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To cite this article: Judith Schenz, Markus A. Weigand & Florian Uhle (2019): Molecular and
biomarker-based diagnostics in early sepsis: current challenges and future perspectives, Expert
Review of Molecular Diagnostics, DOI: 10.1080/14737159.2020.1680285
DOI: 10.1080/14737159.2020.1680285
Molecular and biomarker-based diagnostics in early sepsis: current
challenges and future perspectives
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Judith Schenz1, Markus A. Weigand1 and Florian Uhle1*
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Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
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*Corresponding author:
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Florian Uhle
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email: florian.uhle@med.uni-heidelberg.de
Molecular and biomarker-based diagnostics in early sepsis: current
challenges and future perspectives
Judith Schenz, M.Sc.a, Markus A. Weigand, MDa and Florian Uhle, Ph.D.a*
Affiliations
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Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
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* Corresponding author
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Dr. Florian Uhle
Dept. of Anesthesiology
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Heidelberg University Hospital
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Im Neuenheimer Feld 110
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69120 Heidelberg
Mail: florian.uhle@med.uni-heidelberg.de
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Molecular and biomarker-based diagnostics in early sepsis: current
challenges and future perspectives
Abstract
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symptoms. Rapid and targeted application of therapy strategies is crucial for patient’s
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outcome.
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Areas covered: Faster and better diagnostics with high accuracy is promised by novel
host response biomarkers and a wide variety of direct pathogen identification
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technologies, which have emerged over the last years. This review will cover both - host
response-guided diagnostics and methods for direct pathogen detection. Some of the
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markers and technologies are already market-ready, others are more likely aspirants.
We will discuss them in terms of their performance and benefit for use in clinical
diagnostics.
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biomarkers and technologies still has to be verified. Combining these technologies and
clinical routine parameters with bioinformatic methods (e.g., machine-learning
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Keywords:
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Article highlights:
• Rapid diagnosis of sepsis is urgently needed but still challenging. Novel host response
biomarkers and a plethora of technologies for direct pathogen detection promise faster
biology.
detection approaches.
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• Amplification-based systems detect an a priori determined panel of pathogens. The
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as the presence of PCR inhibitors and the sample volume.
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• Most amplification free technologies do not require purification, extraction, or
1. Introduction
Sepsis is defined as a life-threatening organ dysfunction resulting from dysregulated host
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response to infection [1]. It is still a major challenge for healthcare systems worldwide and
has an incidence of more than 400 per 100,000 person-years in high-income countries [2].
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Mortality ranges between around 20% and over 40% depending on the severity of syndrome
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and patients’ predisposition [3]. It is controversially debated whether the incidence has risen
or remained stable in recent years [4]. Nevertheless, despite a higher proportion of severe
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cases, the overall mortality falls [5]. Underlying reasons are both the adherence to
standardized treatment bundles [6] and an improvement in general intensive care treatment
[3]. Rapid and accurate diagnostics permit a fast and targeted use of available therapy
strategies, a prerequisite for a further decrease of morbidity and mortality [7]. Estimating the
sepsis-induced healthcare costs is difficult, since there is high heterogeneity in the applied
calculation methods [8]. However, early diagnosis is also relevant from the economic view,
since the earlier the diagnosis is made, the lower the costs are [9].
these symptoms can also occur in a variety of other clinical conditions, e.g., heart failure [10]
or pancreatitis [11]. The extent of a patient’s organ dysfunction can be assessed clinically
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using the sequential organ failure assessment score (SOFA), which has been postulated more
than 20 years ago as a metascore for following the patient’s clinical trajectory [12]. If a
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patient presents with a de novo increase of at least two points in combination with a clinical or
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microbiological suspicion or proof of infection, the diagnostic criteria of sepsis according to
the latest Sepsis-3 definition are fulfilled [1]. The new definition was extensively debated, as
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it was statistically modeled for prognosis, resulting in an enrichment of more severe ill
patients with infection, but not for specific diagnosis. In addition, a sterile, non-infectious
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systemic inflammatory response syndrome (SIRS) can also induce life-threatening organ
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dysfunction [13]. Ideally, a comprehensive diagnostic test for sepsis not only detects the
dysregulated host response but also discriminates between a sterile and an infectious cause
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within short turnaround time. Going beyond, providing insights about the causative pathogen
(e.g., bacteria vs. viruses in respiratory disease) and its resistance pattern are desirable, since
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diagnostics serves the choice of adequate therapy strategies. Ease of use, low demands
concerning preanalytical handling and cost-effectiveness are vital for a diagnostic test, not
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only in economically highly developed regions but especially in low- and middle-income
countries. It is also important to note, that, in comparison, the causative pathogen spectrum
responsible for the majority of cases differs largely among different regions in the world [14].
