Molecular methods in the diagnostic microbiology laboratory

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Molecular methods in diagnostic Microbiology :

Dr.T.V.Rao MD Molecular methods in diagnostic Microbiology Dr.T.V.Rao MD 1

Molecular methods in Diagnosis :

Molecular methods in Diagnosis The introduction of molecular methods will not only depend on their performance for each individual microorganism, but also on the clinical relevance of the diagnostic question asked, the prevalence of the clinical problem and whether the new methods are added to the procedures in use or will replace them . Therefore no general rules can be proposed, strategies have to be elaborated for each infectious agent or clinical syndrome. Dr.T.V.Rao MD 2

When we really need molecular methods ?:

Molecular diagnosis is most appropriate for infectious agents that are difficult to detect, identify, or test for susceptibility in a timely fashion with conventional methods. When we really need molecular methods ? Dr.T.V.Rao MD 3

There is an urgent need for molecular methods in ……:

Strategies concerning the use of molecular diagnostic techniques for the diagnosis of Mycobacterium tuberculosis, Chlamydia trachomatis, meningo-encephalitis syndrome and respiratory infections , are need of the time. There is an urgent need for molecular methods in …… Dr.T.V.Rao MD 4

Need for novel methods in diagnosis of Infections:

Identification of the infectious agent(s) is essential to provide an accurate diagnosis, appropriately manage patient care and in certain cases reduce the risk of transmission within the community and health care settings. To meet these challenges, innovative technologies have been developed that detect single pathogens, multiple syndrome related pathogens and genotypic drug resistance Need for novel methods in diagnosis of Infections Dr.T.V.Rao MD 5

Molecular methods are revolutionizing:

Molecular methods are revolutionizing The use of molecular biology techniques, such as nucleic acid probing and amplification, provides the potential for revolutionizing how we diagnose infecting pathogens and determining the relation between nosocomial isolates. In clinical microbiology, this means that we will be able to detect smaller amounts of DNA or RNA of pathogens than is currently possible, that the time required to identify and determine the antimicrobial susceptibility of slow-growing pathogens will be dramatically reduced, and that the diagnosis of nonculturable organisms will become possible. Dr.T.V.Rao MD 6

Diagnostic microbiology changing from phenotypic methods to Molecular methods:

Diagnostic microbiology changing from phenotypic methods to Molecular methods In hospital epidemiology, the use of such techniques has already provided tests with exceptional discriminatory power. Molecular techniques allow more efficient typing of all pathogens, and permit discrimination between strains of organisms that were previously phenotypically identical or uncharacterizable. Currently, cost and complexity limit the applicability of these techniques ; however, they are likely to be developed for routine laboratory use in the next decade, and their impact will be considerable. Dr.T.V.Rao MD 7

Molecular methods are necessary if the traditional methods provide poor results ?:

8 Molecular methods are necessary if the traditional methods provide poor results ? Microscopy gives false positive results - - T.vaginalis, N.gonorrhoeae Intracellular pathogens – viruses, M.genitalium Low sensitivity – Chlamydia sp.,Neisseria sp. Seropositivity is common – Chlamydia sp . Subtyping is mandatory – HSV, HPV, HCV Microbial growth is slow – M. tuberculosis The 7th Baltic Congress in Laboratory Medicine, Pärnu 11.09.2004 Dr.T.V.Rao MD

Molecular diagnostics – how it works?:

9 Molecular diagnostics – how it works? Every organism contains some unique , species specific DNA sequences Molecular diagnostics makes the species specific DNA visible The 7th Baltic Congress in Laboratory Medicine, Pärnu 11.09.2004 Dr.T.V.Rao MD

Emerging molecular methods in diagnosis :

Emerging molecular methods in diagnosis HYBRIDIZATION- Direct detection of nucleic acids AMPLIFICATION METHODS- Target amplification Probe amplification Signal amplification SEQUENCING & ENZYMATIC DIGESTION . Dr.T.V.Rao MD 10

Molecular applications in infectious diseases :

Molecular applications in infectious diseases DNA hybridization - first used to demonstrate relatedness among bacteria • Nucleic acid probe technology: for detection of: -Antimicrobial resistance genes -Presence of organisms – mycobacteria, legionella -These methods may require growth • Nucleic acid amplification methods – for detection, identification & characterization of organisms Growth is not necessary Dr.T.V.Rao MD 11

