swabs and transport media can be obtained separately: ●
- Nylon flocked swab (Copan P/N 502CS01, 503CS01) O
- Viral transport medium, 3 mL (Copan P/N 330C, 3C047N, BD Universal o Transport Medium, Remel M4RT or Remel M5)

These ancillary reagents allow NPS and NS specimens from patients to be collected, preserved and transported to laboratory prior to analysis with the Xpert Xpress CoV-2/Flu/RSV plus test.

Mentions image processing

Not Found

Mentions AI, DNN, or ML

Not Found

Input Imaging Modality

Not Found

Anatomical Site

nasopharyngeal swab (NPS) and anterior nasal swab (NS) specimens

Indicated Patient Age Range

Not Found

Intended User / Care Setting

Not Found

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

Not Found

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

The clinical performance of the Xpert Xpress CoV-2/Flu/RSV plus test was evaluated in a multi-site, observational and method comparison study that included 33 geographically diverse sites in the United States (US) using specimens collected from individuals showing signs and symptoms of respiratory infection. Of the 33 sites participated in specimen collection only, 27 performed Xpert testing and specimen collection, and 1 site performed Xpert testing as well as comparator and discrepant testing.

Specimens tested included prospective clinical NPS and NS specimens collected in UTM/VTM. Prospectively collected fresh clinical specimens (Category I) tested in the study were from a larger US specimen collection protocol. Fresh (98.9%) and frozen (1.1%) specimens meeting the eligibility criteria were prospectively collected and tested in 2022. Due to low prevalence of Flu/RSV in 2022, archived prospectively collected frozen clinical specimens (Category II) collected during the 2016-2017 influenza season were used to supplement the sample size. These specimens represent contemporary Flu/RSV strains. Since these specimens were collected prior to the COVID-19 pandemic, they were expected to be negative for SARS-CoV-2 and therefore tested only for the Flu A, Flu B, and RSV targets.

Specimens were tested using Xpert Xpress CoV-2/Flu/RSV plus side-by-side with a U.S.FDA-cleared molecular respiratory panel that includes SARS-CoV-2 and a U.S. FDAcleared molecular Flu A/B/RSV assay, in a randomized and blinded fashion.

Positive Percent Agreement (PPA) and Negative Percent Agreement (NPA), and nondeterminate rate were determined by comparing the results of the Xpert Xpress CoV-2/Flu/RSV plus test relative to the results of a U.S. FDA-cleared molecular respiratory panel for the SARS-CoV-2 target, and a U.S.FDA-cleared molecular Flu A/B/RSV assay for the Flu A, Flu B, and RSV targets, respectively.

Discrepant results between Xpert Xpress CoV-2/Flu/RSV plus and the comparator for the SARS-CoV-2 target were investigated using a U.S. FDA EUA SARS-CoV-2 molecular test. Discrepant results between the Xpert Xpress CoV-2/Flu/RSV plus and the comparator for the Flu A/B/RSV targets were investigated using a U.S. FDA-cleared molecular respiratory panel.

A total of 5051 specimens, including 2536 NPS and 2515 NS specimens that vielded valid results by both the Xpert Xpress CoV-2/Flu/RSV plus and the U.S. FDA-cleared molecular respiratory panel were included in the performance evaluation for SARS-CoV-2. A total of 5954 specimens, including 3011 NPS and 2943 NS (specimens that yielded valid results by both the Xpert Xpress CoV-2/Flu/RSV plus and the U.S. FDA-cleared molecular Flu A/B/RSV assay were included in the performance evaluation for Flu A, Flu B, and RSV targets.

Summary of Performance Studies

Study Type: Analytical performance studies (Analytical Sensitivity/Limit of Detection, Analytical Reactivity (Inclusivity), Analytical Specificity (Exclusivity), Microbial Interference, Competitive Interference, Potentially Interfering Substances, Carryover Contamination, Single-Site Precision, Reproducibility) and Clinical Performance.

Sample Size:
Analytical Sensitivity: 20 replicates per virus/lot combination.
Analytical Reactivity (Wet-testing): 3 replicates for each strain. Total 102 respiratory viral strains (18 SARS-CoV-2, 69 influenza, 15 RSV).
Analytical Specificity (Wet Testing): 3 replicates of each microorganism pool.
Microbial Interference: 8 replicates of positive samples for each target virus and each potential microbial interference strain combination.
Competitive Interference: 3 replicates for each target strain and each competitive strain combination.
Potentially Interfering Substances: 8 replicates for positive and negative samples for each substance tested.
Carryover Contamination: 40 positive and 42 negative samples.
Single-Site Precision: 80 observations per panel member (negative, 4 low positive, 4 moderate positive).
Reproducibility: 144 observations per panel member (negative, 4 low positive, 4 moderate positive) across 3 sites, 2 operators, and 3 lots.
Clinical Performance: 5051 specimens (2536 NPS, 2515 NS) for SARS-CoV-2 and 5954 specimens (3011 NPS, 2943 NS) for Flu A, Flu B, and RSV.

Standalone Performance: Not applicable, as results are compared to predicate or reference devices.

Key Results:
Analytical Sensitivity (LoD):
NPS Matrix: SARS-CoV-2 (USA-WA1/2020) 138 copies/mL, 1st WHO International Standard 94 IU/mL, Flu A/Idaho/07/2018 0.007 TCID50/mL, Flu A/California/07/2009 0.0022 TCID50/mL, Flu B/Washington/2/2019 12.9 CEID50/mL, RSV A/2/Australia/61 0.33 TCID50/mL, RSV B/9320/MA/77 0.37 TCID50/mL, etc.
NS Matrix: SARS-CoV-2 (USA-WA1/2020) 64 copies/mL, 1st WHO International Standard 143 IU/mL, Flu A/Idaho/07/2018 0.012 TCID50/mL, Flu A/California/07/2009 0.0028 TCID50/mL, Flu B/Washington/2/2019 26.3 CEID50/mL, RSV A/2/Australia/61 0.28 TCID50/mL, RSV B/9320/MA/77 0.27 TCID50/mL, etc.

Analytical Reactivity (Inclusivity): All 102 SARS-CoV-2, Flu, and RSV strains tested positive in all 3 replicates.

Analytical Specificity (Exclusivity): 100% analytical specificity (no cross-reactivity with 48 common respiratory microorganisms and human coronaviruses tested in wet-testing or predicted by in silico analysis).

Microbial Interference: No microbial interference observed for 10 potentially interfering microorganisms.

Competitive Interference: Flu A/Idaho/07/2018 at >1.7e5 RNA copies/mL inhibited detection of Flu B at 3x LoD. Flu A/Idaho/07/2018 at >1.7e6 RNA copies/mL inhibited detection of RSV A at 3x LoD. SARS-CoV-2 at >1e5 RNA copies/mL inhibited detection of Flu B at 3x LoD. No other competitive interference observed.

Potentially Interfering Substances: Interference observed with FluMist at 6.7e-4% (v/v) for SARS-CoV-2, RSV A, RSV B; human PBMC at 1 x 10^6 cells/mL for Flu B; snuff at 1% (w/v) for Flu A and Flu B; Zicam at 15% (w/v) for Flu A, Flu B, and RSV A. Interference was mitigated at lower concentrations of these substances.

Carryover Contamination: No specimen or amplicon carry-over contamination observed. All 40 positive samples correctly reported, and all 42 negative samples correctly reported.

Single-Site Precision: Agreement rates ranged from 96.3% to 100% for low positive and 100% for moderate positive samples across all targets. Negative samples showed 100% agreement.

Reproducibility: Overall percent agreement for all samples ranged from 98.6% to 100%.

Clinical Performance:
NPS Specimens:
SARS-CoV-2: PPA 97.1% (95%CI: 95.1-98.2), NPA 98.2% (95%CI: 97.5-98.7)
Flu A: PPA 99.0% (95%CI: 96.3-99.7), NPA 99.1% (95%CI: 98.7-99.4)
Flu B: PPA 96.6% (95%CI: 88.5-99.1), NPA 100% (95%CI: 99.9-100.0)
RSV: PPA 98.6% (95%CI: 92.5-99.8), NPA 100% (95%CI: 99.9-100.0)
Initial non-determinate rate for NPS: 2.4%; final: 0.3%.

NS Specimens:
SARS-CoV-2: PPA 98.2% (95%CI: 96.6-99.1), NPA 98.8% (95%CI: 98.3-99.2)
Flu A: PPA 98.0% (95%CI: 95.0-99.2), NPA 99.3% (95%CI: 99.0-99.6)
Flu B: PPA 100% (95%CI: 89.8-100.0), NPA 99.9% (95%CI: 99.7-100.0)
RSV: PPA 95.8% (95%CI: 88.5-98.6), NPA 100% (95%CI: 99.9-100.0)
Initial non-determinate rate for NS: 2.4%; final: 0.6%.

Co-infection rates for Xpert Xpress CoV-2/Flu/RSV plus were 0.3% (3/1200) for 2022 specimens (SARS-CoV-2, Flu A, RSV targets) and 1.7% (11/652) for 2016-2017 & 2022 specimens (Flu A, Flu B, RSV targets).

Key Metrics

Positive Percent Agreement (PPA), Negative Percent Agreement (NPA), Confidence Interval (CI), Limit of Detection (LoD), Coefficient of Variation (%CV).

Predicate Device(s)

BioFire Respiratory Panel 2.1 (DEN200031)

Reference Device(s)

Not Found

Predetermined Change Control Plan (PCCP) - All Relevant Information

Not Found

Regulation Number and Section

§ 866.3981 Device to detect and identify nucleic acid targets in respiratory specimens from microbial agents that cause the SARS-CoV-2 respiratory infection and other microbial agents when in a multi-target test.