Over the last years, novel host response biomarkers as well as a wide variety of
technologies for the identification of pathogens have emerged, promising a better diagnostic
accuracy. In this review, we will deal with those markers and technologies in the context of
their performance and benefit for use in early clinical diagnostics. With regard to the current
consensus definition for sepsis diagnosis [1], we will point out both the diagnostic
possibilities detecting the dysregulated host response (Table 1 & 2) as well as the triggering
infection (Table 3). Our aim is to provide a comprehensive overview of the current state of
development and evidence for diagnostic in adult patients. Nevertheless, diagnostic can rarely
be separated from prognosis and therapy decision, meaning that these areas at least partially
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will be touched despite the diagnostic focus.
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2. Host response-guided diagnostic
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The Sepsis-3 definition underlines the dysregulated host response to infection as a
a sophisticated approach.
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Serum lactate is included in the Sepsis-3 definition as diagnostic criteria of septic shock.
Serum lactate levels greater than 2 mmol/l despite an adequate fluid resuscitation together
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with the continuous dependency on vasopressors defines patients with septic shock [15].
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Blood lactate is a widely available parameter but on the other hand, an extremely unspecific
marker of cellular stress or microcirculatory disturbances [16], hampering its use for early
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sepsis diagnosis. Nevertheless, the assessment of blood lactate levels has been incorporated
into the recent guidelines of the Surviving Sepsis Campaign to guide hemodynamic therapy
monitoring and patient’s risk stratification [17]. Lactate clearance, which means the decline of
plasma lactate level towards reference values, is commonly used as a surrogate parameter to
judge the therapy success of fluid resuscitation, hinting towards a reestablishment of tissue
perfusion [18]. However, very recently a head-to-head comparison of lactate versus capillary
refill time for therapy guidance found no difference between these concepts [19].
immune response and involved in lymphocyte activation, fever, and induction of acute phase
response. In a meta-analysis including six case-control studies, IL-6 identified adult patients
with sepsis with a sensitivity of 85% and a specificity of 62% [20]. This poor performance as
a diagnostic biomarker is hardly surprising since IL-6 and related cytokines are produced
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from innate immune cells (e.g., monocytes and neutrophils) during various inflammatory
reactions and not limited to infections. The concentration of C-reactive protein (CRP) is a
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routinely available diagnostic laboratory parameter. CRP is an acute-phase reactant, produced
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and released by the liver in response to rising levels of pro-inflammatory cytokines (mainly
IL-6). Therefore, CRP, too, is not exclusively produced in response to an infection. Sterile
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inflammatory reactions with a high cytokine production secondarily lead to increased CRP
levels, too. In a meta-analysis by Simon et al. which included in total 905 patients, CRP was
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75% and a specificity of 67%. However, it was shown to be slightly better suited to
differentiate between bacterial and viral infections (sensitivity of 86% and specificity of 70%)
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[21]. In this regard, it is routinely used in the context of lower respiratory infections [22].
PCT is secreted by the C cells of the thyroid and neuroendocrine cells in the lung and bowel.
