BioOhio Notes on Dr. Sebastian Faro's Presentation
August 18, 2014
This is a summary of my notes derived from a presentation given by Dr. Sebastian Faro, Women’s Medical Center, Houston. The venue was the BioOhio conference and was held in Aurora, Ohio on August 5, 2014. There were two separate presentations, one in the morning and another in the afternoon. Slightly more than twenty people attended the morning panel and another 12 or so in the afternoon. The 32 or so attendees represented approximately 25 percent of all BioOhio registrants and included personnel from the Cleveland Clinic and other core providers of medical services.
Dr. Faro and his son Dr. Jonathan Faro are internationally respected experts on women’s reproductive health and have conducted research for more than three years with the BioNanoFilter (BNF) patented by NanoLogix, Inc. They have expanded their research to include the NanoLogix N-Assay multi-well technology (N-Assay) and applied that technology not only to Group B Strep (GBS) but have adapted the method to other infectious diseases and conditions including sepsis, enterococcus, c. albicans, MRSA, c. difficile, and gonorrhea.
Part of this process has involved building specific diagnostic “panels” in connection with sepsis and neonatal diagnosis. This approach significantly expands the utility of the methodology since an array of potential sources and types of infection can be evaluated simultaneously rather than sequentially. The N-Assay not only provides almost immediate initial identification of potential problems with infection but reduces the incubation period to only six hours during which antibiotic sensitivity and potential effectiveness in a patient’s treatment are accurately evaluated. The N-Assay provides an unbatched, low cost, simple to use test.
Dr. Faro’s presentation led me to the conclusion that the N-Assay technology is a “game changer” across a range of distinct and dangerous conditions of bacterial infections. The identification of disease and the effective management of the individual patient is the role of the doctor. This suggests strongly that the N-Assay test represents the future direction of medical diagnosis and effective treatment through targeted and precise antibiotic infusion.
T he conclusion gained from Dr. Faro’s presentation is that there is no other methodology that can come close to matching the N-Assay technology on the significant range of diagnostic qualities detailed in 2013 by the Infectious Disease Society of America. The Society stated that a diagnostic test that could produce reliable results in one hour was needed to have a positive impact on patient care. The reliability of the test and its functional utility in a variety of important settings depended on the results being:
• Accurate
• Composed of heat stable reagents
• Having an extended shelf life
• Was portable
• Low cost relative to other methods
• Suitable for diagnosis of a broad range of clinical samples
• Required minimal technical skills
• Was rapid
• Sensitive
• Specific for each disease for which it was being used
• Provided on-demand individual testing rather than being delayed for large batched pools in order to reduce expense.
Dr. Faro indicated the current tests are simply not good enough to satisfy the full range of these critical criteria. They are also ill-suited to help deal with the array of emerging challenges related to infectious diseases. This includes the serious and growing problem of rampant antibiotic (AB) resistance caused by the almost automatic large scale generic infusion of antibiotic treatments that make up the treatment protocols in situations where a bacterial infection is diagnosed.
The rise in AB-resistant strains makes it essential that antibiotic overuse is avoided because a result of antibiotic overuse coupled with imprecisely targeted AB applications is the rapid growth in resistance by microbes that adapt to medicines to the point of rendering them ineffective. Dr. Faro commented on the fact that many doctors use antibiotics like they were “turning on a faucet”. This not only leads to a more rapid development of antibiotic resistance but entirely independent of the issue of AB resistance, the fact is that antibiotics are not simply benign substances. Antibiotics are quite dangerous drugs that can have important impacts on patient health.
An important aspect of Dr. Faro’s presentation is that the N-Assay test is machine-readable. He explained that the researchers modified the process in a way that they were able to shift to the ELISA format involving a simple plate reader. This resulted in being able to “achieve accurate test results in thirty (30) minutes rather than six hours. One breakthrough is that there is now no culture step required to achieve the rapid result.” Since it is color-coded and machine-readable ELISA eliminates inter-observer subjectivity and variability.
I nfectious Diseases with which the N-Assay is Concerned
Below are several brief capsules relating to the infectious conditions Dr. Faro and the research team are examining through intensive work with the NanoLogix N-Assay technology. They relate to Group B Strep, Sepsis, Enterococcus, MRSA, Candida Albicans, and Gonorrhea. Taken together with Dr. Faro’s conclusion that the N-Assay technology offers a clear step beyond existing diagnostic technologies related to these dangerous infectious diseases the breakthroughs the N-Assay technology represents on a range of critical needs, not only in the US and Europe but globally, is of vital importance for the protection of human health but also has great commercial benefit. The “capsules” are as follows.
