DNA FLOW TECHNOLOGY

PT. GRAHA MEGATAMA INDONESIA

Deteksi Patogen (virus, bakteri, jamur)

Berbasis Molekuler

Dalam waktu 4 JAM

 Perusahaan IVD dari Spanyol

 Bagian dari Vitro Group: VITRO S.A., Master Diagnostica S.L.

 Didirikan di Granada pada 1993, pindah ke area Campus of Health

Sciences (PTS) di Granada pada 2012 (luas 2000 m2: R&D, QC, produksi,
laboratorium, gudang, kantor, dapur, dan aula pertemuan)

 Produk meliputi Diagnostik Molekuler & Immunohistochemistry

 HARDWARE :

HybriSpot INSTRUMENTS

CHIP HIBRIDISASI

+
CHIPS HIBRIDISASI
HPV DIRECT 36 genotypes
SEPSIS 40 pathogen + 20 antibiotic resistance markers
AMR 20 antibiotic resistance markers
BACTERIAL CNS 9 Bacteria + 1 Fungi

STD DIRECT 9 BACTERIA + 2 VIRUSES

RESPIRATORY 17 viruses + 4 atypical Bacteria
TICK BORNE 7 BACTERIA
AKREDITASI & SERTIFIKASI
 WORK FLOW
Thermal Cycler PCR

Clinical Sample

Hybridization Result
 Results interpretation

HYBRIDIZATION
RESULT Full automated picture
Software interpretation

Final results

Controls
HPV DIRECT FLOW
CHIP

Screening Genotipe HPV Penyebab

Kanker Serviks

No Additional
DNA extraction /
purification steps
required
 DATA KANKER DI INDONESIA
Angka kejadian penyakit kanker di Indonesia (Januari 2019)

136,2/100.000 Data kenaikan tumor/kanker di Indonesia

penduduk 2018

2017
Data kanker tertinggi
untuk perempuan 2016

Tahun
2015
Kanker payudara Kanker serviks
2014
42,1/100.000 13,9/100.000
penduduk 2013
penduduk
0 5 10 15 20 25 30
%
Tingkat kematian akibat kanker Kenaikan kanker di Indonesia
meningkat 5% per tahunnya

Kanker payudara Kanker serviks

17/100.000 penduduk 13,9/100.000 penduduk Sumber: Biro Komunikasi dan Pelayanan Masyarakat, Kementerian Kesehatan
RI, 31 Januari 2019
40% 59%
 SOLUSI PENCEGAHAN KANKER SERVIKS

HPV PAP Smear

Genotype IVA Test

Screening kanker serviks lebih Screening kanker serviks pada

dini, virus HPV < CIN 2 > CIN 2

TES MOLEKULER (HPV GENOTYPE) HPV DIRECT FLOW CHIP

Distribusi HPV Genotype di Indonesia Panel terluas 35 genotype, 18 High risk dan 17 Low risk
Juni 2011-Juli 2016 18 High-risk : 16, 18, 26, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, 68, 73, 82
16 15.15
17 Low risk : 6, 11, 40, 42, 43, 44, 54, 55, 61, 62, 67, 69, 70, 71, 72, 81, 84
14 12.88
12
10
* Vaksin HPV terlengkap saat ini di Indonesia:
9.2
%
8 7.01 6.81 * Deteksi HPV Genotype dari KalGen, mencakup:
6 4.14
5.85 5.67
4.61 4.07
5.31 15 High risk : 16, 18, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, 68 Vaksin Gardasil 9
3.53 3.44
4 2.16 2.14 1.64 1.69 1.69 1.12
6 Low risk : 6, 11, 42, 43, 44, 81 7 High risk 16, 18, 31, 33, 45, 52, 58
2 1.03 0.88
0 2 Low risk 6 dan 11
16 18 31 33 35 39 45 51 52 53 56 58 59 66 68 6 11 42 43 44 81
Sumber: Data distribusi HPV genotype, www.kalbe.co.id
HPV Types
 SAMPEL
HPV DIRECT FLOW
CHIP

Deteksi simultan dan genotyping dari 35 genotipe HPV CERVICAL

SWAB
(18 high risk & 17 low risk) dalam satu kali tes

 Tanpa purifikasi DNA

 Kompatibel dengan sampel liquid-based
cytology, cytological swabs dan paraffin- LIQUID BASED CYTOLOGY
embedded samples
 Telah divalidasi secara klinis dan saintifik:
• WHO LabNet Proficiency
• Scientific publications

PARAFFIN EMBEDDED TISSUE

SEPSIS FLOW
CHIP

No Additional
DNA extraction /
purification steps
required
02 What is
SEPSIS?

