Workflow for risk assessment and patient management using procalcitonin and mid-region proadrenomedullin

Abstract

The present invention belongs to the field of clinical diagnosis. In particular, the present invention relates to assessing the severity of a subject suspected of infection or having an infection by determining the level of procalcitonin (hereinafter: PCT) (SEQ ID No: 1) and / or proadrenomedullin (hereinafter: proADM) (SEQ ID No: 3) or a partial peptide or fragment thereof, in particular mid-region proadrenomedullin (MR-proADM) (SEQ ID No: 2) in a patient sample, wherein the subject may have physiological signs of infection or increased risk factors, in particular from an infectious disease, and the present invention relates to its workflow. In addition, the present invention relates to assessments related to infection, such as exclusion / determination of patients and stratification, risk assessment, in particular to avoid re-hospitalization and hospital and post-discharge deaths.

Description

Technical Field

[0001] The present invention belongs to the field of clinical diagnosis. In particular, the present invention relates to assessing the severity of a subject suspected of infection or having an infection by determining the level of procalcitonin (hereinafter: PCT) and / or proadrenomedullin (hereinafter: proADM)) (SEQ ID No: 3) or a partial peptide or fragment thereof, in particular mid-region proadrenomedullin (MR-proADM) (SEQ ID No: 2) in a patient sample, wherein the subject may have physiological signs of infection or increased risk factors, in particular from an infectious disease, and the present invention relates to its workflow. In addition, the present invention relates to assessments related to infection, such as exclusion / determination of patients and stratification, risk assessment, in particular to avoid re-hospitalization and, for example, death in hospital or after discharge.

[0002] Due to the assessed severity, clinical decisions should be made, such as administering medications or entering and exiting the clinical site and initiating and / or changing or stopping treatment (e.g., antibiotics, oxygen, fluids) and / or improving monitoring and / or initiating further diagnostic pathways to improve the patient's diagnosis and related treatment assessment. Background Art

[0003] PCT is known to be a marker for bacterial infection and sepsis. High blood or serum levels of this peptide prohormone indicate a serious infection.

[0004] PCT reflects the severity of bacterial infection and is particularly useful for monitoring the progression of infection to sepsis, severe sepsis or septic shock. PCT can be used to measure the activity of systemic inflammatory responses associated with infection, control the success of antibacterial therapy and estimate prognosis (Assicot et al., 1993. Lancet 341:515-8; Clec'h C et al., 2004. Crit Care Med 32:1166-9; Lee et al., 2004. Yonsei Med J 45:29-37; Meisner et al., 2005. Curr Opin Crit Care 11:473-480; Wunder et al., 2004. Inflamm Res 53:158-163). Increased PCT levels in patients with sepsis are associated with mortality (Oberhoffer et al., 1999. Clin Chem Lab Med 37:363-368).

[0005] During bacterial infection, plasma PCT concentrations are usually above 0.25 ng / ml, and PCT concentrations can rise above the normal range but below the concentrations, which are known to be associated with bacterial infections requiring antibacterial treatment, and these PCT concentrations are associated with adverse event prognosis in these patients (Sinnig et al., 2011. Circ J 75: 1184-1191; Kelly et al., 2010. Biomarkers 15: 325-331). In addition, as a critical value for the presence of bacterial infection or sepsis, a level of> 0,1 ng / ml PCT is indicated.

[0006] PCT has been used to guide antibiotic therapy in patients with symptoms of infection (e.g., impaired breathing or respiratory rate (e.g., shortness of breath or cough), abnormal body temperature (less than 36°C or more than 38°C (fever)), impaired digestive system (e.g., diarrhea, nausea, or vomiting), urinary problems, impaired circulation (e.g., rapid pulse, pain, signs of inflammation). In patients presenting to the emergency department (ED) with symptoms of lower respiratory tract infection, PCT is measured, and only patients with PCT concentrations >0.25 ng / mL or >0.5 ng / mL are treated with antibiotics (Christ-Crain et al., 2004. Lancet 363:600-7). In patients with community-acquired pneumonia (CAP), antibiotic therapy is based on serum PCT concentrations (strongly discouraged when PCT concentrations <0.1 ng / mL; discouraged when PCT concentrations <0.25 ng / mL; encouraged when PCT concentrations >0.25 ng / mL, and strongly encouraged when PCT concentrations >0.5 ng / mL; increments of 50-80% decrease in PCT indicate the point at which antibiotics should be discontinued) (Christ-Crain et al., 2006. Am J Resp Crit Care Med 174:84-93; Schuetz et al., 2009. JAMA 302(10)1059-1066). PCT guidance significantly reduced antibiotic use in CAP without worsening patient outcomes. Similarly, PCT-guided therapy using the same decision threshold as above also significantly reduced antibiotic use for acute respiratory tract infections in primary care without worsening patient outcomes (Briel et al., 2008. Arch Intern Med 168:2000-7; Burkhardt et al., 2010. Eur Resp J Express; doi:10.1183 / 09031936.00163309).

[0007] Therefore, it is recommended to measure the PCT level in the body fluid sample of the patient with infectious disease before starting the potentially harmful antibiotic therapy. High blood or serum PCT levels indicate the presence of severe bacterial infection or even sepsis, and the corresponding patient needs to be treated with antibiotics. PCT values ​​below 0,1ng / mL indicate non-infectious diseases, non-bacterial infections, but also indicate the early stages of bacterial infection. It is recommended to re-measure in the next 6-12 hours or at least the next 24 hours to exclude bacterial infection if it is decided to admit the patient to the hospital. This patient group was ignored in the past.

[0008] Furthermore, the prior art describes how to determine pro-adrenomedullin (proADM) and adrenomedullin in diagnostics (EP0622458B1, Lewis LK, Smith MW, Yandle TG, Richards AM, Nicholls MG. Adrenomedullin (1-52) measured in human plasma by radioimmunoassay: plasma concentration, adsorption, and storage. Clin Chem 1998; 44: 571-7; Ueda S, Nishio K, Minamino N, Kubo A, Akai Y, Kangawa K et al., Increased plasma levels of adrenomedullin in patients with systemic inflammatory response syndrome. Am J Respir Crit Care Med 1999; 160: 132-6; Kobayashi K, Kitamura K, Etoh T, Nagatomo Y, Takenaga M, Ishikawa T et al., Increased plasma adrenomedullin levels in chronic congestive heart failure. Am Heart J 1996; 131: 994-8; Kobayashi K, Kitamura K, Hirayama N, Date H, Kashiwagi T, Ikushima I et al., Increased plasma adrenomedullin in acute myocardial infarction. Am Heart J 1996; 131: 676-80), particularly for the purpose of diagnosing sepsis (EP1121600B1).

[0009] EP1488209B1 discloses MR-proADM for diagnostic purposes (Struck J, Tao C, Morgenthaler NG, Bergmann A. Identification of an Adrenomedullin precursor fragment in plasma of sepsis patients. Peptides 2004; 25: 1369-72; Morgenthaler NG, Struck J, Alonso C, Bergmann A. Measurement of mid-regional pro-adrenomedullin in plasma with an immunoluminometric assay. Clin Chem 2005; 51: 1823-9; Christ-Crain M, Morgenthaler NG, Stolz D, Muller C, Bingisser R, Harbarth S, et al. Pro-adrenomedullin to predict severity and outcome in community-acquired pneumonia [ISRCTN04176397]. Crit Care 2006;10:R96; Christ-Crain M, Morgenthaler NG, Struck J, Harbarth S, Bergmann A, Muller B. Mid-regional pro-adrenomedullin asa prognostic marker in sepsis: an observational study. Crit Care 2005;9:R816-24).

[0010] PCT combined with additional risk assessment and prognostic aids that focus on the patient's overall condition unrelated to infection can maximize patient safety and physician confidence in guiding appropriate therapy and treatment (Schuetz P, Mueller B. The role of immune and metabolic biomarkers for improved management of sepsis patients. Expert Rev Clin Immunol. 2014 Sep; 10(9): 1255-1262).

[0011] In the emergency department (ED) and intensive care unit (ICU), MR-proADM and its precursor proADM provide a more accurate and rapid risk assessment of septic conditions in patients (Travaglino F, De Berardinis B, Magrini L, et al., Utility of Procalcitonin (PCT) and Mid regional pro-Adrenomedullin (MR-proADM) in risk stratification of critically ill febrile patients in Emergency Department (ED). A comparison with APACHE II score. BMC Infect Dis. 2012; 12: 184), as well as an additional assessment of the risk of further clinical complications that may arise from the original septic condition, which may include blood clot formation, tissue death, hypoxia, impaired organ blood flow, and ultimately organ dysfunction and failure. In fact, tissue hypoxia may occur even when normal organ blood flow is observed, making it extremely difficult to detect.

[0012] However, there is a need for improved, in particular rapid assessment of patients presenting at the clinical setting, such as primary care or ambulance, preferably ED or ICU, to increase clinical safety of patients and to support physicians with regard to patient care, in particular therapeutic intervention or management or guidance. DETAILED DESCRIPTION

[0013] definition:

[0014] Unless defined otherwise, technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which the invention belongs. Additional definitions for the following terms and other terms are set forth throughout the specification.

[0015] The terms “a,” “an,” and “the” do not denote a limitation of quantity, but rather denote the presence of “at least one” of the referenced item.

[0016] As used in this application, the terms "about" and "approximately" are used as equivalents. Any number with or without about / approximately used in this application is intended to cover any normal fluctuations understood by a person of ordinary skill in the relevant art. As used herein, the term "about" or "approximately" refers to a value similar to the reference value when applied to one or more target values. In certain embodiments, unless otherwise stated or apparent from the context, the term "about" or "approximately" refers to a range of values ​​falling within a range of 5% or less in either direction (greater than or less than) of the reference value (unless the number exceeds 100% of the possible value).

[0017] Patient management in ED or other clinical sites leads to a heavy responsibility of clinical staff, with rapid and correct decision-making about the treatment, particularly therapeutic intervention or management or guidance of the patient. Patients usually present clinical signs of infection that may be very similar to other non-infectious conditions or diseases, such as respiratory problems and other problems that may be relevant to non-infectious conditions such as asthma or poisoning. It is very important to identify infection or risk of infection and to select and manage the medical classification relevant to the severity of the disease about further treatment. Patients (such as patients with comorbidities, especially elderly people or children with impaired immune response) who get infected or have increased risk of complications are usually not easy to manage. Failure to assess the patient may increase the risk of death and serious events such as sepsis or organ dysfunction. It is important to discharge patients with low severe disease states, especially those relevant to the risk of death, to avoid complications and / or readmission (post-discharge stage), including readmission.

[0018] Therefore, complex decision trees or matrices supported by combinations of markers with one or more critical levels (synonymous: threshold levels) may be needed to provide a workflow for the management of such patients.