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Typically, serum PCT levels are below the limit of detection of common assays. During
systemic inflammation, blood PCT levels rise, in particular in those caused by Gram-negative
bacterial infections, but less pronounced also in patients with Gram-positive bacteremia and
candidemia [23]. PCT measurement is superior to CRP measurement not only to distinguish
between bacterial and viral infections but also between a bacterial or a non-infectious cause of
systemic inflammation [21]. In a meta-analysis including 30 studies with overall 3,244 critical
ill patients, PCT was shown to distinguish between sepsis and sterile SIRS with a pooled
sensitivity of 77% and a pooled specificity of 79%. In surgical patients, it has a slightly higher
diagnostic accuracy than in medical patients [24]. A very recent, but significantly smaller
analysis, reported comparable results [25]. However, other analyses revealed lower accuracies
with respect to diagnosis [26]. Further, a recent meta-analysis showed that currently there is
not enough evidence for PCT alone being sufficient to distinguish bacteremia and candidemia.
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Notwithstanding, in combination with other biomarkers like β-glucan, it may improve
diagnostic accuracy [27]. The actual strength of PCT lies not in the one-time measurement for
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diagnosis, but as a prognostic marker for disease progression and mortality when measured
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sequentially [28,29] as well as for antibiotic therapy guidance [30]. In this context, it has been
available allowing rapid, bedside detection without being dependent on opening hours of a lab
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service.
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binding protein (LBP) complex, subsequently facilitating the LPS-induced TLR4 activation.
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By metalloproteinase shedding from the cell surface, the CD14-LPS-LBP complex is released
into the blood where proteases can further cleave it, resulting in presepsin formation. Due to
its origin in bacterial pattern recognition, the level of free presepsin in the blood is considered
inclusion criteria revealed an overall sensitivity of 83% and a specificity of 78%. The
introduction of presepsin as a diagnostic criterion improved sepsis probability from 56% (pre-
test probability among all subjects) to 81% (post-test probability for a positive result).
19 studies, reported comparable results with a sensitivity of 84% and a specificity of 73%.
Moreover, the authors reported a similar diagnostic accuracy for presepsin (area under the
receiver operating characteristic curve (AUC 0.87) as for PCT (AUC 0.84) in critically ill
adults [32]. Wu et al. performed a subgroup analysis for the diagnostic accuracy of presepsin
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and PCT in the emergency department (ED) (AUC 0.90 vs. 0.88) and intensive care unit
(ICU) (AUC 0.87 vs. 0.82). In contrast to others, they could not find a difference between
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presepsin and CRP (AUC 0.85 and 0.85) although this would have been expected since PCT
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is considered to have better accuracy than CRP [33]. As for PCT, there is a commercially
Such soluble forms of proteins released into the circulation during immune reactions
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are a direct outflow of immune cell activation and promise to have a higher specificity for
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infiltrating tissues after bacterial infection. The soluble form (sTREM-1) is released when
these phagocytes are activated. A meta-analysis published in 2012 examined the ability of
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sTREM-1 in plasma to differentiate between sepsis caused by a bacterial infection and sterile,
accuracy (AUC 0.87) for the diagnosis of sepsis with a pooled sensitivity of 79% and a pooled
specificity of 80% [34]. Based on these results, sTREM-1 is not superior to the biomarkers
presented so far. sTREM-1 is not only released into the blood, but also found in other body
fluids such as cerebrospinal fluid [35], urine [36] or fluids obtained during diagnostic
procedures like bronchoalveolar lavage fluids (BALF). With an AUC of 0.91, sTREM-1 in
BALF is a good diagnostic marker for bacterial lung infections in ICU patients [37],
indicating that sTREM-1 might be a useful biomarker for diagnosis in such specimens.
Detecting the expression level of specific immune cell surface receptors is another
approach to identify suitable biomarkers. Neutrophil CD64 expression has been evaluated
and classified as a useful marker for improving early diagnostic accuracy. Wang et al.
revealed a pooled sensitivity and specificity of 76% and 85%, respectively, considering 8
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studies in their meta-analysis [38]. Cellular markers can be assessed by flow cytometry,
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in fast routine diagnostic difficult to accomplish outside of specialized centers.
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Mid-regional pro-adrenomedullin (MR-proADM) is explored as a biomarker for the
detection of current and future organ failure instead of the dysregulated immune response.
