Education

1997 : SMAK Depkes Makassar

Dr. Miswar Fattah, MSi
Makassar, 6th June 1978
2002 : Chemistry - UNHAS
2006 : Master of Science in Clinical Chemistry,
Biomedicine- UNHAS
2012 : Doctor of Medicine – Clinical chemistry,
UNHAS

Current positio n

1. Specialty & Research Laboratory Manager, Prodia Clinical Laboratory 2018

2. PATELKI : Vice President of PATELKI 2017-Now & Member of Collegium PATELKI 2015 - Now
3. HKKI Scientific division : Reference Interval & Decision limit, Indonesian Association for Clinical
Chemistry 2013- Now
4. President of AACLS
5. Member of Board of Directors of Asian Association of Medical Laboratory Science (AAMLS) 2017 - Now
 NEXT GENERATION DIAGNOSTICS:
MULTIPLEX & SYNDROME BASED DIAGNOSTICS TESTING

MaCPALM 2019
Makassar, July 13, 2019

Miswar Fattah
Specialty & Research Laboratory
Prodia Clinical Laboratory
miswar.fattah@prodia.co.id
miswarfattah@gmail.com
10 FUTURE LAB MED
• More Specialize & Unique Test
• More Simple Technology & Fast Results
• Shift from single to the multiplex & Syndrome based Test
• Increase of xPOCT
• Less Sample / mini sample
• High Personalize Test
• High IT utilization (Big Data, IoT & AI)
• Remove gap home care, Health care, research facility
• More Preventive test
• Increase DCT, test GO HOME
• •
•
•
TWEETPEE FROM PIXIE SCIENTIFIC
(A SMART DIAPER)
LESS SAMPLE & EASY PHLEBOTOMY
URINE TEST GO HOME

• 0
 ANALOGY OF MULTI-LAYER GOOGLE MAPS AND PATIENT
INFORMATION GOES TO PRECISION MEDICINE

https://newsroom.fmcna.com/whitepapers/personalized-nephrology
100000 Healthy

50000
5000
NoSIRS

PS
1
-., (
- ,.,... 1-lo,M -v(
°'" c11..-Y1U1..
Bactenll In blood No
Temperature 38'1:
NoSIRS
PS
en suite tory
Healthy - - - Oesllnatlon path with optimal policy

•
SlmHar palieflt trajeaories
Current patient atate
- I
-
-50 SIRS
Respiratory Rate 20 SIRS -
-10000 Bact8f8ml8
WBC 12.9
Bacteremia . I
I
I . I
-12500 BPS BPS

-- --
4
SBP 91.8 I
-15000 PSS PSS
,,,... I

--
............... ....--....... SEPSIS

20 - ......... 72.3

�-
-40000 SEPSIS
I I I
-<0000
·100000 Oea1h
D--��

State diagram
-
ol...!:a:::::;::::::::;::::::::a;;==:::'..�'....:::;::!....::;;:::::'.....,,..c._L.:s���·'.'_ Ls�1:•�_J Sepllc-
Deatho

Belief
1 2 3 4 5 6 7
Day
6

Drug History
9 10 11 12 13 14

1
·n
Cetlriaxone
0.B

.,
•••
Sepals
..... 0.1
0
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� 5
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Q.
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&

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Events

0 . ..
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c.,,..,.-
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II re •
Metronidazole, Ceftriaxone 500mg,2g
Septic Alternative Action
Shoe
ancom cm OOOm
Geographic Information System
of a Human Being

(Topol E, 2014)
TREND OF MULTIPLEX DRIVE BY TECHNOLOGY

xMAP

Qplex array
Biocode

Firefly Phi Barcode

 DRIVER & BARRIER MULTIPLEX TESTING
Driver Barrier

lncreaslng prevalence of Infectious diseases

Fast turnaround time (TATI

Emergence of more accurate molecular point of care (POq technologies

Complexity and added cost of management of POCT
Advancing POC technology and the expansion of the test menu devices and tests, llmltlng market growth potential

Growing home-testing market to encourage further adoption of POC dev ces Competltion with centralized tabs and hospital stat
labs, reducing the rate of POCT adoption
CUA-waived status for lncreas ng the number of Infectious disease tests, enabling their usage by
healthcare providers in non·tradltlonat laboratory settings, Including physicians' offices