(a)
Identification. A device to detect and identify nucleic acid targets in respiratory specimens from microbial agents that cause the SARS-CoV-2 respiratory infection and other microbial agents when in a multi-target test is an in vitro diagnostic device intended for the detection and identification of SARS-CoV-2 and other microbial agents when in a multi-target test in human clinical respiratory specimens from patients suspected of respiratory infection who are at risk for exposure or who may have been exposed to these agents. The device is intended to aid in the diagnosis of respiratory infection in conjunction with other clinical, epidemiologic, and laboratory data or other risk factors.(b)
Classification. Class II (special controls). The special controls for this device are:(1) The intended use in the labeling required under § 809.10 of this chapter must include a description of the following: Analytes and targets the device detects and identifies, the specimen types tested, the results provided to the user, the clinical indications for which the test is to be used, the specific intended population(s), the intended use locations including testing location(s) where the device is to be used (if applicable), and other conditions of use as appropriate.
(2) Any sample collection device used must be FDA-cleared, -approved, or -classified as 510(k) exempt (standalone or as part of a test system) for the collection of specimen types claimed by this device; alternatively, the sample collection device must be cleared in a premarket submission as a part of this device.
(3) The labeling required under § 809.10(b) of this chapter must include:
(i) A detailed device description, including reagents, instruments, ancillary materials, all control elements, and a detailed explanation of the methodology, including all pre-analytical methods for processing of specimens;
(ii) Detailed descriptions of the performance characteristics of the device for each specimen type claimed in the intended use based on analytical studies including the following, as applicable: Limit of Detection, inclusivity, cross-reactivity, interfering substances, competitive inhibition, carryover/cross contamination, specimen stability, precision, reproducibility, and clinical studies;
(iii) Detailed descriptions of the test procedure(s), the interpretation of test results for clinical specimens, and acceptance criteria for any quality control testing;
(iv) A warning statement that viral culture should not be attempted in cases of positive results for SARS-CoV-2 and/or any similar microbial agents unless a facility with an appropriate level of laboratory biosafety (
e.g., BSL 3 and BSL 3+, etc.) is available to receive and culture specimens; and(v) A prominent statement that device performance has not been established for specimens collected from individuals not identified in the intended use population (
e.g., when applicable, that device performance has not been established in individuals without signs or symptoms of respiratory infection).(vi) Limiting statements that indicate that:
(A) A negative test result does not preclude the possibility of infection;
(B) The test results should be interpreted in conjunction with other clinical and laboratory data available to the clinician;
(C) There is a risk of incorrect results due to the presence of nucleic acid sequence variants in the targeted pathogens;
(D) That positive and negative predictive values are highly dependent on prevalence;
(E) Accurate results are dependent on adequate specimen collection, transport, storage, and processing. Failure to observe proper procedures in any one of these steps can lead to incorrect results; and
(F) When applicable (
e.g., recommended by the Centers for Disease Control and Prevention, by current well-accepted clinical guidelines, or by published peer-reviewed literature), that the clinical performance may be affected by testing a specific clinical subpopulation or for a specific claimed specimen type.(4) Design verification and validation must include:
(i) Detailed documentation, including performance results, from a clinical study that includes prospective (sequential) samples for each claimed specimen type and, as appropriate, additional characterized clinical samples. The clinical study must be performed on a study population consistent with the intended use population and compare the device performance to results obtained using a comparator that FDA has determined is appropriate. Detailed documentation must include the clinical study protocol (including a predefined statistical analysis plan), study report, testing results, and results of all statistical analyses.
(ii) Risk analysis and documentation demonstrating how risk control measures are implemented to address device system hazards, such as Failure Modes Effects Analysis and/or Hazard Analysis. This documentation must include a detailed description of a protocol (including all procedures and methods) for the continuous monitoring, identification, and handling of genetic mutations and/or novel respiratory pathogen isolates or strains (
e.g., regular review of published literature and periodic in silico analysis of target sequences to detect possible mismatches). All results of this protocol, including any findings, must be documented and must include any additional data analysis that is requested by FDA in response to any performance concerns identified under this section or identified by FDA during routine evaluation. Additionally, if requested by FDA, these evaluations must be submitted to FDA for FDA review within 48 hours of the request. Results that are reasonably interpreted to support the conclusion that novel respiratory pathogen strains or isolates impact the stated expected performance of the device must be sent to FDA immediately.(iii) A detailed description of the identity, phylogenetic relationship, and other recognized characterization of the respiratory pathogen(s) that the device is designed to detect. In addition, detailed documentation describing how to interpret the device results and other measures that might be needed for a laboratory diagnosis of respiratory infection.
(iv) A detailed device description, including device components, ancillary reagents required but not provided, and a detailed explanation of the methodology, including molecular target(s) for each analyte, design of target detection reagents, rationale for target selection, limiting factors of the device (
e.g., saturation level of hybridization and maximum amplification and detection cycle number, etc.), internal and external controls, and computational path from collected raw data to reported result (e.g., how collected raw signals are converted into a reported signal and result), as applicable.(v) A detailed description of device software, including software applications and hardware-based devices that incorporate software. The detailed description must include documentation of verification, validation, and hazard analysis and risk assessment activities, including an assessment of the impact of threats and vulnerabilities on device functionality and end users/patients as part of cybersecurity review.
(vi) For devices intended for the detection and identification of microbial agents for which an FDA recommended reference panel is available, design verification and validation must include the performance results of an analytical study testing the FDA recommended reference panel of characterized samples. Detailed documentation must be kept of that study and its results, including the study protocol, study report for the proposed intended use, testing results, and results of all statistical analyses.
(vii) For devices with an intended use that includes detection of Influenza A and Influenza B viruses and/or detection and differentiation between the Influenza A virus subtypes in human clinical specimens, the design verification and validation must include a detailed description of the identity, phylogenetic relationship, or other recognized characterization of the Influenza A and B viruses that the device is designed to detect, a description of how the device results might be used in a diagnostic algorithm and other measures that might be needed for a laboratory identification of Influenza A or B virus and of specific Influenza A virus subtypes, and a description of the clinical and epidemiological parameters that are relevant to a patient case diagnosis of Influenza A or B and of specific Influenza A virus subtypes. An evaluation of the device compared to a currently appropriate and FDA accepted comparator method. Detailed documentation must be kept of that study and its results, including the study protocol, study report for the proposed intended use, testing results, and results of all statistical analyses.
(5) When applicable, performance results of the analytical study testing the FDA recommended reference panel described in paragraph (b)(4)(vi) of this section must be included in the device's labeling under § 809.10(b) of this chapter.
(6) For devices with an intended use that includes detection of Influenza A and Influenza B viruses and/or detection and differentiation between the Influenza A virus subtypes in human clinical specimens in addition to detection of SARS-CoV-2 and similar microbial agents, the required labeling under § 809.10(b) of this chapter must include the following:
(i) Where applicable, a limiting statement that performance characteristics for Influenza A were established when Influenza A/H3 and A/H1-2009 (or other pertinent Influenza A subtypes) were the predominant Influenza A viruses in circulation.
(ii) Where applicable, a warning statement that reads if infection with a novel Influenza A virus is suspected based on current clinical and epidemiological screening criteria recommended by public health authorities, specimens should be collected with appropriate infection control precautions for novel virulent influenza viruses and sent to State or local health departments for testing. Viral culture should not be attempted in these cases unless a BSL 3+ facility is available to receive and culture specimens.
(iii) Where the device results interpretation involves combining the outputs of several targets to get the final results, such as a device that both detects Influenza A and differentiates all known Influenza A subtypes that are currently circulating, the device's labeling must include a clear interpretation instruction for all valid and invalid output combinations, and recommendations for any required followup actions or retesting in the case of an unusual or unexpected device result.
(iv) A limiting statement that if a specimen yields a positive result for Influenza A, but produces negative test results for all specific influenza A subtypes intended to be differentiated (
i.e., H1-2009 and H3), this result requires notification of appropriate local, State, or Federal public health authorities to determine necessary measures for verification and to further determine whether the specimen represents a novel strain of Influenza A.(7) If one of the actions listed at section 564(b)(1)(A) through (D) of the Federal Food, Drug, and Cosmetic Act occurs with respect to an influenza viral strain, or if the Secretary of Health and Human Services determines, under section 319(a) of the Public Health Service Act, that a disease or disorder presents a public health emergency, or that a public health emergency otherwise exists, with respect to an influenza viral strain:
(i) Within 30 days from the date that FDA notifies manufacturers that characterized viral samples are available for test evaluation, the manufacturer must have testing performed on the device with those influenza viral samples in accordance with a standardized protocol considered and determined by FDA to be acceptable and appropriate.
(ii) Within 60 days from the date that FDA notifies manufacturers that characterized influenza viral samples are available for test evaluation and continuing until 3 years from that date, the results of the influenza emergency analytical reactivity testing, including the detailed information for the virus tested as described in the certificate of authentication, must be included as part of the device's labeling in a tabular format, either by:
(A) Placing the results directly in the device's labeling required under § 809.10(b) of this chapter that accompanies the device in a separate section of the labeling where analytical reactivity testing data can be found, but separate from the annual analytical reactivity testing results; or
(B) In a section of the device's label or in other labeling that accompanies the device, prominently providing a hyperlink to the manufacturer's public website where the analytical reactivity testing data can be found. The manufacturer's website, as well as the primary part of the manufacturer's website that discusses the device, must provide a prominently placed hyperlink to the website containing this information and must allow unrestricted viewing access.

Summary

0

Date: August 17, 2023

Image /page/0/Picture/1 description: The image shows 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 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.

Cepheid % Yen Nguyen Senior Manager, Regulatory Affairs Cepheid 904 Caribbean Drive Sunnyvale, California 94089

Re: K231481

Trade/Device Name: Xpert Xpress CoV-2/Flu/RSV plus Regulation Number: 21 CFR 866.3981 Regulation Name: Device To Detect And Identify Nucleic Acid Targets In Respiratory Specimens From Microbial Agents That Cause The SARS-Cov-2 Respiratory Infection And Other Microbial Agents When In A Multi-Target Test Regulatory Class: Class II Product Code: QOF, OOI Dated: May 22, 2023 Received: May 23, 2023

Dear Yen Nguyen:

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.

1

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

Joseph Briggs -S

Joseph Briggs, Ph.D. Deputy Branch Chief Division of Microbiology Devices OHT7: Office of In Vitro Diagnostics Office of Product Evaluation and Quality Center for Devices and Radiological Health

Enclosure

2

Indications for Use

510(k) Number (if known) K231481

Device Name Xpert Xpress CoV-2/Flu/RSV plus

Indications for Use (Describe)

The Xpert Xpress CoV-2/Flu/RSV plus test, performed on the GeneXpert Infinity Systems, is an automated multiplexed real-time reverse transcriptase chain reaction (RT-PCR) test intended for use in viro qualitative detection and differentiation of severe acute respiratory syndrome coronavirus (SARS-CoV-2), influenza B, and/or respiratory syncytial virus (RSV) viral RNA in nasopharyngeal swab specimens collected from individuals with signs and symptoms of respiratory tract infection. Clinical signs and symptoms of respiratory tract infection due to SARS-CoV-2, influenza A, influenza B, and RSV can be similar.

The Xpert Xpress CoV-2/Flu/RSV plus is intended for use in the differential detection of SARS-CoV-2, influenza B and or RSV RNA and aids in the diagnosis of COVID-19, influenza and/or RSV infections if used in conjunction with other clinical and epidemiological information, and laboratory findings. SARS-CoV-2, influenza B, and RSV viral RNA are generally detectable in nasopharyngeal swab anterior nasal swab specimens during the acute phase of infection.

Positive results are indicative of the identified virus, but do not rule out bacterial infection or co-infection with other pathogens not detected by the test. The agent(s) detected by the Xpert Xpress COV-2/Flu/RSV plus test may not be the definite cause of disease.

Negative results do not preclude SARS-CoV-2, influenza B, and/or RSV infection. The results of this test should not be used as the sole basis for diagnosis, treatment, or other patient management decisions.

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 shows the Cepheid company logo, which includes a stylized blue wing-like design above the company name. Below the logo, the text "Xpert® Xpress CoV-2/Flu/RSV plus" is displayed. This text likely refers to a diagnostic test developed by Cepheid, indicating it is a rapid test for COVID-19, influenza, and respiratory syncytial virus.

510(k) Summary for Xpert® Xpress CoV-2/Flu/RSV plus

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Image /page/4/Picture/0 description: The image shows the Cepheid logo and the text "Xpert® Xpress CoV-2/Flu/RSV plus". The Cepheid logo is a blue graphic with the word "Cepheid." next to it. The text "Xpert® Xpress CoV-2/Flu/RSV plus" is written in a smaller font below the logo.

5.	510(K) SUMMARY	3
5.1.	DEVICE DESCRIPTION	4
5.2.	DEVICE INTENDED USE	5
5.3.	SUBSTANTIAL EQUIVALENCE	6
5.4.	PERFORMANCE STUDIES	9
5.4.1.	ANALYTICAL PERFORMANCE	9
5.4.2.	CLINICAL PERFORMANCE	28
5.5.	CONCLUSIONS	34

Image /page/5/Picture/0 description: The image shows the Cepheid logo and the text "Xpert® Xpress CoV-2/Flu/RSV plus". The Cepheid logo is a blue graphic with the word "Cepheid" next to it. The text "Xpert® Xpress CoV-2/Flu/RSV plus" is below the logo. The image is likely an advertisement for a medical test.

5. 510(k) Summary

As required by 21 CFR Section 807.92(c).

| Submitted by: | Cepheid
904 Caribbean Drive
Sunnyvale, CA 94089
Phone number: (669) 246-2271 |
|-----------------------------------|--------------------------------------------------------------------------------------------------------|
| Contact: | Yen H. Nguyen, Ph.D. |
| Date of Preparation: | May 22, 2023 |
| Device: | |
| Trade name: | Xpert® Xpress CoV-2/Flu/RSV plus |
| Common name: | Xpert Xpress CoV-2/Flu/RSV plus |
| Type of Test: | Qualitative real-time reverse transcription polymerase chain
reaction (RT-PCR) and detection test |
| Regulation number: | 21 CFR 866.3981 |
| Classification name: | Multi-Target Respiratory Specimen Nucleic Acid Test
Including SARS-CoV-2 and Other Microbial Agents |
| Primary Product code: | QOF |
| Secondary Product code: | OOI |
| Classification
Advisory Panel: | Microbiology (83) |
| Prescription Use: | Yes |
| Predicate Device
Assay: | BioFire Respiratory Panel 2.1 (DEN200031) |

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Device Description 5.1.

The Xpert Xpress CoV-2/Flw/RSV plus test is an automated in vitro diagnostic test for the simultaneous qualitative detection and differentiation of SARS-CoV-2, Flu A, Flu B, and RSV viral RNA in nasopharyngeal swab (NPS) and anterior nasal swab (NS) specimens collected from individuals showing signs and symptoms of respiratory viral infection.

The Xpert Xpress CoV-2/Flu/RSV plus test is performed on GeneXpert Instrument Systems (GeneXpert Dx, GeneXpert Infinity-48s and GeneXpert Infinity-80 systems), which consist of an instrument, computer, and preloaded software for running tests and viewing the results. The GeneXpert Instrument Systems automate and integrate sample preparation, nucleic acid extraction and amplification, and detection of the target sequences in simple or complex samples using real-time reverse transcription (RT)-polymerase chain reaction (PCR) and PCR assays. Depending on the instrument, the GeneXpert Instrument Systems can have from 1 and up to 80 randomly accessible modules, each capable of performing separate sample preparation and real-time RT-PCR and PCR tests. Each module contains a syringe drive for dispensing fluids (i.e., the syringe drive activates the plunger that works in concert with the rotary valve in the cartridge to move fluids between chambers), an ultrasonic horn for lysing cells or spores, and a proprietary I-CORE® thermocycler for performing real-time RT-PCR and PCR as well as detection. The systems require the use of single-use disposable cartridges that hold the RT-PCR reagents and host sample purification, nucleic acid amplification, and detection of the target sequences. Because the cartridges are selfcontained, cross-contamination between samples is minimized.

