KITGEN spol. s r.o. Laboratory for molecular diagnostics V Hůrkách 3 158 00 Prague CZECH REPUBLIC

Molecular Microbiology – Requisition Form (, fungi, DNA/RNA viruses, microscopic parasites)

Patient: Referring clinician:

Name: Name:

Address: ID: ID of the patient:

Insurance type: Address:

Diagnosis: Stamp and signature:

Biological material (please specify):

………………………………………………………

Date and time of sampling:

Required tests (tick please):

A. MOLECULAR DETECTION OF BACTERIA Detection range of the Real-Time PCR assay Acinetobacter baumannii Aggregatibacter actinomycetemcomitans Aggregatibacter actinomycetemcomitans Anaplasma phagocytophilum, , Anaplasma spp. Anaplasma ovis, Anaplasma marginale Atopobium vaginae Atopobium vaginae Bacillus anthracis Bacillus anthracis spp. , Bordetella bronchiseptica Bordetella bronchiseptica Bordetella pertussis Borrelia burgdorferi, Borrelia afzelii, Borrelia Borrelia burgdorferi sensu lato garinii , Brucella mellitensis, Brucella Brucella spp. suis, Brucella canis Burkholderia cepacia, Burkholderia cenocepacia, Burkholderia multivorans, Burkholderia pseudomallei, , Burkholderia amfibaria, Burkholderia Burkholderia spp. vietnamensis, Burkholderia thailadensis Campylobacter spp. , Campylobacter coli

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KITGEN spol. s r.o. Laboratory for molecular diagnostics V Hůrkách 3 158 00 Prague CZECH REPUBLIC

Candidatus neoehrlichia mikurensis Candidatus neoehrlichia mikurensis Citrobacter spp. , Clostridium perfringens, Clostridium tetani, Clostridium botulinum, Clostridium novyi, Clostridium histolyticum, Clostridium difficile, Clostridium spp. Clostridium sordellii Clostridium difficile, toxin A Clostridium difficile, toxin A Clostridium difficile, toxin B Clostridium difficile, toxin B Staphylococcus haemolyticus, Staphylocouccus hominis, Staphylococcus epidermidis, Staphylococcus capitis, Staphylococcus auricularis, Staphylococcus hyicus, Staphylococcus felis, Staphylococcus intermedius, Staphylococcus saprophyticus, Coagulase-negative Staphylococci (more Staphylococcus xylosus, Staphylococcus than 40 species) schleiferi and other less frequent CoNS Corynebacterium diphtheriae, Corynebacterium pseudotuberculosis, Corynebacterium ulcerans, Corynebacterium amycolatum, Corynebacterium striatum, Corynebacterium tuberculostearicum, Corynebacterium pseudogenitalium, Corynebacterium spp. Corynebacterium minutissimum Ehrlichia chaffeensis / aerogenes Enterobacter cloacae / aerogenes Enterococcus faecalis Enterococcus faecalis Enterococcus faecium Enterococcus faecium Escherichia coli Francisella tularensis Fusobacterium nucleatum Fusobacterium nucleatum Gardnerella vaginalis Gardnerella vaginalis influenzae group A-F Helicobacter pylori Chlamydia psitacci, Chlamydophila pneumoniae, Chlamydia trachomatis, Chlamydia caviae, Chlamydia pecorum, Chlamydia abortus, Chlamydia muridarum, Chlamydia avium, Chlamydia (Chlamydophila) spp. Chlamydophila felis Chlamydia trachomatis Chlamydia trachomatis Chlamydophila pneumoniae Chlamydophila pneumoniae Klebsiella oxytoca Klebsiella pneumoniae Legionella micdadei Legionella micdadei Legionella pneumophila Leptospira interrogans; Leptospira icterohaemorrhagiae, Leptospira grippotyphosa, Leptospira spp. Leptospira pomona, Leptospira canicola Listeria monocytogenes Listeria monocytogenes Moraxella catarrhalis Morganella morganii Morganella morganii

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KITGEN spol. s r.o. Laboratory for molecular diagnostics V Hůrkách 3 158 00 Prague CZECH REPUBLIC