[0019] The object of the present invention relates to improved assessment of the severity of infection in patients, including risk assessment and related clinical decision making, in particular discharge, hospitalization, and re-hospitalization of patients after discharge.

[0020] The object of the invention is achieved by the stated claims.

[0021] Surprisingly, it has been found that the assessment of severity, and the determination and / or exclusion of infection and the severity of the disease state, by using PCT and pro-ADM, in particular MR-proADM, in a complementary manner, allows for improved management of clinical decisions due to the stratification of subjects in order to establish their workflow.

[0022] Therefore, the present invention relates to a method for assessing severity, in particular a method for assessing severity in a subject suspected of infection or having an infection, the method comprising the following steps:

[0023] (i) providing a body fluid sample from the subject;

[0024] (ii) determining the level of procalcitonin (PCT) (SEQ ID No. 1) or a fragment or precursor thereof or a fragment thereof having a length of at least 12 amino acid residues in said sample, and

[0025] The level of pro-adrenomedullin (proADM) (SEQ ID No: 3) or a partial peptide or fragment thereof having a length of at least 12 amino acid residues, in particular mid-region pro-adrenomedullin (MR-proADM) (SEQ ID No: 2), or a precursor or fragment thereof having a length of at least 12 amino acid residues, and

[0026] (iii) determining the severity of an infection, in particular of a subject suspected of an infection or having an infection, by comparing said determined PCT level and proADM level, in particular MR-proADM level or said fragments thereof level, with a threshold level.

[0027] Surprisingly, the present invention relates to the synergistic effect of PCT and pro-ADM or fragments thereof for the management of patients with infection or suspected infection and the severity of infection. If the PCT level is below 0,1 ng / mL and pro-ADM or fragments thereof, in particular MR-proADM, is below 0,88 nmol / L, such patients should be advantageously discharged from the clinical site, in particular the ED, due to the assessed severity of the condition and the corresponding low mortality rate. In particular, if PCT is equal to or above 0,1 ng / ml and pro-ADM or fragments thereof, in particular MR-proADM, is below 0,88 nmol / L, the serious risk regarding mortality not related to the infection is still low and the decision to discharge the patient is made. In this case, the treatment is manageable in an outpatient setting, for example, by prescribing oral or topical medications such as antibiotics, rather than invasive forms of application.

[0028] A preferred embodiment of the present invention relates to the following cases of severity assessment. Therefore, the present invention relates to a method for assessing the severity of an infection, in particular a subject suspected of infection or having an infection, the method comprising the following steps:

[0029] (i) providing a body fluid sample from the subject;

[0030] (ii) determining the level of procalcitonin (PCT) or a fragment or precursor thereof or a fragment thereof having a length of at least 12 amino acid residues or a fragment thereof in said sample, and

[0031] The level of pro-adrenomedullin (proADM) (SEQ ID No: 3) or a partial peptide or fragment thereof having a length of at least 12 amino acid residues, in particular mid-region pro-adrenomedullin (MR-proADM) (SEQ ID No: 2) or a precursor or fragment thereof having a length of at least 12 amino acid residues, and

[0032] (iii) determining the severity of an infection, in particular of a subject suspected of having an infection or having an infection, by comparing said determined PCT level and proADM level, in particular MR-proADM level or said fragments thereof, with a threshold level,

[0033] (iv) wherein when the threshold level of PCT is below 0.06 ng / ml, more preferably below 0.08 ng / ml, most preferably below 0.1 ng / ml and the threshold level of proADM or a fragment thereof is below 0.6 nmol / L, more preferably below 0.75 nmol / L, most preferably below 0.88 nmol / L, the subject has Non-serious infection ,

[0034] and / or

[0035] (v) wherein the subject has a PCT threshold level of less than 0.06 ng / ml, more preferably less than 0.08 ng / ml, most preferably less than 0.1 ng / ml and the proADM or fragment thereof threshold level is equal to or higher than 0.6 nmol / L, more preferably equal to or higher than 0.75 nmol / L, most preferably equal to or higher than 0.88 nmol / L and is not equal to or higher than 1.1 nmol / L, more preferably not equal to or higher than 1.2 nmol / L, most preferably not equal to or higher than 1.28 nmol / L. Rarely serious infection ,

[0036] and / or

[0037] (vi) wherein when the threshold level of PCT is below 0.06 ng / ml, more preferably below 0.08 ng / ml, most preferably below 0.1 ng / ml and the threshold level of proADM or a fragment thereof is equal to or higher than 1.1 nmol / L, more preferably equal to or higher than 1.2 nmol / L, most preferably equal to or higher than 1.28 nmol / L, the subject has Low severity infection ,

[0038] and / or

[0039] (vii) wherein when the threshold level of PCT is equal to or higher than 0.06 ng / ml, more preferably equal to or higher than 0.08 ng / ml, most preferably equal to or higher than 0.1 ng / ml and the threshold level of proADM or a fragment thereof is lower than 0.6 nmol / L, more preferably lower than 0.75 nmol / L, most preferably lower than 0.88 nmol / L, the subject has Very low severity Infect ,

[0040] and / or

[0041] (viii) wherein the subject has a PCT threshold level of 0.06 ng / ml or higher, more preferably 0.08 ng / ml or higher, and most preferably 0.1 ng / ml or higher and the proADM or fragment thereof threshold level is 0.6 nmol / L or higher, more preferably 0.75 nmol / L or higher, and most preferably 0.88 nmol / L or higher, and is not 1.1 nmol / L or higher, more preferably 1.2 nmol / L or higher, and most preferably 1.28 nmol / L or higher. Low severity infection ,

[0042] and / or

[0043] (ix) wherein when the threshold level of PCT is equal to or higher than 0.06 ng / ml, more preferably equal to or higher than 0.08 ng / ml, most preferably equal to or higher than 0.1 ng / ml and the threshold level of proADM or a fragment thereof is equal to or higher than 1.1 nmol / L, more preferably equal to or higher than 1.2 nmol / L, most preferably equal to or higher than 1.28 nmol / L, the subject has Severe infection ,

[0044] and / or

[0045] (x) wherein when the threshold level of PCT is below 0.06 ng / ml, more preferably below 0.08 ng / ml, most preferably below 0.1 ng / ml and the threshold level of proADM or a fragment thereof is equal to or higher than 1.30 nmol / L, more preferably equal to or higher than 1.40 nmol / L, most preferably equal to or higher than 1.50 nmol / L, the subject has Severe infection ,

[0046] and / or

[0047] (xi) wherein when the threshold level of PCT is below 0.06 ng / ml, more preferably below 0.08 ng / ml, most preferably below 0.1 ng / ml and the threshold level of proADM or a fragment thereof is equal to or higher than 2.25 nmol / L, more preferably equal to or higher than 2.50 nmol / L, most preferably equal to or higher than 2.75 nmol / L, the subject has Severe infection ,

[0048] and / or

[0049] xii) wherein when the threshold level of PCT is equal to or higher than 0.06 ng / ml, more preferably equal to or higher than 0.08 ng / ml, most preferably equal to or higher than 0.1 ng / ml and the threshold level of proADM or a fragment thereof is equal to or higher than 1.30 nmol / L, more preferably equal to or higher than 1.40 nmol / L, most preferably equal to or higher than 1.50 nmol / L, the subject has High severity infection ,

[0050] and / or

[0051] xiii) wherein when the threshold level of PCT is equal to or higher than 0.06 ng / ml, more preferably equal to or higher than 0.08 ng / ml, most preferably equal to or higher than 0.1 ng / ml and the threshold level of proADM or a fragment thereof is equal to or higher than 2.25 nmol / L, more preferably equal to or higher than 2.50 nmol / L, most preferably equal to or higher than 2.75 nmol / L, the subject has Very high severe infection .

[0052] The cases are described as progressing in severity from less severe to more severe and most severe, which is related to the classification of the patients.

[0053] Therefore, due to the assessed severity, the cases (iv-xiii) can be distinguished from each other to exclude or adjudicate patients.

[0054] therefore,

[0055] (iv) involving Non-serious infection Patients should be excluded from serious infection and do not require hospitalization and / or discharged accordingly.

[0056] (v) Involving Rarely serious infection Patients should be judged to have possible infectious or non-infectious serious conditions and need to be hospitalized without isolation.

[0057] (vi) Involving Low severity infection Patients should be judged to have possible infectious or non-infectious serious conditions and need to be hospitalized without isolation.

[0058] (vii) Involvement Very low serious infection Patients should be excluded from serious infection and do not require hospitalization and / or discharged accordingly.

[0059] (viii) Involving Low severity infection Patients should be diagnosed with severe infection and require hospitalization and isolation.

[0060] (ix) Involving Severe infection Patients should be considered to have severe infection and strictly require hospitalization, isolation and more frequent monitoring.

[0061] (x) Involving Severe infection Patients should be assessed as having a possible infection or a high risk of acquiring an infection or a non-infectious serious condition with a high risk of complications (25% risk of death) and requiring hospitalization without isolation.

[0062] (xi) Involving Severe infection Patients should be classified accordingly as having a possible infection or a high risk of acquiring an infection or a non-infectious serious condition in which the risk of complications is extremely high (35% risk of death) and require hospitalization, especially in a special ward such as an ICU requiring isolation.

[0063] (xii) Involving Very serious infection Patients should be judged to be at high risk of severe infection and complications (risk of death is 25%) and strictly require hospitalization and isolation.

[0064] (xiii) Involving Very serious infection Patients should be judged to be at extremely high risk of severe infection and complications (35% risk of death) and should strictly require hospitalization and admission to special wards such as ICU and isolation.

[0065] Also provided is a method of treating a patient suspected of having an infection, the method comprising the steps of the above aspects, and in addition

[0066] (ii) If the patient is designated as (x) Severely infected patients, (xi) Severely infected patients, (xii) Very seriously infected patients Patients or (xiii) patients with very serious infections , antibiotics are administered to patients in an ICU setting.

[0067] Also provided is a method of treating a patient suspected of having an infection, the method comprising the steps of the above aspects, and in addition

[0068] (ii) If the patient is designated as (vi) low Patients with severe infection or (viii) patients with low severity infection , antibiotics should be administered to patients in the hospital but outside the ICU setting.

[0069] Also provided is a method of treating a patient suspected of having an infection, the method comprising the steps of:

[0070] (i) providing a body fluid sample from the subject;

[0071] (ii) determining the level of procalcitonin (PCT) or a fragment or precursor thereof or a fragment thereof having a length of at least 12 amino acid residues or a fragment thereof in said sample, and

[0072] The level of pro-adrenomedullin (proADM) (SEQ ID No: 3) or a partial peptide or fragment thereof having a length of at least 12 amino acid residues, in particular mid-region pro-adrenomedullin (MR-proADM) (SEQ ID No: 2) or a precursor or fragment thereof having a length of at least 12 amino acid residues, and

[0073] (iii) If the level of PCT is higher than 0.06 ng / ml and the level of proADM is higher than 0.6 nmol / L, administer antibiotics to the patient.