The lndustr(s continued push for a treatment paradigm shift to value·based and patient·
centered care
MULTIPLEX TESTING FOR RESEARCH

Adipokine Apolipoprotein Cytokine viral Kidney Function Ig Isotyping

infection
 NEXT GENERATION DIAGNOSTICS

MULTIPLEX TESTING IN MICROBIOLOGY

 IDEAL DIAGNOSTICS

Sensitive Simple

Specific Rapid

Reasonable Cost Everywhere

WE NEED FOR MORE FASTER DIAGNOSTICS

Physician ch•cks
•
: In th• a bsenc• of
• Broad therapy RPSults a rrM
'
patH!nt for : t�t resuns physki.;in • ceounues wh,1• from lab. spec,flc
symptoms : his to administer waitinii for results th•rapy
: broad therapy from the lab commenc�s
Br�d-spectrum Br�d-spectrum Broad-spectrum
Specific lhe_r.ipy
Therapy Therapy Therapy

� � �
J.JI j.JI j.JI
� Gram /· F,nal 10 ess�
Cl
2-3 days
� I
I
I

lab techmcian
rece•= patient
l P•thoeens are 1nrttt1nii pathocen
sample, screened for Is Identified and ,ts
pathoeensare put morpholoilcal suscept1bthtY to
on overnight characterl<tks (ee antibt0t1cs is
Incubation Gram stalnlna) determined
INTRODUCTION

• One of the Role of clinical microbiologist in identify bacterial, viral,

fungal and parasitic agent that cause human disease

• Significant emerging technology (PCR, qPCR, high- throughput

sequencing and MALDI-TOF MS changing clinical microbiology strategy

• Multiplex testing : simultaneous detection of multiple target

SYNDROME- AND DISEASE BASED APPROACH

• Growing number of emerging pathogen makes it difficult for physicians to memorize the
actual list pathogen

• Change approach from testing most common agent first followed for rare agent to broad
syndrome-or disease base

• To date diagnostic kit have been developed for syndrome – or disease base kit : endocarditis,
pericarditis, diarrhoea, osteitis, meningitis, encepehalitis, uveitis, keratitis, sepsis, respiratory,
etc

• All of this kits are multiplex testing

Fournier et al. Nature Reviews, Microbiology 2013; 11: 574 - 584

WHY WE NEED MULTIPLEX

• Several pathogen cause similar clinical symptoms

• Rapid identification
(reduce mortality, Cost and
duration of hospitalization)

• to reduce delay associated re-sampling or retesting

• To choose better antimicrobials (antiviral / antibiotics drugs) – avoid resistance

• Pediatric, elderly and Immunocompromised patient
Kaleta, E & Wolk DM, CLN; May 2012: 38, 5
ACUTE DIARRHEA

What do we routinely test for?

Bacteria

Parasite

Virus
ACUTE DIARRHEA
What is he actual prevalence

Virus
Bacteria

Parasite
Positive result = stop testing = save healthcare spending?
A. xTAG GPP

nI • •l+* •
B. Verigene EP
-�
-• - -
. .
.
--.::v
C. FilmArray GI
 SEPSIS TEST
Blood from hospital
patient with Bacterial Viral
suspected infection 30-Day Mortality
Infection Infection

Not likely
viral
0.5

:,,
..
:r.
'

.
Example test report

··•••·-· ·-·
' ' '

'•.IL:�L..L::..:..:::....:.:.:.._.:....!...:..:..::L:...�
• 11 In ICW lmlcticW'I ( ) badll'III « W'II?
• Oilll)ltllntl'ECl,'ICU, kllk.dlb,11 �II
--
RESULTS – ANTIMICROBIAL STEWARDS

• Time to results: 1.3 vs 22h

• Time to escalation faster on both PCR groups (5h vs 24h)
• 25% reduction in use of broad spectrum antimicrobials
• No different in clinical outcomes & overall cost of
hospitalization
MULTIPLEX TECHNOLOGY IN INFECTIOUS DISEASE
Reference
Laboratory NGS

MALDI TOF
Complexity

LCMSMS
PCR, ELISA - Flowcytometry

PCR, ELISA- xMAP

PCR, ELISA- phi barcode

PCR film array

PCR Genexpert Ideal Xtechnology
Multiplex
Single lateral flow
Performance & Plex Number
XPOCT

Dincer, C., et.al Trends in Biotechnology 35, 728–742 (2017).

