Applications of Clinical Microbial Next-Generation Sequencing American Academy of Microbiology 1752 N Street, NW Washington, DC 20036 academy.asm.org A report from the Applications of Clinical Microbial Next-Generation Sequencing Report on an American Academy of Microbiology Colloquium held in Washington, DC, in April 2015. The American Academy of Microbiology (Academy) is the honorific branch of clinical pathogens. This report has been reviewed by the majority of participants, the American Society for Microbiology (ASM), a nonprofit scientific society with and every effort has been made to ensure that the information is accurate and nearly 40,000 members. Fellows of the Academy have been elected by their complete. The contents reflect the views of the participants and are not intended peers in recognition of their outstanding contributions to the microbial sciences. to reflect official positions of the Academy or ASM. Through its colloquium program, the Academy draws on the expertise of these The Academy acknowledges Peggy A. Reel for her assistance in editing this report. fellows to address critical issues in the microbial sciences. Contents of the report may be distributed further as long as the authorship This report is based on the deliberations of experts who gathered for two days of the Academy is acknowledged and this disclaimer is included. to discuss a series of questions developed by the steering committee regarding the use of next-generation sequencing for faster detection and identification of BOARD OF GOVERNORS, AMERICAN ACADEMY OF MICROBIOLOGY Michele S. Swanson, Ph.D., Chair Terence Dermody, M.D. Steven Lindow, Ph.D. University of Michigan Vanderbilt University University of California, Berkeley Martin J. Blaser, M.D. Gerry Fink, Ph.D. Margaret McFall-Ngai, Ph.D. New York University Massachusetts Institute of Technology University of Wisconsin-Madison Donald A. Bryant, Ph.D. Stan Fields, Ph.D. Mary Ann Moran, Ph.D. Pennsylvania State University University of Washington University of Georgia Nancy Craig, Ph.D. James M. Hughes, M.D. Graham C. Walker, Ph.D. Johns Hopkins University School of Medicine Emory University Massachusetts Institute of Technology COLLOQUIUM STEERING COMMITTEE George Weinstock, Ph.D., Chair Nathan Ledeboer, Ph.D., D(ABMM) Heike Sichtig, Ph.D. The Jackson Laboratory for Genomic Medicine Medical College of Wisconsin Food and Drug Administration Brittany Goldberg, M.D. Eddy Rubin, M.D., Ph.D.* Children’s National Medical Center Department of Energy Joint Genome Institute PARTICIPANTS Marc W. Allard, Ph.D. Amy S. Gargis, Ph.D. Gustavo Palacios, Ph.D. Food and Drug Administration U.S. Centers for Disease Control U.S. Army Medical Research Institute of Infectious Andrew K Benson, Ph.D. and Prevention Diseases Center for Genomic Sciences University of Nebraska-Lincoln Elodie Ghedin, Ph.D. Adam Phillippy, Ph.D. Carey-Ann Burnham, Ph.D., D(ABMM) New York University National Biodefense Analysis and Washington University School of Medicine Center for Genomics & Systems Biology Countermeasures Center Susan Butler-Wu, Ph.D., D(ABMM) Kelly Hoon Gary W. Procop, M.D., M.S. University of Washington Illumina Cleveland Clinic Charles Chiu, M.D., Ph.D. William Klimke, Ph.D. Julie Segre, Ph.D. University of California, San Francisco National Center for Biotechnology National Human Genome Research Institute National Institutes of Health National Institutes of Health Chris Detter, Ph.D. Michael Lorenz, Ph.D. Shanmuga Sozhamannan, Ph.D. Department of Defense Defense Threat Reduction Agency University of Texas Health Science Center The Tauri Group, LLC, supporting the Critical Reagents Program William M. Dunne, Ph.D., Timothy Minogue, Ph.D. D(ABMM), F(AAM, IDSA, CCM) U.S. Army Medical Research Institute of Infectious bioMerieux, Inc. Diseases Division of Diagnostic Systems Jennifer Gardy, Ph.D. Randall J. Olsen, M.D., Ph.D. University of British Columbia Houston Methodist Hospital British Columbia Centre for Disease Control ACADEMY STAFF ASM LEADERSHIP RAPPORTEUR Marina Moses, M.S., Dr.P.H. Daniel Peniston Joe Campos, Ph.D., Chelsie Geyer, Ph.D. Director Colloquium and Public D(ABMM), F(AAM) ASM Secretary Chelsie Geyer, Ph.D. Outreach Program Assistant Children’s National Colloquium Post-Doctoral Fellow Erin Seglem * Was not able to attend collo- Medical Center quium but reviewed the report On the cover: Normal flora with Streptococcus pyogenes Board of Governors Program Assistant as a participant Image retrieved from American Society of Microbiology (ASM) Copyright 2016 | American Academy of Microbiology | 1752 N Street, NW | Washington, DC 20036 | academy.asm.org DNA double helix artwork retrieved from chs-bio-vanea.blogspot.com Summary Summary Next-generation sequencing (NGS) has the potential to