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O'Neal HR, Sheybani R, Kraus CK, Self WH, Shah AM, Thomas CB, Tse HTK, Scoggins R. Cellular host response sepsis test for risk stratification of patients in the emergency department: A pooled analysis. Acad Emerg Med 2024. [PMID: 38643433 DOI: 10.1111/acem.14923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/06/2024] [Accepted: 03/31/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVES Sepsis is one of the most common, costly, and misdiagnosed conditions in U.S. emergency departments (EDs). ED providers often treat on nonspecific signs, subjective suspicion, or presumption of infection, resulting in over- and undertreatment. An increased understanding of host response has opened a new direction for sepsis diagnostics. The IntelliSep test is a U.S. Food and Drug Administration-cleared cellular host response diagnostic that could help distinguish sepsis in ED settings. Our objective was to evaluate the potential of the cellular host response test to expedite appropriate care for patients who present with signs of infection. METHODS We performed a pooled analysis of five adult (≥18 years) cohorts enrolled at seven geographically diverse U.S. sites in separate studies. Structured blinded adjudication was used to classify presence or absence of sepsis, and only patients with high confidence in the adjudicated label were included (n = 1002), defined as patients for whom there was consensus in the determination of sepsis per the Sepsis-3 and severe sepsis per the Sepsis-2 definitions between both the independent adjudication panel and the site-level physician. RESULTS Among patients with signs or suspicion of infection, the test achieved similar or better performance compared to other indicators in identifying patients at high risk for sepsis (specificity > 83%) and significantly superior performance in identifying those at low risk (sensitivity > 92%; 0% sepsis-associated mortality). The test also stratified severity of illness, as shown by 30-day in-hospital mortality (p < 0.001), hospital length of stay (p < 0.01), and use of hospital resources (p < 0.001). CONCLUSIONS Our data suggest that the cellular host response test provides clinically actionable results for patients at both high and low risk for sepsis and provides a rapid, objective means for risk stratification of patients with signs of infection. If integrated into standard of care, the test may help improve outcomes and reduce unnecessary antibiotic use.
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Affiliation(s)
- Hollis R O'Neal
- Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
- Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana, USA
| | | | - Chadd K Kraus
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt Institute for Clinical and Translational Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ajay M Shah
- Cytovale, Inc., San Francisco, California, USA
| | - Christopher B Thomas
- Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
- Franciscan Missionaries of Our Lady Health System, Baton Rouge, Louisiana, USA
| | | | - Robert Scoggins
- Cytovale, Inc., San Francisco, California, USA
- Pulmonary & Critical Care, Kootenai Health, Coeur d'Alene, Idaho, USA
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O'Neal HR, Sheybani R, Janz DR, Scoggins R, Jagneaux T, Walker JE, Henning DJ, Rosenman E, Mahler SA, Regunath H, Sampson CS, Files DC, Fremont RD, Noto MJ, Schneider EE, Shealey WR, Berlinger MS, Carver TC, Walker MK, Ledeboer NA, Shah AM, Tse HTK, DiCarlo D, Rice TW, Thomas CB. Validation of a Novel, Rapid Sepsis Diagnostic for Emergency Department Use. Crit Care Explor 2024; 6:e1026. [PMID: 38333076 PMCID: PMC10852401 DOI: 10.1097/cce.0000000000001026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024] Open
Abstract
OBJECTIVES To assess the in vitro IntelliSep test, a microfluidic assay that quantifies the state of immune activation by evaluating the biophysical properties of leukocytes, as a rapid diagnostic for sepsis. DESIGN Prospective cohort study. SETTING Five emergency departments (EDs) in Louisiana, Missouri, North Carolina, and Washington. PATIENTS Adult patients presenting to the ED with signs (two of four Systemic Inflammatory Response Syndrome criteria, where one must be temperature or WBC count) or suspicion (provider-ordered culture) of infection. INTERVENTIONS All patients underwent testing with the IntelliSep using ethylene diamine tetraacetic acid-anticoagulated whole blood followed by retrospective adjudication for sepsis by sepsis-3 criteria by a blinded panel of physicians. MEASUREMENTS AND MAIN RESULTS Of 599 patients enrolled, 572 patients were included in the final analysis. The result of the IntelliSep test is reported as the IntelliSep Index (ISI), ranging from 0.1 to 10.0, divided into three interpretation bands for the risk of sepsis: band 1 (low) to band 3 (high). The median turnaround time for ISI results was 7.2 minutes. The ISI resulted band 1 in 252 (44.1%), band 2 in 160 (28.0%), and band 3 in 160 (28.0%). Sepsis occurred in 26.6% (152 of 572 patients). Sepsis prevalence was 11.1% (95% CI, 7.5-15.7%) in band 1, 28.1% (95% CI, 21.3-35.8%) in band 2, and 49.4% (95% CI, 41.4-57.4%) in band 3. The Positive Percent Agreement of band 1 was 81.6% and the Negative Percent Agreement of band 3 was 80.7%, with an area under the receiver operating characteristic curve of 0.74. Compared with band 1, band 3 correlated with adverse clinical outcomes, including mortality, and resource utilization. CONCLUSIONS Increasing ISI interpretation band is associated with increasing probability of sepsis in patients presenting to the ED with suspected infection.