As you read through the information below it may be useful to understand the scale and diversity of the numerous markets for which the N-Assay testing technology possesses a substantial “edge”. There are more than 4,000,000 pregnancies annually just in the US. The CDC protocols require GBS testing of pregnant women between the 35-37th weeks. In a number of instances retesting will be required after targeted treatment to determine if a treated GBS-situation has been reduced to a safe level.
Sepsis and Enterococcus infections collectively number in the tens of millions annually. MRSA is estimated to result in 20,000 deaths each year and this is only the “tip of the iceberg” in terms of the number of people who need to be tested for the infection. Gonorrhea infections run at a rate of over 800,000 per year and early detection and rapid intervention with the most effective and targeted treatment protocols is vital, as is informing affected individuals about the condition to avoid further spread.
From the perspective of human health it is unfortunate that there are so many people are affected by these bacterial infections to the point of debilitating illnesses and even death. The development of the N-Assay diagnostic testing capability at a minimum helps to prevent the spread of some of the diseases and also offers the enhanced ability to intervene with effective treatments at an earlier point than now exists.
Group B Strep: “Infection with group B streptococcus (GBS)… is infection with bacteria of the genus Streptococcus…; Group B streptococcal infection can cause serious illness and sometimes death, especially in newborn infants, the elderly, and patients with compromised immune systems. Group B streptococci are also prominent veterinary pathogens, because they can cause bovine mastitis (inflammation of the udder) in dairy cows. http://www.ask.com/wiki/Group_B_streptococcal...?qsrc=3044
Enterococcus: “Important clinical infections caused by Enterococcus include urinary tract infections, bacteremia, bacterial endocarditis, diverticulitis, and meningitis. …From a medical standpoint, an important feature of this genus is the high level of intrinsic antibiotic resistance. Some enterococci are intrinsically resistant to β-lactam-based antibiotics (penicillins, cephalosporins, carbapenems), as well as many aminoglycosides. In the last two decades, particularly virulent strains of Enterococcus that are resistant to vancomycin (vancomycin-resistant Enterococcus, or VRE) have emerged in nosocomial infections of hospitalized patients, especially in the US. …VRE may be treated with quinupristin/dalfopristin (Synercid) with response rates of approximately 70%. Tigecycline has also been shown to have anti-enterococcal activity as has rifampicin. …Enterococci are able to form biofilm in the prostate gland making their eradication difficult.” http://www.ask.com/wiki/Enterococcus?qsrc=3044
Sepsis : “Sepsis is a potentially fatal whole-body inflammation (a systemic inflammatory response syndrome or SIRS) caused by severe infection. Sepsis can continue even after the infection that caused it is gone. Severe sepsis is sepsis complicated by organ dysfunction. Septic shock is sepsis complicated by a high lactate level or by shock that does not improve after fluid resuscitation. Bacteremia is the presence of viable bacteria in the blood. …Sepsis causes millions of deaths globally each year. Sepsis is caused by the immune system's response to a serious infection, most commonly bacteria….” http://www.ask.com/wiki/Sepsis?qsrc=3044
MRSA : “Dangerous MRSA bacteria expand into communities”. “A USA TODAY examination finds that MRSA infections, particularly outside of health care facilities, are much more common than government statistics suggest. They sicken hundreds of thousands of Americans each year in various ways, from minor skin boils to deadly pneumonia, claiming upward of 20,000 lives. The inability to detect or track cases is confounding efforts by public health officials to develop prevention strategies and keep the bacteria from threatening vast new swaths of the population.” http://www.usatoday.com/story/news/nation/201...s/3991833/.
“ Candida albicans is a … causal agent of opportunistic oral and genital infections in humans, and candidal onychomycosis, an infection of the nail plate. Systemic fungal infections (fungemias) including those by C. albicans have emerged as important causes of morbidity and mortality in immunocompromised patients (e.g., AIDS, cancer chemotherapy, organ or bone marrow transplantation). C. albicans biofilms may form on the surface of implantable medical devices. In addition, hospital-acquired infections by C. albicans have become a cause of major health concerns.” http://en.wikipedia.org/wiki/Candida_albicans.”