The Xpert Xpress CoV-2/Flu/RSV plus test includes reagents for the detection of SARS-CoV-2, Flu A. Flu B and RSV viral RNA from NPS and NS specimens. The primers and probes in the Xpert Xpress CoV-2/Flu/RSV plus test are designed to amplify and detect unique sequences in the genes that encode the following proteins: SARS-CoV-2 nucleocapsid (N), SARS-CoV-2 envelope (E), SARS-CoV-2 RNA-dependent RNA polymerase (RdRP), influenza A matrix (M), influenza A basic polymerase (PB2), influenza A acidic protein (PA), influenza B matrix (M), influenza B non-structural protein (NS), and the RSV A and RSV B nucleocapsid. A Sample Processing Control (SPC) and a Probe Check Control (PCC) are also included in the cartridge utilized by the GeneXpert instrument. The SPC is present to control for adequate processing of the sample and to monitor for the presence of potential inhibitor(s) in the RT-PCR reaction. The SPC also ensures that the RT-PCR reaction conditions (temperature and time) are appropriate for the amplification reaction and that the RT-PCR reagents are functional. The PCC verifies reagent rehydration, PCR tube filling, and confirms that all reaction components are present in the cartridge including monitoring for probe integrity and dye stability.

The Xpert Xpress CoV-2/Flu/RSV plus test is designed for use with NPS or NS specimens collected with nylon flocked swabs and placed into viral transport medium (VTM), Universal Transport Medium (UTM), or eNAT®. The ancillary specimen collection kits, swabs and transport media validated for use with the Xpert Xpress CoV-2/Flu/RSV plus test included:

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. Nasopharyngeal Sample Collection Kit for Viruses

Copan UTM® 3C057N (Flexible Minitip Flocked Swab with UTM® Medium о without Beads)
Copan eNAT® Molecular Collection and Preservation Medium P/N O 6U074S01 (Flexible Minitip Flocked Swab with eNAT® Medium)
Becton Dickinson Universal Viral Transport Kit P/N 220531 (Flexible Minitip O Flocked Swab with UVT Medium)
Nasal Sample Collection Kit for Viruses .
- Copan UTM® 3C064N (Regular Flocked Swab with UTM® Medium without o Beads)
- Copan eNAT® Molecular Collection and Preservation Medium P/N O 6U073S01 (Regular Flocked Swab with eNAT® Medium)
Alternatively, swabs and transport media can be obtained separately: ●
- Nylon flocked swab (Copan P/N 502CS01, 503CS01) O
- Viral transport medium, 3 mL (Copan P/N 330C, 3C047N, BD Universal o Transport Medium, Remel M4RT or Remel M5)

These ancillary reagents allow NPS and NS specimens from patients to be collected, preserved and transported to laboratory prior to analysis with the Xpert Xpress CoV-2/Flu/RSV plus test.

5.2. Device Intended Use

The Xpert® Xpress CoV-2/Flu/RSV plus test, performed on the GeneXpert® Dx and GeneXpert® Infinity Systems, is an automated multiplexed real-time reverse transcriptase polymerase chain reaction (RT-PCR) test intended for use in the simultaneous in vitro qualitative detection and differentiation of severe acute respiratory syndrome coronavirus (SARS-CoV-2), influenza A, influenza B, and/or respiratory syncytial virus (RSV) viral RNA in nasopharyngeal swab anterior nasal swab specimens collected from individuals with signs and symptoms of respiratory tract infection. Clinical signs and symptoms of respiratory tract infection due to SARS-CoV-2, influenza A, influenza B, and RSV can be similar.

The Xpert Xpress CoV-2/Flu/RSV plus is intended for use in the differential detection of SARS-CoV-2, influenza A, influenza B and/or RSV RNA and aids in the diagnosis of COVID-19, influenza and/or RSV infections if used in conjunction with other clinical and epidemiological information, and laboratory findings. SARS-CoV-2, influenza B, and RSV viral RNA are generally detectable in nasopharyngeal swab and anterior nasal swab specimens during the acute phase of infection.

Positive results are indicative of the presence of the identified virus, but do not rule out

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bacterial infection or co-infection with other pathogens not detected by the test. The agent(s) detected by the Xpert Xpress CoV-2/Flu/RSV plus test may not be the definite cause of disease.

Negative results do not preclude SARS-CoV-2, influenza A, influenza B, and/or RSV infection. The results of this test should not be used as the sole basis for diagnosis, treatment, or other patient management decisions.

5.3. Substantial Equivalence

Table 5-1 shows the similarities and differences between Xpert Xpress CoV-2/Flu/RSV plus and the predicate device, BioFire Respiratory Panel 2.1 (DEN20031).

Attribute	Investigational Device	Predicate Device - DEN200031
	Cepheid	BioFire Diagnostics, LLC
	Xpert® Xpress CoV-2/Flu/RSV plus	BioFire Respiratory Panel 2.1
		21 CFR 866.3981
Regulation	Same	Devices to detect and identify nucleic acid targets in respiratory samples from microbial agents that cause the SARS-CoV-2 respiratory infection and other microbial agents when in a multi-analyte test
Product Code/
Classification
Name	Same	QOF
Multi-target respiratory specimen nucleic acid test including SARS-CoV-2 and other microbial agents
Device Class	Same	II (Special Controls)
Technology/
Detection	Real-time reverse transcription polymerase chain reaction (RT-qPCR)	Nested multiplex RT-PCR followed by high resolution melting analysis to confirm identity of amplified product
Intended Use	The Xpert® Xpress CoV-2/Flu/RSV plus test, performed on the GeneXpert® Dx and GeneXpert® Infinity Systems, is an automated multiplexed real-time reverse transcriptase polymerase chain reaction (RT-PCR) test intended for use in the simultaneous in vitro qualitative detection and differentiation of severe acute respiratory syndrome coronavirus (SARS-CoV-2), influenza A, influenza B, and/or respiratory syncytial virus (RSV) viral RNA in nasopharyngeal swab and anterior nasal swab specimens collected from individuals with signs and symptoms of respiratory tract infection. Clinical signs and symptoms of respiratory tract	The BioFire Respiratory Panel 2.1 (RP2.1) is a PCR-based multiplexed nucleic acid test intended for use with the BioFire® FilmArray® 2.0 or BioFire® FilmArray® Torch Systems for the simultaneous qualitative detection and identification of multiple respiratory viral and bacterial nucleic acids in nasopharyngeal swabs (NPS) obtained from individuals suspected of respiratory tract infections, including COVID-19.
Nucleic acids from the respiratory viral and bacterial organisms identified by this test are generally detectable in NPS specimens during the acute phase of infection. The detection and identification of specific viral
Attribute	Investigational Device	Predicate Device - DEN200031
	Cepheid	BioFire Diagnostics, LLC
	Xpert® Xpress CoV-2/Flu/RSV plus	BioFire Respiratory Panel 2.1
	infection due to SARS-CoV-2, influenza
A, influenza B, and RSV can be similar.

The Xpert Xpress CoV-2/Flu/RSV plus is
intended for use in the differential
detection of SARS-CoV-2, influenza A,
influenza B and/or RSV RNA and aids in
the diagnosis of COVID-19, influenza
and/or RSV infections if used in
conjunction with other clinical and
epidemiological information, and
laboratory findings. SARS-CoV-2,
influenza A, influenza B, and RSV viral
RNA are generally detectable in
nasopharyngeal swab and anterior nasal
swab specimens during the acute phase of
infection.

Positive results are indicative of the
presence of the identified virus, but do not
rule out bacterial infection or co-infection
with other pathogens not detected by the
test. The agent(s) detected by the Xpert
Xpress CoV-2/Flu/RSV plus test may not
be the definite cause of disease.

Negative results do not preclude SARS-
CoV-2, influenza A, influenza B and/or
RSV infection. The results of this test
should not be used as the sole basis for
diagnosis, treatment, or other patient
management decisions. | and bacterial nucleic acids from individuals
exhibiting signs and/or symptoms of
respiratory infection is indicative of the
presence of the identified microorganism
and aids in the diagnosis of respiratory
infection if used in conjunction with other
clinical and epidemiological information.
The results of this test should not be used as
the sole basis for diagnosis, treatment, or
other patient management decisions.
The following organism types and subtypes
are identified using the BioFire RP2.1:
• Adenovirus
• Coronavirus 229E
• Coronavirus HKU1
• Coronavirus NL63
• Coronavirus OC43
• Severe Acute Respiratory Syndrome
Coronavirus 2 (SARS-CoV-2)
• Human Metapneumovirus
• Human Rhinovirus/Enterovirus
• Influenza A, including subtypes
• H1, H3 and H1-2009
• Influenza B
• Parainfluenza Virus 1
• Parainfluenza Virus 2
• Parainfluenza Virus 3
• Parainfluenza Virus 4
• Respiratory Syncytial Virus
• Bordetella parapertussis
• Bordetella pertussis
• Chlamydia pneumoniae
• Mycoplasma pneumoniae

Negative results in the setting of a
respiratory illness may be due to infection
with pathogens that are not detected by this
test, or lower respiratory tract infection that
may not be detected by an NPS specimen.
Positive results do not rule out co-infection
with other organisms. The agent(s) detected
by the BioFire RP2.1 may not be the
definite cause of disease. Additional
laboratory testing (e.g., bacterial and viral
culture, immunofluorescence, and
radiography) may be necessary when
evaluating a patient with possible
respiratory tract infection. |
| Attribute | Investigational Device
Cepheid
Xpert® Xpress CoV-2/Flu/RSV plus | Predicate Device – DEN200031
BioFire Diagnostics, LLC
BioFire Respiratory Panel 2.1 |
| Assay Targets | SARS-CoV-2, Influenza A, Influenza B, RSV viral RNA | • Adenovirus
• Coronavirus 229E
• Coronavirus HKU1
• Coronavirus NL63
• Coronavirus OC43
• Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)
• Human Metapneumovirus
• Human Rhinovirus/Enterovirus
• Influenza A, including subtypes
• H1, H3 and H1-2009
• Influenza B
• Parainfluenza Virus 1
• Parainfluenza Virus 2
• Parainfluenza Virus 3
• Parainfluenza Virus 4
• Respiratory Syncytial Virus
• Bordetella parapertussis
• Bordetella pertussis
• Chlamydia pneumoniae
• Mycoplasma pneumoniae |
| Specimen Type | • Nasopharyngeal swab (NPS)
• Anterior nasal swab (NS) | • Nasopharyngeal swab (NPS) |
| Transport
Media | • Universal Transport Medium (UTM) / Viral Transport Medium (VTM)
• eNAT | • Universal Transport Medium (UTM)/ Viral Transport Medium (VTM)
• Saline |
| Test Format | Same | Single Use |
| Automation | Same | Automated Nucleic Acid Extraction, Detection and Results Interpretation |
| Assay Results | Same | Qualitative |
| Internal
Control | Sample Processing Control (SPC)
Probe Check Control (PCC) | Sample Processing Control
PCR and Melt Analysis Control |
| Instrument
Systems | Cepheid GeneXpert® Instrument Systems | BioFire® FilmArray® 2.0 or
BioFire® FilmArray® Torch Systems |
| Time to Result | ~ 36 min for sample preparation and RT-PCR | ~ 45 minutes |

Table 5-1: Comparison of Similarities and Differences Between Xpert Xpress CoV-2/Flu/RSV plus and the Predicate Device

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Image /page/9/Picture/0 description: The image shows the Cepheid logo with the text "Cepheid." next to it. Below the logo is the text "Xpert® Xpress CoV-2/Flu/RSV plus". The text appears to be advertising a product or service related to CoV-2, Flu, and RSV.

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Image /page/10/Picture/0 description: The image shows the Cepheid logo and the text "Xpert® Xpress CoV-2/Flu/RSV plus". The Cepheid logo is a blue, stylized wing-like shape. The text is in a sans-serif font and is black.

The following performance data (analytical and clinical) were provided in support of the substantial equivalence determination.

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Image /page/11/Picture/0 description: The image displays the Cepheid logo, which includes a stylized blue graphic above the company name. Below the logo, the text "Xpert® Xpress CoV-2/Flu/RSV plus" is printed in a clear, legible font. The text indicates a product or test related to CoV-2, Flu, and RSV, suggesting it is a diagnostic tool.

5.4. Performance Studies

5.4.1. Analytical Performance

Analytical Sensitivity - Clinical Nasopharyngeal Swab (NPS) Matrix

The analytical sensitivity of the Xpert Xpress CoV-2/Flu/RSV plus test was first estimated by using 2 reagent lots and testing limiting dilutions of viruses (NATtrol SARS-CoV-2, 1st World Health Organization (WHO) International Standard for SARS-CoV-2. Flu A H1. Flu A H3 , Flu B Victoria linage, Flu B Yamagata lineage, RSV A and RSV B) in pooled negative clinical NPS-UTM/VTM matrix, following the guidance in Clinical and Laboratory Standards Institute (CLSI) document EP17-A2. The LoD is defined as the lowest concentration for each strain at which 95% (19/20) of replicates yield a positive result. The estimated LoD values as determined by Probit regression analysis were verified using 2 lots of Xpert Xpress CoV-2/Flu/RSV plus reagents, by testing 20 replicates per virus/lot combination. The highest (least sensitive) LoD value for the two lots was reported as the final, verified LoD. The verified LoD values for the viruses tested are summarized in Table 5-2.