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The mid-regional fragment of the pro-adrenomedullin is more stable than the biologically
active adrenomedullin (ADM), which is expressed in a wide variety of tissues, but mainly by
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endothelial and vascular smooth muscle cells. ADM is biologically involved in the regulation
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of vasodilation and vascular integrity and MR-proADM is found in high levels in septic
patients [39]. It was discovered to be predictive at an early stage for disease progression in
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patients with suspected infections in the ED [40] and to be superior to established markers,
discrimination of all patients with sepsis from patients with systemic inflammation from non-
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infectious etiology in real life. Parlato et al. conducted a multicenter cohort study enrolling
279 ICU patients with the presence of SIRS and evaluated 53 biomarkers for diagnostic
performance for infection diagnosis. Surprisingly, CRP proved to be the best biomarker
available, while others like, e.g., PCT provided no information above chance [42]. This study
underlines that the quest for suitable biomarker combinations has not ended and requires a
great effort. Importantly, markers must ultimately work in the intended environment (ED or
ICU), raising the need to consider respective pre-test probabilities and influencing factors
during discovery. It is unclear if it will be possible to find a single marker able to detect all
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2.3.1 … biomarkers
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Celeras Dx (part of Cube Dx GmbH, St. Valentin, Austria) a commercial test under
development pursues this strategy. Using the principle of microarrays, the company
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developed a multiplex technology called hybcell. Similar to classic competitive
immunoassays, the targeted molecules from the sample are competing with fluorescence-
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labelled antigens for the bond to immobilized specific antibodies. The so called xA panel
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comprises a set of 9 different biomarkers indicating an inflammatory reaction (CRP, PCT,
serum amyloid A, Substance P), the failure of individual organs (Cystatin C, Myoglobin,
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currently available indicating the diagnostic accuracy of this panel in a real-life clinical
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setting. However, the individual markers are highly characterized and only with an
algorithmic approach to combine the results into a binary decision support for the physician,
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Using biomechanical properties of immune cells is an entirely different way to approach the
diagnostic challenge. A commercial test still under development is based on altered cell
deformability (Cytovale, San Francisco CA, USA). Using a combination of microfluidics and
single cell imaging, thousands of cells per second are analyzed. A pilot study revealed higher
deformability of granulocytes from patients with sepsis compared to healthy controls [43]. For
lymphocytes, no difference was found. There are two major limitations: The authors included
only 25 patients with sepsis and they have chosen healthy volunteers as a comparator.
Including critically ill patients or patients with sterile SIRS instead would have been clinically
more appropriate.
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A third fundamentally different approach is the use of gene expression-based methods,
primarily from whole blood. This rests on the fact that the host response to the infection leads
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to a specific change in the patient’s blood transcriptome. Such a comprehensive host response
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analysis postulates to provide information for accurate differentiation of sepsis and sterile
transcriptome pattern.
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Currently, two commercial tests based on this concept are under development.
SeptiCyte LAB (Immunexpress Inc., Seattle WA, USA) is a host response-targeted, PCR-
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based test detecting the expression level of four genes (CEACAM4, LAMP1, PLAC8,
PLA2G7) in whole blood [44]. These levels are offset against each other leading to the
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calculation of a score called SeptiScore. The test is FDA-cleared for clinical evaluation of its
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usefulness in critically ill patients on the first day after ICU admission to differentiate
between sepsis and SIRS. A validation study conducted by the developers, including 447
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critical care patients, yielded a sensitivity of 92% and a specificity of 65% [45]. Meanwhile,
several independent studies have been published with less optimistic results concerning the
clinical performance. These are reviewed extensively elsewhere [46]. The assay’s current
Information about the pathogen and potential resistances are lacking at the moment. However,
Sampson et al. published another gene set (ISH15, IL16, OASL, ADGRE5), able to identify a
viral infection causing the systemic inflammation [47]. The authors claim that combining both
The second test is called HostDX Sepsis (Inflammatix, Burlingame CA, USA). It is
based on the expression level of eleven host genes (CEACAM1, ZDHHC19, 210
DPB1) [48]. The mathematically calculated score was named Sepsis MetaScore. The test
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distinguished with a sensitivity of 95% and a specificity of 60% between neonates with sepsis
and healthy ones in a validation study conducted by the developers [49]. Similar to the
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developers of the SeptiCyte LAB test, further research is undertaken to improve the test
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towards the causative pathogen: Sweeney et al. published a group of seven genes (IFI27, JUP,
LAX1, HK3, TNIP1, GPAA1, CTSB) sufficient to classify between bacterial and viral
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infections [50].