Mycobacterium tuberculosis, Mycobacterium ulcerans, Mycobacterium gordonae, Mycobacterium scrofulaceum, Mycobacterium bovis, Mycobacterium malmoense, Mycobacterium xenopi, Mycobacterium kansasii, Mycobacerium intracellulare, Mycobacterium Mycobacterium spp. avium subsp. avium, Mycobacterium fortuitum Mycoplasma genitalium Mycoplasma genitalium Mycoplasma hominis Mycoplasma hominis Mycoplasma pneumoniae Mycoplasma pneumoniae Mycoplasma salivarium, Mycoplasma buccale, Mycoplasma cloacale, Mycoplasma canis, Mycoplasma capricolum, Mycoplasma caviae, Mycoplasma phocae, Mycoplasma heamominutum, Mycoplasma suis, Mycoplasma maculosum, Mycoplasma primatum, Mycoplasma spermatophilum, Mycoplasma equigenitalium, Mycoplasma elephantis, Mycoplasma phocicerebrale, Mycoplasma phocirhinis, Mycoplasma phocidae, Mycoplasma arginini, Mycoplasma pulmonis, Mycoplasma Mycoplasma spp. orale, Mycoplasma flocculare Neisseria gonorrhoeae Neisseria meningitidis Nocardia nova, Nocardia asteroides, Nocardia Nocardia spp. aobensis, Nocardia brasiliensis Porphyromonas endodontalis Porphyromonas endodontalis Porphyromonas gingivalis Porphyromonas gingivalis Prevotella intermedia Prevotella intermedia Proteus mirabilis / putida Pseudomonas aeruginosa / putida rickettsii, Rickettsia helvetica, , , , , Rickettsia spp. Salmonella enteric subsp. enterica type Enteritidis, Typhimurium, Newport, Anatum, subsp. enterica Montevideo, Paratyphi A, Infantum Serratia marcescens , , Shigella Shigella spp. dysenteriae Staphylococcus aureus Staphylococcus aureus Stenotrophomonas maltophilia Stenotrophomonas maltophilia Streptococcus pneumoniae Streptococcus pneumoniae Streptococcus anginosus, Streptococcus pyogenes, Streptococcus agalactiae, Streptococcus dysgalactiae, Streptococcus parasanguinis, Streptococcus oralis, avium, Streptococcus constellatus, Streptococcus equi, Streptococcus equisimillis, Streptococcus haemolyticus, Streptococcus milleri, Streptococcus mutans, Streptococcus porcinus, Streptococcus salivarius, Streptococcus suis, Streptococcus spp. (more than 70 Streptococcus zooepidemicus, Streptococcus species) canis and other less frequent species

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KITGEN spol. s r.o. Laboratory for molecular diagnostics V Hůrkách 3 158 00 Prague CZECH REPUBLIC

Tannerella forsythia Tannerella forsythia Treponema denticola Treponema denticola Treponema pallidum Treponema pallidum Tropheryma whipplei Tropheryma whipplei Ureaplasma urealyticum, Ureaplasma diversum, Ureaplasma gallorale, Ureaplasma felinum, Ureaplasma cati, Ureaplasma canigenitalium, Ureaplasma spp. Ureaplasma parvum , Yersinia pseudotuberculosis, Yersinia spp. subsp. enterocolitica G(-): Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, Serratia marcescens, Enterobacter cloacae/aerogenes, Proteus mirabilis, Pseudomonas aeruginosa/putida, Acinetobacter baumannii, Stenotrophomonas maltophilia G(+): Staphylococcus aureus, Coaguláza-negativní staphylokoky (Staphylococcus epidermidis, S. haemolyticus, S. hominis, S. intermedius, S. xylosus), Streptococcus pneumoniae, Streptococcus spp. (Streptococcus agalactiae, S. anginosus, S. constellatus, S. dysgalactiae, S. infantarius, S. intermedius, S. minor, S. mitis, S. mutans, S. oligofermentans, S. oralis, S. parasanguinis, S. peroris, S. pseudopneumoniae, S. pyogenes, S. salivarius, S. sanguinis, S. thermophilus, S. viridans), Enterococcus faecium, Enterococcus Bacteria-Multiplex faecalis Klebsiella pneumoniae, Staphylococcus aureus, Enterobacter cloacae, Streptococcus Bacteria-Multiplex A pneumoniae, Klebsiella oxytoca Coagulase-negative staphylococci (over 40 species), Serratia marcescens, Enterococcus faecium, Proteus mirabilis, Acinetobacter Bacteria-Multiplex B baumannii Streptococcus spp. (over 70 species), Pseudomonas aeruginosa / putida, Escherichia coli, Stenotrophomonas maltophilia, Bacteria-Multiplex C Enterococcus faecalis Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, Listeria MeningitisPlexB1 monocytogenes, Staphylococcus aureus Klebsiella pneumoniae, Klebsiella oxytoca, Escherichia coli, Staphylococcus haemolyticus, Staphylocouccus hominis, Staphylococcus epidermidis, Staphylococcus capitis, Staphylococcus auricularis, Staphylococcus hyicus, Staphylococcus felis, Staphylococcus intermedius, Staphylococcus saprophyticus, Staphylococcus xylosus, Staphylococcus schleiferi, Streptococcus anginosus, Streptococcus pyogenes, Streptococcus agalactiae, Streptococcus dysgalactiae, Streptococcus parasanguinis, Streptococcus oralis, avium, Streptococcus constellatus, MeningitisPlexB2 Streptococcus equi, Streptococcus equisimillis,