Virus/Strain	LoD Concentration
USA-WA1/2020 (NATtrol)	138 copies/mL
1st WHO International Standard	94 IU/mL
Flu A/Idaho/07/2018	0.007 TCID50/mL
Flu A/California/07/2009	0.0022 TCID50/mL
Flu A/Hong Kong/45/2019	0.44 FFU/mL
Flu A/Victoria/361/2011	0.05 TCID50/mL
Flu B/Washington/2/2019	12.9 CEID50/mL
Flu B/Wisconsin/10/2016	2.4 TCID50/mL
RSV A/2/Australia/61	0.33 TCID50/mL
RSV A/Long/MD/56	0.17 TCID50/mL
RSV B/9320/MA/77	0.37 TCID50/mL
RSV B/Wash/18537/62	0.2 TCID50/mL

Table 5-2. Xpert Xpress CoV-2/Flu/RSV plus Limit of Detection in Clinical NPS-UTM/VTM Matrix

Analytical Sensitivity - Clinical Anterior Nasal Swab (NS) Matrix

The analytical sensitivity of the Xpert Xpress CoV-2/Flu/RSV plus test in clinical anterior nasal swab (NS) matrix was first estimated by using 2 lots and testing limiting dilutions of viruses (NATtrol SARS-CoV-2, 1st World Health Organization (WHO) International Standard for SARS-CoV-2, Flu A H1, Flu A H3, Flu B Victoria linage, Flu B Yamagata lineage, RSV A and RSV B) in pooled negative clinical NS UTM/VTM matrix, following the guidance in Clinical and Laboratory Standards Institute (CLSI) document EP17-A2. The estimated LoD values as determined by Probit regression analysis were verified using 2 lots of Xpert Xpress CoV-2/Flu/RSV plus reagents, by testing 20 replicates per virus/lot

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combination. The highest (least sensitive) LoD value for the two lots was reported as the final, verified LoD. The verified LoD values for the viruses tested are summarized in Table 5-3.

Virus/Strain	LoD Concentration
USA-WA1/2020 (NATtrol)	64 copies/mL
1st WHO International Standard	143 IU/mL
Flu A/Idaho/07/2018	0.012 TCID50/mL
Flu A/California/07/2009	0.0028 TCID50/mL
Flu A/Hong Kong/45/2019	0.49 FFU/mL
Flu A/Victoria/361/2011	0.065 TCID50/mL
Flu B/Washington/2/2019	26.3 CEID50/mL
Flu B/Wisconsin/10/2016	2.41 TCID50/mL
RSV A/2/Australia/61	0.28 TCID50/mL
RSV A/Long/MD/56	0.22 TCID50/mL
RSV B/9320/MA/77	0.27 TCID50/mL
RSV B/Wash/18537/62	0.4 TCID50/mL

Table 5-3. Xpert Xpress CoV-2/Flu/RSV plus Limit of Detection in Clinical NS-UTM/VTM Matrix

Analytical Reactivity (Inclusivity)

SARS-CoV-2 in silico Analyses

The inclusivity of Xpert Xpress CoV-2/Flu/RSV plus was evaluated using in silico analysis of the assay amplicons in relation to SARS-CoV-2 sequences available in the GISAID gene database as of June 15, 2022. The sequences were separated into the lineages of interest based on the Pango Lineage assigned to each genome by GISAID, and those with ambiguous nucleotides were removed. Thus, the following inclusivity analyses focus on the combined, non-ambiguous sequences from the variants of interest and variants of concern as of June 15, 2022. These constituted 10.310.839 sequences for the E target. 10.428.014 sequences for the N2 target, and 10,178,602 sequences for the RdRP target. Table 5-4 summarizes the effective predicted inclusivity for E, N2 and RdRP amplicons for the variants of interests and concern.

Table 5-4. Predicted Inclusivity for E, N2 and RdRP Amplicons for
SARS-CoV-2 Variants of Interests and Concern

| Amplicon | Exact Match | 1 Mismatch | 2 or More Mismatches | % Total 80% homology with two Pangolin RSV A isolates. Therefore, the RSV A primer and probe may cross-react with Pangolin RSV A if the strain is circulating in a human population and present in a sample tested with the Xpert Xpress CoV-2/Flu/RSV plus test. While there was some homology ≥80% to human genomic DNA, the matches were to different chromosomal regions, and there were no cases where a forward and reverse primer for a specific target matched to the same human genomic DNA fragment.

In silico exclusivity analysis using the five Flu amplicons (Flu A MP, Flu A PB2, Flu A PA, Flu B MP and Flu B NS) against the GenBank database produced no significant matches to non-influenza-related sequences. Similarly, no matches to RSV isolates from other species or to genomic sequences from non-RSV species were observed with the RSV B amplicon. While no matches of the RSV A amplicon to genomic sequences from non-RSV species of >80% homology were observed, the RSV A amplicon shared a 95% identity with two Pangolin RSV A isolates.

No cross reactivity with non-SARS-CoV-2, non-influenza and non-RSV viruses listed in Table 5-6 is expected based on the in silico analysis.

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Table 5-6. Microorganisms Analyzed in the in silico Analysis for the SARS-CoV-2 Target

Microorganisms from the Same Genetic Family	High Priority Organisms
Human coronavirus 229E	Viruses
Human coronavirus OC43	Adenovirus (e.g., C1 Ad. 71)
Human coronavirus HKU1	Cytomegalovirus
Human coronavirus NL63	Enterovirus (e.g., EV68)
SARS-coronavirus	Epstein-Barr virus
MERS-coronavirus	Human Metapneumovirus (hMPV)
Bat coronavirus	Influenza A & B
	Measles
	Mumps
	Parainfluenza virus 1-4
	Parechovirus
	Respiratory syncytial virus
	Rhinovirus
	Bacteria
	Bacillus anthracis
	Bordetella pertussis
	Bordetella parapertussis
	Candida albicans
	Chlamydia pneumoniae
	Chlamydia psittaci
	Corynebacterium diphtheriae
	Coxiella burnetii (Q-Fever)
	Escherichia coli
	Fusobacterium necrophorum
	Haemophilus influenzae
	Lactobacillus sp.
	Legionella non-pneumophila
	Legionella pneumophila
	Leptospira
	Moraxella catarrhalis
	Mycobacterium tuberculosis
	Mycoplasma genitalium
	Mycoplasma pneumoniae
	Neisseria elongata
	Neisseria meningitidis
	Pneumocystis jirovecii (PJP)
	Pseudomonas aeruginosa
	Staphylococcus aureus
	Staphylococcus epidermidis
	Staphylococcus salivarius
	Streptococcus pneumoniae
	Streptococcus pyogenes

Microorganisms from the Same Genetic Family	High Priority Organisms
	Fungi
	Aspergillus sp

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Image /page/18/Picture/0 description: The image shows the Cepheid logo and the text "Xpert® Xpress CoV-2/Flu/RSV plus". The Cepheid logo is a blue, stylized wave-like shape. The text is in black and appears to be the name of a product or service offered by Cepheid. The "®" symbol indicates that "Xpert" is a registered trademark.

Wet Testing

In addition to the in silico analysis of the SARS-CoV-2, influenza A, influenza B, and RSV oligonucleotides and amplicons for cross-reactivity, the analytical specificity of the Xpert Xpress CoV-2/Flu/RSV plus test was evaluated by bench testing a panel of 48 microorganisms, comprising 4 human coronaviruses, 1 MERS coronavirus and 43 common respiratory pathogens or those potentially encountered in the nasopharynx. The panel was tested in different pools of microorganisms in simulated matrix; if a pool produced a positive result, then each member of the pool would have been tested individually. Three replicates of each pool were tested. A sample was considered negative if all three replicates were negative. The bacterial and yeast strains were tested at concentrations of ≥ 1 x 10° CFU/mL except for Chlamydia pneumoniae which was tested at 1.2 x 106 IFU/mL and Lactobacillus reuteri which was tested at 5 x 107 copies/mL of genomic DNA. Viruses were tested at concentrations of ≥ 1 x 105 TCID50/mL. The analytical specificity was 100%. Results are shown in Table 5-7.

Count	Strain	Tested Concentration	SARS-CoV-2	Flu A	Flu B	RSV
0	Negative Control	NA	NEG	NEG	NEG	NEG
00	Positive Control (NATFRC-6C)	NA	POS	POS	POS	POS
1	Human coronavirus NL63	1.17e5 TCID50/mL	NEG	NEG	NEG	NEG
2	MERS-coronavirus	1.17e5 TCID50/mL	NEG	NEG	NEG	NEG
3	Human coronavirus 229E	1.21e5 TCID50/mL	NEG	NEG	NEG	NEG
4	Human coronavirus OC43	1.02e5 TCID50/mL	NEG	NEG	NEG	NEG
5	Human coronavirus HKU1a	1.23e6 copies/mL	NEG	NEG	NEG	NEG
6	Adenovirus Type 1	4.07e5 TCID50/mL	NEG	NEG	NEG	NEG
7	Adenovirus Type 7	1.15e5 TCID50/mL	NEG	NEG	NEG	NEG
8	Cytomegalovirus	1.0e5 TCID50/mL	NEG	NEG	NEG	NEG
9	Echovirus	1.14e5 TCID50/mL	NEG	NEG	NEG	NEG
10	Enterovirus	2.80e5 TCID50/mL	NEG	NEG	NEG	NEG
11	Epstein Barr Virus	5.60e6 TCID50/mL	NEG	NEG	NEG	NEG
12	HSV	1.97e5 TCID50/mL	NEG	NEG	NEG	NEG
13	Human metapneumovirus	4.07e5 TCID50/mL	NEG	NEG	NEG	NEG
14	Human parainfluenza Type 1	1.0e5 TCID50/mL	NEG	NEG	NEG	NEG
15	Human parainfluenza Type 2	1.2e5 TCID50/mL	NEG	NEG	NEG	NEG
16	Human parainfluenza Type 3	1.2e5 TCID50/mL	NEG	NEG	NEG	NEG
17	Human parainfluenza Type 4	1.19e6 TCID50/mL	NEG	NEG	NEG	NEG
18	Measles	1.2e5 TCID50/mL	NEG	NEG	NEG	NEG
19	Mumps virus	1.2e5 TCID50/mL	NEG	NEG	NEG	NEG
20	Rhinovirus Type 1A	1.0e5 TCID50/mL	NEG	NEG	NEG	NEG
21	Acinetobacter baumannii	1.30e7 CFU/mL	NEG	NEG	NEG	NEG
22	Bordetella pertussis	6.40e7 CFU/mL	NEG	NEG	NEG	NEG
23	Burkholderia cepacia	1.90e8 CFU/mL	NEG	NEG	NEG	NEG
24	Candida albicans	6.30e6 CFU/mL	NEG	NEG	NEG	NEG

Table 5-7. Respiratory Microorganisms and Human Coronavirus Tested, Concentrations and Xpert Xpress CoV-2/Flu/RSV plus Test Results

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Image /page/19/Picture/0 description: The image shows the Cepheid logo, which includes a blue graphic and the word "Cepheid." The text below the logo reads "Xpert® Xpress CoV-2/Flu/RSV plus." This text likely refers to a diagnostic test or product offered by Cepheid, possibly related to COVID-19, influenza, and respiratory syncytial virus.

Count	Strain	Tested Concentration	SARS-CoV-2	Flu A	Flu B	RSV
25	Candida parapsilosis	1.45e6 CFU/mL	NEG	NEG	NEG	NEG
26	Citrobacter freundii	1.73e8 CFU/mL	NEG	NEG	NEG	NEG
27	Corynebacterium sp.	1.27e7 CFU/mL	NEG	NEG	NEG	NEG
28	Enterococcus faecalis	5.87e7 CFU/mL	NEG	NEG	NEG	NEG
29	Escherichia coli	1.55e8 CFU/mL	NEG	NEG	NEG	NEG
30	Hemophilus influenzae	6.62e6 CFU/mL	NEG	NEG	NEG	NEG
31	Lactobacillus reuteri b	5.0e7 copies/mL	NEG	NEG	NEG	NEG
32	Legionella pneumophila	1.42e8 CFU/mL	NEG	NEG	NEG	NEG
33	Moraxella catarrhalis	2.46e6 CFU/mL	NEG	NEG	NEG	NEG
34	Mycoplasma pneumoniae	2.7e6 CFU/mL	NEG	NEG	NEG	NEG
35	Neisseria meningitides	4.2e6 CFU/mL	NEG	NEG	NEG	NEG
36	Neisseria mucosa	1.0e8 CFU/mL	NEG	NEG	NEG	NEG
37	Propionibacterium acnes	8.25e7 CFU/mL	NEG	NEG	NEG	NEG
38	Pseudomonas aeruginosa	1.05e7 CFU/mL	NEG	NEG	NEG	NEG
39	Staphylococcus haemolyticus	2.66e6 CFU/mL	NEG	NEG	NEG	NEG
40	Staphylococcus aureus	5.87e7 CFU/mL	NEG	NEG	NEG	NEG
41	Staphylococcus epidermidis	2.47e7 CFU/mL	NEG	NEG	NEG	NEG
42	Streptococcus agalactiae	1.75e7 CFU/mL	NEG	NEG	NEG	NEG
43	Streptococcus pneumoniae	2.26e7 CFU/mL	NEG	NEG	NEG	NEG
44	Streptococcus pyogenes	9.0e6 CFU/mL	NEG	NEG	NEG	NEG
45	Streptococcus salivarius	4.19e6 CFU/mL	NEG	NEG	NEG	NEG
46	Streptococcus sanguinis	8.67e6 CFU/mL	NEG	NEG	NEG	NEG
47	Chlamydia pneumoniae	1.20e6 CFU/mL	NEG	NEG	NEG	NEG
48	Mycobacterium tuberculosis
(avirulent)	1.20e6 CFU/mL	NEG	NEG	NEG	NEG

NA - Not Applicable

ªLive virus was not available. Synthetic RNA was used.

bLive organism was not available. Genomic DNA was used.