Recently, the diagnostic accuracies of both tests were independently validated using
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gene expression data prospectively collected in the context of a randomized controlled trial in
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an ICU. This study revealed an AUC of 0.80 using the Sepsis MetaScore and an AUC of 0.68
for the SeptiScore. In less heterogeneous subpopulations, the diagnostic performance raised in
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The various commercial concepts are promising, but based on the current technology
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complex clinical settings. Above all, time is a critical dimension and tests aiming to answer
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the necessity for antimicrobial therapy must yield information within minutes to project into
clinical benefit.
3. Pathogen identification
The most recent international consensus definition emphasize that sepsis, in contrast to sterile,
identification of the causative pathogens is favorable, not only for diagnostic purposes.
Effective source control and initiation of antimicrobial therapy are decisive to eliminate the
causative trigger of the syndrome. Each hour delay in the beginning of antimicrobial therapy
leads to an increased mortality rate [52]. In best case scenario, a rapid pathogen identification
can inform a targeted antibiotic therapy. As discussed above, host-derived biomarkers might
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hint towards the class of triggering pathogens thus supporting the choice for antimicrobial
therapy. However, microbial diagnostic specifies the causative pathogen and its individual
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resistance properties.
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3.1 Current gold standard: blood culture-based approaches
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Conventional blood culture is still the gold standard in this regard. The grown and identified
pathogens serve as basis for subsequent, direct testing of antimicrobial susceptibility. Over the
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last years, the introduction of different new post-culture technologies improved and shortened
the pathogen identification in positive cultures [53]. However, the time between blood
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draw/inoculation and positivity of blood culture remains to be the weak spot. Depending on
the initial pathogen load and the growth rate, it takes several hours to days. Thus, these
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essential diagnostic tools remain inadequate to support early diagnosis and treatment
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decisions. This current diagnostic practice leads to empiric therapy choices using broad-
the beginning, which is associated with a fivefold reduced survival [54]. Depending on the
study population and disease severity, between 30% [55] and 70% [56] of the patients are
blood culture-negative. Reasons for this may be the choice of appropriate culture media, non-
cultivable bacteria [57] or viral etiology, inappropriate pre-analytic handling [58], prior
antibiotic treatment [59] or a low or no pathogen load in the bloodstream. Such failings limit
Direct pathogen-detection from whole blood, other body fluids (e.g., urine, sputum) or fluids
from diagnostic procedures (e.g., BALF, smear) would overcome these limitations. Several
innovative technologies addressing this challenge have emerged recently. Many of those
direct detection methods are based on the amplification of microbial nucleic acids. However,
the concentration of these nucleic acids in the blood is low and host nucleic acids may hamper
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the accuracy. Polymicrobial samples may additionally complicate the determination.
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Sophisticated test developments tackle these issues by combining several technologies.