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KITGEN spol. s r.o. Laboratory for molecular diagnostics V Hůrkách 3 158 00 Prague CZECH REPUBLIC

Streptococcus haemolyticus, Streptococcus milleri, Streptococcus mutans, Streptococcus porcinus, Streptococcus salivarius, Streptococcus suis, Streptococcus zooepidemicus, Streptococcus canis, Borrelia burgdorferi, Borrelia afzelii, Borrelia garinii Leptospira interrogans; Leptospira icterohaemorrhagiae, Leptospira grippotyphosa, Leptospira pomona, Leptospira canicola, Bartonella henselae, Bartonella quintana, Brucella abortus, Brucella mellitensis, Brucella suis, Brucella canis, , Rickettsia helvetica, Rickettsia parkeri, Rickettsia massiliae, Rickettsia peacockii, Rickettsia sibirica, Rickettsia raoultii, Mycobacterium tuberculosis, Mycobacterium ulcerans, Mycobacterium gordonae, Mycobacterium scrofulaceum, Mycobacterium bovis, Mycobacterium malmoense, Mycobacterium xenopi, Mycobacterium kansasii, Mycobacerium intracellulare, Mycobacterium MeningitisPlexB3 avium subsp. avium, Mycobacterium fortuitum Clostridium perfringens, Clostridium tetani, Clostridium botulinum, Clostridium novyi, Clostridium histolyticum, Clostridium difficile, Clostridium sordellii, Clostridium difficile toxin A, ClostridiumPlex Clostridium difficile toxin B Mycoplasma salivarium, Mycoplasma buccale, Mycoplasma cloacale, Mycoplasma canis, Mycoplasma capricolum, Mycoplasma caviae, Mycoplasma phocae, Mycoplasma heamominutum, Mycoplasma suis, Mycoplasma maculosum, Mycoplasma primatum, Mycoplasma spermatophilum, Ureaplasma urealyticum, Ureaplasma diversum, Ureaplasma gallorale, Ureaplasma felinum, Ureaplasma cati, Ureaplasma canigenitalium, Ureaplasma parvum, Chlamydia psitacci, Chlamydophila pneumoniae, Chlamydia trachomatis, Chlamydia caviae, Chlamydia abortus, Chlamydia muridarum, Chlamydia pecorum, Chlamydia MollicutesPlex2 avium, Chlamydophila felis, Chlamydia pecorum Legionella micdadei, Legionella pneumoniae, Nocardia nova, Nocardia asteroides, Nocardia aobensis, Nocardia brasiliensis, Streptococcus pneumoniae, Pseudomonas aeruginosa, Pseudomonas putida, Bordetella pertussis, PneumoniaPlex Moraxella catarrhalis Treponema pallidum, Neisseria gonorrhoeae, Candida albicans, Trichomonas vaginalis, UroPlexBFP Gardnerella vaginalis, Atopobium vaginae

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KITGEN spol. s r.o. Laboratory for molecular diagnostics V Hůrkách 3 158 00 Prague CZECH REPUBLIC

