Journal of Clinical Microbiology

Introduction: Rapid pathogen identification, resistance detection, and susceptibility profiling improve antimicrobial prescribing and associated outcomes, but fragmented workflows lead to inefficiencies and are costly. We evaluated a research-use-only (RUO) approach using ASTar(R) remnant bacterial suspension from routine AST for MALDI-TOF MS pathogen identification and Lateral Flow Assay (LFA)-based detection of targeted resistance mechanisms. Methods: Gram-negative (GN) bacterial strains from reference and curated resistance collections (CDC1, ARLG2, ATCC3) [n=119] were contrived into blood culture bottles and processed in the ASTar 16 System using the ASTar BC G- Kit (Q-linea AB, Sweden). Under RUO conditions, remnant bacterial suspensions were collected ~1-2 h after ASTar run initiation and analyzed using NG Test CTX-M Multi, NG Test CARBA-5, NG Test Acineto-5 RUO, and MALDI-TOF MS. Results: Mean ({+/-} SD) remnant suspension volume was 2722 L ({+/-} 300 L). All samples yielded high confidence MALDI-TOF MS scores (>2.0), with five initially scoring <2.0 and resolving on repeat testing. LFA results showed full agreement with reference isolates for blaCTX-M positive/negative (30/30) and with 60 or 61 target carbapenemase-positive/negative isolates. Testing of a subset of samples to mimic reflex workflows with ASTar phenotypic results did not affect LFA performance 24 (n=26; 23 Enterobacterales, 3 P. aeruginosa and 9 A. baumannii). Cost savings can be realised versus commercial multiplex PCR. Conclusion: This integrated approach of ~6 h rapid phenotypic AST with same-run identification and resistance detection (1-2 h from instrument start) or reflex testing upon availability of ASTar results may support earlier susceptibility results and offer cost savings to current workflows.

BackgroundAztreonam-avibactam (AZA) is a recently approved agent active against metallo-{beta}-lactamase-producing Enterobacterales. However, independent evaluations of commercially available antimicrobial susceptibility testing (AST) products remain limited. MethodsWe evaluated 56 carbapenem-resistant Enterobacterales isolates using four newly available AZA AST products, including two gradient diffusion (bioMerieux Etest; Liofilchem MIC Test Strip) and two disk diffusion (Hardy, Liofilchem) tests across three Mueller-Hinton agar manufacturers at two independent clinical laboratories. A diverse isolate collection enriched for nonsusceptible and breakpoint-adjacent MICs was used to rigorously assess categorical agreement. Broth microdilution (BMD) was used as the reference method. Essential agreement (EA), categorical agreement (CA), error rates, and reproducibility were analyzed. ResultsAll four commercial AST products demonstrated acceptable analytical performance compared with reference BMD. Gradient diffusion demonstrated high EA (bioMerieux 94.3%, Liofilchem 90.5%), whereas CA ranged from 83.3% to 89.0% across all four products. Minor errors accounted for all categorical discrepancies, and occurred almost exclusively among breakpoint-adjacent isolates. Media-related variability was modest, and quality control performance was generally high, with strong within-site precision and consistent performance across laboratories. ConclusionsThis study provides the first comprehensive head-to-head comparison of commercial AZA susceptibility testing products and supports their implementation in clinical microbiology laboratories.