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Affiliation(s)
- Hollis R O'Neal
- Pulmonary and Critical Care, Louisiana State University Health Sciences Center, Baton Rouge, LA
- Pulmonary & Critical Care, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA
| | | | - David R Janz
- Pulmonary & Critical Care, University Medical Center, New Orleans, LA
| | - Robert Scoggins
- Pulmonary and Critical Care, Kootenai Health, Coeur d'Alene, ID
| | - Tonya Jagneaux
- Pulmonary and Critical Care, Louisiana State University Health Sciences Center, Baton Rouge, LA
- Pulmonary & Critical Care, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA
| | - James E Walker
- Pulmonary and Critical Care, Louisiana State University Health Sciences Center, Baton Rouge, LA
- Pulmonary & Critical Care, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA
| | - Daniel J Henning
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | | | - Simon A Mahler
- Departments of Emergency Medicine, Epidemiology and Prevention, and Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Hariharan Regunath
- Critical Care Medicine and Infectious Diseases, University of Maryland-Baltimore Washington Medical Center, Glen Burnie, MD
- Division of Infectious Diseases, Department of Medicine, University of Missouri School of Medicine, Columbia, MO
| | - Christopher S Sampson
- Department of Emergency Medicine, University of Missouri School of Medicine, Columbia, MO
| | - D Clark Files
- Pulmonary and Critical Care Medicine, Wake Forest University School of Medicine, Winston Salem, NC
| | | | - Michael J Noto
- Allergy, Pulmonary, and Critical Care Medicine, Emory University School of Medicine, Atlanta, GA
| | - Erica E Schneider
- Pulmonary and Critical Care, Bon Secours Mercy Health System, Richmond, VA
| | - Wesley R Shealey
- Department of Medicine, Infectious Disease, Creighton University School of Medicine, Phoenix, AZ
| | - Matthew S Berlinger
- Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Thomas C Carver
- Division of Trauma, Critical Care, and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Morgan K Walker
- Critical Care Medicine, National Institutes of Health, Bethesda, MD
| | - Nathan A Ledeboer
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
| | | | - Henry T K Tse
- Pulmonary & Critical Care, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA
| | - Dino DiCarlo
- Department of Bioengineering and Biomedical Engineering, University of California, Los Angeles, CA
| | - Todd W Rice
- Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Christopher B Thomas
- Pulmonary and Critical Care, Louisiana State University Health Sciences Center, Baton Rouge, LA
- Pulmonary & Critical Care, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA
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Kraus CK, O’Neal HR, Ledeboer NA, Rice TW, Self WH, Rothman RE. Variability in Provider Assessment of Sepsis and Potential of Host Response Technology to Address this Dilemma-Results of an Online Delphi Study. J Pers Med 2023; 13:1685. [PMID: 38138912 PMCID: PMC10744443 DOI: 10.3390/jpm13121685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/27/2023] [Accepted: 11/14/2023] [Indexed: 12/24/2023] Open
Abstract
Potentially septic patients have a huge clinical and economic impact on hospitals and often present to the emergency department (ED) with undifferentiated symptoms. The triage of these patients is complex and has historically relied heavily upon provider judgment. This study aims to evaluate the consistency of provider judgment and the potential of a new host response sepsis test to aid in the triage process. A modified Delphi study involving 26 participants from multiple specialties was conducted to evaluate provider agreement about sepsis risk and to test proposed actions based on the results of a sepsis test. The participants considered case vignettes of potentially septic patients designed to represent diagnostic dilemmas. Provider assessment of sepsis risk in these cases ranged from 10% to 90% and agreement was poor. Agreement about clinical actions to take in response to testing improved when participants considered their own hypothetical borderline cases. New host response testing for sepsis may have the potential to improve sepsis diagnosis and care and should be applied in a protocolized fashion to ensure consistency of results.