RAPID TEST FOR INFECTIOUS DISEASE

Kim, H., Chung, D.-R. & Kang, M. Analyst 144, 2460–2466 (2019).
 EXAMPLE XPOCT
Two-color LFAs for the m.ultlplex lgG/lgM detect(on or Dengue virus (lgG/lg_M)
s.eve_rat febrile lllnesses Chfkungunya virus (tgG/lgM)
Antibodies against HIV-1 arid -2.
Multiplex detection of humeral Immune r-esponses. to
Myoboa�rium cub�rcu/osls, and HepaUtls C
lnfec.t.lous disease paLhogens
Virus In plasma
TJ·u·ee-colored mult.lplexed lateral flow POC sensor for Dengue virus NS1 protein. Ye.now F-f!!!Vet Virus
the simultaneous dLagnos.ls of severe acute f�brlle NS1 protein, and Ebola virus, Zaire strain
Multlpte.xlng on
fllnesses gtycoi><otein GP
a sl n,gle strl p
Fast dlagnos,s of Scrub typhus in many endemk.
lgG and 1gM antibodies to 0. t:sutsugarnushl
regions
Stable multiplex LFA using AMP for the simultaneous
detection and identification of Ship toxln-produclng STEC 01.57, 026, and 0111
Esch�lchJo coll {STEC) serog_roup
Multl-plex diagnosis of HIV and HCV to Identify tlle co• Antl.. HIV tgG, Antl-HCV tgG, Anti-HAV lgG and
Infected Individuals lgM
Both detect.Ion and dlfferentLatlon of Influenza A and
Influenza A and 8 vin..,ses antigen
B type viruses In respiratory samples
Multiplex lmmuno-dlsc sensor fa< bacterial lnfe.ct:fon P�udornonos oerug;noso, Stophyloc.occ.u.s
Multlple.Jtlng with caused cystic fibrosis oureus
a mult.lple strip E. coll 015 7:H7. S. porotyphl A. S. porotyphl a.
Rapid, sl.multaneo-us detection of 10 epidemic
S. porotyphl C. S. typhl,, S. �nt�rltldis. S.
foodbome pathogens for food safety and Iow•
cho/eroe:sul-s� V. cho/tro 01, V. cholera 0139,.
occurrence of foodbome disease
and v, porohoemolytlcus
Integration of lateral fi<>'IN and Mala'1a antigen Plosrnodlurn folciporum
Mosqullo-control me.asunl!s In many endemic areas
h1s.tldlne-rlc.h protein 2
MULTIPLEXING LATERAL FLOW IMMUNOASSAY FOR
SIMULTANEOUS DETECTION OF AG/AB
(B)

i
Ta�et
lgG
;:�:i'."::t.
�t�· w �
Ta,gel
lgM

I Test region

1:
' Ill .i.l.i
(C) (D)
MULTIPLEX TESTING PANEL FOR DISEASE /
CLINICAL CONDITION

Respiratory syndrome panel

Gastrointestinal panels

Sepsis panel

Sexually transmitted disease

Viral encephalitis
 COMMON TECHNOLOGY IN MULTIPLEX TESTING
*List of technologies is not all inclusive Multiplex Seeplex, MagicPlex; Seegene
qPCR – Probe BD Max System/Jaguar
SeptiFast, Roche
base
(modify or
with melting
Multiplex PCR - analysis) Multiplex PCR –
eSensor , Genemark Voltammetry Liquid phase bead
base array
xTAG; Luminex
Qiaplex; Qiagen

Multiplex
Multiplex PCR – Technology
ESI Mass pathogen
spectrometry panel* Multiplex PCR
- Microarray

PLEX-ID; Abbott Molecular Infinity system,;Autogenomics

Clart Pneumovir; Genomica
Multiplex PCR
Multiplex PCR
– Capillary
– nested qPCR
Scalable Target Analysis Electropho-
Routine (STAR) resis Melting curve Film array Technology, Biofire
Technology; PrimerDx now bioMérieux
MULTIPLEX PCR

• Simultaneous amplification of multiple

target using sequence specific primer

• Amplification occurs depend of the

presence of the target

• Detection can do direct or performed

after multiplex PCR depend of methods
ANYPLEX II PANELS
Anyplex™ II RV16 Detection Anyplex™ II STI-7 Detection detects 7 Magicplex™ Sepsis Real-time Test
major STI causing pathogens screens
detects 16 respiratory viruses

v ., . SlretJtoor:,cin .. spp.. V 2 • Enteroooc,c,, oa epp..