“ Gonorrhea (colloquially known as the clap) is a common human sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae. … In both men and women, if gonorrhea is left untreated, it may spread locally, causing epididymitis or pelvic inflammatory disease or throughout the body, affecting joints and heart valves. The common treatment is with ceftriaxone (Rocephin), as antibiotic resistance has developed to many previously used medications. This is typically given in combination with either azithromycin or doxycycline, as gonorrhea infections may occur along with chlamydia, an infection that ceftriaxone does not cover. Some strains of gonorrhea have begun showing resistance to this treatment, which will make infection more difficult to treat.” http://www.ask.com/wiki/Gonorrhea?qsrc=3044.
Clostridium difficile is increasing and is dangerous. The Center for Disease Control states: “People getting medical care can catch serious infections called healthcare-associated infections (HAIs). … C. difficile causes diarrhea linked to 14,000 American deaths each year.”
A SUMMARY OF DR. SEBASTIAN FARO’S PRESENTATION
I. The Group B Strep (GBS) Breakthrough and the Protection of Women’s Health
Between 25-30% of pregnant women are “colonized” by GBS. “Colonization” means the bacteria are present and that the women and child are at potential risk if it spreads into an infection. Group B Strep (GBS) requires a universal screen for pregnant women in their 35-37 week period of pregnancy. It is vital for doctors to anticipate possible problems in patient management and this is why the GBS screening is essential.
The Center for Disease Control (CDC) now recommends universal screening at 35-37 weeks of gestation. The screen is to determine the existence and degree of colonization of GBS due to the morbidity and mortality potential from the infection. The GBS infection in women beyond “regular” child bearing years (mid to late thirties included) represent a high morbidity and mortality potential further exacerbated by such other conditions as diabetes, HIV and other infectious conditions. More mature patients are therefore at greater risk and require screening to ensure that surgical outcomes will be improved.
Another issue of significant medical concern is that ten percent (10%) of women deliver prematurely and this increases the morbidity and mortality (M & M) potential for the newly born infant due to their immune systems not being fully developed. GBS “M & M” is a particular problem in the very young and very old. For women who go into preterm labor there is a significant risk of the premature rupturing of membranes. These women are placed on an antibiotic mix but up to 60% of E-coli strains are resistant to ampicillin. The # 1 source of neonatal infection is E-coli.
In testing for Group B Strep the CDC recommends at this point that the following targets are met.
• A 48 hour culture for verify the existence and extent of GBS.
• Further determination of antibiotic susceptibility that requires an added 2-3 days.
The current methods in use mean that obtaining the final result in the GBS assessment regime using existing methods can take as much as five days. Given the health implications in play there are important needs to protect the health of women and the infant. The needs include a Rapid Diagnostic Test that:
• Identifies antimicrobial sensitivities.
• Is accurate.
• Takes less than an hour in the initial “indicator broths” and
• Produces final data within 24 hours.
The N-Assay test satisfies these criteria. Others do not. At this point the PCR and NAAT tests are good but limited for a variety of reasons. They are expensive, require specialized training, and have to be done in larger batches in labs in order to attempt to reduce the cost. PCR also cannot distinguish between live and dead bacteria. PCR also can’t provide de novo antimicrobial resistance information.
The importance of the ability to perform individual sample testing of specimens versus the need to “batch” a substantial number of unrelated samples is that no hospital will do a lab test on a single sample rather than a batch. This is due to the cost of tests using the current technologies. Another critical factor is that the tests are often done overnight in hospitals and the labs are not fully staffed at that time, nor are the most highly capable technicians on duty. This can result in interpretational problems.
II. The N-Assay Satisfies Key Diagnostic and Operational Needs and Better Protects Women’s Health
There are many different strains of strep but GBS is the specific strain we need to isolate and treat to protect women’s health. This requires the ability to test for that specific strain. The N-Assay system does this and importantly, 1. the test uses traditional culture methods that don’t require new investment or training and, 2. the test results produce significantly enhanced specificity with dramatically reduced time lapse.
The N-Assay can quantify the “bacterial burden” (extent of infection) in 6.5 hours and this allows the physician to identify and weigh the real risk for the patient of infection either in connection with surgery or childbirth. If a patient is going to have surgery it is even more important to know the level of the bacterial burden because there are many “foreign bodies” (sutures, pads, prosthetic mesh, etc.) involved in surgery. These “foreign bodies” can greatly increase the infection risk. A woman’s vagina has at least thirty different kinds of bacteria that are both non-pathogenic and pathogenic in nature. A majority of those bacterial types are pathogenic.