Microbial Interference

Microbial interference of the Xpert Xpress CoV-2/Flu/RSV plus test caused by the presence of bacterial or viral strains that might be encountered in human upper respiratory tract specimens, was evaluated by testing a panel of 10 potentially interfering microorganisms, consisting of 7 viral strains and 3 bacterial strains. Contrived samples consisted of SARS-CoV-2, Flu A, Flu B, RSV A, or RSV B viruses seeded at 3x the Limit of Detection (LoD) into simulated nasopharyngeal swab (NPS)/nasal swab (NS) matrix in the presence of Adenovirus Type 1C, Human Coronavirus OC43, Rhinovirus Type 1A, Human metapneumovirus, Human parainfluenza Types 1, 2, and 3 (each seeded at 1x109 TCID50mL). Hemophilus influenzae (seeded at 1x100 CFU/mL), Staphylococcus aureus or Staphylococcus epidermidis (each seeded at 1x10' CFU/mL).

Eight (8) replicates of positive samples were tested for each target virus (SARS-CoV-2, Flu A, Flu B, RSV A, or RSV B) and each potential microbial interference strain combination. For each target, all 8 of 8 replicate samples were correctly identified using the Xpert Xpress CoV-2/Flu/RSV plus test. No microbial interference by the viral or bacterial strains was reported.

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Image /page/20/Picture/0 description: The image shows the Cepheid logo with the text "Xpert® Xpress CoV-2/Flu/RSV plus" below it. The Cepheid logo is a stylized blue graphic element. The text is in a sans-serif font, with "Xpert" having a registered trademark symbol.

Competitive Interference

Competitive interference of the Xpert Xpress CoV-2/Flu/RSV plus caused by co-infections were evaluated by testing contrived samples of individual SARS-CoV-2, Flu A. Flu B or RSV strains at 3x LoD in the presence of different target strains at a higher concentration in a simulated background matrix. The concentration at 3x LoD was 414 copies/mL for SARS-CoV-2 (inactivated USA-WA1/2020); 0.021 TCIDso/mL for Flu A/Idaho/072018, 38.7 CEIDso/mL for Flu B/Washington/2/2019; 0.99 TCIDso/mL for RSV A/2/Australia/61), and 1.11 TCID50/mL for RSV B/9320/MA/77. The competitive strains were evaluated at >108 RNA copies/mL, as determined by droplet digital PCR (ddPCR).

Replicates of 3 were tested for each target strain and each competitive strain combination. The virus at high concentration shows no competitive inhibitory effects if 3 of 3 replicates for the target strain report positive results. If the results reported less than 3 of 3 positive replicates, the concentration of the competing virus was reduced by 10-fold increments until no interference was observed. The results for competitive interference study are presented in Tables 5-8 through 5-12 for high concentration of Flu A, Flu B, RSV A, RSV B and SARS-CoV-2, respectively.

Table 5-8. Summary of Competitive Interference Study with Flu A at High Concentration

| Test Viruses at
3X LoD | Interferent
Virus | Correct Calls (n/3) | | | |
|---------------------------|----------------------|------------------------------|------------------------------|------------------------------|------------------------------|
| | | at 1.7e8
RNA
copies/mL | at 1.7e7
RNA
copies/mL | at 1.7e6
RNA
copies/mL | at 1.7e5
RNA
copies/mL |
| Flu B | Flu A | 0/3 | 0/3 | 2/3 | 3/3 |
| RSV A | Flu A | 0/3 | 0/3 | 3/3 | Not tested |
| RSV B | Flu A | 3/3 | Not tested | Not tested | Not tested |
| SARS-CoV-2 | Flu A | 3/3 | Not tested | Not tested | Not tested |

				Table 5-9. Summary of Competitive Interference Study with Flu B at High Concentration

| Test Viruses
at 3X LoD | Interferent
Virus | Correct Calls
(n/3)
at 1.4e5
RNA copies/mL |
|---------------------------|----------------------|-----------------------------------------------------|
| Flu A | | 3/3 |
| RSV A | Flu B | 3/3 |
| RSV B | | 3/3 |
| SARS-CoV-2 | | 3/3 |

Table 5-10. Summary of Competitive Interference Study with RSV A at High Concentration
Interferent	Concentration	% Inhibition
RSV B	100 ng/mL	0%
Influenza A	100 ng/mL	0%
hMPV	100 ng/mL	0%

| Test Viruses
at 3X LoD | Interferent
Virus | Correct Calls
(n/3)
at 4.6e6
RNA copies/mL |
|---------------------------|----------------------|-----------------------------------------------------|
| Flu A | | 3/3 |
| Flu B | RSV A | 3/3 |
| SARS-CoV-2 | | 3/3 |

21

| Test Viruses at
3X LoD | Interferent
Virus | Correct Calls (n/3)
at 1.9e5
RNA copies/mL |
|---------------------------|----------------------|--------------------------------------------------|
| Flu A | | 3/3 |
| Flu B | RSV B | 3/3 |
| SARS-CoV-2 | | 3/3 |

			Table 5-11. Summary of Competitive Interference Study with RSV B at High Concentration

Table 5-12. Summary of Competitive Interference Study with SARS-CoV-2 at High Concentration

| Test Viruses
at 3X LoD | Interferent
Virus | Correct Calls (n/3) | |
|---------------------------|----------------------|-------------------------|-------------------------|
| | | at 1e6
RNA copies/mL | at 1e5
RNA copies/mL |
| Flu A | SARS-CoV-2 | 3/3 | Not tested |
| Flu B | SARS-CoV-2 | 1/3 | 3/3 |
| RSV A | SARS-CoV-2 | 3/3 | Not tested |
| RSV B | SARS-CoV-2 | 3/3 | Not tested |

The study showed that Flu A/Idaho/07/2018 at concentrations above 1.7e5 RNA copies/mL inhibited detection of Flu B at 3x LoD, and at concentrations above 1.7e6 RNA copies/mL inhibited detection of RSV A at 3x LoD (Table 5-8). In addition, SARS-CoV-2 at concentrations above 1e5 RNA copies/mL inhibited detection of Flu B at 3x LoD (Table 5-12). No other competitive interference was observed for the potential co-infections evaluated in the study at the concentrations tested.

Potentially Interfering Substances

Substances that are normally found in or may be introduced into clinical NPS or NS matrix that could potentially interfere with accurate detection of SARS-CoV-2, Flu A. Flu B and RSV were evaluated with direct testing on the Xpert Xpress CoV-2/Flu/RSV plus.

Potentially interfering substances in the nasal passage and nasopharynx may include, but are not limited to: blood, nasal secretions or mucus, and nasal and throat medications used to relieve congestion, nasal dryness, irritation, or asthma and allergy symptoms, as well as antibiotics and antivirals. Positive and negative samples were prepared in simulated nasopharyngeal swab (NPS)/ nasal swab (NS) matrix. Negative samples (N = 8) were tested in the presence of each substance to determine the effect on the performance of the sample processing control (SPC). Positive samples (N = 8) were tested per substance with viruses spiked at 3x the LoD determined for each strain. Positive samples tested with the Xpert Xpress CoV-2/Flu/RSV plus included one SARS-CoV-2, two influenza A HIN1, two influenza A H3N2, two influenza B and two RSV (RSV A and RSV B) strains. The substances, with active ingredients and test concentrations, that were evaluated are listed in Table 5-13.

22

Substance ID	Substance/Class	Substance/Active Ingredient	Concentrations Tested
No substance	Control	Simulated NPS/NS Matrix	100% (v/v)
Albuterol Sulfate	Beta-adrenergic
bronchodilator	Albuterol Sulfate (5mg/mL)	0.83 mg/mL (equivalent
to 1 dose per day)
Afrin	Nasal Spray	Oxymetazoline, 0.05%	15% (v/v)
BD Universal
Transport Medium	Transport Media	N/A	100% (v/v)
Blood	Blood	Blood (Human)	2% (v/v)
Copan Swab M	Transport Media	N/A	100% (v/v)
FluMist Quadrivalent	Vaccine	Live attenuated influenza
viruses	6.7e-4% (v/v)
6.7e-6% (v/v)
6.7e-7% (v/v)
Fluticasone
Propionate Nasal
Spray	Nasal corticosteroid	Fluticasone Propionate	5 µg/mL
Human peripheral
blood mononuclear
cells	Human cells	PBMC	1 x 106 cells/mL
0.5 x 106 cells/mL
0.25 x 106 cells/mL
Ibuprofen	Nonsteroidal anti-
inflammatory drug	Ibuprofen 200 mg/tablet	5% w/v
Menthol	Throat lozenges, oral
anesthetic and analgesic	Benzocaine, Menthol	1.7 mg/mL
Mucin	Mucin	Purified Mucin protein (Bovine
or porcine submaxillary gland)	0.1 (w/v)
Mupirocin	Antibiotic, nasal
ointment	Mupirocin (20 mg/g = 2%)	10 mg/mL
PHNY	Nasal Drops	Phenylephrine, 1%	15% (v/v)
Remel M4RT	Transport Media	N/A	100% (v/v)
Remel M5	Transport Media	N/A	100% (v/v)
Saline	Saline Nasal Spray	Sodium Chloride (0.65%)	15% (v/v)
Snuff	Tobacco product	Nicotine	1% (w/v)
0.5% (w/v)
0.25% (w/v)
0.1% (w/v)
Tamiflu	Anti-viral drugs	Zanamivir	7.5 mg/mL
Tobramycin	Antibacterial, systemic	Tobramycin	4 µg/mL
Zicam	Nasal Gel	Luffa opperculata, Galphimia
glauca, Histaminum
hydrochloricum Sulfur (0.05%)	15% (w/v)
7.5% (w/v)
Zinc	Zinc supplement	Zinc Gluconate	0.1 µg/mL

	Table 5-13. Potentially Interfering Substances Tested
--	-------------------------------------------------------	--	--	--

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Image /page/23/Picture/0 description: The image shows the Cepheid logo, which includes a blue graphic and the word "Cepheid." in black text. Below the logo is the text "Xpert® Xpress CoV-2/Flu/RSV plus" in black text. The text describes a test for CoV-2, Flu, and RSV.

The results from the study (Table 5-14) show that for most cases, 8 out of 8 replicates reported positive results for each combination of virus and substance tested and no interference was observed. In the presence of FluMist at 6.7e-4% (v/v), interfering effects were observed when testing SARS-CoV-2, RSV A and RSV B strains. Inhibitory effects were not observed when testing these viruses in the presence of FluMist at 6.7e-6% (v/v) except for RSV A/Long/MD/56. For RSV A/Long/MD/56, the inhibitory effect was not observed when FluMist concentration was further reduced to 6.7e-7% (v/v). In the presence of human PBMC at 1 x 10° cells/mL, interfering effects were observed when testing Flu B/Washington /2/2019. Inhibitory effects were not observed when the PBMC concentration was reduced to 2.5 x 10° cells/mL. In the presence of snuff at 1% (w/v), interfering effects were observed when testing Flu A /California/07/2009 and Flu B/Washington/2/2019. Inhibitory effects were not observed when testing the viruses at a snuff concentration of 0.1% (w/v). In the presence of Zicam at 15% (w/v), interfering effects were observed when testing Flu A, Flu B and RSV A strains. Inhibitory effects were not observed when testing the viruses in the presence of Zicam at 7.5% (w/v).