B. MOLECULAR DETECTION OF FUNGI Detection range of the Real-Time PCR assay Aspergillus fumigatus Aspergillus fumigatus Aspergillus fumigatus, Aspergillus caelatus, Aspergillus protuberus, Aspergillus campestris, Aspergillus flavus, Aspergillus pseudotamarii, Aspergillus carneus, Aspergillus striatus, Aspergillus oryzae, Aspergillus fasciculatus, Aspergillus sydowii, Aspergillus nidulans, Aspergillus fumigatiaffinis, Aspergillus taichungensis, Aspergillus versicolor, Aspergillus hennebergii, Aspergillus tamarii, Aspergillus ustus, Aspergillus heteromorphus, Aspergillus terricola, Aspergillus cervinus, Aspergillus kambarensis, Aspergillus thomii, Aspergillus candidus, Aspergillus kanagawaensis, Aspergillus toxicarius, Aspergillus niger, Aspergillus nutans, Aspergillus tritici, Aspergillus terreus, Aspergillus ochraceus, Aspergillus unguis, Aspergillus parasiticus, Aspergillus Aspergillus spp. viridinutans, Aspergillus parvulus Blastomyces dermatitidis Blastomyces dermatitidis Candida albicans Candida albicans Candida crusei Candida crusei Candida dubliniensis Candida dubliniensis Candida glabrata Candida glabrata Candida tropicalis Candida tropicalis Candida albicans, Candida crusei, Candida dubliniensis, Candida glabrata, Candida tropicalis, Candida inconspicua, Candida lusitaniae, Candida fabianii, Candida orthopsilosis, Candida metapsilosis, Candida Candida spp. guillermondii, Candida norwegiensis Cladosporium cladosporioides Cladosporium cladosporioides Cryptococcus neoformans Cryptococcus neoformans Cryptococcus carnescens, Cryptococcus neoformans, Cryptococcus flavenscens, Cryptococcus spp. Cryptococcus aureus Coccidioides immitis Coccidioides immitis Fusarium avenaceum, Fusarium oxysporum, Fusarium poae, Fusarium sporotrichoides, Fusarium spp. Fusarium virguliforme Histoplasma capsulatum Histoplasma capsulatum Mucor spp. Mucor indicus, Mucor plumbeus Pneumocystis jiroveci Pneumocystis jiroveci Rhizopus spp. Rhizopus microsporus, Rhizopus oryzae Trichophyton mentagrophytes, Trichophyton Trichophyton spp. rubrum, Trichophyton interdigitale Candida albicans, Candida krusei, Candida glabrata, Candida tropicalis, Candida dubliniensis, Candida inconspicua, Candida lusitaniae, Candida (Pichia) fabianii, Candida parapsilosis, Candida tropicalis, Candida (Pichia) gulliermondii, Fusarium spp., Cladosporium cladosporioides, Pneumocystis Fungi-Multiplex jiroveci, Mucoraceae (Rhizopus microsporus,

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KITGEN spol. s r.o. Laboratory for molecular diagnostics V Hůrkách 3 158 00 Prague CZECH REPUBLIC

Rhizopus oryzae, Mucor plumbeus, Mucor indicus), Cryptococcus spp. (Cryptococcus aureus, Cryptococcus carnescens, Cryptococcus flavescens, Cryptococcus neoformans), Aspergillus fumigatus, Aspergillus spp. (Aspergillus flavus, Aspergillus oryzae, Aspergillus nidulans, Aspergillus versicolor, Aspergillus ustus, Aspergillus cervinus, Aspergillus candidus, Aspergillus niger, Aspergillus terreus), Trichophyton mentagrophytes, Trichophyton rubrum, Trichophyton interdigitale Candida krusei, Fusarium spp., Candida glabrata, Candida albicans, Candida Fungi-Multiplex A dubliniensis Aspergillus fumigatus, Candida parapsilosis, Candida tropicalis, Candida spp., Trichophyton mentagrophytes, Trichophyton rubrum, Fungi-Multiplex B Trichophyton interdigitale Rhizopus microsporus, Rhizopus oryzae, Mucor plumbeus, Mucor indicus, Cryptococcus neoformans, Cryptococcus spp., Aspergillus Fungi-Multiplex C spp., Pneumocystis jiroveci Aspergillus fumigatus, Cryptococcus carnescens, Cryptococcus neoformans, Cryptococcus flavenscens, Cryptococcus aureus, Candida albicans, Histoplasma capsulatum, Blastomyces dermatitis, MeningitisPlexF Coccidioides immitis

C. MOLECULAR DETECTION OF PARASITES Detection range of the Real-Time PCR assay Acanthamoeba castellanii, Acanthamoeba comandoni, Acanthamoeba mauritaniensis, Acanthamoeba polyphaga, Acanthamoeba lenticulata, Acanthamoeba culbertsoni, Acanthamoeba rhysodes, Acanthamoeba royreba, Acanthamoeba divionensis, Acanthamoeba spp. Acanthamoeba paradivionensis Babesia divergens, Babesia caballi, Babesia gibsoni, Babesia canis vogeli, Babesia occultans, Babesia bovis, Babesia canis canis, Babesia spp. Babesia rossi Balamuthia mandrillaris Balamuthia mandrillaris Cryptosporidium hominis, Cryptosporidium Cryptosporidium spp. parvum Dientamoeba fragilis Dientamoeba fragilis Entamoeba histolytica Entamoeba histolytica Giardia intestinalis Giardia intestinalis Leishmania major, Leishmania tropica, Leishmania donovani, Leishmania infantum, Leishmania mexicana, Leishmania amazonensis, Leishmania naiffi, Leishmania guyanensis, Leishmania brasiliensis, Leishmania spp. Leishmania panamensis, Leishmania chagasi

