title: A Molecular Host Response Assay to Discriminate Between Sepsis and Infection-Negative Systemic Inflammation in Critically Ill Patients: Discovery and Validation in Independent Cohorts.
abstract: BACKGROUND
  Systemic inflammation is a whole body reaction having an infection-positive (i.e., sepsis) or infection-negative origin. It is important to distinguish between these two etiologies early and accurately because this has significant therapeutic implications for critically ill patients. We hypothesized that a molecular classifier based on peripheral blood RNAs could be discovered that would (1) determine which patients with systemic inflammation had sepsis, (2) be robust across independent patient cohorts, (3) be insensitive to disease severity, and (4) provide diagnostic utility. The goal of this study was to identify and validate such a molecular classifier.
  
  
  RESULTS
  We conducted an observational, non-interventional study of adult patients recruited from tertiary intensive care units (ICUs). Biomarker discovery utilized an Australian cohort (n = 105) consisting of 74 cases (sepsis patients) and 31 controls (post-surgical patients with infection-negative systemic inflammation) recruited at five tertiary care settings in Brisbane, Australia, from June 3, 2008, to December 22, 2011. A four-gene classifier combining CEACAM4, LAMP1, PLA2G7, and PLAC8 RNA biomarkers was identified. This classifier, designated SeptiCyte Lab, was validated using reverse transcription quantitative PCR and receiver operating characteristic (ROC) curve analysis in five cohorts (n = 345) from the Netherlands. Patients for validation were selected from the Molecular Diagnosis and Risk Stratification of Sepsis study (ClinicalTrials.gov, NCT01905033), which recruited ICU patients from the Academic Medical Center in Amsterdam and the University Medical Center Utrecht. Patients recruited from November 30, 2012, to August 5, 2013, were eligible for inclusion in the present study. Validation cohort 1 (n = 59) consisted entirely of unambiguous cases and controls; SeptiCyte Lab gave an area under curve (AUC) of 0.95 (95% CI 0.91-1.00) in this cohort. ROC curve analysis of an independent, more heterogeneous group of patients (validation cohorts 2-5; 249 patients after excluding 37 patients with an infection likelihood of "possible") gave an AUC of 0.89 (95% CI 0.85-0.93). Disease severity, as measured by Sequential Organ Failure Assessment (SOFA) score or Acute Physiology and Chronic Health Evaluation (APACHE) IV score, was not a significant confounding variable. The diagnostic utility of SeptiCyte Lab was evaluated by comparison to various clinical and laboratory parameters available to a clinician within 24 h of ICU admission. SeptiCyte Lab was significantly better at differentiating cases from controls than all tested parameters, both singly and in various logistic combinations, and more than halved the diagnostic error rate compared to procalcitonin in all tested cohorts and cohort combinations. Limitations of this study relate to (1) cohort compositions that do not perfectly reflect the composition of the intended use population, (2) potential biases that could be introduced as a result of the current lack of a gold standard for diagnosing sepsis, and (3) lack of a complete, unbiased comparison to C-reactive protein.
  
  
  CONCLUSIONS
  SeptiCyte Lab is a rapid molecular assay that may be clinically useful in managing ICU patients with systemic inflammation. Further study in population-based cohorts is needed to validate this assay for clinical use.
authors.affiliation: Immunexpress, Seattle, Washington, United States of America.
authors.forename: Leo
authors.initials: L
authors.lastname: McHugh
authors.affiliation: Immunexpress, Seattle, Washington, United States of America.
authors.forename: Therese A
authors.initials: TA
authors.lastname: Seldon
authors.affiliation: Immunexpress, Seattle, Washington, United States of America.
authors.forename: Roslyn A
authors.initials: RA
authors.lastname: Brandon
authors.affiliation: Immunexpress, Seattle, Washington, United States of America.
authors.forename: James T
authors.initials: JT
authors.lastname: Kirk
authors.affiliation: Immunexpress, Seattle, Washington, United States of America.
authors.forename: Antony
authors.initials: A
authors.lastname: Rapisarda
authors.affiliation: Biosurgical Ingenuity, Paddington, Queensland, Australia.
authors.forename: Allison J
authors.initials: AJ
authors.lastname: Sutherland
authors.affiliation: Department of Intensive Care Medicine, Mater Health Services, South Brisbane, Queensland, Australia.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Presneill
authors.affiliation: Department of Pathology, Mater Health Services, South Brisbane, Queensland, Australia.|School of Medicine, University of Queensland, St. Lucia, Queensland, Australia.|Mater Research Institute, University of Queensland, St. Lucia, Queensland, Australia.
authors.forename: Deon J
authors.initials: DJ
authors.lastname: Venter
authors.affiliation: Burns Trauma and Critical Care Research Centre, University of Queensland, St. Lucia, Queensland, Australia.|Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Herston, Queensland, Australia.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Lipman
authors.affiliation: Emphron Informatics, Toowong, Queensland, Australia.
authors.forename: Mervyn R
authors.initials: MR
authors.lastname: Thomas
authors.affiliation: Department of Intensive Care, University Medical Center Utrecht, Utrecht, the Netherlands.|Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Peter M C
authors.initials: PM
authors.lastname: Klein Klouwenberg
authors.affiliation: Center of Experimental and Molecular Medicine, Academic Medical Center, Amsterdam, the Netherlands.|Division of Infectious Diseases, Academic Medical Center, Amsterdam, the Netherlands.
authors.forename: Lonneke
authors.initials: L
authors.lastname: van Vught
authors.affiliation: Center of Experimental and Molecular Medicine, Academic Medical Center, Amsterdam, the Netherlands.|Division of Infectious Diseases, Academic Medical Center, Amsterdam, the Netherlands.
authors.forename: Brendon
authors.initials: B
authors.lastname: Scicluna
authors.affiliation: Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Marc
authors.initials: M
authors.lastname: Bonten
authors.affiliation: Department of Intensive Care, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Olaf L
authors.initials: OL
authors.lastname: Cremer
authors.affiliation: Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, the Netherlands.|Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands.
authors.forename: Marcus J
authors.initials: MJ
authors.lastname: Schultz
authors.affiliation: Center of Experimental and Molecular Medicine, Academic Medical Center, Amsterdam, the Netherlands.|Division of Infectious Diseases, Academic Medical Center, Amsterdam, the Netherlands.
authors.forename: Tom
authors.initials: T
authors.lastname: van der Poll
authors.affiliation: Immunexpress, Seattle, Washington, United States of America.
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Yager
authors.affiliation: Immunexpress, Seattle, Washington, United States of America.
authors.forename: Richard B
authors.initials: RB
authors.lastname: Brandon
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000032:analysis; D016022:Case-Control Studies; D015331:Cohort Studies; D016638:Critical Illness; D019937:Diagnostic Techniques and Procedures / Q000295:instrumentation* / Q000592:standards; D005260:Female; D006801:Humans; D007249:Inflammation / Q000175:diagnosis* / Q000209:etiology; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D011793:Queensland; D012372:ROC Curve; D020133:Reverse Transcriptase Polymerase Chain Reaction; D018805:Sepsis / Q000175:diagnosis* / Q000209:etiology; D055815:Young Adult
chemical_list: D015415:Biomarkers