Process

Definition
 Perbedaan waktu antara metode kultur dan molekuler dalam mengidentifikasi patogen

SAMPLE
4 hours Day-1 1d4h Day-2 Day-3

-Colony bacteria Identification of

Bacteria and
Culture -Gram staining
sensitivity of
method
Positive blood antibiotics
Still culturing
culture
Getting identification of
HybriSpotD
pathogens (bacteria &
NA Flow
fungi) with genes
technology
resistance antibiotics

Getting identification of
pathogens (bacteria &
fungi) with genes
resistance antibiotics
Content Here Content Here Content Here Content Here
 Antibiotics mechanism

Concentration-
dependent
Time-dependent
 Bacteria identification method
Culture HybriSpot
DNA Flow Technology
Identification of bacteria based on
Identification of bacteria based on
biochemical reaction tests
the conservation area of the
bacteria itself using the multiplex
PCR and hybridization method
SEPSIS FLOW
CHIP

Deteksi simultan lebih dari 36 patogen dan 20

gen resistensi antibiotik yang mengakibatkan
sepsis

4 Gram + bacteria
4 Gram - bacteria
4 Fungi
4 Gen resistensi antibiotik: MRSA
(mecA), vanA, vanB, ESBL dan
carbapenemases
B: kontrol hibridisasi (biotin)
CI: kontrol exogenous
BG: kontrol endogenous (gen β-globin)
SEPSIS FLOW
CHIP
Deteksi molekuler dari 36 patogen bakteri dan fungi penyebab
bacteriaemia, fungaemia

Deteksi molekuler 20 gen resistensi antimikroba dari

bakteri dan fungi penyebab bacteriaemia, fungaemia.
SEPSIS FLOW
CHIP
GENE DETECTED PERHAPS RESISTANCE ANTIBIOTIC GENE DETECTED PERHAPS RESISTANCE ANTIBIOTIC
Carbapenem Penicillin
Aztreonam Carbapenem
mecA
All β-lactam (*except Ceftaroline, vim
1st, 2nd, 3rd, 4th generation
Ceftobiprole)
Vancomycin
cephalosporin
vanA Penicillin
Teicoplanine
vanB Vancomycin gim, spm, ndm, sim, Carbapenem
Penicillin IMP 3, 15, 19
1st, 2nd, 3rd generation cephalosporin
Monobactim
kpc, sme, nmc/imi
Penicillin
1st & 3rd generation cephalosporin Carbapenem
Penicillin OXA23, OXA24, 1st generation cephalosporin
blaSHV
1st generation cephalosporin
OXA48, OXA51, OXA58 *note : perlu dilakukan tes susceptibility
Penicillin
blaCTX-M, ges emipenem, meropemen, ertapemen,
1st, 2nd, 3rd generation cephalosporin ceflacor, cefotaxime, ceftazidime

Sampel:
POSITIVE BLOOD CULTURE
RECTAL SWAB BACTERIAL COLONY
AMR FLOW
CHIP

No Additional
DNA extraction /
purification steps
required
 PENCEGAHAN PERSEBARAN RESISTENSI ANTIMIKROBA
(DUKUNG PROGRAM PPRA) & UPDATE AKREDITASI INTERNASIONAL

1 Screening
Screening Pasien diperbolehkan digabung
Hasil
NEGATIVE dengan pasien lainnya
Keperluan AMR screening

rawat inap Fungsi: menghindari transmisi

Pasien (penularan/penyebaran) di seluruh TINDAKAN DEKOLONISASI
POSITIVE Pemberian antibiotik mupirocin
datang Rumah Sakit & chlorhexidine
Keperluan
operasi Screening Hasil NEGATIVE
Pasien diberikan antibiotik
berdasarkan aturan sebelum
AMR screening
operasi

Fungsi: menghindari infeksi daerah

PERHATIKAN RESISTENSI
operasi (IDO) POSITIVE Pemberian antibiotik diluar
yang resisten

2 Surveilens pada pasien / pembawa AMR

Fungsi: 1) Mengurangi transmisi di rumah sakit
2) Mengurangi infeksi di rumah sakit & fasilitas kesehatan lainnya
3) Data surveilens untuk menilai efektifitas cuci tangan &
tindakan preventif lainnya
 DATA RESISTENSI ANTIMIKROBA & BAKTERI YANG MEMBAWANYA