The way the N-Assay test works is that a specific antibody is designed and “plated” to which a specific bacterial type such as GBS is attracted and becomes bound. The test enables the identification of not only the type of bacteria but the extent of its colonization. We can identify bacterial burdens on the level of 106th and do so in six hours. This is the point of “bacterial burden” at which we can feel comfortable determining that there is high potential for serious problems.
The initial study we conducted involved 356 women in the 35-37 week gestation period. The results achieved for GBS were exciting but we have gone on to modify the method over the past year to further improve and expand the test beyond Group B Strep to other serious infectious diseases. One critical modification was that we were able to shift to what is called the ELISA format. In doing so, we now can achieve accurate test results in thirty (30) minutes rather than six hours. One breakthrough is that there is now no culture step required to achieve the rapid result. ELISA also eliminates inter-observer variability. [Note: “The enzyme-linked immunosorbent assay (ELISA) is a [machine-readable] test that uses antibodies and color change to identify a substance.”]
An important added improvement we have developed is that even though we can identify the degree of bacterial burden with great rapidity, there is an overnight culturing step using a particular antibiotic that allows for determination of the individual patient’s susceptibility to that antibiotic. This significantly improves our knowledge of the antibiotic (AB) sensitivity to a specific type and whether the most effective antibiotic is being used.
For OB/GYNs this is very important because they are the second most sued group of doctors in the US behind only neurosurgeons. This makes GBS screening very important due to neonatal morbidity and mortality. Even if those problems do not immediately manifest, the “down the line” consequences of untreated GBS during pregnancy involve a wide range of health problems as the child develops. A birth that seems normal can turn into a “horror story” for parents who find a developing set of severe and debilitating problems affecting their child. One of the first places they look will be the hospital, doctor and associated processes. Estimates suggest the average cost of treating a GBS-infected infant in a Neonatal Intensive Care Unit (NICU) is $30,100. But in Sebastian Faro’s judgment and based on his experience he estimates the cost is around $100,000. Plus most of the exposed children have significant problems with health over their lifetime.
III. The N-Assay Provides a Simple and Accurate Two Part Test
• The first stage involves a thirty minute initial detection of the specific bacteria and bacterial burden.
• The second stage tests for antibiotic susceptibility and also relates to potential penicillin resistance.
The N-Assay format has great potential for the identification and antibiotic susceptibility assessment in relation to a number of the most prevalent and serious types of bacterial infections. [See above capsules on infectious diseases]
IV. The Global Impact of Group B Strep
There are 134 million births worldwide annually. There is a GBS colonization rate of 20-30 % and this means there are as many as 26.8 million babies potentially infected with GBS each year. There is a great need for this diagnostic tool in Third World countries where the majority of the births are occurring and medical care limited, inadequate or non-existent. In those countries penicillin is often given prophylactically. This results in heightened resistance to antibiotics and as already mentioned antibiotic resistance is a rapidly growing problem on a global scale in relation to numerous diseases. The very high penicillin usage is also quite expensive along with being increasingly ineffective and creating further AB resistance problems.
NanoLogix Report on the Superior Durability of Its Products
At this point it may be helpful to insert the following information recently released by NanoLogix relating to ongoing tests that have reached completion. Dr. Faro’s presentation did not include this information but it struck me that its importance is readily ascertainable, not only for US and European contexts but particularly for military health uses, the World Health Organization needs in developing countries with limited access to advanced medical facilities, and in the point of detection and treatment situations found in many Third World medical situations. The recent issued NanoLogix report is as follows.
“NanoLogix received notification at the end of July of results for two time and temperature related tests that have been performed by a renowned independent third-party lab. In the first test, NanoLogix Tryptic Soy Agar (TSA) petri plates packed in the company's proprietary FlatPacks reached the 2-year point for room-temperature (RT) storage. The final test results for culturing of bacillus anthracis Ames (Anthrax) on the two-year-old plates were superior to the results obtained with competitor's one-week-old TSA plates, with NanoLogix's TSA plates performing as the equivalent to freshly poured plates. NanoLogix has elected to end the study, as the supply of FlatPacks that were furnished to the third-party lab two years ago predicated upon an initial four-month test for the DOD has been exhausted. The company recently completed its own testing of FlatPack packaged TSA petri plates stored for 3 years in cold storage with E-coli 0157 H7 as the test bacteria and observed results similar to those of the third-party lab 2 year RT test for Anthrax.