[0074] In a preferred embodiment of the invention referring to the case determination, the PCT measurement must be repeated preferably within at least 6-12 hours or 24 hours after the first measurement in order to control a possible infection state (v, vi, x, xi) or to monitor the response to treatment, for example with antibiotics (vi, vii, viii, xii, xiii). This method allows to find false negative patient groups in the early stages of infection, or to monitor subjects with an increased risk of acquiring an infection or developing complications.

[0075] In another preferred embodiment of the present invention concerning said hospitalized cases (v, vi, vii, viii, ix, x, xi, xii, xiii), regular re-measurement of PCT and / or proADM or fragments thereof is performed for monitoring severity and therapeutic management of the same sample.

[0076] Furthermore, the cases (iv-ix) can be further distinguished from each other as follows:

[0077] If (iv) is applicable, antibiotics are not administered to the subject.

[0078] If (v) is applicable, antibiotics are not administered to the subject and, optionally, a further PCT measurement should be performed on the patient's sample within at least 6-12 hours or 24 hours for clarification or work-up.

[0079] If (vi) is applicable, antibiotics are administered to the subject and, optionally for clarification or work-up, PCT is further measured to identify viral or fungal infections or early stages of bacterial infections.

[0080] If (vii) applies, it is possible to not use antibiotics in the subject, especially when the PCT value is below the typical cut-off value for initiating antibiotic action (e.g. 0,25 ng / mL), or to start antibiotic action when the PCT value is above the typical cut-off value for initiating antibiotic action or in patients at increased risk of developing serious infections. Possible antibiotics can be applied non-invasively (e.g. orally or topically).

[0081] If (viii) applies, it may be possible to withhold antibiotics from the subject, particularly when the PCT value is below the typical cut-off value for initiating antibiotic action (e.g. 0,25 ng / mL), or to initiate antibiotic action when the PCT value is above the typical cut-off value for initiating antibiotic action or in patients at increased risk of developing a serious infection, and optionally a further PCT measurement should be performed on the patient's sample within at least 6-12 hours or 24 hours for clarification or work-up.

[0082] If one of (ix x, xi, xii, xiii) is applicable, antibiotics are immediately administered to the subject.

[0083] If one of (x, xi, xii, xiii) applies, antibiotics are immediately administered to the subject and further determination of PCT and / or proADM or fragments thereof should be performed on the patient's sample within at least 6-12 hours or 24 hours for clarification or work-up. The patient is at high risk for complications (25%-35% risk of death) and therefore requires further monitoring, especially with regard to organ dysfunction, diagnostic interventions (more biomarkers or parameters), and treatment to stabilize the patient, such as administration of oxygen, fluids, antibiotics (intravenous), organ protective measures such as renal replacement, mechanical ventilation. Re-measurements support the assessment of treatment efficacy.

[0084] The term "may not be used" means that it is preferred and recommended not to use, ie the administration of antibiotics should be avoided, or, if necessary, low doses of antibiotics or topical treatments are preferred. For further clarification or investigation, a blood culture test may be performed on a sample from the patient.

[0085] The term "may be administered" means that administration is preferred and recommended, i.e., antibiotic administration should be performed, preferably low dose antibiotics or topical treatments in low severity infections if necessary. For further clarification or investigation, blood culture tests may be performed on samples from the patient.

[0086] In the case of low severity infection (e.g., with respect to complications and mortality), topical or oral treatment with medications such as antibiotics or anti-inflammatory drugs is required. Clinical staff may choose to discharge the patient. The application in more severe infections such as moderate or severe infections should preferably be systemic such as intravenous or intramuscular, but at least oral or topical or a combination thereof.

[0087] However, in all cases (iv-xiii), determinations of PCT and proADM or fragments thereof may be performed to predict an increase or decrease in the level of PCT and / or proADM or fragments thereof. To this end, the determinations may be performed separately or simultaneously. Preferably, re-measurements of PCT and / or proADM or fragments thereof should be performed in a routine manner to avoid false negatives in infected patients and / or to monitor treatment response.

[0088] Therefore, in another preferred embodiment of the present invention, the method for assessing the severity of an infection is suitable for executing clinical decisions, in particular the use of drugs and other health products or additives, in particular antibiotics, oxygen, fluids for advanced treatment and therapy, and the initiation and / or modification or discontinuation of treatment, in particular in an intensive care unit or emergency room or other special care unit, to include the decision to hospitalize a patient, including the administration of drugs or entry and exit of the clinical site, including improved monitoring and / or initiation of further diagnostic pathways to improve the assessment of the patient's diagnosis and related treatment, and including the isolation or non-isolation of the patient to protect other patients, in particular hospitalized patients.

[0089] In particular, in all cases (vi., ix, x, xi, xii and xiii) where proADM or its fragments are equal to or higher than 1,28 nmol / L, one or more of the following measures i.)–iv.) apply:

[0090] i) blood culture testing from a central venous line and / or different sources and samples (e.g. blood, serum, plasma, urine, CSF, body fluids, etc.),

[0091] ii) oral or intravenous administration of antibiotics according to guidelines, preferably using a combination of antibiotics,

[0092] iii) If the test result in i) is negative and the PCT is less than 0.1 ng / ml, stop administering antibiotics,

[0093] iv) Monitor blood test results like lactate, FBC (full blood count), U&E (urea and electrolytes), LFT (liver function test), CRP, coagulation etc.

[0094] However, the determination of PCT and / or proADM or fragments thereof may be performed to predict an increase or decrease in the level of PCT and / or proADM or fragments thereof. To this end, the determinations may be performed separately or simultaneously. Preferably, the re-measurement of PCT and / or proADM or fragments thereof should be performed in a routine manner to avoid false negative infected patients and / or to monitor treatment response.

[0095] In summary, the present invention relates to a workflow and can advantageously manage the risk assessment of patients with suspected infection or infection, particularly those at increased risk, who present in a clinical setting such as primary care or an ambulance, preferably an ED or an ICU. Figure 1 shown.

[0096] Furthermore, the present inventors have found that, independently of the determination of PCT levels, the following threshold levels of pro-adrenomedullin (proADM) (SEQ ID No: 3) or a partial peptide or fragment thereof having a length of at least 12 amino acid residues, in particular mid-region pro-adrenomedullin (MR-proADM) (SEQ ID No: 2) or a precursor or fragment thereof having a length of at least 12 amino acid residues, allow evaluation for further clinical decision making.

[0097] Therefore, in another aspect, the present invention provides a method for assessing the severity of an infection in a subject, the method comprising the steps of:

[0098] (i) providing a body fluid sample from the subject;

[0099] (ii) Independent of PCT level determination

[0100] the level of pro-adrenomedullin (proADM) (SEQ ID No: 3) or a partial peptide or fragment thereof having a length of at least 12 amino acid residues, in particular mid-region pro-adrenomedullin (MR-proADM) (SEQ ID No: 2) or a precursor or fragment thereof having a length of at least 12 amino acid residues, and

[0101] (iii) determining the severity of the infection by comparing said determined proADM level, in particular MR-proADM level or said fragment level thereof, with a threshold level,

[0102] a.) wherein a threshold level equal to or greater than 0.88 nmol / L refers to a clinical decision to assess the subject / patient for hospital admission, and / or

[0103] b.) wherein a threshold level equal to or higher than 1.50 nmol / L is intended to identify high risk infected or non-infected patients with an approximate mortality rate of at least 25%, and / or

[0104] c.) wherein a threshold level equal to or above 2.75 nmol / L is intended to identify very high risk infected or non-infected patients with an approximate mortality rate of at least 35%, and / or

[0105] d.) wherein a threshold level equal to or above 2.75 nmol / L refers to the clinical decision to assess the subject / patient for admission to the ICU.

[0106] In another aspect, the present invention provides a method for treating a patient with a severe infection, the method comprising the steps of:

[0107] (i) providing a body fluid sample from the subject;

[0108] (ii) Independent of PCT level determination

[0109] the level of pro-adrenomedullin (proADM) (SEQ ID No: 3) or a partial peptide or fragment thereof having a length of at least 12 amino acid residues, in particular mid-region pro-adrenomedullin (MR-proADM) (SEQ ID No: 2) or a precursor or fragment thereof having a length of at least 12 amino acid residues, and

[0110] (iii) determining the severity of the infection by comparing said determined proADM level, in particular MR-proADM level or said fragment level thereof, with a threshold level,

[0111] (iv) If the MR-proADM level is equal to or higher than 1.50 nmol / L, treat the patient with antibiotics.

[0112] In some embodiments, if the MR-proADM level is equal to or higher than 2.75 nmol / L, the patient is treated with antibiotics in the ICU.

[0113] In particular, in all cases in which proADM or its fragments are equal to or above 1,50 nmol / L, one or more of the following measures i.)–vi.) apply:

[0114] i) Oxygen is provided through a mask (about 15L / min)

[0115] ii) administering fluid bolus therapy, particularly intravenous boluses, to rapidly administer Hartmann's solution (also known as Ringer's lactate solution),

[0116] iii) Blood culture testing from central venous lines, different sources and samples (e.g. urine, CSF, body fluids, etc.),

[0117] iv) oral or intravenous administration of antibiotics according to guidelines, preferably using a combination of antibiotics,

[0118] v) Monitor blood test results such as lactate, FBC (full blood count), U&E (urea and electrolytes), LFT (liver function test), CRP, coagulation, etc.,

[0119] vi) monitor urine output / fluid balance,

[0120] In particular, in all cases in which proADM or fragments thereof is equal to or above 2.75 nmol / L, the following measures vii.) additionally apply:

[0121] vii) Monitoring of organ dysfunction, including review of clinical parameters and other life-sustaining measures.

[0122] However, the determination of PCT and / or proADM or fragments thereof may be performed to predict an increase or decrease in the level of PCT and / or proADM or fragments thereof. To this end, the determinations may be performed separately or simultaneously. Preferably, the re-measurement of PCT and / or proADM or fragments thereof should be performed in a routine manner to avoid false negative infected patients and / or to monitor treatment response.

[0123] In summary, the present invention relates to a workflow and can advantageously manage the risk assessment of patients with suspected infection or infection, particularly those at increased risk, who present in a clinical setting such as primary care or an ambulance, preferably an ED or an ICU. Figure 2 shown.

[0124] In the scope of the present invention, "procalcitonin (PCT)" is understood to be a human protein or polypeptide or a fragment thereof having an amino acid sequence of 1-116 amino acids or 2-116 amino acids (PCT 2-116) or 3-116 amino acids (PCT 3-116), as described in EP0656121B1 and DE10027954A1. Therefore, the length of the PCT fragment is at least 12 amino acids, preferably greater than 50 amino acids, more preferably greater than 110 amino acids. PCT may include post-translational modifications, such as glycosylation, lipidation or derivatization. PCT itself is a precursor of calcitonin and katacalcin. The amino acid sequence of PCT1-116 is provided as SEQ ID NO: 1.