24

Cepheid.

| Substance | Tested | No Virus Control | SARS-CoV-2
USA-WA-1 | Flu A
California/7/2009 | Flu A Idaho/07/2018 | Flu A
Hong Kong/ 45/2019 | Flu A/
Victoria/361/2011 | Flu B
Wisconsin/10/2016 | Flu B
Washington/02/2019 | RSV A
2/Australia/61 | RSV A
Long/MD/56 | RSV B
9320/MA/77 | RSV B
WA/18537/62 |
|---------------------------------------------------------|---------- | Control
Simulated
NPS/NS Matrix
(No substance) | 100% (v/v) | 32/32a | Albuterol
Sulfate | 0.83 mg/mL | Afrin | 15% (v/v) | BD Universal
Transport
Medium | 100% v/v | 16/16 | Blood | 2% (v/v) | Copan Swab M | 100% (v/v) | FluMist | 6.7% (v/v) | | 6.7e-4% (v/v) | | 6.7e-6% (v/v) | | 6.7e-7% (v/v) | Fluticasone
Propionate
Nasal Spray | 5 µg/mL | 16/16 | Human
peripheral blood
mononuclear
cells | 1e6 cells/mL | 8/8 | | 0.5e6 cells/mL | | cells/mL | N/A | N/A | Ibuprofen | 5% (w/v) | Substance | Tested | No Virus Control | SARS-CoV-2
USA-WA-1 | Flu A
California/7/2009 | Flu A Idaho/07/2018 | Flu A
Hong Kong/45/2019 | Flu A/
Victoria/361/2011 | Flu B
Wisconsin/10/2016 | Flu B
Washington/02/2019 | RSV A
2/Australia/61 | RSV A
Long/MD/56 | RSV B
9320/MA/77 | RSV B
WA/18537/62 |
| Menthol | 1.7 mg/mL | Mucin | 0.1% (w/v) | Mupirocin | 10 mg/mL | PHNY | 15% (v/v) | Remel M4RT | 100% (v/v) | Remel M5 | 100% (v/v) | Saline | 15% (v/v) | Snuff | 1% (w/v) | | 0.5% (w/v) | | 0.25 % (w/v) | | 0.1 % (w/v) | Tamiflu | 7.5 mg/mL | Tobramycin | 4 $ | Zicam | 15% (w/v) | Zicam | 7.5% (w/v) | Zinc | 0.1 $ Concentration
----------------------------|------------------|------------------------|----------------------------|---------------------|-----------------------------|-----------------------------|----------------------------|-----------------------------|-------------------------|---------------------|---------------------|----------------------|
| 24/24 | 24/24 | 16/16 | 16/16 | 24/24b | 24/24 | 32/32 | 32/32b | 32/32 | 24/24 | 24/24 |
| 16/16 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 |
| 16/16 | 8/8 | 8/8b | 8/8 | 8/8 | 8/8 | 8/8 | 8/9c | 8/8 | 8/8 | 8/8 | 8/8 |
| 8/8 | 8/8 | 8/8 | 8/8 | 8/8b | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 |
| 16/16 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8a | 8/8b | 8/8b | 8/8 | 8/8 |
| 16/16 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 |
| 8/8 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| N/A | 7/8 | N/A | N/A | N/A | N/A | N/A | N/A | 0/8 | 0/8 | 2/8 | 0/8 |
| N/A | 8/8 | N/A | N/A | N/A | N/A | N/A | N/A | 8/8 | 7/8 | 8/8b | 8/8 |
| N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 8/8a | N/A | N/A |
| 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8a, b | 8/8 | 8/8d | 8/8 | 8/8a | 8/8 |
| 8/8 | 8/8b | 8/8b | 8/8 | 8/8 | 8/8 | 6/8 | 8/8b | 8/8 | 8/8b | 8/8b |
| N/A | N/A | N/A | N/A | N/A | N/A | N/A | 7/8 | N/A | N/A | N/A | N/A |
0.25e6
| N/A | N/A | N/A | N/A | N/A | 8/8 | N/A | N/A | N/A | N/A |
| 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 |
Concentration
| 16/16a | 8/8 | 8/8 | 8/8 | 8/8a | 8/8 | 8/8b | 8/8 | 8/8 | 8/8b | 8/8 | 8/8 |
| 16/16 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8a, b | 8/8 | 8/8 |
| 16/16 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 |
| 16/16 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 |
| 16/16a | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 |
| 16/16 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 |
| 16/16 | 8/8 | 8/8a | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8a |
| 8/8 | 8/8 | 6/8 | 8/8 | 8/8b | 8/8 | 8/8 | 4/8b | 8/8 | 8/8 | 8/8 | 8/8e |
| N/A | N/A | 7/8 | N/A | N/A | N/A | N/A | 3/8 | N/A | N/A | N/A | N/A |
| N/A | N/A | 8/8 | N/A | N/A | N/A | N/A | 7/8 | N/A | N/A | N/A | N/A |
| N/A | N/A | N/A | N/A | N/A | N/A | N/A | 8/8 | N/A | N/A | N/A | N/A |
| 16/16a | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 |
\mu $ g/mL | 16/16 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 |
| 16/16 | 8/8 | 7/8 | 8/8 | 8/8 | 8/8 | 8/8a | 5/8 | 7/8 | 8/8 | 8/8 | 8/8 |
| N/A | N/A | 8/8 | N/A | N/A | N/A | N/A | 8/8 | 8/8 | N/A | N/A | N/A |
\mu $ g/mL | 16/16 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 | 8/8 |

Table 5-14. Number of Correct Results for Xpert Xpress CoV-2/Flu/RSV plus Targets Tested in the Presence of Potentially Interfering Substances

510(k) Summary

25

Image /page/25/Picture/0 description: The image shows the Cepheid logo. The logo consists of a blue graphic element resembling three curved lines or feathers, positioned above the word "Cepheid" in a blue, sans-serif font. A small circle with a dot in the center is placed to the right of the word "Cepheid".

Xpert® Xpress CoV-2/Flu/RSV plus

BOLD: False negative or INVALID results indicating interference from the substance

a. One replicate reported NO RESULT. The run was successfully repeated to obtain the required number of valid replicates.

b. One replicate reported ERROR. The run was successfully repeated to obtain the required number of valid replicates

c. One of 8 replicates reported a Flu B NEGATIVE result. The Flu B Probe check signals were reduced in this sample suggesting an issue with the EZR beat. The test was repeated and gave a Flu B positive result.

d. One of 8 replicates reported INVALID. The run was successfully repeated to obtain 8 valid replicates

e. Two of 8 replicates reported ERROR. The 2 runs were successfully repeated to obtain 8 valid replicates.

26

Image /page/26/Picture/0 description: The image shows the Cepheid logo and the text "Xpert® Xpress CoV-2/Flu/RSV plus". The Cepheid logo is a stylized blue image. The text is in a sans-serif font.

Carryover Contamination

A study was conducted to assess whether the single-use, self-contained Xpert Xpress CoV-2/Flu/RSV plus cartridge prevents specimen and amplicon carryover by testing a negative sample immediately after testing of a very high positive sample in the same GeneXpert module. The negative sample used in this study consisted of simulated NPS/NS matrix and the positive sample consisted of high Flu B and high SARS-CoV-2 virus concentrations (Flu B/Wisconsin/10/2016 at 1.0e6 TCID50/mL and inactivated SARS-CoV-2 USA-WA1/2020 at 1e4 copies/mL) seeded into simulated NPS/NS matrix. The negative sample was tested in a GeneXpert module at the start of the study. Following the initial testing of the negative sample, the high positive sample was processed in the same GeneXpert module immediately followed by another negative sample. This was repeated 20 times in the same module, resulting in 20 positives and 21 negatives for the module. The study was repeated using a second GeneXpert module for a total of 40 positive and 42 negative samples. All 40 positive samples were correctly reported as SARS-CoV-2 POSITIVE; Flu A NEGATIVE; Flu B POSITIVE; RSV NEGATIVE. All 42 negative samples were correctly reported as SARS-CoV-2 NEGATIVE; Flu A NEGATIVE; Flu B NEGATIVE; RSV NEGATIVE with the Xpert Xpress CoV-2/Flu/RSV plus test. No specimen or amplicon carry-over contamination was observed in this study.

Single-Site Precision

The precision of the Xpert Xpress CoV-2/Flu/RSV plus test was established at a single site using a 9-member panel including one negative sample, 4 low positive (~1.5x LoD) samples and 4 moderate positive (~3x LoD) samples. The negative sample consisted of simulated matrix without target microorganism or target RNA. The positive samples were contrived using inactivated NATtrol SARS-CoV-2 (ZeptoMetrix, Buffalo, NY, catalog number NATSARS(COV2)-ST), and cultured viruses Influenza A/Idaho/07/2018, Influenza B/Wisconsin/10/2016, and RSV B/Wash/18537/62 in a simulated NPS/NS matrix.

Testing was conducted over 20 days, using 1 lot of Xpert Xpress CoV-2/Flu/RSV plus cartridges at a single site and with 1 operator to yield a total of 80 observations per panel member (1 Site x 1 Operator x 1 Lot x 20 Days x 2 Runs x 2 Replicates = 80 observations/panel member). The results from the study are summarized in Table 5-15.

27

Panel Member	Agreement	% Agreement (95% CI)
Negative	80/80	100%
(95.4%-100%)
SARS-CoV-2
Low Positive (~1.5x LoD)	79/80	98.8%
(93.3%-99.8%)
SARS-CoV-2
Moderate Positive (~3x LoD)	80/80	100%
(95.4%-100%)
Flu A
Low Positive (~1.5x LoD)	78/80	97.5%
(91.3%-99.3%)
Flu A
Moderate Positive (~3x LoD)	80/80	100%
(95.4%-100%)
Flu B
Low Positive (~1.5x LoD)	77/80	96.3%
(89.5%-98.7%)
Flu B
Moderate Positive (~3x LoD)	80/80	100%
(95.4%-100%)
RSV
Low Positive (~1.5x LoD)	78/80	97.5%
(91.3%-99.3%)
RSV
Moderate Positive (~3x LoD)	80/80	100%
(95.4%-100%)

Table 5-15. Summary of the Precision Results by Panel Member - % Agreement

Reproducibility

The reproducibility of the Xpert Xpress CoV-2/Flu/RSV plus test was established at 3 sites (2 external and 1 internal) using a 9-member panel including 1 negative sample, 4 low positive (~1.5x LoD) and 4 moderate positive (~3x LoD) samples. The negative sample consisted of simulated matrix without target microorganism or target RNA. The positive samples were contrived using inactivated NATtrol SARS-CoV-2 (ZeptoMetrix), cultured viruses Influenza A/ Idaho/07/2018, Influenza B/Wisconsin/ 10/2016, and RSV B/Wash/18537/62 in a simulated NPS/NS matrix. Testing was conducted over 6 days, using 3 lots of Xpert Xpress CoV-2/Flu/RSV plus cartridges at 3 participating sites each with 2 operators to yield a total of 144 observations per panel member (3 Sites x 2 Operators x 3 Lots x 2 Days/Lot x 2 Runs x 2 Replicates = 144 observations/panel member). The results from the study are summarized in Tables 5-16 and 5-17.

The percent agreement of the correct results compared to the expected results analyzed by each of the 6 operators and each site is shown in Table 5-17. In addition, the overall percent agreement for each sample (% total agreement) and the two-sided Wilson Score confidence intervals (CI) are presented in the last column.

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Image /page/28/Picture/0 description: The image shows the Cepheid logo. The logo consists of a stylized blue wing-like design on the left, followed by the word "Cepheid" in a lowercase, sans-serif font. A small circle is present to the right of the word, likely a registration mark.

Xpert® Xpress CoV-2/Flu/RSV plus

| | | Site 1 | | | | Site 2 | | | | Site 3 | | | % Total
Agreement
[95% CI] | |
|-----------------------|---------------|---------------|---------------|----------------|----------------|----------------|---------------|----------------|----------------|---------------------------------|--|--|----------------------------------|--|
| Sample | Op 1 | Op 2 | Site | Op 1 | Op 2 | Site | Op 1 | Op 2 | Site | | | | | |
| Negative | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100% (144/144)
[97.4-100.0] | | | | |
| SARS-CoV-2
Low Pos | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100% (144/144)
[97.4-100.0] | | | | |
| SARS-CoV-2
Mod Pos | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100% (144/144)
[97.4-100.0] | | | | |
| Flu A
Low Pos | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100% (144/144)
[97.4-100.0] | | | | |
| Flu A
Mod Pos | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100% (144/144)
[97.4-100.0] | | | | |
| Flu B
Low Pos | 100%
24/24 | 100%
24/24 | 100%
48/48 | 95.8%
23/24 | 95.8%
23/24 | 95.8%
46/48 | 100%
24/24 | 100%
24/24 | 100%
48/48 | 98.6% (142/144)
[95.1-99.6] | | | | |
| Flu B
Mod Pos | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100%
23/23 | 95.8%
23/24 | 97.9%
46/47 | 99.3% (142/143a)
[96.1-99.9] | | | | |
| RSV
Low Pos | 100%
24/24 | 100%
24/24 | 100%
48/48 | 95.8%
23/24 | 100%
24/24 | 97.9%
47/48 | 100%
24/24 | 100%
24/24 | 100%
48/48 | 99.3% (143/144)
[96.2-99.9] | | | | |
| RSV
Mod Pos | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100%
24/24 | 100%
24/24 | 100%
48/48 | 100% (144/144)
[97.4-100.0] | | | | |

Table 5-16. Summary of the Reproducibility Results - % Agreement

a. One replicate was excluded because it was run on external positive control produced an incorrect result but was inadvertently not reested.