In a second test that was begun in June for determination of the stability of three different types of FlatPack-packaged agars under conditions conforming to MilSpec requirements for "Desert Hot" (to 60+ degrees Centigrade), the Flatpacks provided excellent agar protection and stability in simulated total power loss for periods of 24 hours, 7 days, and 30+ days, with culture results at all periods comparable to refrigerated and room temperature stored FlatPacks. The tests of NanoLogix FlatPacked plates were compared to plates furnished by competitors, with the competitors' plates performing adequately after 24 hours, but being completely desiccated and unusable by the 7-day point.
A peer reviewed paper will be published either in 2014 or early 2015 detailing the actual studies with results and control data.”
V. Expanding the N-Assay Test to Other Pathogens
Now back to My Summarized Notes on Dr. Faro’s Presentation. Efforts over the past year have not only been focused on improving the GBS methodology but expanding the test to other pathogens. This is a critical element of the importance of the N-Assay technology. The exciting aspect of the N-Assay multi-well technology is that it is being established that the NanoLogix technique holds as being effective for different bacterial diseases as long as the right antibody is determined that uniquely bonds to the specific bacteria independent of the other antibodies being used to attract different types of targeted bacteria.
An important development is that the Centers for Medicare and Medicaid will start withholding payment for certain Hospital Acquired Infections (HAIs). Right now they are focused on orthopedic and bariatric procedures for which infections develop but they will probably increase the denial of payment program to include caesarian and other gynecological services. This is something that obviously will generate incentives for hospitals, HMOs and doctors to take even more significant steps to ensure the prevention of infections as well as the early detection and effective antibiotic intervention. The idea is to nip the infectious bacteria “in the bud” when it is most susceptible to focused treatment at the point before it develops into a serious (and non-reimbursable) event.
Dealing with early identification of bacterial burdens for specific infections requires a diagnostic tool that identifies those bacterial infections fast and also allows for the more precise targeting of antibiotic treatment. This is critical. In this situation “speed matters” more than ever before and for a combination of reasons.
What has been discovered in association with the N-Assay is exciting. It includes:
• The fact that adjusting the specific coating antibody to which a specific bacteria is drawn and bound allows the identification of other pathogens.
• The other pathogens with which the test has been adapted to this point include 1. c. albicans, 2. MRSA, 3. enterococcus, and neisserial gonorrhoae.
• The antibiotic susceptibility testing capability is one of the most important aspects of what the methodology provides.
• The work involves the creation of specific testing panels that focus on some of the most prevalent and dangerous bacterial infections. These include a “Sepsis” panel, a “Prenatal” panel, and several others.
• Sepsis is becoming more prevalent because of antibiotic resistance plus it is very dangerous as a complication for patients. The N-Assay Sepsis panel is very important because the infection may take several days to fully manifest. With hospitals and insurance providers establishing requirements that lead to quick discharges and short term stays for patients a patient may be released and then have to come back in several days later as fever, diarrhea and other serious effects increasingly set in. As reimbursement for Hospital Acquired Infections becomes more limited this raises not only a serious issue in patient care but a looming financial dilemma for doctors and hospitals.
• Enterococcus (VRE) is one of the serious infections with which we are dealing and affects 2,000,000 people annually. Estimates are that 23,000 people die from the infection each year. The CDC has classified VRE as a serious threat. It is a major threat in hospital acquired cases of VRE.
• The N-Assay methodology has been applied to VRE and it has been found that there is no cross-sensitivity with GBS. This means the N-Assay can be used to test for each type of “bacterial burden” on the same plate. VRE is generally treated with Vancomycin and there are issues of resistance and sensitivity.
• Gonorrhea is an immediate public threat the CDC has indicated requires “urgent and aggressive” action. There are 800,000 new cases of gonorrhea annually in the US and 246,000 of them are drug resistant. Chlamydia is another bacterial disease and traditionally penicillin was used to treat it. Penicillin is now useless against this disease. A new drug, azithromycin was developed and there were great hopes but AB resistance is already being detected just a few years after initial use. The cost of treating “primary” gonorrhea is over $250,000.
• Clostridium difficile is increasing in the number of cases and is very dangerous. The Center for Disease Control states: “People getting medical care can catch serious infections called healthcare-associated infections (HAIs). … C. difficile causes diarrhea linked to 14,000 American deaths each year. Those most at risk are people, especially older adults, who take antibiotics and also get medical care. CDC provides guidelines and tools to the healthcare community to help prevent Clostridium difficile infections as well as provides resources to help the public safeguard their own health.” http://www.cdc.gov/hai/organisms/cdiff/cdiff_infect.html.
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