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3.2.1 Amplification-based systems
As early as 2006, the multiplex PCR-based SeptiFast test (Roche Diagnostics, Rotkreuz,
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Switzerland) was introduced. It is CE-marked and commercially available in the European
Union. Within a turnaround time of 6 hours, the test can detect 25 different bacteria and fungi
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responsible for a large proportion of sepsis cases in Europe. Compared to conventional blood
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culture diagnostics, the SeptiFast test reaches a sensitivity level of 68% and a specificity of
86% in a meta-analysis including 41 clinical diagnostic accuracy studies with a total of 7,727
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patients [60]. Despite this rather low sensitivity, indicating that the test misses pathogens
being detected by blood culture, Mongelli et al. reported that most pathogens detected via
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SeptiFast, but not via blood culture, could be found in other sample specimen taken from
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other sites of the same patients, indicating to be associated with the sepsis-triggering infection
[61]. The manufacturer states that down to 1.5ml blood are sufficient for a reliable result. This
small quantity may be advantageous in many circumstances. At the same time, it should be
considered, that this is achieved at the expense of a higher sensitivity, due to the low levels of
circulating pathogen-derived nucleic acids as well as the presence of PCR inhibitors such as
iron or immunoglobulins [62]. Currently, the test cannot replace, but rather reasonably
SepsiTest (Molzym, Bremen, Germany) combines 16S and 18S ribosomal RNA gene
PCR with Sanger sequencing technology and currently is able to detect 1,359 bacteria and
fungi [63] from a broad range of body fluids and other specimens derived from medical
interventions. This broad detection range overcomes one of the major drawbacks of the panel-
based SeptiFast test. The test is commercially available in Europa. The turnaround time for
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the whole test is around 8 – 10 hours. However, the combined approach leads to an interim
result within <4 hours providing information about the presence of bacteremia or fungaemia
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without further information about the exact pathogen. Currently, both tests based on nucleic
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acid testing cannot replace culture-based diagnostic in terms of the availability of information
on antibiotic resistances. For the SeptiFast test, a mecA test is available at least. In
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comparison with the diagnostic tests based on host-derived factors, another severe limitation
of both tests is that they are not available in a point-of-care format, but require specialized
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staff and accredited labs to perform. Based on the same principle, Molzym has developed an
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automated test (Micro-Dx), too, but currently it detects less species compared to the
SepsiTest. This is indicating that molecular diagnostic approaches are under ongoing
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development and it is very likely that currently existing limitations can be overcome in the
foreseeable future. On the downside, promising and broadly developed systems may be pulled
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back from the market. This has happened to the IRIDICA system (Abbott, Lake Bluff IL,
USA) of late. The system comprised a variety of detectable microbes, comparable with the
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SepsiTest [64]. Despite a commercial availability in Europa since 2014 and an only recently
completed trial for FDA clearance, the production was terminated, not mainly for
performance issues but due to logistical and financial deliberations [65]. This process
emphasizes that ingenious technologies and clinical impact alone are not sufficient to
revolutionize diagnostics in the long term. Nevertheless, a randomized crossover trial with the
intention to shed light on the cost-benefit calculation revealed a weak dominance of direct
pathogen detection using SeptiFast compared to conventional diagnostic procedures for
patients with severe sepsis [66]. A meta-analysis conducted by Stevenson et al. assessed both
clinical power and cost-effectiveness of all three tests. They found higher specificity than
sensitivity levels for all three tests, but none was statistically significant superior to the current
gold standard. Because they did not find enough evidence, the authors draw no definitive
conclusion concerning the cost-effectiveness of direct pathogen tests [67]. The BioFire
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FilmArray System (BioMerieux, Marcy-l’Étoile, France) and Unyvero (Curetis, Holzgerlingen,
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by providing focus-specific panels, e.g., for pneumonia, meningitis, or abdominal infections.
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Both systems use tailored single-use cartridges, which detect in a culture-free, PCR-based
manner those species commonly causing these infections. In case of a known or suspected
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focus this is feasible.
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The T2MR technology (T2 biosystems, Lexington MA, USA) differs from the previously
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technology, meaning in this case that the behavior of water molecules within a magnetic field
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is detected. So far, the T2Bacteria panel and the T2Candida panel are the only systems for
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pathogen detection directly from blood, which are FDA-cleared and CE-marked. The method
does not require any purification, extraction or amplifications step leading to a faster
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Moreover, the T2Bacteria panel displayed not only specificity but also sensitivity levels well
above 90% in a prospective multicenter study analyzing samples from 1,427 patients [68].