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Affiliation(s)
- Chadd K. Kraus
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network (LVHN), University of South Florida (USF) Morsani College of Medicine, Tampa, FL 33602, USA
| | - Hollis R. O’Neal
- Department of Critical Care Medicine, Louisiana State University, Baton Rouge, LA 70803, USA;
| | - Nathan A. Ledeboer
- Department of Pathology & Laboratory Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Todd W. Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Richard E. Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
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Sorrells MG, Seo Y, Magnen M, Broussard B, Sheybani R, Shah AM, O’Neal HR, Tse HTK, Looney MR, Di Carlo D. Biophysical Changes of Leukocyte Activation (and NETosis) in the Cellular Host Response to Sepsis. Diagnostics (Basel) 2023; 13:1435. [PMID: 37189536 PMCID: PMC10138275 DOI: 10.3390/diagnostics13081435] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/03/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Sepsis, the leading cause of mortality in hospitals, currently lacks effective early diagnostics. A new cellular host response test, the IntelliSep test, may provide an indicator of the immune dysregulation characterizing sepsis. The objective of this study was to examine the correlation between the measurements performed using this test and biological markers and processes associated with sepsis. Phorbol myristate acetate (PMA), an agonist of neutrophils known to induce neutrophil extracellular trap (NET) formation, was added to whole blood of healthy volunteers at concentrations of 0, 200, and 400 nM and then evaluated using the IntelliSep test. Separately, plasma from a cohort of subjects was segregated into Control and Diseased populations and tested for levels of NET components (citrullinated histone (cit-H3) DNA and neutrophil elastase (NE) DNA) using customized ELISA assays and correlated with ISI scores from the same patient samples. Significant increases in IntelliSep Index (ISI) scores were observed with increasing concentrations of PMA in healthy blood (0 and 200: p < 10-10; 0 and 400: p < 10-10). Linear correlation was observed between the ISI and quantities of NE DNA and Cit-H3 DNA in patient samples. Together these experiments demonstrate that the IntelliSep test is associated with the biological processes of leukocyte activation and NETosis and may indicate changes consistent with sepsis.
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Affiliation(s)
| | - Yurim Seo
- Departments of Medicine and Laboratory Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | - Melia Magnen
- Departments of Medicine and Laboratory Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | - Bliss Broussard
- Department of Biological Sciences, Nicholls State University, Thibodaux, LA 70310, USA
| | | | | | - Hollis R. O’Neal
- LSU Health Sciences Center/Our Lady of the Lake Regional Medical Center, Baton Rouge, LA 70808, USA
| | | | - Mark R. Looney
- Departments of Medicine and Laboratory Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | - Dino Di Carlo
- Departments of Bioengineering and Mechanical and Aerospace Engineering, University of California Los Angeles, Los Angeles, CA 90095, USA
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