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12 Molecular diagnostics is a set of methods to study primary structure (sequence) of DNA Hybridization with complementary sequences Amplification (synthesis) of species specific sequences PCR – polymerase chain reaction The 7th Baltic Congress in Laboratory Medicine, Pärnu 11.09.2004 -A-A-T-T-C-G-C-G-A-T-G- - T-T-A-A-G-C-G-C-T-A-C - -A-A-T-T-C-G-C-G-A-T-G- -A-A-T-T-C-G-C-G-A-T-G- -A-A-T-T-C-G-C-G-A-T-G- -A-A-T-T-C-G-C-G-A-T-G- -A-A-T-T-C-G-C-G-A-T-G- Dr.T.V.Rao MD

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Dr.T.V.Rao MD 13

ESTABLISHMENT OF A PCR LABORATORY:

ESTABLISHMENT OF A PCR LABORATORY To perform PCR for the repetitive detection of a specific sequence, three distinct laboratory areas are required. The specific technical operations, reagents ,and personnel considerations Dr.T.V.Rao MD 14

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15 PCR laboratory Sample handling DNA preparation Clean room Stock solutions Laboratory Mixing site Thermocycler Amplification Detection Documentation QC & QA Quality control & assurance R & D ( Research and development) Alternatives: - commercial kits - robots + kits No alternative Dr.T.V.Rao MD

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16 The 7th Baltic Congress in Laboratory Medicine, Pärnu 11.09.2004 Advantages Molecular methods High sensitivity and specificity Detects pathogen, not immune response Quick results High transport toleration In-house (home-brew) PCR methods Cost effective High sensitivity High quality Fast implementation of scientific discoveries Customer friendly R&D is absolutely necessary Dr.T.V.Rao MD

Uses and Advantages in Testing by PCR Methods:

Clinical diagnostics: detection and quantification of infectious microorganisms, cancer cells and genetic disorders Capable of amplifying long targets, up to 6.0 kb One-tube system allows rapid, sensitive and reproducible analysis of RNA with minimal risk of sample contamination Amplifies products from a wide variety of total RNA or mRNA sources Uses and Advantages in Testing by PCR Methods Dr.T.V.Rao MD 17

Prevention of Contamination in PCR Laboratory:

PCR contamination be considered as a form of infection . If standard sterile techniques that would be applied to tissue culture or microbiological manipulations are applied to PCR, then the risk of contamination will be greatly reduced . Above all else, common sense should prevail. Prevention of Contamination in PCR Laboratory Dr.T.V.Rao MD 18

Avoiding contamination:

Avoiding contamination The single most important source of PCR product contamination is the generation of aerosols of PCR amplicons that is associated with the post-PCR analysis. Methods for eliminating this aerosol range from physical design of laboratories and use of specific pipettes to chemical and enzymatic approaches. The choice of method is often dependent on the frequency of amplification of a target amplicon and the relative amounts and concentrations of the amplicons created by the PCR. Dr.T.V.Rao MD 19

Commercial kits support the research methods:

Commercial kits for the molecular detection and identification of infectious pathogens have provided a degree of standardization and ease of use that has facilitated the introduction of molecular diagnostics into the clinical microbiology laboratory Commercial kits support the research methods Dr.T.V.Rao MD 20

Nucleic acid probes enters in molecular based diagnostics:

The use of nucleic acid probes for identifying cultured organisms and for direct detection of organisms in clinical material was the first exposure that most laboratories had to commercially available molecular tests Nucleic acid probes enters in molecular based diagnostics Dr.T.V.Rao MD 21

Molecular Diagnostics for Infectious Diseases:

Molecular Diagnostics for Infectious Diseases Molecular Diagnostics for Infectious Disease features emerging and novel technologies, from deep sequencing for microbial diagnostics to rapid molecular methods impacting the detection and control of hospital infections. The program will also feature the use of mass spec for pathogen detection in the clinical setting. These new technologies have the potential to save time, cost, and eventually lives. Some of the challenges to be addressed include clinical adoption and validation, as well as regulatory issues. Dr.T.V.Rao MD 22

Beginning Nucleic Acid Amplification :