ObjectiveThis study was designed to evaluate the diagnostic performance of fluorescence-based rapid on-site specimen evaluation (F-ROSE) for antimicrobial susceptibility testing of Helicobacter pylori (H. pylori) and to compare test performance before and after iterative optimization of fluorescence image acquisition and of the artificial intelligence (AI) recognition algorithm, using two consecutive rounds of paired testing, so as to provide trial data supporting clinical implementation of rapid susceptibility testing. MethodsForty patients with a urea breath test (UBT) or rapid urease test (RUT) positive for H. pylori within the preceding 2 weeks, together with strongly positive endoscopic findings, were prospectively enrolled. In order of enrollment they were allocated to two rounds in which F-ROSE was compared with culture-based susceptibility testing. Twenty patients were tested in round 1 on an automated fluorescence immunoassay scanner running the original algorithm; a further 20 were tested in round 2 with the optimized algorithm. With in vitro culture and E-test as the reference standard, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of F-ROSE were calculated for each round for amoxicillin, levofloxacin hydrochloride and clarithromycin, and agreement between methods was assessed with Cohens kappa. Receiver operating characteristic (ROC) analysis was used to identify the optimal cutoff of the fluorescence residual rate (FRR) and to determine how far threshold adjustment improved performance. ResultsCulture succeeded in 15 patients in round 1 and in 14 patients in round 2, leaving 29 evaluable samples. Overall diagnostic performance after algorithm optimization was clearly better than before. Pooled across the three antibiotics, sensitivity was 92.9%, specificity 71.0% and accuracy 77.8% before optimization; after optimization sensitivity rose to 100.0%, specificity increased slightly to 74.2% and accuracy to 81.0%. NPV reached 100.0% for all three agents after optimization, and no resistant isolate was missed. The gain was largest for clarithromycin, for which sensitivity rose from 85.7% to 100.0%, accuracy from 66.7% to 78.6% and kappa from 0.348 to 0.571, indicating a clear improvement in agreement between the two methods. ROC analysis showed that drug-specific optimal cutoffs derived from the Youden index improved specificity appreciably compared with the uniform 50% FRR threshold currently applied, the gain being most evident for levofloxacin hydrochloride. ConclusionsWith sharper fluorescence images and an improved AI recognition algorithm, F-ROSE performs better in H. pylori susceptibility testing, and the reduction in missed resistant strains is particularly noteworthy; the assay is therefore a plausible option for rapid susceptibility screening in clinical practice. Multicenter studies with larger samples are still required to confirm the stability of the technique.

Antimicrobial-resistant Neisseria gonorrhoeae (Ng) poses a growing global public health threat. Existing tools available for Ng genome analysis carry notable limitations, including incomplete resistance marker coverage, absence of species identification, and lack of phylogenetic capability. We developed neiss-flow, a highly parallelized Nextflow pipeline for Ng genome analysis that integrates five subworkflows: read preprocessing, species identification, de novo assembly, antimicrobial resistance (AMR) profiling, and recombination-aware phylogenetic analysis with outbreak detection. neissflow performs extensive quality control on reads, assemblies, variant calls, and phylogenetic results. Validation was performed on two datasets: a mixed-species dataset (n=158; 105 Ng and 53 non-gonococcal species) for sensitivity/specificity assessment, and a reproducibility dataset (n=283 replicate sequences from 17 reference strains) for consistency and phylogenetic validation. neissflow achieved 100% sensitivity and specificity for Ng species identification compared with MALDI-TOF and PubMLST methods. All nine AMR and typing analytes demonstrated [&ge;]98.1% concordance with PubMLST genotype calls. Genotype-phenotype validation confirmed perfect concordance for key resistance determinants including gyrA mutations with ciprofloxacin resistance, 23S rRNA mutations with high-level azithromycin resistance, and tetM plasmid gene with high-level tetracycline resistance. Reproducibility analysis demonstrated 99.97% concordance across 3,093 analyte calls. Phylogenetic validation demonstrated 100% accuracy for both strain-level and intra-MLST clustering. neissflow is a robust, accessible, and standardized pipeline, positioning it as a valuable tool for public health laboratories engaged in Ng AMR monitoring and outbreak investigations. ImportanceNeisseria gonorrhoeae (Ng) is the second most common reported bacterial sexually transmitted infection and has developed resistance to all clinically relevant antibiotics. Surveillance of Ng resistance informs clinical recommendations for treatment of gonococcal infections. Whole genome sequencing (WGS) offers powerful insights into resistance mechanisms and transmission dynamics. However, many public health laboratories lack the resources needed to analyze these data effectively. We developed neissflow as an end-to-end, accessible Ng WGS analysis pipeline. neissflow demonstrated exceptional accuracy and reproducibility across diverse reference datasets. neissflow enables broader adoption of whole-genome sequencing-based surveillance and supports timely public health responses to emerging antimicrobial resistance in Ng by lowering technical barriers.