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KITGEN spol. s r.o. Laboratory for molecular diagnostics V Hůrkách 3 158 00 Prague CZECH REPUBLIC

Naegleria fowleri, Naegleria australiensis, Naegleria philippinensis, Naegleria canariensis, Naegleria italica, Naegleria andersoni, Naegleria iovaniensis, Naegleria clarki, Naegleria pagei, Naegleria spp. Naegleria fultoni Toxoplasma gondii Toxoplasma gondii Toxoplasma gondii, Acanthamoeba spp., Balamuthia mandrillaris, Naegleria spp., MeningitisPlexP Plasmodium falciparum Giardia intestinalis, Entamoeba histolytica, GITparasites-Multiplex II Cryptosporidium parvum, Dientamoeba fragilis D. MOLECULAR DETECTION OF RNA VIRUSES Detection range of the Real-Time PCR assay Influenza A Influenza A Influenza A, H1N1 Influenza A, H1N1 Influenza B Influenza B RSV RSV Poliovirus, Coxsackie A / B virus, Echovirus, Enterovirus Enterovirus type 68 – 71 Hepatitis A Hepatitis A Hepatitis C Hepatitis C Hepatitis E Hepatitis E HIV-1 HIV-1 Mumps virus Mumps virus WNV-1 WNV-1 Tick-borne Encephalitis virus (TBEV) Tick-borne Encephalitis virus (TBEV) Zika virus Zika virus Tick-Borne Encephalitis virus (TBEV), Poliovirus, Coxsackie A/B virus, Echovirus, Enterovirus type 68-71, Zika virus, Mumps virus, EncephalitisPlexV1 HIV-1, West Nile virus

E. MOLECULAR DETECTION OF DNA VIRUSES Detection range of the Real-Time PCR assay HSV-1 HSV-1 HSV-2 HSV-2 CMV CMV EBV EBV VZV VZV HHV-6 HHV-6 HHV-7 HHV-7 HHV-8 HHV-8 Adenovirus A-F Adenovirus A-F Polyomavirus JCV JCV Polyomavirus BKV BKV Parvovirus B19 B19 Hepatitis B Hepatitis B HPV-16,HPV-18,HPV-31,HPV-45,HPV- 39/56,HPV-52/53,HPV-59/66,HPV-68/73,HPV- HPV-HighRiskPlex 26/51/82,HPV-33/35/58 EncephalitisPlexV2 HSV-1, HSV-2, CMV, EBV, VZV, HHV-7

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KITGEN spol. s r.o. Laboratory for molecular diagnostics V Hůrkách 3 158 00 Prague CZECH REPUBLIC

F. MOLECULAR PANDETECION OF MICROORGANISMS Detection range of the assay Qualitative pandetection of bacteria using Test with no detection limit using Sanger Sanger Sequencing Sequencing; suitable for primarily sterile biological materials or materials with one predominant major microorganism Qualitative pandetection of fungi using Test with no detection limit using Sanger Sanger Sequencing Sequencing; suitable for primarily sterile biological materials or materials with one predominant major microorganism Quantitative pandetection of bacteria Test with no detection limit using Next using Next Generation Sequencing Generation Sequencing (NGS); suitable for any biological material, even for materials containing highly mixed microbial flora Quantitative pandetection of fungi using Test with no detection limit using Next Next Generation Sequencing Generation Sequencing (NGS); suitable for any biological material, even for materials containing highly mixed microbial flora Quantitative pandetection of DNA Test with no detection limit using Next microorganisms using Next Generation Generation Sequencing (NGS); suitable Sequencing preferably for cell-free biological materials

Quantitative pandetection of RNA Test with no detection limit using Next microorganisms using Next Generation Generation Sequencing (NGS); suitable Sequencing preferably for cell-free biological materials

The tests are carried out by: Details on the sample admission:

KITGEN spol. s r.o. Date and time of sample admission: Laboratory for molecular diagnostics V Hůrkách 3 158 00 Prague Czech Republic www.kitgen.eu Sample accepted by / person responsible: tel: +420 732 517 266 e-mail: [email protected]

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