EPID 525 Lecture 3 Introduction to Molecular Methods in Clinical Microbiology Specimen processing Target detection Post-amplification detection “Real-time” detection Quality assurance Specimen processing - efficient target recovery - maintain integrity of nucleic acid target - removal of amplification inhibitors - elimination of components affecting substrates - sterilization of potentially hazardous organisms Specimen processing (cont.) Nucleic acid extraction (total) - proteinase K digestion - phenol-chloroform extraction - precipitation with salts and ethanol - wash pellet with cold ethanol - resuspend in sterile water Specimen processing (cont.) Nucleic acid extraction (RNA only) - treat with guanidinium ITC RNA complexes with guanidinium DNA and protein are removed - precipitation with salts and ethanol - wash pellet with cold ethanol - resuspend in sterile RNase-free water RNazol, Tel-Test Specimen processing (cont.) Heat treatment of specimens - specimen is added to water or buffer - heating or boiling releases NA - aliquot used as template for assay Specimen processing (cont.) Silica particle methods - take advantage of NA binding properties of silica - add digested specimen to column - wash with buffer - elute with water - can specifically elute RNA by adding a DNase step Qiagen spin columns Specimen processing (cont.) Tissue: prior homogenation required CSF: “clean” specimen Blood (whole or fractionated) DO NOT use heparin tubes HIV plasma (RNA), CMV whole blood (DNA) Urine : “clean” specimen Sputum: prior digestion and decontamination req. Feces: “dirty” specimen with inhibitors Automation Specimen processing MagNA Pure (Roche) TECAN (Roche) BioRobot (Qiagen) NucliSens (BioMerieux) TECAN MagNA Pure Step A: The sample material, e.g. cells (up to 5x106), blood (up to 1000µl), or 10 mg of homogenized tissue is placed into the wells of the sample cartridge. Step B/C: The binding/lysis buffer and proteinase K is added to the sample. Step D: Magnetic glass particles are added to the lysed sample. The DNA binds to the surface of the particles. Step E: The magnetic glass particles with the adsorbed DNA are recovered from the wells of the processing cartridge by applying a magnet from the outside of the pipette tips. Step F-H: The DNA is washed and eluted from the glass particles whereas the glass particles are retained in the reaction tip and discarded. Target detection Target-directed probes - Gen-Probe for culture confirmation - Digene Hybrid Capture for HPV Target amplification - PCR for DNA targets - Reverse transcriptase (RT)-PCR for RNA - NASBA, TMA Signal amplification - Bayer Branched DNA (bDNA) assays Target detection (cont.) Target-directed probes - Synthetic genomic sequences specific for an organism of interest - Hybridize with DNA or RNA targets in specimen (direct specimen or culture isolate) - Probes are labeled with enzymes, antigenic, chemiluminescent moieties, or radioisotopes Digene Hybrid Capture Gen-Probe Culture ID http://www.vysis.com/Hybridization_12956.asp Target detection (cont.) Target amplification - Polymerase chain reaction (PCR) of DNA targets - Primer-initiated; requires thermostable polymerase Denaturation of ds DNA Annealing of primers Extension of primers 94°C 50°C or higher 72°C ~1 min. each, repeat for 25 to 40 cycles http://bric.postech.ac.kr/labinfo/n_protocol/service_view.php?nProtocolId=961 http://bric.postech.ac.kr/labinfo/n_protocol/service_view.php?nProtocolId=961 Target detection (cont.) Target amplification - Reverse transcriptase (RT)-PCR of RNA targets Conversion of RNA to cDNA using RT Primer-initiated; 42°C, 1 hr. Random hexamers oligodT PCR primers cDNA is used as template for PCR Target detection (cont.) Target amplification - Nucleic acid sequence-based amplification (NASBA) - Transcription-mediated amplification (TMA) Multiple RNA copies of targets generated Use RT and/or T7 RNA polymerase Detect product with labeled probes