BackgroundMetagenomic next-generation sequencing (mNGS) has the potential to transform clinical diagnostics for bloodstream infections (BSIs). However, its clinical utility is currently limited by several challenges, including the extraction of DNA from blood cultures. Our aim was to develop, evaluate, and optimize an in-house method for host depletion and bacterial DNA extraction from positive blood cultures to enable rapid mNGS-based pathogen detection and antimicrobial resistance profiling, informing clinical management of BSIs. Methods151 clinical blood cultures (115 positive and 36 negative) were processed for DNA extraction using an in-house-developed SEPSINN method for host depletion and bacterial DNA extraction. mNGS on the MinION was performed, and the results for pathogen identification and antimicrobial susceptibility predictions were compared with the routine clinical workflow. SEPSINN was also evaluated against a commercial DNA extraction method to assess its effectiveness in depleting host DNA and recovering bacterial DNA. ResultsThe SEPSINN method achieved up to 1000-fold depletion of host DNA and outperformed the commercial DNA extraction method. At the sample level, mNGS achieved 100% accuracy, specificity, and sensitivity, identifying at least one pathogen in all 115 positive blood cultures. At the pathogen level, mNGS showed 98% accuracy (120/123), specificity, and sensitivity. For antimicrobial susceptibility predictions, mNGS achieved an accuracy of 95% (1382/1451), a sensitivity of 88% (203/230), and a specificity of 97% (1179/1221). Moreover, the method also identified fungi, indicating a wider taxonomic range. mNGS resulted in an approximately 4-hour turnaround time for pathogen identification and resistance profiling. ConclusionsThe method can provide information on BSI clinical management within approximately 24 hours of receiving the sample, including the time required for culture positivity. This represents an important advancement in the clinical management of BSIs, with the potential to save lives and promote antibiotic stewardship.

Background: Phenotypic antibiotic susceptibility testing (AST) for Helicobacter pylori (H. pylori) has relied on bacterial culture for three decades, requiring 5-7 days to yield results. Genotypic rapid tests can only detect known resistance mutations and fail to reliably identify amoxicillin resistance. To our knowledge, no culture-free rapid phenotypic AST method for H. pylori has been previously reported. Methods: We developed a phenotypic AST method based on fluorescence rapid on-site evaluation (ROSE) technology that completely bypasses bacterial culture. Gastric mucosal biopsy specimens from 40 H. pylori-positive patients were homogenized and co-incubated with an acridine orange/ethidium bromide (AO/EB)-based viability staining reagent and three first-line antibiotics (amoxicillin, clarithromycin, and levofloxacin) at concentrations corresponding to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints for H. pylori, at 37C for 1 hour. Fluorescence intensity was measured using a microplate reader. A reduction in fluorescence relative to an antibiotic-free control indicated susceptibility, whereas no significant reduction indicated resistance. Conventional culture-based AST (E-test) served as the reference method. The overall concordance rate, sensitivity, specificity, and Cohen's kappa coefficient were calculated. Results: Fourteen of the 40 samples had unsuccessful culture and were excluded, leaving 26 samples for statistical analysis of each antibiotic. The overall concordance rates between the ROSE method and culture-based AST were 84.6% (22/26) for amoxicillin, 76.9% (20/26) for levofloxacin, and 69.2% (18/26) for clarithromycin. Cohen's kappa coefficients indicated moderate agreement for all three antibiotics ({kappa} = 0.523, 0.539, and 0.412, respectively). Unlike genotypic methods, the ROSE method successfully assessed amoxicillin susceptibility in all 40 patients, a critical first-line antibiotic for which no reliable genetic resistance marker currently exists. The turnaround time was approximately 1 hour (55-65 minutes), compared with 5-7 days for culture-based methods; preliminary estimates indicated a cost reduction of approximately 3,000-5,000 Chinese yuan (CNY) per patient, mainly attributable to the elimination of culture media, prolonged incubation, and repeat clinic visits. Conclusions: This study reports, for the first time, a culture-free 1-hour phenotypic AST for H. pylori. The method enables same-day, susceptibility-guided treatment decisions, addressing an unmet clinical need spanning three decades. Algorithm optimization and a prospective randomized controlled trial are currently underway to further improve diagnostic accuracy and validate clinical utility.

Background Current molecular diagnostics for Mycobacterium tuberculosis (MTB) require complex nucleic acid extraction procedures and laboratory infrastructure, limiting their use as point-of-care (POC) tests in resource-limited settings. To address these barriers, we developed an extraction-free one-pot CRISPR assay for rapid detection of MTB directly from minimally processed sputum specimens. Methods The assay integrates ambient-temperature chemical lysis, recombinase polymerase amplification, and CRISPR-Cas12a detection within a single closed-tube workflow. A conserved region of the MTB-specific IS6110 insertion sequence was targeted for detection. Analytical performance was evaluated using serially diluted MTB genomic DNA standards, followed by clinical validation using 100 archived sputum specimens, including 50 MTB-positive samples and 50 MTB-negative controls. Results The extraction-free assay detected MTB genomic DNA within 30 minutes and achieved an analytical limit of detection of 100 copies per reaction. In clinical validation, the assay correctly identified 48 of 50 MTB-positive specimens and 49 of 50 MTB-negative specimens, yielding 96.0% sensitivity and 98.0% specificity. Conclusions This study demonstrates the feasibility of extraction-free one-pot CRISPR-Cas12a detection of MTB directly from sputum specimens. By eliminating conventional nucleic acid extraction while maintaining high analytical sensitivity and diagnostic performance, the platform may facilitate future development of rapid molecular diagnostics for POC and resource-limited settings.