[0125] Adrenomedullin (ADM) is encoded as a precursor peptide ("prepro-Adrenomedullin" or "pre-proADM") comprising 185 amino acids, provided herein as SEQ ID NO: 4. ADM, and in particular the biologically active ADM form, comprises positions 95-146 of the pre-proADM amino acid sequence and is a splice product thereof.

[0126] "Pro-Adrenomedullin" ("Pro-ADM") refers to pre-proADM without the signal sequence (amino acids 1 to 21), i.e., amino acid residues 22 to 185 of pre-proADM. "Mid-region pro-Adrenomedullin" ("MR-proADM") refers to amino acids 45-92 of pre-proADM. The amino acid sequence of MR-proADM is provided as SEQ ID NO:2. It is also contemplated herein that peptides and fragments thereof of pre-proADM or MR-proADM can be used in the methods described herein. For example, the peptides and fragments thereof can comprise amino acids 22-41 of pre-proADM (PAMP peptides) or amino acids 95-146 of pre-proADM (mature adrenomedullin). The C-terminal fragment of proADM (amino acids 153 to 185 of preproADM) is referred to as adrenaline. A proADM peptide or a fragment of MR-proADM comprises, for example, 5 or more amino acids. Thus, the fragment of proADM can, for example, be selected from the group consisting of MR-proADM, PAMPs, epinephrine and mature or biologically active adrenomedullin, wherein preferably the fragment is MR-proADM.

[0127] Thus, in the context of the present invention, the fragment of proADM may preferably be selected from the group consisting of MR-proADM, PAMPs, epinephrine and mature adrenomedullin, most preferably herein said fragment is MR-proADM.

[0128] MR-proADM (EP 1488209 B1) exhibits great plasma stability, which is particularly advantageous. Furthermore, the length of the MR-proADM fragment is at least 12 amino acids, preferably greater than 25 amino acids, more preferably greater than 40 amino acids.

[0129] Furthermore, the present invention encompasses the precursors of MR-proADM, namely proADM (SEQ ID No. 3) and preproADM (SEQ ID No. 4) as well as fragments thereof. Within the scope of the present invention, "pro-Adrenomedullin (proADM)" is understood to be a human protein or polypeptide having a sequence of 1-185 amino acids. Thus, the length of the proADM fragment is at least 12 amino acids, preferably greater than 80 amino acids, more preferably greater than 150 amino acids. proADM may include post-translational modifications, such as glycosylation, lipidation or derivatization.

[0130] This precursor peptide contains, in particular, a 21 amino acid signal sequence at the N-terminus and is called "pre-adrenomedullin" (pre-proADM) (Kitamura K, Sakata J, Kangawa K, Kojima M, Matsuo H, Eto T. Cloning and characterization of cDNA encoding a precursor for human adrenomedullin, Biochem Biophys Res Commun 1993: 194: 720-725). Pre-proADM contains 185 amino acids and has a sequence according to SEQ ID No: 4. Known fragments of pre-pro-ADM include PAMP (AA 22-41), MR-pro-ADM (mid-region pro-adrenomedullin) (AA 45-92) (SEQ ID No: 2), ADM (adrenomedullin) and the biologically active form of ADM (AA 95-146), CT-pro-ADM (epinephrine) (AA 153-185) and "pro-adrenomedullin" (proADM) (AA22-185) (SEQ ID No: 3).

[0131] To date, only a few of the peptide fragments formed during the cleavage of pre-proADM have been more precisely characterized, in particular the physiologically active peptide adrenomedullin (ADM) and the "PAMP", a peptide consisting of 20 amino acids (22-41) that follows the 21 amino acids of the signal peptide in pre-proADM.

[0132] EP0622458B1 also describes N-terminal fragments of (pro)adrenomedullin, such as PAMP, for use in diagnosis (Hashida S, Kitamura K, Nagatomo Y, Shibata Y, Imamura T, Yamada K, et al., Development of an ultra-sensitive enzyme immunoassay for human pro-adrenomedullin N-terminal peptide and direct measurement of two molecular forms of PAMP in plasma from healthy subjects and patients with cardiovascular disease. Clin Biochem 2004; 37: 14-21).

[0133] EP 2 111 552 B1 also describes a C-terminal fragment of (pro)pro-adrenomedullin, CT-pro-ADM (adrenaline), for use in diagnosis.

[0134] As used herein, the term "subject or synonym patient" refers to a human or non-human living organism who is receiving medical care or should receive medical care due to a disease, particularly an infection. This includes people without clear disease who are being examined for signs of pathology. Thus, the methods and assays described herein are applicable to both human and veterinary diseases.

[0135] In the sense of the present invention, the term "patient with increased risk" refers in particular to a subject with a higher tendency to get an infection or develop complications. Such patients may have comorbidities or physical or mental limitations, such as autoimmune disorders, diabetes; or host response defects, such as patients with cancer or loss of function of parts of the immune system (e.g. tonsils) or patients receiving immunosuppressive medications (e.g. after transplantation or HIV); or specific elderly groups, such as the elderly or young children or infants; or patients with organ defects such as cardiovascular defects, such as heart failure, myocarditis, pericarditis, heart valve defects, atherosclerosis or renal failure, respiratory disorders such as COPD, asthma or mucoviscidosis; skin defects, such as burns or more extensive skin inflammation; gastrointestinal defects, such as Morbus Crohn, gastritis or gallstones; or liver defects, such as hepatitis, cirrhosis or drug / alcohol dependence or addiction; or cognitive impairment, such as unconscious patients or dementia, or taking drugs that increase the risk of serious adverse events; or obesity.

[0136] In the sense of the present invention, the term "therapeutic intervention or management or guidance" refers to the decision of medical activities based on the clinical picture in combination with biomarker values ​​or clinical parameters. If the determined PCT and / or ADM values ​​indicate a serious condition or infection or an increased risk of getting an infection or complication, medical measures are taken, such as the administration of drugs such as antibiotics and / or pharmaceutical products and / or minimally invasive or invasive procedures such as surgery and / or organ support measures, such as the application of fluids such as Hartmann's solution, transfusion of blood or blood fragments, fluid boluses to maintain or restore fluid balance, circulation and metabolism and / or support of breathing by, for example, oxygen, ventilation (e.g. mechanical ventilation) and / or organ support measures, such as hemodilution, apheresis, renal replacement therapy such as dialysis, immunosuppressive drugs such as steroids, pain treatment or isolation of the patient from other patients.

[0137] In the sense of the present invention, the term "infection" refers to the invasion of the body tissues of an organism by the propagation of pathogenic agents such as bacteria, viruses, fungi or parasites, as well as the response of host tissues to the infectious agents and the toxins they produce. Infectious diseases, also known as transmissible diseases or infectious diseases, are illnesses caused by infection. Such infectious diseases can preferably be treated by administering antibiotics.

[0138] The term "infection" as used in vi-xiii includes the description of the above explanations, and in particular for cases with PCT below 0.1 ng / mL, early stages of infection, early stages of bacterial infection, non-bacterial infection or other non-infectious diseases or conditions, which can be assessed as severe by combined measurement of proADM or its fragments, especially equal to or higher than 0.88 nmol / L, 1.28 nmol / L, 1.5 nmol / L or 2.75 nmol / L.

[0139] In a preferred embodiment, the present invention relates to infections caused by bacteria, i.e. bacterial infections. Disorders and / or symptoms vary depending on the type of bacteria and the location of the bacterial infection. These disorders and / or symptoms often overlap with other diseases or conditions and may be selected from the group comprising headache, pain in a particular part of the body (e.g., abdomen), temperature disorders (>38°C (fever), >36°C), respiratory symptoms selected from the group comprising cough, sputum, dyspnea, shortness of breath, and pleural pain; a finding during auscultation (e.g., rales, crepitus) and a sign of infection (core body temperature>38°C, shivering) and a sign of digestive tract infection (nausea, vomiting, diarrhea), urinary system problems, circulatory disorders such as rapid pulse, blood pressure disorders, age, compromised immune system, and other signs or risk factors of infection.

[0140] Typical symptoms of infection are localized redness, warmth, swelling, and pain. One of the hallmarks of a bacterial infection is localized pain, which is pain in a specific part of the body. For example, if there is a cut and it becomes infected with bacteria, pain will occur at the site of infection. Bacterial sore throats are often characterized by increased pain on one side of the throat. If the pain only occurs in one ear, an ear infection is more likely to be a bacterial infection.

[0141] As mentioned above, bacterial infection symptoms vary depending on the type of infection. Depending on the area of ​​infection, the symptoms may vary. However, even if the area is slightly infected, symptoms are always present. When bacterial infection is found in the respiratory tract, symptoms related to the throat and breathing are found. Throat infections are very common among people living in areas with high pollution. Pneumonia is common in children and the elderly because their natural immunity will be low. Bronchitis, sinusitis, and pharyngitis are also found in people with bacterial infections. When bacterial infection is in the respiratory tract, colored nasal discharge and headaches are usually present.

[0142] When an infection is found in the digestive tract, such as gastroenteritis, the symptoms are mostly related to digestive problems. Inflammation and pain in the stomach are common. Diarrhea and vomiting are other symptoms that indicate a gastrointestinal infection. Severe bacterial infection symptoms may also lead to nausea, metabolic imbalances such as excess stomach acid, and dehydration.

[0143] A foul or fishy odor in the vaginal area is a symptom of vaginal infection. A woman’s vagina has several bacteria that are beneficial to the organ. However, if the production of this bacteria is irregular, it can lead to infection. Symptoms of bacterial infection in the urinary tract include itching and pain in the urinary organ. Vaginal infections and urinary tract infections should not be ignored as they can lead to further inflammation of internal organs such as the kidneys.

[0144] Meningitis is a serious consequence of a bacterial infection in the membranes that cover the brain and spinal cord. Although this can also occur in adults, infants are more susceptible to this problem. Common bacterial infection symptoms of meningitis are body and neck stiffness, headache, irritability, fever or below normal body temperature, and rash.

[0145] Erysipelas is an acute bacterial infection of the dermis that causes inflammation. Patients usually present within 48 hours of the initial infection with symptoms that include high fever, shaking, chills, headache, and vomiting. Erythematous skin lesions enlarge rapidly and have sharply demarcated, raised edges. It presents as a red, swollen, warm, hardened, and painful rash that resembles an orange peel in terms of consistency. More severe infections may cause blisters, bullae, and ecchymoses and may cause skin necrosis. Lymph nodes may swell and lymphedema may occur. Occasionally, red streaks extending to the lymph nodes may be seen. The infection may occur anywhere on the skin, including the face, arms, fingers, legs, and toes, but it tends to favor the extremities. Fatty tissue is most susceptible to infection, and typically in the facial area around the eyes, ears, and cheeks.