Isothermal reaction Target detection (cont.) Signal amplification - Branched DNA (bDNA) assay (Bayer) Target probes Label probes Preamplifiers Amplifiers Substrate O O OCH 3 -2 OPO3 HIV-1 MICROWELL Add lysis buffer to disrupt virus and release RNA Hybridize target probes, preamplifiers and amplifiers to microwell and HIV-1 RNA MICROWELL Hybridize label probes to amplifiers, add dioxetane substrate, and measure chemiluminescence Post-amplification detection Gel electrophoresis Colorimetric microtiter plate Chemiluminescence Real-time fluorescence detection http://bric.postech.ac.kr/labinfo/n_protocol/service_view.php?nProtocolId=961 Post-amplification detection (cont.) Gel electrophoresis Agarose or polyacrylamide gel with EtBr Post-amplification detection (cont.) Colorimetric microtiter plate - product captured by probe attached to plate - enzyme-conjugated probes catalyze colorimetric reaction - read on a spectrophotometer Chemiluminescence - conjugated capture probes catalyze chemiluminescent reaction - read on a luminometer Post-amplification detection (cont.) Real-time fluorescence detection - dual-labeled probe included in reaction “reporter” and “quencher” - intact probe emits low flourescence - Taq cleaves reporter from bound probe - amount of reporter cleaved is proportional to the amount of amplicon produced Other detectors: SYBR Green dyes Molecular beacons SYBR green FRET hybridization TaqMan hydrolysis Molecular beacons Sunrise Scorpion ChemBioChem 2003, 4, 1120-1128 Melting curve analysis Real-time quantitation Automation Amplification and detection COBAS (Roche) CT/NG, HCV, HBV, CMV COBAS TaqMan 48 LightCycler Quality assurance RNase-free materials and environment - wear gloves - DEPC-treated water Separation of work areas and unidirectional flow - reagent prep - specimen prep - amplification and detection Quality assurance (cont.) Prevention of amplicon cross-contamination - UNG - barrier tips, topical decontamination - closed systems - blank wells or tubes Processing controls - spiked specimens Amplification controls - internal controls - failure indicates inhibition Interpretation of results Dead vs. live pathogens - molecular “tests of cure” ex. persistent dead Chlamydia Presence of nucleic acid vs. disease - results taken in context of clinical presentation ex. HSV in CSF Causal vs. casual - difference between “necessary” and “necessary and sufficient” ex. HPV and cervical cancer Applications of Molecular Methods in Clinical Microbiology Laboratory detection of microbial pathogens Culture (“biological amplification”) Growth Analysis of macromolecular composition Analysis of metabolic by-products Detection of: Organism’s protein components (antigens) using antibodies Patient’s immune response (serology) Specific, characteristic nucleic acid sequences (“enzymatic amplification”) Why Nucleic Acid Amplification Tests [NAAT] ? When conventional methods are: 1. Too slow (e.g., mycobacteria, legionella) 2. Too insensitive (asymptomatic HIV, viral infection of central nervous system, etc.) 3. Too cumbersome (e.g., virus isolation) 4. Not available (unculturable agents: HPV, HCV) The Promises of NAATs Higher sensitivity and specificity Shorter turn-around-time Overall reduction in patient care costs Some organisms detected by PCR M. tuberculosis Legionellae B. burgdorferii H. influenzae B.pertussis N. meningitidis T. pallidum H. pylori F. tularensis C. difficile E. coli T. whipelii van, mec HIV HTLV CMV HSV HHV VZV EBV Hepatides HPV Rubella Influenza Rhino Env Adeno Rabies Parvo B19 Arbo Yellow Fever Lassa JC/BK Candidae Cryptococcus Trypanosoma Toxoplasma Naegleria…. Applications Detection of uncultureables or slow growers Organism ID via 16S rRNA sequencing Prognostication by subtype analysis Disease monitoring by quantitation Genotypic approaches to resistance testing Outbreak investigations Case 1 Patient S.M., 8 month old female Full term delivery, normal weight