The evaluation of reproducibility and within-laboratory precision of the underlying analyte Ct values for the Xpert Xpress COV-2/Flu/RSV plus test was analyzed using nested Analysis of Variance (ANOVA). The mean Ct, standard deviation (SD), and coefficient of variation (%CV) between-sites, between-lots, between-days, between-runs and within-run for each panel member are presented in Table 5-17.

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Image /page/29/Picture/9 description: The image shows the Cepheid logo. The logo consists of a blue graphic element resembling stylized wings or feathers, positioned to the left of the word "Cepheid." The word "Cepheid" is written in a simple, sans-serif font, and there is a small circle or dot to the right of the word.

Xpert® Xpress CoV-2/Flu/RSV plus

				Variance Source
				Site		OP		Lot		Day		Run		Within-
Run		Total
Sample	Analyte	N	Mean Ct	SD	CV
(%)	SD	CV
(%)	SD	CV
(%)	SD	CV
(%)	SD	CV
(%)	SD	CV
(%)	SD	CV
(%)
Negative	SPC	144	30.8	0.1	0.4	0.0	0.0	0.9	2.9	0.5	1.5	0.0	0.0	1.3	4.2	1.6	5.3
SARS-CoV-2
Low Pos	SARS-CoV-2	144	37.4	0.0	0.0	0.2	0.5	0.1	0.2	0.0	0.0	0.3	0.7	0.4	1.1	0.5	1.4
SARS-CoV-2
Mod Pos	SARS-CoV-2	144	36.2	0.0	0.1	0.1	0.3	0.0	0.0	0.1	0.3	0.2	0.4	0.4	1.0	0.4	1.2
Flu A
Low Pos	Flu A1	144	35.7	0.2	0.6	0.0	0.0	0.1	0.2	0.0	0.0	0.0	0.0	0.6	1.6	0.6	1.7
Low Pos	Flu A2	135b	37.9	0.3	0.8	0.0	0.0	0.2	0.5	0.0	0.0	0.4	1.1	0.9	2.5	1.1	2.9
Flu A
Mod Posa	Flu A1	144	34.7	0.0	0.0	0.1	0.2	0.0	0.0	0.1	0.3	0.0	0.0	0.4	1.2	0.4	1.3
	Flu A2	144	36.6	0.0	0.1	0.0	0.0	0.2	0.4	0.0	0.0	0.0	0.0	0.5	1.5	0.6	1.5
Flu B
Low Pos	Flu B	144	36.3	0.3	0.8	0.0	0.1	0.0	0.0	0.1	0.2	0.3	0.7	0.7	2.1	0.8	2.3
Flu B
Mod pos	Flu B	142c	35.1	0.0	0.0	0.1	0.4	0.1	0.3	0.3	0.8	0.0	0.0	0.7	2.0	0.8	2.2
RSV
Low Pos	RSV	144	35.8	0.1	0.2	0.0	0.0	0.2	0.4	0.0	0.0	0.0	0.0	0.6	1.7	0.6	1.8
RSV
Mod Pos	RSV	144	34.8	0.1	0.2	0.0	0.0	0.1	0.4	0.0	0.0	0.2	0.5	0.5	1.4	0.5	1.5

Table 5-17. Summary of Nested ANOVA by Coefficient of Variation

One replicate from Site 2 used the reagent lot 102 instead of the intended reagent lot 401. In the nested ANOVA analysis, this replicated under the a. intended lot 401 following the principle of "analyze as intended".

Nine replicates were excluded due to zero Flu A2 Ct values. b.

One replicate was excluded due to the B C. value; one replicate was excluded due to the incorrect external positive control result preceding the retest. C.

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5.4.2. Clinical Performance

The clinical performance of the Xpert Xpress CoV-2/Flu/RSV plus test was evaluated in a multi-site, observational and method comparison study that included 33 geographically diverse sites in the United States (US) using specimens collected from individuals showing signs and symptoms of respiratory infection. Of the 33 sites participated in specimen collection only, 27 performed Xpert testing and specimen collection, and 1 site performed Xpert testing as well as comparator and discrepant testing.

Specimens tested included prospective clinical NPS and NS specimens collected in UTM/VTM. Prospectively collected fresh clinical specimens (Category I) tested in the study were from a larger US specimen collection protocol. Fresh (98.9%) and frozen (1.1%) specimens meeting the eligibility criteria were prospectively collected and tested in 2022. Due to low prevalence of Flu/RSV in 2022, archived prospectively collected frozen clinical specimens (Category II) collected during the 2016-2017 influenza season were used to supplement the sample size. These specimens represent contemporary Flu/RSV strains. Since these specimens were collected prior to the COVID-19 pandemic, they were expected to be negative for SARS-CoV-2 and therefore tested only for the Flu A, Flu B, and RSV targets. Available demographic data from the individuals from whom Category I and Category II specimens were collected are presented in Table 5-18.

| Prospectively Collected
Fresh and Frozen Specimens
from 2022
(Category I and Category II) | NP Swab
(N=2672) | NS
(N=2659) | Overall
(N=5331) |
|----------------------------------------------------------------------------------------------------|---------------------|----------------|---------------------|
| Gender | | | |
| Female | 1568 (58.7%) | 1634 (61.5%) | 3202 (60.1%) |
| Male | 1104 (41.3%) | 1025 (38.5%) | 2129 (39.9%) |
| Age Group (Years) | | | |
| ≤5 | 9 (0.3%) | 183 (6.9%) | 192 (3.6%) |
| 6-21 | 623 (23.3%) | 562 (21.1%) | 1185 (22.2%) |
| 22-59 | 1676 (62.7%) | 1553 (58.4%) | 3229 (60.6%) |
| ≥60 | 364 (13.6%) | 361 (13.6%) | 725 (13.6%) |
| Race | | | |
| American Indian or Alaska
Native | 5 (0.2%) | 6 (0.2%) | 11 (0.2%) |
| Asian | 73 (2.7%) | 80 (3.0%) | 153 (2.9%) |
| Asian, White | 8 (0.3%) | 1 (0.0%) | 9 (0.2%) |
| Black or African American | 734 (27.5%) | 730 (27.5%) | 1464 (27.5%) |
| Black or African American,
White | 10 (0.4%) | 12 (0.5%) | 22 (0.4%) |
| Native Hawaiian or Other Pacific
Islander | 6 (0.2%) | 2 (0.1%) | 8 (0.2%) |
| Other Mixed (N≤3) | 4 (0.1%) | 5 (0.2%) | 9 (0.2%) |

				Table 5-18. Demographic Summary for Category I and II Specimens
--	--	--	--	-----------------------------------------------------------------

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Image /page/31/Picture/0 description: The image contains the logo for Cepheid. The logo consists of a stylized blue wing-like graphic on the left, followed by the word "Cepheid." in a sans-serif font. A small circle is present to the right of the word.

Xpert® Xpress CoV-2/Flu/RSV plus

| Prospectively Collected
Fresh and Frozen Specimens
from 2022
(Category I and Category II) | NP Swab
(N=2672) | NS
(N=2659) | Overall
(N=5331) |
|----------------------------------------------------------------------------------------------------|---------------------|----------------|---------------------|
| White | 1685 (63.1%) | 1641 (61.7%) | 3326 (62.4%) |
| Participant Declined to Answer,
or Unknown | 147 (5.5%) | 182 (6.8%) | 329 (6.2%) |
| Ethnicity | | | |
| Hispanic | 228 (8.5%) | 213 (8.0%) | 441 (8.3%) |
| Non-Hispanic | 2333 (87.3%) | 2323 (87.4%) | 4656 (87.3%) |
| Participant Declined to Answer,
or Unknown | 111 (4.2%) | 123 (4.6%) | 234 (4.4%) |
| Specimen Testing | | | |
| Fresh | 2641 (98.8%) | 2631 (98.9%) | 5272 (98.9%) |
| Frozen | 31 (1.2%) | 28 (1.1%) | 59 (1.1%) |
| COVID-19 Vaccination Status | | | |
| Vaccinated | 1969 (73.7%) | 1865 (70.1%) | 3834 (71.9%) |
| Not Vaccinated | 665 (24.9%) | 764 (28.7%) | 1429 (26.8%) |
| Unknown | 38 (1.4%) | 30 (1.1%) | 68 (1.3%) |
| Testing Environment | | | |
| CLIA Waiver | 1603 (60.0%) | 1619 (60.9%) | 3222 (60.4%) |
| Laboratory/NPT | 1069 (40.0%) | 1040 (39.1%) | 2109 (39.6%) |
| Prospectively Collected Frozen
Specimens from 2016-2017
Influenza Season
(Category II) | NPS
(N=422) | NS
(N=368) | Overall
(N=790) |
| Gender | | | |
| Female | 211 (50.0%) | 223 (60.6%) | 434 (54.9%) |
| Male | 211 (50.0%) | 145 (39.4%) | 356 (45.1%) |
| Age Group (Years) | | | |
| 60 | 39 (9.2%) | 41 (11.1%) | 80 (10.1%) |

Specimens were tested using Xpert Xpress CoV-2/Flu/RSV plus side-by-side with a U.S.FDA-cleared molecular respiratory panel that includes SARS-CoV-2 and a U.S. FDAcleared molecular Flu A/B/RSV assay, in a randomized and blinded fashion.

Positive Percent Agreement (PPA) and Negative Percent Agreement (NPA), and nondeterminate rate were determined by comparing the results of the Xpert Xpress CoV-2/Flu/RSV plus test relative to the results of a U.S. FDA-cleared molecular respiratory panel for the SARS-CoV-2 target, and a U.S.FDA-cleared molecular Flu A/B/RSV assay for the Flu A, Flu B, and RSV targets, respectively.

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Discrepant results between Xpert Xpress CoV-2/Flu/RSV plus and the comparator for the SARS-CoV-2 target were investigated using a U.S. FDA EUA SARS-CoV-2 molecular test. Discrepant results between the Xpert Xpress CoV-2/Flu/RSV plus and the comparator for the Flu A/B/RSV targets were investigated using a U.S. FDA-cleared molecular respiratory panel.

A total of 5051 specimens, including 2536 NPS and 2515 NS specimens that vielded valid results by both the Xpert Xpress CoV-2/Flu/RSV plus and the U.S. FDA-cleared molecular respiratory panel were included in the performance evaluation for SARS-CoV-2. A total of 5954 specimens, including 3011 NPS and 2943 NS (specimens that yielded valid results by both the Xpert Xpress CoV-2/Flu/RSV plus and the U.S. FDA-cleared molecular Flu A/B/RSV assay were included in the performance evaluation for Flu A, Flu B, and RSV targets.

For the NPS specimens (both fresh and frozen specimens, combined), Xpert Xpress CoV-2/Flu/RSV plus demonstrated a PPA and NPA of 97.1% and 98.2% for SARS-CoV-2, respectively: 99.0% and 99.1% for Flu A. respectively: 96.6% and 100.0% for Flu B, respectively; 98.6% and 100.0% for RSV, respectively (Table 5-19). The initial nondeterminate rate for the Xpert Xpress CoV-2/Flu/RSV plus test was 2.4% (74/3094). On repeat testing, 66 specimens yielded valid results. The final non-determinate rate for the Xpert Xpress CoV-2/Flu/RSV plus test was 0.3% (8/3094).

