INTRODUCTION
The DNA, RNA or proteins of an infectious
agent in a clinical sample can be used to help identify the agent in many
cases. New techniques and applications of the techniques are being developed
for the analysis of infectious agents. It also helps in disease prognosis and
monitoring the response to treatment. The advantages of molecular techniques
are their sensitivity, specificity and safety. Molecular methods have been
found to be advantageous in situations in which conventional methods are slow,
insensitive, expensive or not available.
MOLECULAR METHODS
Molecular methods are classified into three
categories :
A. Hybridization
B. Amplification
C. Sequencing and enzymatic digestion of nucleic
acids.
A. Hybridization
DNA probes can be used like antibodies as
sensitive and specific tools to detect, locate and quantitate specific nucleic
acid sequences in clinical specimens. Nucleic acid probes are segments of DNA
or RNA labelled with radioisotopes or enzymes or fluorescent dyes that can
hybridize to complementary nucleic acid with high degree of specificity.
A number of DNA probes have been developed for
direct detection of micro-organisms in clinical specimens and for
identification of organisms after isolation of culture. Applications of DNA
probe technology in microbiology are:
- Nucleic acid probes for direct detection of groupA streptococci, Chlamydia trachomatis and Neisseria gonorrhoeae are available.
- Probes for identification of group A streptococci, group B streptococci, enterococci, Haemophilus influenzae, Mycobacteria, N. gonorrhoeae, Staphylococcus aureus, Streptococcus pneumoniae, Campylobacter sp., Histoplasma capsulatum, Blastomyces dermatidis and Coccidioides immitis isolated in culture are also available.
- DNA
probes for detection of LT and ST toxins of E. coli are available.
B. Amplified Methods
1. Polymerase chain reaction (PCR)
2. Transcription mediated amplification (TMA)
3. Nucleic acid sequence amplification (NASBA)
4. Ligase chain reaction (LCR)
1. Polymerase Chain Reaction (PCR)
It is the target amplification system. The
polymerase chain reaction (PCR) can detect single copies of viral DNA by
amplifying the DNA many million-fold and is one of the newest techniques of
genetic analysis.
In this technique, a sample is incubated with
two short DNA oligomers, termed primers, that are complementary to the ends of
a known genetic sequence of the viral DNA, a heat-stable DNA polymerase (Taq or
other polymerases obtained from thermophilic bacteria), nucleotides, and
buffers. The oligomers hybridize to the appropriate sequence of DNA and act as
primers for the polymerase, which copies that segment of the DNA. The sample is
then heated to denature the DNA (separating the strands of the double helix)
and cooled to allow hybridization of the primers to the new DNA. Each copy of
DNA becomes a new template. The process is repeated many (30-50) times to
amplify the original DNA sequence in an exponential manner. A target sequence
can be amplified a million-fold in a few hours using this method. PCR has been
applied in clinical laboratory for diagnosis of various infectious agents.
Besides originally described PCR, other types
of PCR include reverse-transcriptase PCR (RT-PCR), nested PCR and multiplex
PCR.
i. RT-PCR:
Reverse transcription PCR (RT-PCR) amplifies an RNA target. In this technique,
target is RNA instead of DNA. The unique step to this procedure is the use of
the enzyme reverse transcriptase that directs synthesis of DNA from the viral
RNA template. Once the DNA has been produced, relatively routine PCR technology
is applied to obtain amplification.
ii. Nested PCR: Nested PCR involves the sequential use of two
primer sets. The first set is used to amplify a target sequence. The amplicon
obtained is then used as the target sequence for a second amplification using
primers internal to those of the first amplicon. Essentially, this is an
amplification of a sequence internal to an amplicon. The advantage of this
approach is extreme sensitivity and confirmed specificity without the need for
using probes.
iii. Multiplex PCR: Multiplex PCR is a method by which more than
one primer pair is included in the PCR mixture. This will help in amplification
of more than one target sequence in a clinical specimen. The control amplicon
should always be detectable after PCR. Multiplex PCRs are usually less
sensitive than PCRs with single set of primers.
iv. Arbitrary primed PCR: Arbitrary primed PCR uses short primers that
are not specifically complementary to a particular sequence of a target DNA. By
comparing fragment migration patterns following agarose gel electrophoresis,
strains or isolates can be judged to be the same, similar or unrelated.
v. Quantitative PCR: Quantitative PCR is an approach that combines
the power of PCR for the detection and identification of infectious agents with
the ability to quantitate the actual number of targets originally in the
clinical specimen. It can be used for studying and understanding the disease
state (e.g., acquired immunodeficiency syndrome [AIDS]), the prognosis of
certain infections, and the effectiveness of antimicrobial therapy.
vi. Real time PCR: Real time PCR combines rapid thermo cycling
with the ability to detect target by fluorescently labeled
probes as the hybrids are formed, i.e. in real time. This technology allows for
high throughput of samples, multiplexing reactions, quantitation of target and
on-line monitoring.
2. Transcription Mediated Amplification (TMA)
Transcription mediated amplification (TMA) is
an isothermal RNA amplification method and use three enzymes: Reverse
Transcriptase (RT), RNAase H and T7 DNA dependent RNA polymerase. RNA target is
reverse transcribed into cDNA and then RNA copies are synthesized with the help
of RNA polymerase. A 109 fold amplification of the target RNA can be
achieved in about 2 hours.
Advantages of TMA include no requirement for a
thermal cycler and contamination risk is minimized TMA based assays are
available for detection of M. tuberculosis, C trachomatis, N gonorrhoeae,
Hepatitis virus (HCV) and Human Immunodeficiency Virus 1 (HIV-1).