Nucleic acid amplification provides the ability to selectively amplify specific targets present in low concentrations to detectable levels; thus, amplification-based methods offer superior performance, in terms of sensitivity, over the direct (non-amplified) probe-based tests. PCR (Roche Molecular Systems, Branchburg, NJ ) was the first such technique to be developed and because of its flexibility and ease of performance remains the most widely used molecular diagnostic technique in both research and clinical laboratories. Beginning Nucleic Acid Amplification Dr.T.V.Rao MD 23

PCR in Clinical Microbiology:

PCR in Clinical Microbiology Molecular detection has mostly come to the clinical microbiology laboratory in the form of PCR technology, initially involving single round or nested procedures with detection by gel electrophoresis. Dr.T.V.Rao MD 24

Helps Rapid Detection:

Helps Rapid Detection Polymerase chain reaction (PCR) techniques have led the way into this new era by allowing rapid detection of microorganisms that were previously difficult or impossible to detect by traditional microbiological methods. Dr.T.V.Rao MD 25

Advances on PCR Methods:

Advances on PCR Methods Fairly recently, a new method of PCR quantification has been invented. This is called “ real-time PCR” because it allows the scientist to actually view the increase in the amount of DNA as it is amplified. Dr.T.V.Rao MD 26

New Technologies – Real Time Assays:

New Technologies – Real Time Assays The Real Time assays are proving to better technologies 1 Rapid 2 Quantitative measurement 3 Lower contamination rate 4 Higher sensitivity 5 Higher specificity 6 Easy standardization Now a new gold standard for rapid diagnosis of virus infection in the acute phase samples. Dr.T.V.Rao MD 27

New Technologies – Real Time Assays:

New Technologies – Real Time Assays The Real Time assays are proving to better technologies 1 Rapid 2 Quantitative measurement 3 Lower contamination rate 4 Higher sensitivity 5 Higher specificity 6 Easy standardization Now a new gold standard for rapid diagnosis of virus infection in the acute phase samples. Dr.T.V.Rao MD 28

RT - PCR:

RT - PCR Proving to be Accurate Precise Easy to perform RT PCR technologies are easy to transfer research Laboratory protocols to Diagnostic Laboratories Dr.T.V.Rao MD 29

OVERVIEW of RT - PCR:

OVERVIEW of RT - PCR tissue extract RNA copy into cDNA (reverse transciptase) do real-time PCR analyze results Dr.T.V.Rao MD 30

Real Time Reporters:

All real time PCR systems rely upon the detection and quantization of fluorescent reporter, the signal of which increases in direct proportion of the amount of PCR product in a reaction. Real Time Reporters Dr.T.V.Rao MD 31

REAL TIME PCR Cyber Green:

REAL TIME PCR Cyber Green USING SYBER ® GREEN The simplest and economical format the reporter is the double strand DNA specific dye SYBR ® Green Called as Molecular Probe. Dr.T.V.Rao MD 32

Uses of Automated RT - PCR:

Uses of Automated RT - PCR Several viral infections can be detected in acute phase serum samples. Increasing used in for early and accurate detection of all most human viruses including Measles, Mumps, Herpes simplex viruses, Rota viruses Noro virus,Influenzae virus type A and B, Respiratory Syncitical virus, SARS, Dengue Japanese Encephalitis, Hepatitis B and C, West Nile, Chikungunya,HIV, Avian flu virus, Dr.T.V.Rao MD 33

Multiplex PCR in Real Time:

Multiplex PCR in Real Time Multiplex real time quantitative RT-PCR assays have been developed for simultaneous detection identification and quantification of HBV, HCV and HIV-! In plasma and Serum samples. Dr.T.V.Rao MD 34

Other Emerging Alternatives:

Other Emerging Alternatives Two most popular alternatives to SYBR green are TaqMan ® and Molecular Beacons . Both technologies depend on hybridization probes relying on fluorescence resonance energy transfer.( FRET) and quantization Dr.T.V.Rao MD 35

TaqMAN®:

TaqMAN ® Dr.T.V.Rao MD 36

TaqMAN® Sequencing:

TaqMAN ® Sequencing Dr.T.V.Rao MD 37

TaqMAN® probes:

TaqMAN ® probes Dr.T.V.Rao MD 38

Commercial kits available for better diagnosis:

Commercial amplification-based molecular diagnostic systems for infectious diseases have focused largely on systems for detecting N. gonorrhea , C. trachomatis , M. tuberculosis , and specific viral infections (HBV, HCV, HIV, CMV, and enterovirus) . Given the adaptability of PCR, numerous additional infectious pathogens have been detected by investigator-developed or home-brew PCR assays [ Commercial kits available for better diagnosis Dr.T.V.Rao MD 39

Routine diagnostic failures can be adopted to molecular methods:

Routine diagnostic failures can be adopted to molecular methods Organisms that cannot be grown / difficult to grow (HPV, HBV, HCV, HIV, EBV, CMV) (i) Fastidious, slow-growing agents (M. tuberculosis, Legionella pneumophila) (iii) Highly infectious agents (dangerous to culture) Francisella tularensis Brucella species Coccidioides immitis Dr.T.V.Rao MD 40

Nucleic A probe hybridization:

Nucleic A probe hybridization Organism Specimen Campylobacter spp . Stool culture Chlamydia trachomatis Cervical & urethraswab,urine Enterobacteriaceae Blood culture FISH H. influenza CSF / TS culture L. monocytogenes Culture isolate M. tb, avium, intracellulare, Resp specimen culture M. gordonae, kansasii N. gonorrhoeae Urethral / cervical swab / culture Dr.T.V.Rao MD 41

Nucleic Acid probe hybridization :

Nucleic Acid probe hybridization P. aeruginosa Blood culture FISH S. aureus Blood culture FISH (PNA) MRSA Culture isolate Streptococcus spp . Blood culture FISH S. pneumoniae Culture isolate S. pyogenes Throat swab Streptococcus Gr . B Culture isolâtes C. albicans Blood culture FISH (PNA) C. immitis Culture isolate B. dermatitidis Culture isolate Dr.T.V.Rao MD 42

Nucleic A probe hybridization……:

Nucleic A probe hybridization…… CMV Whole blood, WBC HC, ISH H. capsulatum Culture isolate HBV, HCV Blood bDNA HSV Vesicle fluid Hybrid Capture HIV Blood bDNA HPV Cervical swab / biopsy HC, ISH EB virus CSF ISH Dr.T.V.Rao MD 43

Molecular methods designed for quantitation too:

In addition to qualitative detection of viruses, quantitation of viral load in clinical specimens is now recognized to be of great importance for the diagnosis, prognosis, and therapeutic monitoring for HCV, HIV, HBV, and CMV [ Both PCR and nucleic acid strand-based amplification systems are available for quantitation of one or more viruses Molecular methods designed for quantitation too Dr.T.V.Rao MD 44

Several methods for non cultivable microbes:

Amplification-based methods are also valuable for identifying cultured and non-cultivatable organisms [ Amplification reactions may be designed to rapidly identify an acid-fast organism as M. tuberculosis, M.lepra or may amplify a genus-specific or "universal" target, which then is characterized by using restriction endonuclease digestion, hybridization with multiple probes, or sequence determination to provide species or even subspecies delineation Several methods for non cultivable microbes Dr.T.V.Rao MD 45

Probe hybridization:

Probe hybridization is useful for identifying slow-growing organisms after isolation in culture using either liquid or solid media. Identification of mycobacteria and other slow-growing organisms such as the dimorphic fungi ( Histoplasma capsulatum, Coccidioides immitis, and Blastomyces dermatitidis ) has certainly been facilitated by commercially available probes Probe hybridization Dr.T.V.Rao MD 46

Gene probes are useful ..:

Gene probes are useful .. . All commercial probes for identifying organisms are produced by Gen-Probe and use acridinium ester-labeled probes directed at species-specific rRNA sequences Gen-Probe products are available for the culture identification of Mycobacterium tuberculosis, M. avium-intracellulare complex, M. gordonae, M. kansasii, Cryptococcus neoformans , the dimorphic fungi (listed above), N. gonorrhea, Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Haemophilus influenza, Enterococcus spp., S. agalactiae , and Listeria Monocytogenes . Dr.T.V.Rao MD 47

Detecting Antimicrobial-Drug Resistance:

Detecting Antimicrobial-Drug Resistance Molecular methods can rapidly detect antimicrobial-drug resistance in clinical settings and have substantially contributed to our understanding of the spread and genetics of resistance. Conventional broth- and agar-based antimicrobial susceptibility testing methods provide a phenotypic profile of the response of a given microbe to an array of agents. Although useful for selecting potentially useful therapeutic agents, conventional methods are slow and fraught with problems Dr.T.V.Rao MD 48

Molecular methods – gene chips:

Molecular methods may be used to detect specific antimicrobial-drug resistance genes (resistance genotyping) in many organisms Detection of specific point mutations associated with resistance to antiviral agents is also increasingly important Screening for mutations in an amplified product may be facilitated by the use of high-density probe arrays (Gene chips ) [ . Molecular methods – gene chips Dr.T.V.Rao MD 49

Molecular methods to detect MRSA:

The most common failing is in the detection of methicillin resistance in staphylococci, which may be expressed in a very heterogeneous fashion, making phenotypic characterization of resistance difficult [ . Currently, molecular detection of the resistance gene, mec A , is the standard against which phenotypic methods for detection of methicillin resistance are judged [9,15,16 Molecular methods to detect MRSA Dr.T.V.Rao MD 50

Routine phenotypic detection of antibiotic resistance yet cannot be replaced :

Despite its many potential advantages, genotyping will not likely replace phenotypic methods for detecting antimicrobial-drug resistance in the clinical laboratory in the near future. Molecular methods for resistance detection may be applied directly to the clinical specimen, providing simultaneous detection and identification of the pathogen plus resistance characterization ] Routine phenotypic detection of antibiotic resistance yet cannot be replaced Dr.T.V.Rao MD 51

Genotypic detection carries more importance in virology :

Likewise, they are useful in detecting resistance in viruses, slow-growing or nonviable organisms, or organisms with resistance mechanisms that are not reliably detected by phenotypic methods [ Genotypic detection carries more importance in virology Dr.T.V.Rao MD 52

Molecular methods have limitations:

Molecular methods have limitations However, because of their high specificity, molecular methods will not detect newly emerging resistance mechanisms and are unlikely to be useful in detecting resistance genes in species where the gene has not been observed previously. Furthermore, the presence of a resistance gene does not mean that the gene will be expressed, and the absence of a known resistance gene does not exclude the possibility of resistance from another mechanism. Phenotypic antimicrobial susceptibility testing methods allow laboratories to test many organisms and detect newly emerging as well as established resistance patterns. Dr.T.V.Rao MD 53

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Advantages Molecular methods High sensitivity and specificity Detects pathogen, not immune response Quick results High transport toleration In-house (home-brew) PCR methods Cost effective High sensitivity High quality Fast implementation of scientific discoveries Customer friendly R&D is absolutely necessary Dr.T.V.Rao MD 54

Our vision to future diagnosis of infectious diseases :

Our vision to future diagnosis of infectious diseases With the ability to test for an unlimited number of potential pathogens simultaneously, next-generation sequencing has the potential to revolutionize infectious diseases diagnostics In the microbiology laboratory, this technology will likely replace the traditional “one test, one bug” approach to pathogen diagnostics The deep sequence information being generated  is rapidly surpassing our capacity to analyze the data and will necessitate the development of highly parallel computational frameworks, such as cloud computing In adapting this technology for clinical diagnostics, interpretation of data, appropriate quality control standards, and fulfilling regulatory requirements will be critical One powerful application of next-generation sequencing is  discovery of novel pathogens that may be associated with acute or chronic illnesses Dr.T.V.Rao MD 55

Why we must be familiar with molecular methods :

In Many Developed countries several Diagnostic methods are switched on to Molecular Methods. No scientific journal is willing to accept or publish any article without incorporation of Molecular Methods. Antibiotic drug resistance is a growing concern, to the world, unless molecular identification is performed on responsible genetic mechanisms no effective scientific conclusions can be drawn to contain the spread. Why we must be familiar with molecular methods Dr.T.V.Rao MD 56

Follow me for Articles of Interest on infectious diseases and Microbiology ..:

Dr.T.V.Rao MD 57 Follow me for Articles of Interest on infectious diseases and Microbiology ..

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Created by Dr. T.V.Rao MD for ‘e’ learning resources Microbiologists in the Developing World Email doctortvrao@gmail.com Dr.T.V.Rao MD 58

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