S. il!;lill.!Ctiile E. f.1ec.1lis
S.pyogene.s E g;;illln;;irurn
- Adenovirus (AdV) - Chlamydia tree homatls (CD (CEO O 8 6) S. pneumoniae E f;;iecium
- Influenza A virus (FluA) - Neissena gononhoeae (NG)
- Influenza B virus (FluB) V 3 . St.ileJI¥ W O -C'l:I ll1J 9IJP..
- Trlchomonas var;;lnalls (TV)
- Parainfluenza virus1 (PIV1 ) - Mycoplasma norrnrno (M H) S ep,derrnld,.s
S. haernolyticu.s
- Parainfluenza virus2 (PIV2) - Mycoplasma r;;enltallum (MG) S. .1ureus
- Parainfluenza virus3 (PIV3) - U reaplasma urealytic um (U U)
- Parainfluenza virus4 (PIV 4) - U reeoteame oervurn (UP) V 4.Grarn (-) bactel"ia-A V 5. Gram(-) l>aclet'ia-A
- Rhinovirus A/B/C (HRV) - Internal control P. .1eruginos.1 S. rno1rcescens
- Internal control (IC) A. baumann1i B. fr;;igilis
S maltophll1a s typhi
06.Grarn(-)�B V 7. Gram(-) 1-aeria- B
PanelB
JC pneumon1ae E coll
«. oxytoca E csoeo ee
- Respiratory syncytial virus A (RSV A) P. miro1bilis E. .1erogenes
- Respiratory syncytial virus B (RSV B)
- Bocavirus 1 f2t314 (HBoV) V8.Fl.9,gi V 9 • Fungi
- Coronavirus 229E (CoV 229E) C. albican.s C. glabrata
- Coronavirus NL63 (CoV NL63) C. tropic.1Jis C. Xrus-ei
C par;;ip.s,Jo.s,s A fum,g;;itu.s
- Coronavirus OC43 (CoV OC43)
- Metapneumovirus (MPV)
- Enterovirus (HEV)
- Internal control (IC)
XTAG PATHOGEN PANELS
• Respiratory panel : AdV; influenza virus A (H1, H3); influenza virus B; MPV; PIV1, -2, -3;
RSV (A/B); RhV/EV

• Gastrointestinal Panel :

Benefit : time required for results fast 5-6 hours, degree of multiplex >15
Throughput moderate/high, available for quantitative,

Limitation : not full integrated, cannot for near patient facility, moderate carryover contamination risk, high complexity
INFINITI PANELS

• INFINITI® RVP Plus INFINITI® STD-6 QUAD

Benefit : time required for results fast 6 -10 hours, degree of multiplex >15
Throughput moderate/high,