3. Nucleic Acid Sequence-Based Amplification
(NASBA)
Both TMA and NASBA are examples of
transcription-mediated amplification. These isothermal assays use three enzymes:
Reverse Transcriptase (RT), RNAase H, and T7 DNA dependent RNA polymerase. Like
TMA, it is also an isothermal RNA amplification method. The method is similar
to TMA. RNA target is reverse transcribed into cDNA and then RNA copies are
synthesized with the help of RNA polymerase. It also does not require thermal
cycler. NASBA based kits for detection and quantitation of HIV-1 RNA and CMV RNA
are available.
4. Ligase Chain Reaction (LCR)
Ligase chain reaction (LCR) is an
amplification of probe nucleic acid rather than target nucleic acid. By this
approach, an amplified probe is the final reaction product to be detected,
while the target sequence is neither amplified nor incorporated into this
product.
LCR uses two pairs of probes that span the
target sequence of interest. Once annealed to the target sequence, a space
remains between the probes that is enzymatically closed using a ligase (i.e., a
ligation reaction). On heating, the joined probes are released as a single
strand that is complementary to the target nucleic acid. These newly synthesized
strands are then used as the template for subsequent cycles of probe annealing
and ligations. Through the process, probe DNA is amplified to a level readily
detectable using assays similar to those described for the biotin-avidin
system. Like PCR, LCR also requires thermal cycler.
LCR based amplification has been used to
detect Chlamydia trachomatis and Neisseria gonorrhoeae.
v Applications of Molecular Methods in Clinical
Laboratory
Molecular methods have a significant role in
the following situations in clinical microbiology laboratory.
1. Detection of uncultivable and slow
growing micro-organisms.
2. Role in clinical virology.
3. Disease prognosis.
4. Response to treatment and Detection of drug
resistance
5. Genotyping of microorganism
1. Detection of Uncultivable and Slow Growing
Micro-organisms
The greatest advantage of molecular methods
has been in the discovery of previously unrecognized or uncultivable organisms.
Molecular methods have been used to detect previously unknown agents directly
in clinical specimens by using broad-range primers for a number of
micro-organisms. HCV, and Human Herpes Virus 8 (HHV-8), Bartonella henselae
are some examples of human pathogens first identified from clinical specimens
using molecular methods.
Molecular methods have the ability to detect
nonviable organisms that are not retrievable by cultivation-based methods. These
methods are also useful for fastidious micro-organisms which may die in transit
or may be overgrown by contaminants when cultured. N. gonorrhoeae is one
such example whose nucleic acid can be detected under circumstances in which it
cannot be cultured. The use of improper collection, inappropriate transport
conditions or delay in transport can reduce the viability of the organism but
do not affect the nucleic acid detection.
These can detect and identify organisms that
cannot be grown in culture or are extremely difficult to grow (e.g., hepatitis
B virus and the agent of Whipple's disease)and also more rapid detection and
identification of organisms that grow slowly (e.g., mycobacteria, certain
fungi).
2. Role in Clinical Virology
Molecular methods to replace culture for
detection of bacteria in routine practice are limited because of need to
isolate the organisms for antibiotic sensitivity testing. These methods can actually
replace the culture only in those micro-organisms which have predictable
antibiotic susceptibility and consequently, routine susceptibility testing is
not performed.
Culture-based methods in virology are costly
and antiviral susceptibility testing is not routinely done in clinical
virology. Molecular approaches are often faster, more sensitive and more
cost-effective than the conventional approaches. Seasonal Influenza
A(H1N1)pdm09(Swine flu), Enteroviral meningitis, HSV encephalitis and CMV
infections in immunocompromised patients are examples for which nucleic acid
based tests are relevant and cost-effective for diagnosis.
3. Disease Prognosis
Molecular methods are able to quantitate
infectious agent burden directly in patient specimens , an application that has
particular importance for managing Human Immunodeficiency Virus (HIV)
infections. Thus, it provides important information which may predict disease
progression.
Molecular methods can be used for subtyping of
certain viruses which may provide information about the severity of infection.
HPV causes dysplasia, neoplasia and carcinoma of cervix in women. HPV types 16
and 18 are associated with a high risk of progression to neoplasia, whereas HPV
types 6 and 11 have a low risk.
4. Response to Treatment and Drug Resistance
Molecular methods have been developed to
detect the genes responsible for drug resistance that may not always readily be
detected by phenotypic methods. Examples include detection of the van
genes, which mediate vancomycin resistance among enterococci, and the mec
gene, which encodes resistance among staphylococci and rifampicin resistance in
Mycobacterium tuberculosis.
Molecular techniques have a significant role
in predicting and monitoring patient responses to antiviral therapy. HIV-1
viral load assays have been developed to monitor the response of antiretroviral
therapy. Viral load assays have also been used in monitoring the response to
therapy in patients who are chronically infected with HBV and HCV.
Molecular methods can be used to detect drug
resistance mutations in RT and protease genes ofHIV-1. These mutations lead to
lower levels of sensitivity to antiretroviral drugs and are important causes of
treatment failure. This helps to determine an appropriate treatment in patients
who do not respond to therapy.
5.
Genotyping of microorganism
It is epidemiologically important to know
circulating genotypes of microorganisms particularly for viruses in a
particular region and also severity of disease is different in different
genotypes, e.g. Dengue infection is very severe with type 2 Dengue virus. We
can also trace common source of
infection with help of genotyping.
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