Clostridioides difficile is the leading cause of healthcare acquired infections (HAIs). Healthcare systems lack scalable strategies to identify patients colonized with toxigenic strains to inform prevention programs. We developed a scalable program using rectal swabs, collected for vancomycin resistance Enterococci surveillance, with ex vivo amplification of C. difficile in Cdiff Banana Broth (BB). Confirmatory testing of BB-positive tubes used the rapid C. difficile QuickCheck assay with Cepheid's Xpert(R) C. difficile/Epi (Xpert) to confirm toxin gene carriage for QuickCheck results that were C. difficile glutamate dehydrogenase-positive (GDH) and antigenic toxin-negative. BB with confirmation demonstrated 92% specificity and 100% sensitivity, to a limit of <5 colony forming units (CFU)/swab, versus published values of 100/swab by chromID(R) C. difficile agar and 460/swab by direct Xpert swab testing. The two-step confirmation detected toxigenic C. difficile in cases missed by these other methods. Prospective testing of 797 VRE swabs from 538 ICU and inpatient oncology patients seen at academic and community hospitals demonstrated 11% positivity for toxigenic and 4% for non-toxigenic C. difficile. Among swabs, 32% of toxigenic C. difficile were resulted at 24 hours and 68% at 48 hours. Addition of 17% glycerol to BB-positive aliquots, for -80C storage, supported 100% retrieval of C. difficile >6 months later. BB with confirmation provides a more sensitive method to detect patient colonization with toxigenic C. difficile and, by using VRE surveillance swabs, does not require additional patient samples. The simplified approach can be deployed across healthcare settings to support C. difficile-prevention programs.

Background: Access to accurate tuberculosis (TB) diagnostics remains limited, particularly in high-burden settings. The Pluslife MTB assay is among the first molecular tests specifically designed for swab-based detection of Mycobacterium tuberculosis complex (MTBC) and offers near point-of-care use. Methods: We conducted a prospective diagnostic accuracy study in South Africa to evaluate the performance of the Pluslife assay on tongue swabs (TSs) and sputum swabs (SSs) among symptomatic and asymptomatic adults. Results were compared against liquid culture as the reference standard and Xpert MTB/RIF Ultra (Xpert Ultra) as a comparator. Operational characteristics and ease-of-use were assessed through structured observation and Likert-scale scoring by testing personnel. Results: Of 256 participants enrolled, 92 [36%] were people with HIV (PHIV) and 217 were included in the final analysis. Culture confirmed TB in 41/217 (19%). The Pluslife assay demonstrated sensitivity of 85% (95% CI: 70.8-94.4) on SSs, comparable to Xpert Ultra on sputum (83%, 95% CI: 67.9-92.8), and detected one additional case missed by Xpert Ultra. Sensitivity on TSs was lower (63%, 95% CI: 46.9-77.9), particularly among PHIV. Specificity exceeded 97% across specimen types. Concordance on TSs between Pluslife and Xpert Ultra increased with higher bacterial loads. Operational evaluation showed short hands-on time and high ease-of-use scores, though limitations were noted for patient identifier recording and troubleshooting on the Pluslife MiniDock device. Conclusions: The Pluslife MTB assay on SSs shows comparable performance to existing rapid diagnostics and favorable usability. Tongue swabs remain feasible but less reliable, supporting sputum as the preferred first specimen for TB diagnosis.