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| Target | Specimen
Collection | Numbers of
Specimens | TP | FP | TN | FN | PPA
(%) | 95%CI | NPA
(%) | 95%CI |
|----------------|------------------------|-------------------------|-----|-----|------|-----|------------|--------------|------------|--------------|
| SARS-
CoV-2 | Fresh | 2505 | 454 | 37a | 2000 | 14b | 97 | 95.0 - 98.2 | 98.2 | 97.5 - 98.7 |
| | Frozen | 31 | 8 | 0 | 23 | 0 | 100 | 67.6 - 100.0 | 100 | 85.7- 100.0 |
| | Overall | 2536 | 462 | 37 | 2023 | 14 | 97.1 | 95.1 - 98.2 | 98.2 | 97.5-98.7 |
| Flu A | Fresh | 2562 | 98 | 11c | 2451 | 2d | 98 | 93.0 - 99.5 | 99.6 | 99.2 - 99.8 |
| | Frozen | 449 | 93 | 13e | 343 | 0 | 100 | 96.0 - 100.0 | 96.3 | 93.9 - 97.9 |
| | Overall | 3011 | 191 | 24 | 2794 | 2 | 99.0 | 96.3 - 99.7 | 99.1 | 98.7 - 99.4 |
| Flu B | Fresh | 2562 | 0 | 0 | 2562 | 0 | NA | NA | 100 | 99.9 - 100.0 |
| | Frozen | 449 | 57 | 0 | 390 | 2f | 96.6 | 88.5 - 99.1 | 100 | 99.0 - 100.0 |
| | Overall | 3011 | 57 | 0 | 2952 | 2 | 96.6 | 88.5 - 99.1 | 100 | 99.9 - 100.0 |
| RSV | Fresh | 2562 | 12 | 0 | 2550 | 0 | 100 | 75.8 - 100.0 | 100 | 99.8 - 100.0 |
| | Frozen | 449 | 59 | 0 | 389 | 1g | 98.3 | 91.1 - 99.7 | 100 | 99.0 - 100.0 |
| | Overall | 3011 | 71 | 0 | 2939 | 1 | 98.6 | 92.5 - 99.8 | 100 | 99.9 - 100.0 |

Table 5-19. Xpert Xpress CoV-2/Flu/RSV plus Performance Results for NPS Specimens

TP: True Positive; FP: False Positive; TN: True Negative; C1: 95% two-sided Confidence Interval

Discrepant test results based on a U.S. FDA EUA SARS-CoV-2 molecular test: 15/37 SARS-CoV-2 positive; a. 22/37 SARS-CoV-2 negative

Discrepant test results based on a U.S. FDA EUA SARS-CoV-2 molecular test: 3/14 SARS-CoV-2 positive; b. 10/14 SARS-CoV-2 negative; 1/14 invalid result

Discrepant test results based on a U.S. FDA-cleared molecular respiratory panel: 8/11 Flu A positive; 3/11 Flu A C. negative

Discrepant test results based on a U.S. FDA-cleared molecular respiratory panel: 1/2 Flu A d. negative

Discrepant test results based on a U.S. FDA-cleared molecular respiratory panel: 13/13 tests not performed due e. to specimens being stored for a longer duration than recommended per the package insert

f. Discrepant test results based on a U.S. FDA-cleared molecular respiratory panel: 2/2 test not performed due to specimens being stored for a longer duration than recommended per the package insert

Discrepant test results based on a U.S. FDA-cleared molecular respiratory panel: 1/1 test not performed due to g. specimens being stored for a longer duration than recommended per the package insert

For the NS specimens (both fresh and frozen specimens, combined), Xpert Xpress CoV-2/Flu/RSV plus demonstrated a PPA and NPA of 98.2% and 98.8% for SARS CoV-2, respectively; 98.0% and 99.3% for Flu A, respectively; 100.0% and 99.9% for Flu B, respectively; 95.8% and 100.0% for RSV, respectively (Table 5-20). The initial nondeterminate rate for the Xpert Xpress CoV-2/Flu/RSV plus test was 2.4% (74/3027). On repeat testing, 57 specimens gave valid results upon retest. The final non-determinate rate for the Xpert Xpress CoV-2/Flu/RSV plus test was 0.6% (17/3027).

34

| Target | Specimen
Collection | Numbers of
Specimens | TP | FP | TN | FN | PPA
(%) | 95%CI | NPA
(%) | 95%CI |
|----------------|------------------------|-------------------------|-----|-----|------|----|------------|--------------|------------|--------------|
| | Fresh | 2489 | 442 | 23a | 2017 | 7b | 98.4 | 96.8 - 99.2 | 98.9 | 98.3 - 99.2 |
| SARS-
CoV-2 | Frozen | 26 | 6 | 1c | 18 | 1d | 85.7 | 48.7 - 97.4 | 94.7 | 75.4 - 99.1 |
| | Overall | 2515 | 448 | 24 | 2035 | 8 | 98.2 | 96.6 - 99.1 | 98.8 | 98.3 - 99.2 |
| | Fresh | 2553 | 130 | 6e | 2413 | 4f | 97.0 | 92.6 - 98.8 | 99.8 | 99.5 - 99.9 |
| Flu A | Frozen | 390 | 66 | 12g | 312 | 0 | 100 | 94.5 - 100.0 | 96.3 | 93.6 - 97.9 |
| | Overall | 2943 | 196 | 18 | 2725 | 4 | 98.0 | 95.0 - 99.2 | 99.3 | 99.0 - 99.6 |
| | Fresh | 2553 | 0 | 0 | 2553 | 0 | NA | NA | 100 | 99.8 - 100.0 |
| Flu B | Frozen | 390 | 34 | 3h | 353 | 0 | 100 | 89.8 - 100.0 | 99.2 | 97.6 - 99.7 |
| | Overall | 2943 | 34 | 3 | 2906 | 0 | 100 | 89.8 - 100.0 | 99.9 | 99.7 - 100.0 |
| | Fresh | 2553 | 14 | 0 | 2538 | 1i | 93.3 | 70.2 - 98.8 | 100 | 99.8 - 100.0 |
| RSV | Frozen | 390 | 55 | 0 | 333 | 2j | 96.5 | 88.1 - 99.0 | 100 | 98.9 - 100.0 |
| | Overall | 2943 | 69 | 0 | 2871 | 3 | 95.8 | 88.5 - 98.6 | 100 | 99.9 - 100.0 |

Table 5-20. Xpert Xpress CoV-2/Flu/RSV plus Performance Results for NS Specimens

TP: True Positive; FP: False Positive; TN: True Negative; C1: 95% two-sided Confidence Interval

Discrepant test results based on a U.S. FDA EUA SARS-CoV-2 molecular test: 6/23 SARS-CoV-2 positive; a. 14/23 SARS-CoV-2 negative; 2/23 invalid result; 1/23 discrepant testing was inadvertently not performed

Discrepant test results based on a U.S. FDA EUA SARS-CoV-2 molecular test: 2/7 SARS-CoV-2 positive; 5/7 b. SARS-CoV-2 negative

Discrepant test results based on a U.S. FDA EUA SARS-CoV-2 molecular test: 1/1 SARS-CoV-2 positive C.

d. Discrepant test results based on a U.S. FDA EUA SARS-CoV-2 molecular test: 1/1 SARS-CoV-2 negative
e. Discrepant test results based on a U.S. FDA-cleared molecular respiratory panel: 5/6 Flu A negative
f. Discrepant test results based on a U.S. FDA-cleared molecular respiratory panel: 2/4 Flu A negative
Discrepant test results based on a U.S. FDA-cleared molecular respiratory panel: 12/12 tests not performed due g. to specimens being stored for a longer duration than recommended per the package insert

Discrepant test results based on a U.S. FDA-cleared molecular respiratory panel: 3/3 tests not performed due to h. specimens being stored for a longer duration than recommended per the package insert

i. Discrepant test results based on a U.S. FDA-cleared molecular respiratory panel: 1/1 RSV positive

j. Discrepant test results based on a U.S. FDA-cleared molecular respiratory panel: 2/2 test not performed due to specimens being stored for a longer duration than recommended per the package insert

The number of specimens with positive results for more than one target as detected by Xpert Xpress CoV-2/Flu/RSV plus is presented in Table 5-21 and Table 5-22, where bolded values indicate concordant results.

35

| Infection | | Comparator Results | | | | | Total | Co-Infection
Rate (%) |
|-------------------------------------|-----------------------|--------------------|-------------------------|------------|----------|----------|-------|--------------------------|
| | | SARS-CoV-2
only | SARS-CoV-2 and
Flu A | Flu A only | RSV only | Negative | | |
| Xpert Xpress CoV-
2/Flu/RSV plus | SARS-CoV-2 only | 876 | 1 | 0 | 0 | 57 | 934 | |
| | SARS-CoV-2 and Flu A | 0 | 2 | 1 | 0 | 0 | 3 | |
| | Flu A only | 0 | 0 | 220 | 0 | 17 | 237 | 0.3 |
| | RSV only | 0 | 0 | 0 | 26 | 0 | 26 | |
| | Negative | 22 | 0 | 5 | 1 | 3693 | 3721 | |
| | Total | 898 | 3 | 226 | 27 | 3767 | 4921 | |
| | Co-Infection Rate (%) | 0.3 | | | | | | |

Table 5-21. Multi-Target Detection by Xpert Xpress CoV-2/Flu/RSV plus for Specimens Collected in 2022

As presented in Table 5-21, a total of 4921 Category I specimens collected in 2022 yielded valid results for SARS-CoV-2, Flu A, and RSV targets for both the Xpert Xpress CoV-2/Flu/RSV plus test and the comparator test. The co-infection rate for Xpert Xpress CoV-2/Flu/RSV plus was 0.3% (3/1200) and the rate of co-infection by the comparator was 0.3% (3/1154).

Table 5-22. Flu A, Flu B, and RSV Multi-Target Detection by Xpert Xpress CoV-2/Flu/RSV plus for Specimens Collected in 2016-2017 and 2022

| Infection | | Comparator | | | | | | Total | Co-Infection
Rate (%) | |
|---------------------------------|-----------------|------------|------------|----------|-----------------|---------------|---------------|-------|--------------------------|----------|
| | | Flu A only | Flu B Only | RSV Only | Flu A and Flu B | Flu A and RSV | Flu B and RSV | | | Negative |
| Xpert Xpress CoV-2/Flu/RSV plus | Flu A only | 381 | 0 | 0 | 1 | 1 | 0 | 36 | 419 | |
| | Flu B Only | 0 | 85 | 0 | 0 | 0 | 0 | 2 | 87 | |
| | RSV Only | 0 | 0 | 135 | 0 | 0 | 0 | 0 | 135 | |
| | Flu A and Flu B | 0 | 4 | 0 | 1 | 0 | 0 | 1 | 6 | |
| | Flu A and RSV | 0 | 0 | 1 | 0 | 3 | 0 | 0 | 4 | 1.7 |
| | Flu B and RSV | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 1 | |
| | Negative | 6 | 1 | 3 | 0 | 0 | 0 | 5292 | 5302 | |
| Total | | 387 | 90 | 139 | 2 | 4 | 1 | 5331 | 5954 | |
| Co-Infection
Rate (%) | | 1.1 | | | | | | | | |

As presented in Table 5-22, of the 5954 Category I and II specimens evaluated for Flu A, Flu B and RSV targets, the co-infection rate for Xpert Xpress CoV-2/Flu/RSV plus was 1.7% (11/652) and the rate of co-infection by the comparator was 1.1% (7/623).

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Image /page/36/Picture/0 description: The image shows the Cepheid logo and the text "Xpert® Xpress CoV-2/Flu/RSV plus". The Cepheid logo is a blue stylized image of a bird in flight. The text is in black and is located below the logo.

5.5. Conclusions

The results of the analytical and clinical performance studies summarized above demonstrated that the Xpert Xpress CoV-2/Flu/RSV plus test is substantially equivalent to the predicate device.

Intended Use / Indications for Use

Product codes

Device Description

Mentions image processing

Mentions AI, DNN, or ML

Input Imaging Modality

Anatomical Site

Indicated Patient Age Range

Intended User / Care Setting

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

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

Summary of Performance Studies

Key Metrics

Predicate Device(s)

Reference Device(s)

Predetermined Change Control Plan (PCCP) - All Relevant Information

§ 866.3981 Device to detect and identify nucleic acid targets in respiratory specimens from microbial agents that cause the SARS-CoV-2 respiratory infection and other microbial agents when in a multi-target test.

Re: K231481

Joseph Briggs -S

Indications for Use

CONTINUE ON A SEPARATE PAGE IF NEEDED.

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

510(k) Summary for Xpert® Xpress CoV-2/Flu/RSV plus

TABLE OF CONTENTS

5. 510(k) Summary

Device Description 5.1.

. Nasopharyngeal Sample Collection Kit for Viruses

5.2. Device Intended Use

5.3. Substantial Equivalence

Table 5-1: Comparison of Similarities and Differences Between Xpert Xpress CoV-2/Flu/RSV plus and the Predicate Device

5.4. Performance Studies

5.4.1. Analytical Performance

Analytical Sensitivity - Clinical Nasopharyngeal Swab (NPS) Matrix

Analytical Sensitivity - Clinical Anterior Nasal Swab (NS) Matrix

Table 5-3. Xpert Xpress CoV-2/Flu/RSV plus Limit of Detection in Clinical NS-UTM/VTM Matrix

Analytical Reactivity (Inclusivity)

SARS-CoV-2 in silico Analyses

Table 5-6. Microorganisms Analyzed in the in silico Analysis for the SARS-CoV-2 Target

Wet Testing

Microbial Interference

Competitive Interference

Potentially Interfering Substances

Table 5-14. Number of Correct Results for Xpert Xpress CoV-2/Flu/RSV plus Targets Tested in the Presence of Potentially Interfering Substances

Xpert® Xpress CoV-2/Flu/RSV plus

Carryover Contamination

Single-Site Precision

Reproducibility

Xpert® Xpress CoV-2/Flu/RSV plus

Table 5-16. Summary of the Reproducibility Results - % Agreement

Xpert® Xpress CoV-2/Flu/RSV plus

Table 5-17. Summary of Nested ANOVA by Coefficient of Variation

5.4.2. Clinical Performance

Xpert® Xpress CoV-2/Flu/RSV plus

Table 5-19. Xpert Xpress CoV-2/Flu/RSV plus Performance Results for NPS Specimens

Table 5-20. Xpert Xpress CoV-2/Flu/RSV plus Performance Results for NS Specimens

Table 5-21. Multi-Target Detection by Xpert Xpress CoV-2/Flu/RSV plus for Specimens Collected in 2022

5.5. Conclusions