The test is limited to six species (E. faecium, S. aureus, K. pneumoniae, A. baumannii, P.
aeruginosa, E. coli). Even though this covers a large fraction of the common bacterial sepsis
pathogens, the restricted number is a comparatively large limitation not taking into account
many other bacterial pathogens triggering sepsis. The T2Candida panel also detects only five
Candida spp., but with high overall sensitivity (91.1%) and specificity (99.4%), too [69]. The
technology is also able to detect growth-inhibited Candida cells. Especially after prior
diagnostics [70]. Important to note in dealing with positive T2Candida results is the overall
prevalence of invasive Candida infections. In relation to the start of antifungal treatment, such
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a result should be evaluated differently with a patient in ICU in comparison to a patient in ED
[71]. In addition to the high diagnostic accuracy, the panels currently under development are
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of particular interest in near future. A resistance panel detecting 13 resistance genes as well as
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a panel detecting Candida auris address the clinical need about potential resistances and
emerging pathogens.
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3.2.3 Further amplification free technologies
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There are also some other promising systems for pathogen detection that do not require
amplification of nucleic acids, shortening the delay between sample collection and assay
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result. The cylindric microarray called hybcell (Cube Dx, St. Valentin, Austria) is used as a
platform for direct pathogen detection. Pathogen derived DNA fragments in the sample bind
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Unfortunately, the performance of this technology has only been presented at conferences so
enables unbiased testing and therefore is more comprehensive (including bacteria [72], fungi
[73], and viruses [74]) than the fixed panels. This advantage is purchased at the cost of a
higher turnaround time of currently 24 hours. Analysis and interpretation of the sequencing
data are of particular importance – the lower the pathogenic load still being detectable, the
more crucial is to distinguish between infectious agents and commensals [75,76]. Various
companies such as Karius (Redwood City CA, USA) and Noscendo (Duisburg, Germany)
are working on commercially available solutions to make this method widely available.
Almost none of the technologies presented have already been tested to such an extent
that they can be used as the sole microbiological test. Large multicenter trials are needed to
test the efficacy, added benefit, and practicability in clinical routine. The technologies need to
be tested not only in ICUs, but in particular also in ED settings. This means a higher effort
concerning study design and patient inclusion and holds also true for the host response-guided
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tests. A major problem is the choice of an appropriate reference value. As stated earlier, the
current diagnostic gold standard blood culture is not an analytically robust method. Judging
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the new technologies on the basis of these results could disguise their actual performance.
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Blood culture-positivity typically requires bacterial cell numbers around 10,000 to 1,000,000
CFUs/ml. Most of the new technologies already detect more than one thousandth lower
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concentrations. This raises new demands in regard to the necessity to distinguish true
4. Conclusion
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Latest technological developments in different areas allowed the development of novel rapid
and accurate diagnostic tools for patients with suspected sepsis. Some of these technologies
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are more likely to have candidate status while others are already market-ready. All have the
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potential to revolutionize diagnostics and to lead away from empiric treatment to rapid and
necessary for use in the ED, being the main gateway for most patients with sepsis. In addition,
most tools lack reliable cut-off values allowing easy result interpretation in routine settings.
Prospectively, the further development towards screening tools for patients at risk predicting
sepsis before the onset of the first symptom or at least the progression to organ dysfunction
would enormously improve treatment decisions. This is most likely to succeed with multi-
marker panels, including both host response assessment and direct pathogen detection.
5. Expert Opinion
On the one hand, there is an urgent need for rapid and, above all, accurate tests that support
early diagnosis of sepsis. At the same time, even the most matured commercial technologies
have not yet entered clinical routine, although considerable progress has been made in recent
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years. This apparent contradiction results from the disease itself. Sepsis is a complex
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syndrome with a high degree of heterogeneity of both the underlying pathogens and the
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clinical appearance of patients. Almost all marked-ready developed systems cover only a part
of the sepsis cases and therefore, merely support the diagnosis of a specific patient subgroup.