Background. Urine-based testing offers a promising non-sputum approach for diagnosing paediatric tuberculosis. However, the currently available lipoarabinomannan (LAM) assay shows limited sensitivity in children and is primarily indicated for those living with HIV. Co-detection of LAM with Mycobacterium tuberculosis (Mtb) proteins in urine could provide complementary pathogen-derived biomarkers that improve diagnostic performance. Methods. We developed an ultrasensitive multiplex electrochemiluminescence (ECL) immunoassay to measure Ag85B, CFP-10, ESAT-6, MPT32, and MPT64 in urine. We determined the analytical limits of detection and evaluated the diagnostic performance of individual proteins and LAM using urine samples from children with Confirmed, Unconfirmed, and Unlikely pulmonary tuberculosis enrolled across five high-burden countries (The Gambia, India, Peru, South Africa, and Uganda). Performance was assessed overall, by HIV and nutritional status, and across biomarker combinations. Findings. Urine samples from 630 children were analysed (median age was 4 years [IQR 2-8]; 44% female, 15% living with HIV, 19% underweight, 24% with Confirmed tuberculosis). The ECL assay achieved femtomolar limits of detection (1.5 to 4.0 fM). The sensitivity and specificity of individual Mtb proteins were 12-33% and 98-100%, respectively. Ag85B had the highest sensitivity (33%, 95% CI 26-41) for Confirmed tuberculosis and was similar to LAM. A four-antigen signature (Ag85B, MPT64, MPT32, LAM) was 50% sensitive (95% CI 42-58) and 94% specific (95% CI 90-96), and was significantly more sensitive than LAM alone, in particular among those without HIV. An additional sixteen (10%) of children with Unconfirmed TB had at least one Mtb protein or LAM detected. Interpretation. Multiple Mtb proteins are detectable in paediatric urine with high specificity, and multi-antigen signatures can augment sensitivity versus LAM alone. These findings demonstrate the potential of multi-antigen urine detection for childhood TB and define analytical targets for the development of future point-of-care diagnostics. Funding. National Institutes of Health.

Background New swab-based near-point-of-care (NPOC) tests offer a potentially lower-cost, simpler alternative to Xpert MTB/RIF Ultra (Xpert-Ultra) testing for tuberculosis (TB) diagnosis. However, it is critical to understand how their performance may differ across diverse populations to inform programmatic rollout and real-world clinical decision-making. Methods We modeled the performance of testing sputum swabs with the MiniDock MTB assay and the Xpert MTB/RIF (Xpert) using positive percentage agreement (PPA) with Xpert-Ultra, disaggregated by semi-quantitative grade. PPA for MiniDock MTB was derived from a random-effects meta-analysis of three diagnostic accuracy studies. PPA for Xpert was derived from data from an early diagnostic study. PPA estimates were applied to 1,248 positive Xpert-Ultra test results from Phase 1 of the Start4All study across seven countries, disaggregated by facility-based (n=1,033) and community-based (n=215) participant recruitment, comparing a single overall PPA to an Xpert Ultra semi-quantitative grade-stratified model (from Trace to High). Results Pooled overall PPA was 84.8% (95% CI: 67.1-93.8%) for MiniDock MTB and 93.1% (90.3-95.2%) for Xpert. Grade-stratified modeling revealed lower PPAs at "Very Low" and "Trace" semi-quantitative grades: MiniDock MTB 56.5% and 33.8%; Xpert 66.7% and 23.1%, respectively. When grade-stratified estimates were applied to the Start4All data, both tests performed similarly, missing 241/1,248 and 228/1,248 positive Xpert-Ultra results, respectively. The single-value model overestimated performance most markedly in community settings, predicting 10.8% and 19.1% more positive results than the grade-stratified model for MiniDock MTB and Xpert, respectively. Conclusion MiniDock MTB sputum swabs perform comparably to Xpert when assessed using grade-stratified modeling. Both tests are likely to miss a greater proportion of people with Xpert-Ultra positive results in community settings, where paucibacillary disease is more common. Using single point estimates for diagnostic accuracy can substantially overestimate real-world performance, highlighting the importance of evaluating diagnostics across the full spectrum of TB disease.

Trachoma programs are increasingly using serological tools to complement clinical indicators and to measure current and historical transmission of Chlamydia trachomatis (Ct). In January 2024, the Amhara Trachoma Program in Ethiopia implemented the Pgp3 lateral flow assay (LFA) for trachoma serosurveillance through the regional public health laboratory system. Three Amhara Public Health Institute Trachoma Molecular Laboratory scientists were trained and passed competency testing on the assay. The scientists then conducted LFA testing on dried blood spot (DBS) samples collected during a December 2023 trachoma impact survey in Tach Gaynt, Amhara. During testing, 2,542 DBS samples were processed over 12 days. Age-specific seroprevalence and seroconversion rates (SCRs) were estimated. Among children ages 1-5 years, seroprevalence was 20.8% (95% confidence interval [CI]): 17.4-24.7%), and the SCR was 7.9 per 100 child-years (95% CI: 4.6-13.5). Among children ages 1-9 years, seroprevalence was 26.0% (95% CI: 22.9-29.3%), and the SCR was 7.0 per 100 child-years (95% CI: 4.6-10.6). Seroprevalence among individuals ages 15 years and older was 85.8% (95% CI: 83.9-87.4%). Trachomatous inflammation-follicular prevalence among children ages 1-9 years (TF1-9) was 28.6% (95% CI: 22.1-35.4%), and Ct infection among children ages 1-5 years was 5.7%, suggesting ongoing transmission. The concordance between LFA results, TF1-9 prevalence, and Ct infection prevalence supports the utility of the LFA for trachoma surveillance in Ethiopia, with Pgp3 LFA testing performed in a regional public health laboratory. Integrating LFA-based serology into the Ethiopia national trachoma surveillance systems offers a scalable approach to guide programmatic decisions and support trachoma elimination as a public health problem.