[0146] Peritonitis is the inflammation of the peritoneum, the serous membrane that surrounds the abdominal cavity and visceral parts. Peritonitis can be local or extensive, and may be caused by infection (usually caused by the rupture of hollow organs, as may occur in abdominal trauma or appendicitis). The main manifestations of peritonitis are acute abdominal pain, abdominal tenderness and abdominal wall tension. The position of these manifestations depends on whether peritonitis is local (for example, appendicitis or diverticulitis before perforation) or spreads throughout the whole abdomen. In either case, pain typically begins as extensive abdominal pain (relating to the local poor innervation of the visceral peritoneal layer), and may become local (relating to the peritoneal layer of the somatic nerve innervation) at a later time. Perforation of a part of the gastrointestinal tract and peritoneal rupture are the most common causes of infectious peritonitis.

[0147] Cholangitis is an inflammation of the bile ducts. The most common cause is a bacterial infection. The classic triad of symptoms of cholangitis is fever, jaundice, and pain in the right upper abdomen.

[0148] Cholecystitis is an inflammation of the gallbladder and usually presents with pain in the right upper abdomen. It is often accompanied by a low-grade fever, vomiting, and nausea.

[0149] Osteomyelitis refers to infection of the bone or bone marrow. In general, microorganisms may infect the bone by one or more of three basic methods: via the bloodstream, proximity to a localized area of ​​infection, or penetrating trauma, including iatrogenic causes such as internal fixation of a joint replacement or fracture or a tooth following a root canal filling. Signs and symptoms of osteomyelitis include fever, pain in the infected area, swelling, warmth, and redness over the infected area.

[0150] By far the most dangerous bacterial infection leads to sepsis, a severe condition that causes organ dysfunction and results in death. Fever and severe body shaking are symptoms of bacterial infection in sepsis. Patients with sepsis may also experience joint pain. This must be treated immediately to stop the spread of infection to internal organs and to prevent or overcome the cytokine storm and its fatal consequences. In the case of sepsis, the patient will be admitted to the hospital for intensive treatment. The term sepsis may alternatively be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical surgery, organ dysfunction may be preferably indicated by an increase of more than 2 points in the Sequential Organ Failure Assessment (SOFA) score, which is associated with an in-hospital mortality rate greater than 10%. Septic shock may be defined as a subset of sepsis in which particularly severe circulatory, cellular, and metabolic abnormalities produce a higher risk of death than sepsis alone. In the absence of hypovolemia, patients with septic shock may be clinically identified by the need for vasopressors to maintain a mean arterial pressure of more than 65 mm Hg and a serum lactate level greater than 2 mmol / L (>18 mg / dL). Severe sepsis refers to sepsis associated with organ dysfunction, hypoperfusion abnormalities or sepsis-induced hypotension. Hypoperfusion abnormalities include lactic acidosis, oliguria and acute changes in mental status. Sepsis-induced hypotension is defined as systolic blood pressure below about 90 mm Hg or a decrease of about 40 mm Hg or more from baseline in the absence of other causes of hypotension (e.g., cardiogenic shock). Septic shock is defined as severe sepsis in which sepsis-induced hypotension persists despite adequate fluid resuscitation, in the presence of hypoperfusion abnormalities or organ dysfunction (Bone et al., CHEST 101(6):1644-55,1992). The term "sepsis" as used herein relates to all possible stages in the development of sepsis.

[0151] Thus, the severity of the infection is associated with symptoms, illnesses, and adverse events or outcomes such as death, organ dysfunction, or other life-threatening conditions of the patient. In addition to PCT and pro-ADM, the methods and kits of the present invention may also include determining at least one other biomarker, marker, clinical score, and / or parameter.

[0152] As used herein, a parameter is a characteristic, feature, or measurable factor that can help define a particular system. Parameters are important elements for health and physiological related assessments such as risk of disease / disorder / clinical condition, preferably organ dysfunction. In addition, a parameter is defined as a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacological responses to therapeutic interventions. Exemplary parameters may be selected from the group consisting of: Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score (SAPSII score), quick Sequential Organ Failure Assessment score (qSOFA score), Sequential Organ Failure Assessment score (SOFA score), body mass index, weight, age, sex, IGS II, fluid intake, white blood cell count (particularly neutrophil bands, segmented neutrophils, eosinophils, basophils, monocytes, lymphocytes), red blood cell count, platelet count, hemoglobin, hematocrit, sodium, potassium, temperature, blood pressure, dopamine, bilirubin, respiratory rate, oxygen partial pressure, World Federation of Neurosurgical Societies (WFNS) grade and Glasgow Coma Scale (GCS).

[0153] As used herein, terms such as "marker", "surrogate", "prognostic marker", "factor" or "biomarker" or "biological marker" are used interchangeably and relate to a measurable and quantifiable biomarker (e.g., a specific protein or enzyme concentration or fragment thereof, a specific hormone concentration or fragment thereof, or the presence of a biological substance or fragment thereof) that is used as an indicator for health- and physiology-related assessments such as risk of disease / disorder / clinical condition, preferably adverse events. A marker or biomarker is defined as a characteristic that can be objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacological responses to therapeutic interventions. Biomarkers can be measured in a sample (e.g., blood, plasma, urine, or tissue tests).

[0154] The at least one other marker and / or parameter of the subject may be selected from the group consisting of: lactate level, CRP, a Sequential Organ Failure Assessment score (SOFA score) of the subject, a Simplified Acute Physiology Score (SAPSII) of the subject, an Acute Physiology and Chronic Health Evaluation II (APACHE II) score of the subject, and levels of: soluble fms-like tyrosine kinase-1 (sFlt-1), histone H2A, histone H2B, histone H3, histone H4, calcitonin, endothelin-1 (ET-1), arginine vasopressin (AVP), atrial natriuretic peptide (ANP), neutrophil gelatinase-associated lipocalin (NGAL), troponin, brain natriuretic peptide (BNP), C-reactive protein (CRP), pancreatic stone protein (PSP), triggering receptor expressed on myeloid cells 1 (TREM1), interleukin-6 (IL-6), interleukin-1, interleukin-24 (IL-24), interleukin-22 (IL-22), interleukin (IL-20), other IL, Presepsin (sCD14-ST), lipopolysaccharide binding protein (LBP), α-1-antitrypsin, matrix metalloproteinase 2 (MMP2), metalloproteinase 2 (MMP8), matrix metalloproteinase 9 (MMP9), matrix metalloproteinase 7 (MMP7), placental growth factor (PlGF), chromogranin A, S100A protein, S100B protein and tumor necrosis factor α (TNFα), neopterin, arginine vasopressin (AVP, proAVP or Copeptin), atrial natriuretic peptide (ANP, pr o-ANP), E-selectin, ICAM-1, VCAM-1, IP-10, CCL1 / TCA3, CCL11, CCL12 / MCP-5, CCL13 / MCP-4, CCL14, CCL15, CCL16, CCL17 / TARC, CCL18, CC L19, CCL2 / MCP-1, CCL20, CCL21, CCL22 / MDC, CCL23, CCL24, CCL25, CCL26, CCL27, CCL28, CCL3, CCL3L3, CCL4, CCL4L1 / LAG-1, CCL5, CC L6, CCL7, CCL8, CCL9, CX3CL1, CXCL1, CXCL10, CXCL11, CXCL12, CXCL13, CXCL14, CXCL15, CXCL16, CXCL17, CXCL2 / MIP-2, CXCL3, CXCL4 , CXCL5, CXCL6, CXCL7 / Ppbp, CXCL9, IL8 / CXCL8, XCL1, XCL2, FAM19A1, FAM19A2, FAM19A3, FAM19A4, FAM19A5, CLCF1, CNTF, IL11, IL31,IL6, ICAM, leptin, LIF, OSM, IFNA1, IFNA10, IFNA13, IFNA14, IFNA2, IFNA4, IFNA7, IFNB1, IFNE, IFNG, IFNZ, IFNA8, IFNA5 / IFNaG, IFNω / IFNW1, BAFF, 4-1BBL, TNFSF8, CD40LG, CD70, CD95L / CD178, EDA-A1, TNFSF14, LTA / TNFB, LTB, TNFa, TNFSF10, TNFSF11, TNFSF12, TNFSF13, TNFSF15, TNFSF4, IL18, IL18BP, IL1A, IL1B, IL1F10, IL1F3 / IL1RA, IL1F5, IL1F6, IL1F7, IL1F8, IL1RL2, IL1F9, IL33 or fragments thereof.

[0155] Lactate, or lactic acid, is an organic compound with the chemical formula CH3CH(OH)COOH that is found in body fluids, including blood. A blood lactate test is performed to determine the status of acid-base homeostasis in the body. Lactate is a product of cellular metabolism that accumulates when cells lack adequate oxygen (hypoxia) and must be converted to less efficient means of energy production, or when a pathological condition causes overproduction or impaired clearance of lactate. Lactic acidosis can be caused by an inadequate amount of oxygen in cells and tissues (hypoxia). For example, if someone has a condition that may result in a decreased amount of oxygen being delivered to cells and tissues, such as shock, septic shock, or congestive heart failure, a lactate test may be used to help detect and assess the severity of hypoxia and lactic acidosis.

[0156] C-reactive protein (CRP) is a pentameric protein that can be present in body fluids (e.g., plasma). CRP levels can rise in response to inflammation. Measuring and plotting CRP values ​​can prove useful in determining disease progression or treatment effectiveness.

[0157] As used herein, the "Sequential Organ Failure Assessment score" or "SOFA score" is a score used to track the status of a patient during their stay in the intensive care unit (ICU). The SOFA score is a scoring system used to determine the extent of a person's organ function or failure rate. The score is based on six different scores, each for the respiratory, cardiovascular, liver, coagulation, kidney, and nervous systems. Both the average and maximum SOFA scores are predictors of outcome. Within the first 24 to 48 hours in the ICU, an increase in the SOFA score predicts a mortality rate of at least 50% to as high as 95%. Scores below 9 predict a mortality rate of 33%, while scores above 14 may be close to or above 95%.

[0158] As used herein, the quick SOFA score (qSOFA) is a scoring system that indicates a patient's risk of organ dysfunction or death. The score is based on the following three criteria: 1) altered mental status; 2) a decrease in systolic blood pressure of less than 100 mmHg; 3) a respiratory rate greater than 22 breaths per minute. Patients with more than two of these conditions have a greater risk of organ dysfunction or death.

[0159] As used herein, "APACHE II" or "Acute Physiology and Chronic Health Evaluation II" is a scoring system for classifying severity of illness (Knaus et al., 1985). It can be applied within 24 hours of a patient's admission to the intensive care unit (ICU) and can be determined based on 12 different physiological parameters: AaDO2 or PaO2 (depending on FiO2), temperature (rectal), mean arterial pressure, pH arterial, heart rate, respiratory rate, sodium (serum), potassium (serum), creatinine, hematocrit, white blood cell count and Glasgow Coma Scale.