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These test procedures are therefore less suitable for unselected and routine use, e.g., in ED
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settings. An improved diagnostic option, only aiding diagnosis of a subgroup, does not pay
off in real-life, considering the high economically effort, staff training and not lastly, patient
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outcome. The routine use of these test systems is more likely to work in specialised ICUs with
more homogeneous group of patients. Apart from study settings, broad implementation
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currently fails in particular due to a lack of simple, robust cut-off diagnostic values. However,
this situation can also change very quickly, as soon as some of the diversified tests, which are
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still in the early stages of development, are ready for the market. The often erratic,
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status of individual tests being not published for company strategic reasons makes it difficult
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to make a serious statement about when this will be the case. However, it can be mentioned
with considerable certainty that there will be no single, universally applicable test accurately
diagnosing all cases of sepsis. Rather, it can be assumed that different tests will take root in
different divisions (e.g., ICU, ED), based on the predominant patient populations.
Combinations of host-response guided tests with tests that capture the triggering pathogens
and their possible resistances are not only conceivable, but likely and promising as they can
be adapted to local patient populations.
Besides all this, the influence of the human factor must not be underestimated. The quickest
and most accurate diagnostic test will not improve patient’s outcome, when a diagnostic
sample is not further processed immediately or, even worse, is not taken at all, despite
suspicion of infection.
Apart from technical improvements and biomarker research, bioinformatics has also
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developed dramatically [77]. Combining intelligent bioinformatic tools as e.g., machine-
learning algorithms, with results from clinical examination and laboratory parameters has the
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potential to revolutionize diagnosis. This approach increases not only diagnostic accuracy, but
us
can also open up completely new possibilities for therapy control. Patients with sepsis may be
identified in different phases of the disease, even before the onset of symptoms using a neural
an
network analysis of several biomarkers [78,79]. Such approaches are especially helpful for
high-risk patients e.g., postoperative patients or patients staying long on ICU [80] and may
M
also predict the further progression of severe sepsis [81]. It has already been shown that
ed
recorded vital functions and laboratory-based technologies using bioinformatic methods. This
ce
connection of classical and novel diagnostic strategies will lead to a high predicative and
diagnostic accuracy, improved therapy guidance and finally to better patient outcome.
Ac
declare.
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Abbreviations
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AUC: area under the receiver operating characteristic curve
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BALF: bronchoalveolar lavage fluids
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CD14: Cluster of differentiation 14
IL-6: interleukin-6
LPS: lipopolysaccharide
PCT: procalcitonin
t
SIRS: systemic inflammatory response syndrome
ip
cr
SOFA: sequential organ failure assessment score
us
ST: subtype
microcirculatory disturbances
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ip
CRP acute-phase reactant 75% 67% [21]
cr
PCT precursor of the peptide hormone 77% 79% [24,25]
us
calcitonin
cluster of differentiation 14
M
CD64
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amyloid A, Substance P,
Austria)
Cystatin C, Myoglobin,
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NGAL, plasminogen, D-
dimer)
cr
Cytovale Cytovale microfluidic and granulocyte
us
(San Francisco CA, single cell imaging deformability
USA)
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SeptiCyte LAB Immunexpress Inc host gene expression 4 genes
M
PLAC8, PLA2G7)
ed
210 C9orf95/NMRK1,
USA)
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KIAA1370, TGFBI,
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MTCH1, RPGRIP1,
HLA-DPB1)
Table 3. Direct pathogen detection assays
time
t
Switzerland)
ip
SepsiTest Molzym 16S and 18S rRNA PCR 8 - 10 hours 1,359 bacteria
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(Bremen, Germany) and sanger sequencing and fungi
us
BioFire BioMerieux DNA purification and
an 1 hour Tailored
France) to 33 bacterial,
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viral, or
parasitic
ed
targets,
including
pt
resistance
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genes)
pathogens, 3
toxins, 22
resistance
genes)
USA) T2Candida: 5
species
t
ip
hybcell Cube Dx microarray
(St. Valentin,
cr
Austria)
us
Karius (Redwood City CA, an unbiased
USA) testing
next generation around 24
(including
Noscendo (Duisburg, sequencing hours
M
bacteria, virus,
Germany)
fungi)
ed
Abbreviations: DNA: deoxyribonucleic acid, PCR: polymerase chain reaction, rRNA: ribosomal
ribonucleic acid
pt
ce
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