Limitation : not full integrated, cannot for near patient facility, moderate carryover contamination risk, high
complexity, cannot quantification
FILM ARRAY PANEL
Respiratory panel
Aeenovnue
corooevrros HKU1
cceenevrrue NL63
Coronav1rus 229E
ccrcnevrrue OC43
Human Metapneumovirus
Human Rhmovnus/Enterovirus
Influenza A
Bacterial Targets
Bordeteffa pertussis
ChJa-mydoph,fa, pneumonia-e
BLOOD CULTURE IDENTIFICATION (BCID) PANEL
Influenza NH1
Influenza NH3
Influenza NH1-20J9
Influenza B
Paramfluenza Virus 1
Paramfluenza Virus 2
Paramfluenza Virus 3
Paramfluenza Virus 4
Respiratory Syncyhal Virus
Antlmlcroblal resistance genes
Enterococcus
L1slene monocyrogenes
sr...phylococc11s
Staphylococcus aureus
Ac1nelobacter baumanrn,
HaernoptuJus mfluenzae
Ne,sseria menmg1/td1s
P .sevdorno=.s ae,ugmo.sa
Candida eJbJcans
Candida glabra/a
Candida kruse,
mecA - meth1ctlhn -ee.etaece
vanA/B- vancomycm resistance
KPC - ca,bapenem reeretance
GASTROINTESTINAL PANEL
Streptococc,,s
A arornonas
Streptococcus agafecl1ae
CampyJobacter
Streptococcus pneurnorna,e
CJostrld1um d1ff1e1le (t cxm A/8)
Stre{AOCOCCUS pyogenes
PfeBK>rnDnas Bh,geJJoides
Safmoneffa
Yers,n,a enterocof1t,ca
Vibrio
V1bno choleras
E 11terobacteri.'lce...,e
Oi..,rrhe...,ge11ic £.coli!Shige/1..,
Enterobscter cloacae compleK
Escherichia cofl Enteroaggregat1ve E coll (EAEC)
Enteropathogen1c E coll (EPEC)
Klebswlla oxytoca
Enterotoxtgemc E coo (ETEC) II/st
Klebs,e//a pneurnornae
Proteus Sh1ga-hke toxm-producmg E coll (STEC) stx1/stx2
Serrat,a marcescen.s E coh0157
Sh,geffa/Enteromvas1ve E coh (EIEC)
Candida paraps,losls
Candida tropicah.s Cryptospond1um Entarnoeba h,stoJyt,ca
Cyclospora cayetanenSJs G1ard1a Jambha
Adenov1rus F40/41 Rotav,rus A
Aatrovrrus Sapov1rus
Norovnus I/Gii
 •

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MA�DI-TOf ,'I.IS AntlbloL,e restsraoce dcrt.ect,on

l\ntibt,,t,c

0•1-• Ao"r•<
"'mi,hfied D'- .-.. PCR-ESI )TOF M<; hydroly'$is

n»,, lve hlood �>,,.-,.,,.•�-

ullure,
.._ ass spccc romc er PCR i"tm,-,.1·..-t>f\ ldentlf cat.ion
,.C.At;TACTCACTCA'J'C

Urine '5a-"Tnfl4r" J
POCT MULTIPLEX TESTING
F@Ver In returnilng
trilve.Uer.1
Pla-.modium 'PP•
Dengue y,ru!t
f'neumunl.a JnflV<l!"nLa C.s.troent.eritls
vrecoes A:e�1ra1ocy Rorwonrus
s)'ncyt.lal vlrus Adenc>Vlr�1oi�
Mycop(asmo pn1::umonloe crosrr1d1um dlffrtilc
8ordeteUa pertll.li1'i Ht'!llc:obucr1""r pyf'11f"i
�tophy1ucoccus au, l!us
Ptt.NI mocystJ<. Jlf"Ovl"¥:"U S1nl ONA 1!1\.1'ctctor
Lt"gloffltlra 11rlno,f") 4!ntlgl:'n
Pn�vmococcol urinary
.U.Ligt,n

Con"'-'1,u,·

Thermal cycle,- BSLl hood

Von ex
Dr')' b,•n h
1ncub.at0f' C'"r,tnfu<J'"
...... C retrlqe,ator

Sexually u..ns.mlned Phory09-itb Menlnghlt.

enseeses StrC"ptococcus pyogeth!!S Ent�ro,,,,n.,.,"".,
l\1e-lH<-rlo gom,rrtu:""-a"' Erx.tcin-8arrvln..1s V4r•C"�ll<'.'-l.0'-1 ... r V.n..l'I

•
Heq><:!'� ,iMpkx .... i,u-,. pneurnon;oe
Slr't'PIOCVCl"US

�.
HIV Pneumococcol urinary
Chfom)d'io 1rachomatu, anfj:g,("n
Cryp1ococcu.s neaformaru
CONCLUSIONS
• Increase number emerging technology possible for multiplex testing in Clinical
Microbiology

• Clinical microbiology testing move to test syndrome- and disease base panels

• More studies need to fully elucidate characteristic performance for each technology

• Need more exploration economic impact of multiplex testing

• Multiplex testing as next generation diagnostics

TERIMA KASIH