[0160] As used herein, "SAPS II" or "Simplified Acute Physiology Score II" refers to a system for classifying the severity of a disease or condition (see Le Gall JR et al., A new Simplified Acute Physiology Score (SAPS II) based on a European / North American multicenter study. JAMA. 1993; 270 (24): 2957-63). The SAPS II score consists of 12 physiological variables and 3 disease-related variables. The score is calculated from 12 conventional physiological measurements, information about previous health conditions, and some information obtained when admitted to the ICU. The SAPS II score can be determined at any time, preferably on the second day. The "worst" measurement result is defined as the metric associated with the highest score. The SAPS II score ranges from 0 to 163 points. The classification system includes the following parameters: age, heart rate, systolic blood pressure, body temperature, Glasgow Coma Scale, mechanical ventilation or CPAP, PaO2, FiO2, urine output, blood urea nitrogen, sodium, potassium, bicarbonate, bilirubin, leukocytes, chronic disease, and type of admission. There is an S-shaped relationship between mortality and total SAPS II score. When the SAPSII score is 29, the mortality rate of the subjects is 10%, when the SAPSII score is 40, the mortality rate is 25%, when the SAPSII score is 52, the mortality rate is 50%, when the SAPSII score is 64, the mortality rate is 75%, and when the SAPSII score is 77, the mortality rate is 90% (LeGall loc.cit.).

[0161] As used herein, the term "comparison" with respect to the use of PCT and / or proADM or fragments thereof as markers refers to comparing the presence or amount of a marker in a patient with the presence or amount of a marker in a person known to suffer from a given condition or known to be at risk for a given condition. The marker level in a patient sample can be compared with a level known to be associated with a particular prognosis. The marker level of a sample is considered to be associated with a prognosis; that is, a technician can use the marker level to determine whether a patient has a particular risk of suffering an adverse event and respond accordingly. Alternatively, the marker level of a sample can be compared with a marker level known to be associated with a good outcome (e.g., a lower risk of suffering an adverse event).

[0162] As used herein, the term "sample" refers to a bodily fluid sample obtained for the purpose of evaluating, diagnosing, prognosing or assessing a target subject, therapeutic guidance, such as a patient. Preferred test samples include blood, serum, plasma, cerebrospinal fluid, urine, saliva, sputum, and pleural effusion. In addition, those skilled in the art will recognize that some test samples will be more easily analyzed after a fractionation or purification procedure, such as separation of whole blood into serum or plasma components.

[0163] Therefore, in a preferred embodiment of the present invention, the sample is selected from the group consisting of a blood sample, a serum sample, a plasma sample, a cerebrospinal fluid sample, a saliva sample and a urine sample or an extract of any of the above samples. Preferably, the sample is a blood sample, most preferably a serum sample or a plasma sample.

[0164] In the context of the present invention, the term "plasma" is the virtually cell-free supernatant of blood containing an anticoagulant obtained after centrifugation. Exemplary anticoagulants include calcium ion binding compounds such as EDTA or citrate, and thrombin inhibitors such as heparin or hirudin. Cell-free plasma can be obtained by centrifuging anticoagulated blood (e.g., citrated, EDTA or heparinized blood) at 2000 to 3000 g, for example for at least 15 minutes.

[0165] In the context of the present invention, the term "serum" is the liquid portion of whole blood collected after the blood is allowed to clot. When the clotted blood (clotted blood) is centrifuged, serum can be obtained as the supernatant.

[0166] The term "urine" is a fluid product of the body that is secreted by the kidneys and excreted through the urethra through a process called urination (or urination).

[0167] In the sense of the present invention, the term "regular remeasurement" means within a repeated time frame, for example every 6 hours, every 12 hours, very preferably every 24 hours, every 2 days, every 3 days, every 4 days or preferably during a decision-making process, such as before changing hospital location, discharge, admission or stopping treatment or changing treatment.

[0168] In the sense of the present invention, the term "severity assessment" refers to the diagnosis and monitoring of the severity progression and onset of related infections, in particular the detection and marking of infectious diseases at different stages due to their severity. In addition, the term "severity assessment" relates to grouping subjects into different risk groups according to their further prognosis, in particular as provided by the defined cases (ibid). To this end, risk assessment also relates to stratification for the application of preventive and / or therapeutic measures.

[0169] Thus, in the context of the present invention, the term "diagnosis" relates to the identification and detection of an infection in a subject and / or the determination or exclusion of an infection and the associated severity, in particular a severe infection.

[0170] The term "monitoring" relates to following an already diagnosed infection, a condition or complication or risk associated with the infection, such as analyzing the progression of the disease or the effect of a particular treatment on the progression of the infection or a condition or complication or risk associated with the infection, and evaluating the response to treatment. A positive response may shift the marker value into the normal range and generally improve the patient's health status, such as reduced pain, improved breathing, absence of fever, etc., and indicate the correct treatment method and / or the need to change, stop or increase the medical measure or form of application (e.g., from intravenous to oral and vice versa), the change of treatment procedure / drug or medical site (from a normal work station to the ICU and vice versa or discharge).

[0171] The present invention also relates to kits, uses of kits and methods of using such kits. The present invention relates to kits for performing the methods provided above and below. The definitions provided herein, such as those provided with respect to the methods, also apply to the kits of the present invention. In particular, the present invention relates to kits for assessing, risk stratifying, monitoring, guiding treatment and / or controlling treatment of an infection or suspected infection in the subject.

[0172] The sensitivity and specificity of a diagnostic test depends not only on the analytical "quality" of the test, but also on the definition of what constitutes an abnormal result. In practice, a receiver operating characteristic curve (ROC curve) is usually calculated by plotting the relative frequencies of the variable values ​​of the "normal" (i.e., apparently healthy) and "disease" populations (i.e., patients with infection). Depending on the specific diagnostic problem being addressed, the reference group does not necessarily have to be "normal", but may be a group of patients with another disease or condition, which should be distinguished from the target disease group. For any particular marker, the distribution of marker levels for subjects with and without disease may overlap. Under these conditions, the test cannot absolutely distinguish between normal and disease with 100% accuracy, and the overlapping area indicates where the test cannot distinguish between normal and disease. A threshold is selected, above which (or below which, depending on how the marker changes with the disease) the test is considered abnormal, and below which it is considered normal. The area under the ROC curve is a measure of the probability that the perceived measurement will allow the correct identification of the condition. Even in the case where the test results do not necessarily give an exact number, the ROC curve can be used. As long as the results can be ranked, a ROC curve can be generated. For example, the test results of the "disease" sample can be ranked according to degree (e.g., 1 = low, 2 = normal, and 3 = high). This ranking can be associated with the results in the "normal" population and generate a ROC curve. These methods are well known in the art (see, for example, Hanley et al., 1982.Radiology 143:29-36). Preferably, the threshold is selected to provide a ROC curve area greater than about 0.5, more preferably greater than about 0.7. In this context, the term "about" refers to + / -5% of a given measurement value.

[0173] The horizontal axis of the ROC curve represents (1-specificity), which increases with the false positive rate. The vertical axis of the curve represents sensitivity, which increases with the true positive rate. Therefore, for the selected specific critical value, the value of (1-specificity) can be determined, and the corresponding sensitivity can be obtained. The area under the ROC curve is a measure of the probability that the measured marker level will allow the correct identification of a disease or condition (such as prognosis). Therefore, the area under the ROC curve can be used to determine the effectiveness of the test.

[0174] In certain embodiments, markers and / or marker panels are selected to exhibit a sensitivity of at least about 70%, more preferably at least about 80%, even more preferably at least about 85%, even more preferably at least about 90%, and most preferably at least about 95%, in combination with a specificity of at least about 70%, more preferably at least about 80%, even more preferably at least about 85%, even more preferably at least about 90%, and most preferably at least about 95%. In particularly preferred embodiments, both the sensitivity and specificity are at least about 75%, more preferably at least about 80%, even more preferably at least about 85%, even more preferably at least about 90%, and most preferably at least about 95%. In this context, the term "about" refers to + / - 5% of a given measurement result.

[0175] Threshold levels can be obtained, for example, from Kaplan-Meier analysis, in which the occurrence of a disease or the probability of adverse outcome and / or death is associated with, for example, quintiles of each marker in a population. According to this analysis, the risk of an adverse event according to the present invention occurring in subjects with marker levels higher than the 80th percentile is significantly increased. This result is further supported by Cox regression analysis, which adjusts for classical risk factors. The highest quartile is significantly associated with an increased risk of illness according to the present invention or the probability of adverse outcome and / or death compared to all other subjects.

[0176] Other preferred critical values ​​are, for example, the 90th, 95th or 99th percentiles of a reference population. By using a percentile higher than the 80th percentile, the number of false positive subjects identified can be reduced, but those subjects who are at medium risk but still increase risk may be missed. Therefore, the critical value can be adjusted according to being considered more suitable for identifying most risky subjects but at the expense of also identifying "false positives", or being considered more suitable for mainly identifying subjects with high risks but at the expense of missing several subjects with medium risk.

[0177] Other mathematical possibilities for calculating individual risk by using individual marker level values ​​and other prognostic laboratory and clinical parameters are, for example, NRI (net reclassification index) or IDI (integrated discrimination index). The index can be calculated according to Pencina (Pencina MJ et al.: Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond. Stat Med. 2008; 27: 157-172).

[0178] The cut-off values ​​mentioned so far for PCT and pro-ADM and its fragments may vary by up to 5%, 10%, 15%, 16%, 17% and are due to the diagnostic methods and equipment as well as normal biological variations in the patient population. For example, the cut-off value of 0,88 nmol / L mentioned for pro-ADM or its fragments has a variation of 10% within the range of 0,792-0,968 nmol / L and shows no overlap with the other mentioned cut-off values.

[0179] Preferred detection methods include various forms of immunoassays, such as mass spectrometry (MS), luminescent immunoassays (LIA), radioimmunoassays (RIA), chemiluminescent and fluorescent immunoassays, enzyme immunoassays (EIA), enzyme-linked immunoassays (ELISA), luminescent-based bead arrays, magnetic bead-based arrays, protein microarray assays, rapid test formats (e.g., immunochromatographic strip tests), rare cryptate assays, and automated systems / analyzers (e.g., KRYPTOR assays).