gain 1 month PTA (Dec, 02): Resp failure w/ presumed pneumonia Sputum cx pos for H. influenzae and P. aeruginosa Responded to medical and abtc management in PICU Discharged home F/U at Pulm. Clinic (Jan, 03): Noted resp. distress, tachypnea, low oxygen sat CXR: changes consistent with viral pneumonia Current admission Labs: WBC 6.4 K/µl (low normal) ALC ~1 K/µl (low) HCT 30.6 (low) Basic metabolic panel WNL Cultures: Respiratory: P. aeruginosa neg for fungi, AFB, viruses neg for Chlamydia, B. pertussis Stool: neg for viruses Serum: neg for Mycoplasma BAL: PCR+ for Pneumocystis What is going on? Immunodeficiency workup Sweat chloride testing CF gene testing CH-50 analysis Ig testing Oxidative burst testing T cell analysis by flow Normal Negative Normal Slight dec. IgG & IgM Normal CD4+ 117 (LLN 967) CD4:CD8 0.3 (LLN 0.8) Patient HIV+ by serology and qual. PCR Mother HIV+ (previously unknown) Pneumocystis jiroveci (carinii) Previously classified as a protozoa Currently classified as a fungus - based on nucleic acid and biochemical analysis Most healthy children exposed by age 4 Reactivation pneumonia in immunosuppressed - Adults: CD4+ T cells <200/µl - Pediatrics: CD4+ normal - low TMP-SMX prophylaxis reducing incidence GMS DFA Calcofluor PCR at UM Home-brew assay targeting gene encoding Pneumocystis large subunit mitochondrial rRNA Respiratory specimen digested and concentrated Nucleic acid extracted using MagNA Pure Amplify spiked specimen in parallel Specimen tested at multiple dilutions Diluted patient specimens Molecular size markers 600 bp 346 bp Controls - + Spiked Unspiked 600 bp 346 bp Plan to convert to real-time platform Case 2 Patient P.N., 4 year old male no significant past medical history Presents to ED (Aug, 03): 2 week hx loose stools/diarrhea 1 week later, fever to 39.2°C and respiratory symptoms PCP right otitis media, Rx antibiotics Fevers continued Irritability, vomiting, nuchal rigidity for 2 days Clinical diagnosis? Meningitis Bacterial vs. Viral Lab values: WBC: 9300/µl, 60% lymphs Lumbar puncture: WBC: 75/µl 72% neutrophils 8% lymphs 20% monos Protein: 22 mg/dl (normal) Glucose: 60 mg/dl (normal) Gram stain: NOS, few PMNs Clinical course Blood, urine and CSF cultures submitted Bacterial cultures no growth at 48 hrs. patient discharged, completed 10-day course of ceftriaxone 2 days post discharge CSF viral culture + Typical CSF findings in CNS infection Menigitis Cells/l Bacterial Viral Encephalitis 500-10,000 10-500 0-1000 Neutrophils >90% Early >50% Late <20% <50% Glucose (mg/dl) <40 45-85 45-85 CSF/Serum glucose <0.6 >0.6 >0.6 Protein (mg/dl) >150 <100 <100 “Aseptic” Meningitis Aseptic = no bacteria isolated from CSF Most common cause of meningitis; most often viral Symptoms often indistinguishable from bacterial meningitis Lymphocytic pleocytosis in CSF Other causes: bacteria, noninfectious (postsurgery, drugs, lupus, cancer) Enteroviral meningitis EVs cause 75-90% of diagnosed “aseptic” cases Seasonality: Peak during summer – fall Primarily affects children, young adults Fecal-oral route of transmission Self limited – benign clinical course No treatment available Enteroviruses (EVs) Subgroup Serotype Poliovirus Coxsackieviruses A Coxsackieviruses B Echovirus Numbered EVs 1-3 1-22, 24 1-6 1-9, 11-27, 29-31 68-71 Enteroviral Meningitis Diagnosis Culture 70 – 90% sensitive Variety of susceptible cells TAT 5 - 10 days Serology Generally not useful PCR Home brew assays on a variety of platforms Some commercial detection kits available TAT as low as 4 hrs. Utility of PCR in management of EV meningitis Hamilton MS, et al Pediatr Infect Dis J (1999) Reduces hospitalization time Reduces cost of patient stay Robinson C, et al Pediatr Infect Dis J (2002) When results available < 24 hr: Less antibiotic use ~$3000 less hospital charges Critical factors: Can specimen get to lab, be tested, and result reported in < 48 hrs. (i.e. prior to bacterial culture results)?