Existing molecular diagnostic approaches for notifiable avian diseases (NADs) involve a suite of PCR assays that enable both generic detection, and where positive, subtyping of both avian influenza virus (AIV) and Newcastle disease virus (NDV). Novel rapid and direct diagnostic assays for the detection of AIV and NDV were developed and evaluated using unprocessed cloacal (C) and oropharyngeal (OP) poultry swab material. Both assays employ a closed tube direct real-time reverse transcription polymerase chain reaction (RRT-PCR) approach in which viral lysis is achieved by heat treatment and a dedicated PCR compatible buffer, followed by detection using a RRT-PCR approach. Primer and probe sets were designed using globally circulating AIV and NDV sequences collected over the preceding five years, rather than region-specific sequence datasets, so that the assays detect all circulating genotypes. Analytical performance assessment demonstrated that both assays were highly sensitive and specific, successfully detecting all unextracted target antigens without cross reactivity to a panel of other common poultry pathogens. For each assay, viral lysis and amplification were achieved directly from samples at single digit genome copy numbers. Furthermore, low levels of viral RNA could be reliably detected in the presence of C and OP matrix material, providing proof-of-concept for direct detection of these economically significant avian pathogens in a field setting. Additional use case scenarios, including pooled sample screening and combined C/OP testing from individual birds, were also explored. These findings establish a foundation for ongoing studies incorporating paired-sample testing against validated laboratory reference assays.

Background SARS-CoV-2 genomic surveillance is vital for public health, but whole-genome sequencing (WGS) remains costly and inaccessible in many resource-limited settings. We developed and validated a multiplex real-time RT-PCR assay for rapid, economical detection of key mutations associated with variants of interest (VOI) and concern (VOC). Methodology Two multiplex mixes (M1, M2) targeting eight mutations in the ORF1a and Spike genes were designed. Analytical validation included sensitivity, specificity, reproducibility, and limit of detection (LoD) using WHO international standards and a respiratory pathogen panel. In parallel, an in silico analysis evaluated oligonucleotide efficacy against 10.4 million SARS-CoV-2 genomes from GISAID/NCBI, assessing inclusivity, target-site secondary structure (RNAalifold), and hybridization energy (Primer3Plus). Results The assay demonstrated 100% clinical sensitivity among samples with valid RT-PCR results (41/42 samples yielded interpretable results, with one inhibited sample excluded from sensitivity calculation), a LoD of 5.7 log10 IU/mL, and 100% analytical specificity against 32 non-SARS-CoV-2 respiratory pathogens. Six out of eight oligonucleotide sets showed >96% inclusivity; two sets exhibited reduced inclusivity (94.03%, 90.14%) and structural features potentially affecting binding against emerging variants. The assay enables direct identification of major VOCs (Alpha, Beta, Gamma, Delta, Omicron) and indirect detection of multiple VOIs (P.2, Epsilon, Kappa, Eta, Iota, Lambda). Conclusion This standardized multiplex assay provides a rapid, sensitive, and low-cost alternative for SARS-CoV-2 variant surveillance in Cuba and similar settings. The integration of experimental and in silico validation offers a robust, adaptable framework to sustain diagnostic accuracy amid viral evolution, optimizing the allocation of scarce sequencing resources.