RESISTEN MRSA RESISTEN ESBL & CARBAPENEM

70

60
60-65%

50

40
SINGAPURA
% 30 RSCM
22-37%%
20

10

0
2009 2012 2014 2016 2018
Tahun

Antibiotik yang resisten: Antibiotik yang resisten:

Methicilin, Oxacillin, Cefoxitin, Gol. Betalactam Fluoroquinolone, aminoglikosida, cephalosporin gol 3&4,
(penicilin, cephalosporin gol 1,2,3,4, dan carbapenem, trimethoprim, & sulphametoxazole
carbapenem)

Enterobacteriaceae
Golongan
Acinetobacter Pseudomonas Klebsiella Escherichia coli
Sthapylococcus aureus baumanii aeruginosa pneumoniae
 BAHAYA SETIAP BAKTERI

Sthapylococcus
aureus Acinetobacter Pseudomonas Klebsiella Escherichia coli
baumanii aeruginosa pneumoniae

•Sering dijumpai di RS -Banyak terdapat di alam

Pasien dengan: Golongan Enterobacteriaceae
-Dapat menyebabkan penyakit
-luka terbuka •60-70% bakteri sudah
pada manusia dan hewan Terdapat di usus manusia, flora normal
-Pemakaian alat resisten terhadap banyak
-Terutama pada pasien dengan
invasive antibioticktermasuk imunitas menurun cancer, Menyebabkan:
-Imunokomproma
carbapenem kemoterapi, penderita HIV/AIDS
is Infeksi paru, infeksi aliran darah (sepsis), saluran kemih,
Metode penularan: luka operasi dan meningitis
Pasien dengan:
Sangat rentan •Masuk ke rumah sakit (Bila menyerang selain di usus)
•Pemakai alat invasif, ventilator,
terkontaminasi karena dibawa oleh pasien
kateter urin
S. aureus yang terkolonisasi •Luka operasi, luka bakar Pasien dengan:
•Mampu bertahan hidup Sangat rentan terkontaminasi penggunaan alat invasif-ventilator, kateter intravena,
pada permukaan yang kering P. aeruginosa
antibiotic jangka lama
Sangat rentan terkontaminasi gol. Enterobacteriaceae
 PERBANDINGAN METODE

Metode Biakan Metode molekuler

1) Hasil +- 48 jam 1) Hasil 4 jam

2) Sensitivitas dan spesifisitas bervariasi 2) AMR Flow Chip : Sensitivitas 99,5% dan
3) Membutuhkan peralatan lab dan tenaga ahli spesifitas 100%
4) Membutuhkan uji lanjutan untuk beberapa 3) Proses pengerjaan mudah, semua analis bisa
kasus (sub-kultur) mengerjakan
4) Screening/diagnosis infeksi dari berbagai
specimen yang berbeda

PERBANDINGAN TES MOLEKULER

Instrumentation Usage Speciman type (s)
BD MAX Screening, pre-surgical screening Nasal swab
Cepheid GeneXpert Screening, pre-surgical screening, infection Nasal swab, wound swab, Positive Blood
detection Culture (PBC)

Roche cobas Screening Nasal swab

bioMerieux FilmArray infection detection Positive Blood Culture (PBC)
AMR Flow Chip & SEPSIS Flow chip Screening, pre-surgical screening, infection Nasal Swab, Rectal Swab, PBC, Bilasan
detection bronkus
 SAMPE
AM FLOW
CHIP
L
R
Deteksi simultan dari 20 gen resistensi antibiotik yang terdapat pada bakteri
Gram-positif dan Gram-negatif.
Memiliki paten untuk deteksi resistensi carbapenemases.
POSITIVE BLOOD
CULTURE

NASOPHARYNGEAL
SWAB

RECTAL SWAB
STD FLOW
CHIP

No Additional
DNA extraction /
purification steps
required
 One million new sexually transmitted infections (STIs)
occur every single day, the World Health Organization has
estimated.