[0180] The assay can be a homogeneous or heterogeneous assay, a competitive and non-competitive assay. In a particularly preferred embodiment, the assay is in the form of a sandwich assay, which is a non-competitive immunoassay, in which the molecule to be detected and / or quantified is bound to a first antibody and a second antibody. The first antibody can be bound to a solid phase, such as a bead, a surface of a well or other container, a chip or a strip, and the second antibody is, for example, an antibody labeled with a dye, with a radioisotope or a reactive or catalytically active portion. The amount of the labeled antibody bound to the analyte is then measured by an appropriate method. The general compositions and procedures relating to "sandwich assays" are well established and known to the skilled person (The Immunoassay Handbook, David Wild, ed., Elsevier LTD, Oxford; 3rd edition (May 2005), ISBN-13:978-0080445267; Hultschig C et al., Curr Opin Chem Biol. 2006 Feb; 10(1):4-10. PMID: 16376134, incorporated herein by reference).

[0181] In a preferred embodiment, the assay comprises two capture molecules, preferably antibodies, both present in dispersed form in a liquid reaction mixture, wherein a first labeling component is attached to a first capture molecule, wherein the first labeling component is part of a labeling system based on fluorescence or chemiluminescence quenching or amplification, and a second labeling component of the labeling system is attached to a second capture molecule so as to generate a measurable signal upon binding of the two capture molecules to the analyte, which signal allows detection of a sandwich complex formed in a solution containing the sample.

[0182] Even more preferably, the labeling system comprises a rare earth cryptate or a rare earth chelate in combination with a fluorescent dye or a chemiluminescent dye, in particular a dye of the cyanine type.

[0183] In the context of the present invention, fluorescence-based assays include the use of dyes, which may be selected, for example, from the group consisting of: FAM (5- or 6-carboxyfluorescein), VIC, NED, fluorescein, fluorescein isothiocyanate (FITC), IRD-700 / 800, cyanine dyes such as CY3, CY5, CY3.5, CY5.5, Cy7, xanthenes, 6-carboxy-2′, 4′, 7′, 4,7-hexachlorofluorescein (HE X), TET, 6-carboxy-4′,5′-dichloro-2′,7′-dimethoxyfluorescein (JOE), N,N,N′,N′-tetramethyl-6-carboxyrhodamine (TAMRA), 6-carboxy-X-rhodamine (ROX), 5-carboxyrhodamine-6G (R6G5), 6-carboxyrhodamine-6G (RG6), rhodamine, rhodamine green, rhodamine red, rhodamine 110, BODIPY dyes such as BODIPY TMR, Oregon Green, coumarins such as umbelliferone, benzimides such as Hoechst 33258; phenanthridines such as Texas Red, Yakima Yellow, Alexa Fluor, PET, ethidium bromide, acridinium dyes, carbazole dyes, phenoxazine dyes, porphyrin dyes, polymethine dyes, etc.

[0184] In the context of the present invention, chemiluminescent assays include the use of dyes based on the physical principles described in Kirk-Othmer, Encyclopedia of chemical technology, 4th edition, JI Kroschwitz, executive editor; M. Howe-Grant, editor, John Wiley & Sons, 1993, volume 15, pages 518-562, for chemiluminescent materials, which is incorporated herein by reference, including references to pages 551-562. Preferred chemiluminescent dyes are acridinium esters.

[0185] As referred to herein, an "assay" or "diagnostic assay" may be of any type used in the field of diagnostics. Such an assay may be based on the binding of an analyte to be detected to one or more capture probes having a specific affinity. With respect to the interaction between a capture molecule and a target molecule or a target molecule, the affinity constant is preferably greater than 10 8 M -1 .

[0186] In the context of the present invention, a "capture molecule" is a molecule that can be used to bind to a target molecule or target molecule, i.e. an analyte from a sample (i.e., in the context of the present invention, PCT and fragments thereof and / or pro-ADM or fragments thereof). Therefore, the capture molecule must be appropriately shaped spatially and in terms of surface characteristics (e.g., surface charge, hydrophobicity, hydrophilicity, presence or absence of Lewis donors and / or receptors) to specifically bind to the target molecule or target molecule. Therefore, binding can be mediated, for example, by ionic, van der Waals, π-π, δ-π, hydrophobic or hydrogen bond interactions between the capture molecule and the target molecule or target molecule, or a combination of two or more of the above interactions. In the context of the present invention, the capture molecule can, for example, be selected from the group comprising: a nucleic acid molecule, a carbohydrate molecule, a PNA molecule, a protein, an antibody, a peptide or a glycoprotein. Preferably, the capture molecule is an antibody, including fragments thereof having sufficient affinity to the target or target molecule, and includes recombinant antibodies or recombinant antibody fragments, as well as chemically and / or biochemically modified derivatives of the antibody or fragments derived from variant chains thereof having a length of at least 12 amino acids.

[0187] Furthermore, the present invention relates to a computer-based tool for inputting and evaluating data, processing relevant workflow content or said decision tree or matrix and outputting measurement values ​​and management recommendations, for example by using artificial intelligence and / or may include machine learning to support the management of clinical decisions, wherein the reference data is stored on a computer-readable medium and / or is used in the form of a computer-executable code, which is configured for comparing the determined level of PCT or a fragment thereof and / or the determined level of proADM or a fragment thereof with said reference data, and wherein said reference data refers to the threshold levels as indicated above in the embodiments disclosed herein.

[0188] Examples and Figure 3-7

[0189] The present invention is further described by the following examples and figures. These examples and figures are not intended to limit the scope of the present invention, but rather represent preferred embodiments of aspects of the present invention provided to better illustrate the invention described herein.

[0190] patient:

[0191] The mentioned patients had physiological signs or increased risk factors for infection when they entered the ED. Blood samples were collected after entering the ED (time point 0). Concentrations in plasma (for MR-proADM) and serum (for PCT) were measured using the TRACE (Time Resolved Amplified Cryptate Emission) technology in combination with a novel sandwich immunoassay (Kryptor Compact Plus Analyzer, BRAHMS, Hennigsdorf, Germany). The endpoints of the study were, in particular, treatment with antibiotics and 28-day mortality.

[0192] Statistical analysis:

[0193] For categorical variables, use χ 2 Test, and according to the normality of distribution, Student t test or Mann-Whitney U test was used for continuous variables to evaluate the clinical characteristics differences about 28-day mortality. Normally distributed and non-normally distributed variables are represented by mean (standard deviation) and median [first quartile-third quartile], respectively. The association between antibiotic guidance, severity of disease state (especially infection) and mortality prediction within 28 days and other clinical parameters and scores of each biomarker is evaluated using, for example, the area under the receiver operating characteristic curve (AUROC), logistic and Cox regression analysis. Logistic regression models are created separately using biomarkers or scores, or adjusted using variables such as mortality or treatment, and represented by, for example, odds ratio (OR) and 95% confidence interval [95% CI]. Bilateral p<0.05 is considered statistically significant. All data are analyzed using recognized statistical software. Software capable of performing such analysis to establish appropriate reference levels and critical values, such as JMP 12, JMP 13, and Statistical Discovery from SAS, can be used.

[0194] Group:

[0195] The statistical calculations are based on

[0196] In Group 1 involving (iv)

[0197] PCT < 0.1 and MR-proADM < 0.88

[0198] N = 129

[0199] Hospitalization / admission rate: 33.1%

[0200] Antibiotic administration rate: 65.3%

[0201] Intravenous antibiotic administration rate: 22.6%

[0202] Oral antibiotic administration rate: 41.9%

[0203] 28-day mortality rate: 0.0%

[0204] In group 2 involving (v)

[0205] PCT < 0.1 and MR-proADM ≥ 0.88

[0206] N = 68

[0207] Hospitalization / admission rate: 83.8%

[0208] Antibiotic administration rate: 67.7%

[0209] Intravenous antibiotic administration rate: 46.2%

[0210] Oral antibiotic administration rate: 23.1%

[0211] 28-day mortality rate: 8.9%

[0212] In group 3 involving (v)

[0213] PCT < 0.1 and MR-proADM ≥ 0.88 and < 1.28

[0214] N=29

[0215] Hospitalization / admission rate: 82.5%

[0216] Antibiotic application rate: 60.0%

[0217] Intravenous antibiotic administration rate: 35.9%

[0218] Oral antibiotic administration rate: 20.5%

[0219] 28-day mortality rate: 5.0%

[0220] In group 1b involving (vii)

[0221] PCT ≥ 0.1 and MR-proADM < 0.88

[0222] N = 106

[0223] Hospitalization / admission rate: 61.3%

[0224] Antibiotic administration rate: 87.4%

[0225] Intravenous antibiotic administration rate: 32.6%

[0226] Oral antibiotic administration rate: 38.9%

[0227] 28-day mortality rate: 0.0%

[0228] Group 2b referring to (viii):

[0229] PCT < 0.1 and MR-proADM ≥ 0.88

[0230] N = 419

[0231] Hospitalization / admission rate: 96.2%

[0232] Antibiotic administration rate: 92.8%

[0233] Intravenous antibiotic administration rate: 81.6%

[0234] Oral antibiotic administration rate: 10.4%

[0235] 28-day mortality rate: 16.0%

[0236] Group 3b referring to (viii):

[0237] PCT ≥ 0.1 and MR-proADM ≥ 0.88 and < 1.28

[0238] N=99

[0239] Hospitalization / admission rate: 90.0%

[0240] Antibiotic administration rate: 84.3%

[0241] Intravenous antibiotic administration rate: 55.1%

[0242] Oral antibiotic administration rate: 29.2%

[0243] 28-day mortality rate: 0.0%

[0244] Group 4: PCT ≥ 0.1 and MR-proADM ≥ 1.50

[0245] N = 262

[0246] Hospitalization rate: 97.3%

[0247] Antibiotic administration rate: 96.0%

[0248] Intravenous antibiotic administration rate: 92.2%

[0249] Oral antibiotic administration rate: 4.1%

[0250] 28-day mortality rate: 24.7%

[0251] Group 5: PCT ≥ 0.1 and MR-proADM ≥ 2.75

[0252] N = 102

[0253] Hospitalization rate: 98.6%

[0254] Antibiotic administration rate: 98.1%

[0255] Intravenous antibiotic administration rate: 95.9%

[0256] Oral antibiotic administration rate: 2.0%

[0257] 28-day mortality rate: 34.0%

[0258] RRT demand: 15.0%

[0259]

[0260] Supplemental oxygen: 61.6%

[0261] Group 4: PCT < 0.1 and MR-proADM ≥ 1.50

[0262] N = 18

[0263] Hospitalization rate: 94.4%

[0264] Antibiotic administration rate: 88.9%

[0265] Intravenous antibiotic administration rate: 72.2%

[0266] Oral antibiotic administration rate: 22.2%

[0267] 28-day mortality rate: 22.2%

[0268] Group 5: PCT < 0.1 and MR-proADM ≥ 1.50

[0269] N=4

[0270] Figure 3 Shown: Kaplan-Meier curve using the optimized MR-proADM cutoff value of 0.88 nmol / L, which shows complete exclusion of 28-day mortality.

[0271] Figure 4 Shown is the ROC analysis of ADM (black) and PCT (grey) in patients on ED admission to predict 28-day mortality.