Identification of acyclovir-resistant herpes simplex virus (HSV) infections is critical for directing appropriate antiviral therapy, particularly for immunocompromised patients where resistance rates can reach 30%. In 2020, the University of Washington Clinical Virology Laboratory launched the first clinical genotypic HSV drug resistance test in the United States. While genotypic testing offers significantly faster turnaround times than traditional phenotypic assays, interpretation depends on established mutational databases and remains challenging when novel variants are identified. Here, we retrospectively reviewed all HSV acyclovir resistance Sanger sequencing tests performed from January 2020 to November 2025 at this primary national reference laboratory. Mutations identified via clinical sequencing were compared against published databases of HSV UL23 mutations to determine their phenotypic effects. Over the nearly six-year study period, 136 samples were sequenced with a median turnaround time of 10.6 days. Among these, 65 samples (47.8%) harbored acyclovir resistance mutations, including 45 frameshift mutations. Notably, across the 100 samples (73.5%) displaying mutations not known to cause acyclovir resistance at the time of clinical testing, we identified 56 distinct mutations, including 23 without prior characterization. Our national experience demonstrates that genotypic testing accelerates actionable results in clinical practice and confirms that frameshift mutations remain a primary driver of acyclovir resistance. Furthermore, by uncovering these 23 novel variants, this work provides critical targets for future biochemical and phenotypic characterization of HSV UL23 mutations.

Necrotizing soft tissue infections (NSTIs) carry 10 to 30% mortality. Current empirical antimicrobial guidance derives almost entirely from Western cohorts dominated by Streptococcus pyogenes and aerobic-anaerobic consortia, yet whether this microbial paradigm applies to tropical, high-antimicrobial-pressure settings has not been tested with culture-independent methods. We did a prospective cohort study of 169 patients with intraoperatively confirmed NSTI at a North Indian tertiary center (2021 to 2024). Wound tissue underwent aerobic and anaerobic culture, QIIME2-based 16S rRNA gene amplicon sequencing (V3-V4), and targeted SYBR Green quantitative PCR (qPCR) for Acinetobacter baumannii and S. pyogenes. The wound microbiota was overwhelmingly Gram-negative and polymicrobial, anchored by A. baumannii (culture, 33.7%; metagenomics, 49.1%; qPCR, 37.9%), Escherichia coli (32.0%), and Klebsiella pneumoniae (20.7%); S. pyogenes contributed only 4.7% of culture-positive cases. Polymicrobial wounds had higher Shannon diversity (2.59 versus 2.33; P = 0.048) and discrete community composition (PERMANOVA R2 = 0.511; P = 0.010). Culture-metagenomics agreement ranged from almost perfect for Escherichia ({kappa} = 0.849) to slight for Streptococcus ({kappa} = 0.131). North Indian NSTIs present a microbial picture distinct from the Western paradigm, with implications for empirical therapy.

Sample preparation remains a barrier for decentralized, swab-based molecular testing of tuberculosis (TB). Extraction-free workflows offer a simpler alternative, but systematic benchmarking against standard methods is lacking. We evaluated five novel lysis devices, BLINK Shaker Prototype, nPOC-BB, SPS-1, Truelyse, and Thermolyse, against a heat- and bead-beating reference method using contrived M. tuberculosis-spiked tongue and sputum swabs. The primary outcome was lysis efficiency, measured as the relative DNA recovery compared with the reference workflow. Secondary outcomes included nuclease inactivation, biosafety, and usability. In the reference buffer, lysis efficiencies ranged from 51-63% to 95-154% on tongue swabs and 12-54% to 280-644% on sputum swabs across the five devices. In proprietary buffers, performance varied more widely, with lysis efficiencies of 2-4% to 64-80% on tongue swabs and 1% to 94-398% on sputum swabs. Complete biosafety inactivation was achieved by three devices; two showed residual growth (<0.02%). Lysis efficiency of several devices met or exceeded the reference, supporting the feasibility of extraction-free workflows for TB diagnosis, with further optimization of buffer compatibility and biosafety profiles expected to enhance performance.

Tongue swabs (TSs) are a non invasive specimen type for the detection of Mycobacterium tuberculosis complex (MTBC) and can expand access to testing for individuals unable to produce sputum. This study evaluated the diagnostic performance and user acceptability of self collected and health worker (HW) collected tongue swabs using the Xpert MTB/RIF Ultra (Ultra) assay and assessed participant perspectives on self collection. In this prospective, cross sectional study, symptomatic and asymptomatic adults under investigation for TB were enrolled from a high HIV prevalence setting. Each participant provided both a self collected and a HW collected TS, which were tested using Ultra. Ultra TS results were compared to liquid culture as the reference standard and sputum Ultra as a comparator. Participant perspectives on self collection were captured via questionnaires. Sensitivity on Ultra for both self and HW collected TSs was 68% (95% CI:51.9 to 81.9), compared to liquid culture. This sensitivity was significantly higher than that of sputum smear microscopy (46%, 95% CI: 30.7 to 62.6; McNemar's p = 0.003). Tongue swab sensitivity was lower than sputum Ultra (80.5%; p<0.001) and decreased with low bacillary loads. Importantly, TSs enabled MTBC detection in six participants unable to produce sputum. Most participants (>90%) found self collection instructions easy to follow, reporting high confidence and comfort, and trust in results from self collected TSs. This study demonstrates that self collected TSs perform comparably to those collected by health workers for TB detection using Ultra and are both feasible and acceptable in a high TB/HIV burden setting. To maximize impact, clear training instructions and robust linkage to care remain critical priorities.