That means more than 376 million new cases annually of four
infections - chlamydia, gonorrhoea, trichomoniasis, and
syphilis
 MACAM-MACAM PENYAKIT MENULAR SEKSUAL

Disebabkan oleh infeksi

Disebabkan oleh infeksi Treponema Pallidum
Herpesvirus simplex type 1 dan 2

Disebabkan oleh infeksi

Trichomonas vaginalis
Disebabkan oleh infeksi
Disebabkan oleh infeksi
Chlamydia trachomatis
Virus HIV

Disebabkan oleh infeksi

HPV Low-risk

Disebabkan oleh infeksi

Chlamydia trachomatis
 SAMPEL
STD FLOW
CHIP

Deteksi simultan 11 patogen penyebab STD termasuk

lymphogranuloma venereum serovars (L1-L3)
URINE

SPERM

ENDOCERVICAL, THROAT, URETHRAL

& PERIANAL SWABS
 BACTERIAL CNS FLOW
CHIP
Deteksi Patogen Penyebab Infeksi Sistem Saraf Pusat
 BACTERIAL CNS FLOW
CHIP
Deteksi Patogen Penyebab Infeksi Sistem Saraf Pusat

Meningitis is an inflammation of the membranes (meninges)

surrounding your brain and spinal cord
BACTERIAL CNS FLOW
CHIP

Deteksi simultan 9 patogen bakteri dan 1 fungi penyebab infeksi CNS

B: kontrol hibridisasi (biotin)

CI: kontrol exogenous
BG: kontrol endogenous (gen β-globin)
BACTERIAL CNS FLOW
CHIP
JENIS SAMPEL
FLOW
BACTERIAL CNS CHIP

CEREBROSPINAL FLUID
RESPIRATORY FLOW
CHIP

Deteksi Virus dan Bakteri Penyebab Infeksi

Saluran Pernapasan
RESPIRATORY FLOW
CHIP

Influenza A, subtyping: ATYPICAL BACTERIA

 H1N1pmd2009
 H3N2
Influenza B
Human respiratory syncytial virus A
Human respiratory syncytial virus B Bordetella pertussis
Human Metapneumovirus Bordetella parapertussis
Human Parainfluenza, subtyping: Mycoplasma pneumonie
 Human Parainfluenza 1 Chlamydophila pneumoniae
 Human Parainfluenza 2
 Human Parainfluenza 3  
 Human Parainfluenza 4
Adenovirus
Rhinovirus Sample types:
Human Bocavirus  Nasopharyngeal wash
Human Coronavirus, subtyping:  Nasopharyngeal exudate
 hCoV OC43  Brochoalveolar lavage
 hCoV 229E
 hCoV NL63
 hCoV HKU
 Endogenous and exogenous controls
Tick-borne Bacteria FLOW
CHIP
Deteksi Bakteri yang Ditularkan melalui Kutu
Tick-borne Bacteria FLOW
CHIP

Deteksi simultan 7 BAKTERI tick-borne

 
Tick-borne Bacteria FLOW
CHIP

SAMPLE

 
Manusia Hewan

Darah Biopsy Nodus limfa CSF Kutu Animal reservoir

Ixodes ricinucus Rihipicephalus Dermacentor marginatusHyalomma lusitanicum

sanguineus
 TROPICAL DISEASE FLOW CHIP
MULTI-DRUG RESISTANCE FLOW CHIP
Thank You!
 SEPSIS FLOW
CHIP

ESTIMATED MINIMUM INCUBATION TIME OF BLOOD

CULTURE

CFU (Colony-Forming-Units)/mL Blood

 
 SEPSIS FLOW
CHIP

SPECIFICITY SENSITIVITY
Analytical Sensitivity (LoD): Genomic DNA copies of each pathogen
generating positive results in 100% of the replicas analysed with the
hybriSoft software and a threshold value of 4.
 Hasil Pemeriksaan dengan Sepsis Flow
Chip
Omni Pulomas
26 Agustus 2019

Sampel
Patogen ID Resistensi
no
Carbapenemase GES,
1 Candida spp., Klebsiella pneumoniae
Carbapenemase NDM
Candida spp., Staphylococcus spp., Carbapenemase GES,
2
Candida albicans, Klebsiella pneumoniae Carbapenemase NDM
Staphylococcus spp., Staphylococcus
3  
aureus
4 Staphylococcus spp.  
Staphylococcus spp., Staphylococcus
5  
aureus
 HASIL HPV

Halaman 1 Halaman 2
 HASIL SEPSIS

Halaman 1 Halaman 2
 HASIL STD

Halaman 1 Halaman 2
 TROPICAL
FLOW
DISEASE CHIP
CHIP Deteksi simultan dalam satu chip lebih dari 30 patogen
 
(bakteri, protozoa, virus) penyebab penyakit tropis:

TICK-BORNE
BACTERIA

Coming Tropical disease

soon MDR
 TROPICAL DISEASE FLOW
CHIP

Bakteri dan Protozoa yang

Terdeteksi
Mix 1: Bacteria/Protozoas

Disease Detection Spots (11 targets)

Plasmodium falciparum
Plasmodium vivax
Malaria Plasmodium Plasmodium ovale
Plasmodium malariae
CHIP
Plasmodium knowlesi
 
Leishmania major
Leishmania tropica
Leishmaniasis Leishmania Leishmania donovani
Leishmania infantum
Leishmania chagasi

Leptospiraspp.(Species : L. interrogans, L.
Leptospirosis Leptospira spp. borgpetersenenii, L. weilii, L. santarosai, L.
alexandri, L. noguchii, L. kirschneri, L. alstonii)
Coming Tropical disease
soon MDR
 TROPICAL DISEASE FLOW
CHIP

Virus penyebab demam yang

Terdeteksi
Mix 2: Viral Fevers (haemorrhagic + fevers of unknown origin)
Virus Disease Detection Spots (11 targets)
Dengue 1
Dengue 2
Dengue Fever Dengue Virus (DENV)
Dengue 3
Dengue 4
Flavivirus African Zika
CHIP Zika Fever Zika Virus (ZKV)
ASIAN Zika
 
Amarilla Fever Yellow Fever Virus (YFV) (YFV)

Chikungunya Fever Chikungunya Virus (CKV) Virus Chikungunya (CKV)

Alphavirus
Virus Mayaro Fever Mayaro Virus (MAYV) Mayaro Virus (MAYV)

Arenavirus Lassa Fever Lassa Virus (LASV) Lassa Virus (LASV)

Haemorrhagic Fever Crimea- Haemorrhagic Fever Haemorrhagic Fever

Coming Nairovirus Congo Crimea-Congo (FHCCV) Crimea-Congo (FHCCV)
Tropical disease
soon MDR
 TROPICAL DISEASE FLOW
CHIP

Virus penyerang saraf yang Terdeteksi

Mix 3: Neurological Clinical picture
Virus Disease Detection Spots (11 targets)

West Nile fever West Nile Virus (WNV) West Nile Virus (WNV)

Japanese Encephalitis Japanese Encephalitis

Japanese Encephalitis
Virus (JEV) Virus (JEV)
Tick-Borne Encephalitis Tick-Borne Encephalitis
CHIP
Flavivirus Tick-Borne Encephalitis
Virus (TBEV) Virus (TBEV)
  St. Louis’s Encephalitis St. Louis’s Encephalitis
St. Louis’s Encephalitis
Virus (SLEV) Virus (SLEV)

Usutu virus Encephalitis Usutu Virus (USUV) Usutu Virus (USUV)

Lymphocyte Lymphocyte
Lymphocyte
Arenavirus Choriomeningitis
ChoriomeningitisVirus ChoriomeningitisVirus
(LCMV) (LCMV)
East Equine Encephalitis
Virus
Equine Encephalitis Virus West Equine Encephalitis
Alphavirus Equine Encephalitis
spp (EEEV) Virus
Coming Tropical disease Venezuelan Equine
soon MDR
 Antibiotic
MDR
Resistance marker
FLOW
CHIP
Multi- Drug Resistance
Antibiotic Resistance marker

Linezolid cfr ges

msrA sme
mefA/E kpc
Erythromycin, Azithromycin,
ermA nmc/imi
Clarithromycin
ermB sim
ermC gim
aac(6’)-Ib spm
armA Imipenem, Meropenem, ndm
Gentamicin, Amikacin, Ertapenem
rmtB vim
Tobramycin
rmtC imp
rmtF oxa-23-like
sul1 oxa-24-like
Cotrimoxazole sul2   oxa-48-like
sul3 oxa-51-like
CHIP Teicoplanin vanA oxa-58-like

Antibiotic Re sista nce marke r

GyrA (muta tions)

Ciproflox a cin, Norflox acin, ParC (muta tions)
Le vofloxa cin qnrA, qnrB, qnrS
oqxA, oqx B
CTX-M
Cefotax ima , Ce ftazidima,
Ceftriax ona, Cefditore n,Pe nicillin, SHV (SNPs dete ction)
Amoxicillin, Ampicillin
DHA
Penicillin, Fluclox acillin,
Amoxicillin, Clox acillin me cA
vanA
Vancomycin
vanB
Coming Tropical disease Colistina mcr-1
soon MDR Ampicilin, Cefadrox il, Cefa le x in SHV w t