dramatically revolutionize the clinical microbiology laboratory by replacing current time-consuming and labor-intensive techniques with a single, all-inclusive diagnostic test. Traditional methods for identifying organisms such as mycobacteria, some bacterial species, and fungi in particular are often slow, specialized, and organism specific. Culturing, Gram staining, and biochemical and molecular tests are traditional assays that consume the manpower of the clinical microbiology laboratory. From this battery of tests, relevant treatment guidance for the clinician is not always produced. This has been de- scribed elsewhere as a “diagnostic odyssey” or a guessing game for the diagnosis and identifica- tion of infectious diseases. Executing diverse clinical tests can waste precious time for a patient and might be the difference between life and death. In the groundbreaking neuroleptospirosis case described by Wilson et al (2014), 38 different diagnostic tests on various sample types (e.g., cerebrospinal fluid [CSF], brain, urine, stool, sputum, blood, serum, plasma, oropharyngeal/ nasopharyngeal swab) were performed before the diagnosis was ultimately made with NGS. This technology can potentially expedite the turnaround time for a result and allow clinically actionable information to be obtained sooner than a traditional laboratory workup would allow. Data generated from an NGS assay would ideally provide a diagnostic and therapeutic decision in a clinically relevant time frame that would positively enhance patient care and outcome. The American Academy of Microbiology (Academy) conducted a two-day colloquium to review the potential future impact of NGS on clinical microbiology and how barriers for implementation can be overcome through suggested recommendations identified by invited colloquium experts. Main topics discussed at the event are highlighted in an mBio minireview article prepared by the NGS steering committee members. Basic science and applied research coupled with emerging technologies has enabled NGS to transition into the diagnostic laboratory setting to provide clinically actionable results. Insights acquired from NGS methods can be exploited to improve our health as individuals and the greater public health. NGS is poised to broaden our understanding of how microbes inter- act in different ecosystems, as well as their functioning during health and disease in humans, animals, and environments, including both the built and natural (outdoor) settings. Food safety measures and product quality may also be advanced by NGS technology by allowing faster detection of contaminating pathogens that may arise during manufacturing or processing and subsequently trigger outbreak scenarios. Taken together, the functionalities of this sequencing tool can help achieve the main goal of the One Health Initiative, which is to obtain optimal health for people, animals, and various environments (Figure 1). Moreover, NGS will contribute to the Precision Medicine Initiative, a bold and innovative approach for disease treatment, management, and prevention launched by President Obama in his 2015 State of the Union address. At the present time, NGS is being applied to preci- sion medicine to help diagnose human genetic disorders, prenatal disorders, and cancers. For example, Worthey et al (2011) executed whole-exome sequencing, a type of NGS approach, to diagnose a rare immune defect that saved a 15-month-old patient’s life. All standard diag- nostic tests had been exhausted with no definitive cause for the patient’s Crohn’s disease-like illness that was coupled with recurrent episodes of sepsis and infection. Exome sequencing revealed a novel, hemizygous missense mutation in the X-linked inhibitor of apoptosis gene that atypically presented as severe gastrointestinal (GI) disease. This mutation directed clinical management to perform a successful allogeneic hematopoietic progenitor cell transplant that cured the patient’s GI illness. Next-generation sequencing (NGS) is a blanket term that collectively refers to high-throughput DNA sequencing strategies that can produce large amounts of genomic data in a single reaction by diverse methodol- ogies. NGS is also referred to in the literature as “deep,” “high throughput,” or “massively parallel” sequencing. A report from the American Academy of Microbiology | i Figure 1. One Health Initiative: the interdisciplinary global health collaboration. Next-generation sequencing (NGS) capabilities can support the One Health Initiative or the interconnectedness of humans, animals, and the environment. Knowledge gained from the power of NGS can help improve our overall well-being. Republished with permission from the publisher.* Precision medicine recognizes that a “one-size-fits-all” diagnostic