Nucleic acid extraction remains the principal infrastructure barrier to molecular influenza testing outside centralised laboratories, since bead-based purification is normally tied to mains-powered extractors and trained operators. We evaluated SmartLid, a centrifugation-free format in which a removable magnetic key shuttles paramagnetic beads through pre-aliquoted lysis/binding, wash, and elution buffers without pipetting or powered instrumentation, against an automated magnetic-bead extractor (Nextractor NX-48S) on 311 nasopharyngeal specimens from the 2024-2025 influenza season at a National Influenza Centre. Paired eluates were amplified under identical monoplex RT-qPCR conditions for influenza A(H1N1)pdm09, A(H3), and B/Victoria. Both methods gave 100% specificity (47/47 negatives; no false positives). Subtyping succeeded in 263/264 reference-positive specimens after SmartLid extraction versus 241/264 after automated extraction (99.62% versus 91.29%; difference 8.33 percentage points; discordant pairs 23 versus 1; McNemar P < 0.001). Across 240 complete pairs, cycle threshold (Ct) values were lower after SmartLid extraction (median paired difference -2.78 cycles; estimated location shift -2.60 cycles, 95% CI -2.82 to -2.37; P < 0.001) with rank-ordering of specimens conserved between methods (Spearman rho = 0.84). The advantage was preserved across all three subtypes and in both fresh and frozen specimens (adjusted P < 0.001). Specimens recovered only after SmartLid extraction had higher Ct values than dual-detected specimens (median 34.37 versus 28.54; P < 0.001), locating the gain near the assay detection limit. An instrument-free manual format can therefore exceed the extraction efficiency of an automated reference workflow, extending quality-assured influenza subtyping beyond centralised laboratories.

Background: Tuberculosis, especially drug-resistant tuberculosis (DR-TB) including multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains, remains a leading cause of infectious death worldwide. The rapid accumulation of whole-genome sequencing (WGS) data had spurred numerous computational methods for predicting antimicrobial resistance in Mycobacterium tuberculosis. However, heterogeneous datasets, preprocessing pipelines, and evaluation protocols have made fair comparisons impossible and have hindered clinical translation. A critical yet missing resource is a large-scale, unified benchmark to systematically assess and compare existing methods. Methods: We curated an integrated MTB WGS--phenotypic drug susceptibility testing (pDST) dataset from three sources: the CRyPTIC dataset (Comprehensive Resistance Prediction for Tuberculosis: an International Consortium), a published multi-study compilation, and newly curated literature-derived datasets. The final benchmark contains 54,364 paired WGS-pDST records with broad geographic, lineage, and drug coverage. After harmonizing phenotypes and generating standardized variant features, we evaluated seven models (including classical machine learning and deep learning architectures) across 18 drug-level and six clinical resistance category prediction tasks. Results: XGBoost achieved the highest mean drug-level AUPRC (0.674) and F1-score (0.620) and ranked first in AUPRC for 11 of 18 drugs, whereas WDNN achieved the highest mean AUROC. Random forest yielded the highest mean specificity (0.956) and accuracy (0.933), whereas logistic regression achieved the highest mean recall (0.774), highlighting distinct clinical trade-offs. Drug-level difficulty was highly heterogeneous: rifampicin and isoniazid were predicted robustly, whereas bedaquiline, delamanid, linezolid, and clofazimine remained persistently difficult. In clinical resistance category evaluation, RR-TB, MDR-TB, and pan-susceptibility were well predicted, but XDR-TB and other resistance categories constituted major bottlenecks. Conclusions: Under the largest unified benchmark to date, classical machine-learning methods, particularly XGBoost, provided the strongest precision--recall and F1 performance overall, while neural models remained competitive by AUROC. Emerging drugs (bedaquiline, delamanid, linezolid, clofazimine) and XDR cases remain persistently difficult to predict, identifying key bottlenecks for future method development. This benchmark can serve as a community standard for evaluating MTB resistance prediction and the provided evaluation pipeline offers an actionable baseline for regulatory qualification and clinical decision support system validation, accelerating the translation of WGS-based resistance prediction into practice.