[0272]

[0273] Table 1:The area under the curve (AUC and 95% confidence interval (CI)), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), negative likelihood ratio (LR-), and diagnostic odds ratio (OR) of receiver operating characteristic (ROC) analysis for 28-day mortality using MR-proADM and PCT in patients at ED admission.

[0274] Table 1 shows that the MR-proADM cut-off value was 1.5 nmol / l, with an AUC of 0.84 (0.78-0.89), a sensitivity of 0.8 [0.61-0.92], a specificity of 0.79 [0.75-0.82], a PPV of 0.15 [0.12-0.18], a NPV of 0.99 [0.98-0.99], a LR+ of 3.74 [2.96-4.72], a LR- of 0.25 [0.12-0.52] and an OR of 14.7 [5.9-36.7]. Table 1 shows that the PCT cutoff value was 2.0 ng / ml, the AUC was 0.68 (0.59-0.77), the sensitivity was 0.8 [0.61-0.92], the specificity was 0.49 [0.45-0.53], the PPV was 0.07 [0.06-0.08], the NPV was 0.98 [0.96-0.99], the LR+ was 1.58 [1.30-1.91], the LR- was 0.41 [0.2-0.83] and the OR was 3.9 [1.6-9.6].

[0275] Figure 5 ROC analysis of ADM (black) and PCT (grey) at ED entry is shown to identify patients with increasing levels of disease severity as determined by current organ function (SOFA equal to or above 2 points).

[0276]

[0277] Table 2 : Area under the curve (AUC and 95% confidence interval (CI)), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), negative likelihood ratio (LR-), and odds ratio (OR) of receiver operating characteristic (ROC) analysis of MR-proADM and PCT in patients with increasing disease severity on ED admission.

[0278] Table 2 shows that the MR-proADM cut-off value was 1.28 nmol / l, AUC was 0.78 (0.69-0.87), sensitivity was 0.87 [0.66-0.97], specificity was 0.6 [0.56-0.64], PPV was 0.07 [0.06-0.09], NPV was 0.99 [0.98-1.00], LR+ was 2.18 [1.82-2.63], LR- was 0.22 [0.08-0.62] and OR was 10.1 [2.0-34.3]. Table 2 shows that the PCT cut-off value was 0.47 ng / ml, AUC was 0.71 (0.61-0.82), sensitivity was 0.7 [0.47-0.87], specificity was 0.66 [0.63-0.70], PPV was 0.07 [0.05-0.08], NPV was 0.98 [0.97-0.99], LR+ was 2.07 [1.55-2.77], LR- was 0.46 [0.25-0.85] and OR was 4.5 [1.8-11.1].

[0279] Figure 6 ROC analysis of ADM (black) and PCT (grey) in patients requiring antibiotic administration after ED admission is shown.

[0280]

[0281] Table 3 : Area under the curve (AUC and 95% confidence interval (CI)), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), negative likelihood ratio (LR-), and odds ratio (OR) of receiver operating characteristic (ROC) analysis of MR-proADM and PCT in patients requiring antibiotic administration on ED admission.

[0282] Table 3 shows that the MR-proADM cut-off value was 0.88 nmol / l, AUC was 0.77 (0.72-0.81), sensitivity was 0.78 [0.74-0.82], specificity was 0.64 [0.56-0.71], PPV was 0.86 [0.84-0.88], NPV was 0.50 [0.45-0.56], LR+ was 2.16 [1.76-2.65], LR- was 0.34 [0.28-0.42] and OR was 6.4 [4.4-9.3]. Table 3 shows that the PCT cut-off value was 0.1 ng / ml, the AUC was 0.73 (0.69-0.78), the sensitivity was 0.85 [0.81-0.88], the specificity was 0.50 [0.42-0.57], the PPV was 0.83 [0.81-0.85], the NPV was 0.53 [0.47-0.60], the LR+ was 1.69 [1.45-1.97], the LR- was 0.30 [0.24-0.39] and the OR was 5.6 [3.8-8.2].

[0283] Figure 7 ROC analysis of ADM (black) and PCT (grey) in patients requiring hospitalization after ED admission is shown.

[0284]

[0285] Table 4 : Area under the curve (AUC and 95% confidence interval (CI)), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), negative likelihood ratio (LR-), and odds ratio (OR) of receiver operating characteristic (ROC) analysis of MR-proADM and PCT in patients decided to be hospitalized at ED admission.

[0286] Table 4 shows that the MR-proADM cut-off value was 0.88 nmol / l, AUC was 0.78 (0.74-0.82), sensitivity was 0.79 [0.76-0.83], specificity was 0.65 [0.57-0.72], PPV was 0.86 [0.83-0.88], NPV was 0.54 [0.49-0.59], LR+ was 2.26 [1.84-2.77], LR- was 0.32 [0.26-0.39] and OR was 7.1 [4.9-10.4]. Table 4 shows that the PCT cut-off value was 0.19 ng / ml, the AUC was 0.73 (0.69-0.77), the sensitivity was 0.63 [0.59-0.67], the specificity was 0.73 [0.66-0.79], the PPV was 0.86 [0.83-0.89], the NPV was 0.42 [0.39-0.46], the LR+ was 2.31 [1.8-2.95], the LR- was 0.51 [0.44-0.59] and the OR was 4.5 [3.1-6.6].

[0287] The scope of the present invention is not limited by the specific embodiments described herein. In fact, various modifications of the present invention other than those described herein will become apparent to those skilled in the art from the foregoing description and the accompanying drawings. Such modifications are intended to fall within the scope of the appended claims. It should also be understood that all values ​​are approximate and are provided for description.

[0288] sequence

[0289] SEQ ID NO: 1 (amino acid sequence of PCT):

[0290]

[0291] SEQ ID NO: 2 (amino acid sequence of MR-pro-ADM):

[0292]

[0293] SEQ ID NO:3 (amino acid sequence of proADM)

[0294]

[0295] SEQ ID NO:4 (amino acid sequence of pre-proADM)

[0296]

[0297] Sequence Listing <110> BRAHMS GMBH <120> Workflow for risk assessment and patient management using procalcitonin and mid-region proadrenomedullin <130> BRA66WO <140> EP17209151.4 <141> 2017-12-20 <160> 4 <170> PatentIn 3.5 Edition <210> 1 <211> 116 <212> PRT <213> Homo sapiens <400> 1 Ala Pro Phe Arg Ser Ala Leu Glu Ser Ser Pro Ala Asp Pro Ala Thr 1 5 10 15 Leu Ser Glu Asp Glu Ala Arg Leu Leu Leu Ala Ala Leu Val Gln Asp 20 25 30 Tyr Val Gln Met Lys Ala Ser Glu Leu Glu Gln Glu Gln Glu Arg Glu 35 40 45 Gly Ser Ser Leu Asp Ser Pro Arg Ser Lys Arg Cys Gly Asn Leu Ser 50 55 60 Thr Cys Met Leu Gly Thr Tyr Thr Gln Asp Phe Asn Lys Phe His Thr 65 70 75 80 Phe Pro Gln Thr Ala Ile Gly Val Gly Ala Pro Gly Lys Lys Arg Asp 85 90 95 Met Ser Ser Asp Leu Glu Arg Asp His Arg Pro His Val Ser Met Pro 100 105 110 Gln Asn Ala Asn 115 <210> 2 <211> 48 <212> PRT <213> Homo sapiens <400> 2 Glu Leu Arg Met Ser Ser Ser Tyr Pro Thr Gly Leu Ala Asp Val Lys 1 5 10 15 Ala Gly Pro Ala Gln Thr Leu Ile Arg Pro Gln Asp Met Lys Gly Ala 20 25 30 Ser Arg Ser Pro Glu Asp Ser Ser Pro Asp Ala Ala Arg Ile Arg Val 35 40 45 <210> 3 <211> 164 <212> PRT <213> Homo sapiens <400> 3 Ala Arg Leu Asp Val Ala Ser Glu Phe Arg Lys Lys Trp Asn Lys Trp 1 5 10 15 Ala Leu Ser Arg Gly Lys Arg Glu Leu Arg Met Ser Ser Ser Tyr Pro 20 25 30 Thr Gly Leu Ala Asp Val Lys Ala Gly Pro Ala Gln Thr Leu Ile Arg 35 40 45 Pro Gln Asp Met Lys Gly Ala Ser Arg Ser Pro Glu Asp Ser Ser Pro 50 55 60 Asp Ala Ala Arg Ile Arg Val Lys Arg Tyr Arg Gln Ser Met Asn Asn 65 70 75 80 Phe Gln Gly Leu Arg Ser Phe Gly Cys Arg Phe Gly Thr Cys Thr Val 85 90 95 Gln Lys Leu Ala His Gln Ile Tyr Gln Phe Thr Asp Lys Asp Lys Asp 100 105 110 Asn Val Ala Pro Arg Ser Lys Ile Ser Pro Gln Gly Tyr Gly Arg Arg 115 120 125 Arg Arg Arg Ser Leu Pro Glu Ala Gly Pro Gly Arg Thr Leu Val Ser 130 135 140 Ser Lys Pro Gln Ala His Gly Ala Pro Ala Pro Pro Ser Gly Ser Ala 145 150 155 160 Pro His Phe Leu <210> 4 <211> 185 <212> PRT <213> Homo sapiens <400> 4 Met Lys Leu Val Ser Val Ala Leu Met Tyr Leu Gly Ser Leu Ala Phe 1 5 10 15 Leu Gly Ala Asp Thr Ala Arg Leu Asp Val Ala Ser Glu Phe Arg Lys 20 25 30 Lys Trp Asn Lys Trp Ala Leu Ser Arg Gly Lys Arg Glu Leu Arg Met 35 40 45 Ser Ser Ser Tyr Pro Thr Gly Leu Ala Asp Val Lys Ala Gly Pro Ala 50 55 60 Gln Thr Leu Ile Arg Pro Gln Asp Met Lys Gly Ala Ser Arg Ser Pro 65 70 75 80 Glu Asp Ser Ser Pro Asp Ala Ala Arg Ile Arg Val Lys Arg Tyr Arg 85 90 95 Gln Ser Met Asn Asn Phe Gln Gly Leu Arg Ser Phe Gly Cys Arg Phe 100 105 110 Gly Thr Cys Thr Val Gln Lys Leu Ala His Gln Ile Tyr Gln Phe Thr 115 120 125 Asp Lys Asp Lys Asp Asn Val Ala Pro Arg Ser Lys Ile Ser Pro Gln 130 135 140 Gly Tyr Gly Arg Arg Arg Arg Arg Ser Leu Pro Glu Ala Gly Pro Gly 145 150 155 160 Arg Thr Leu Val Ser Ser Lys Pro Gln Ala His Gly Ala Pro Ala Pro 165 170 175 Pro Ser Gly Ser Ala Pro His Phe Leu 180 185

Claims

1. Use of at least two capture molecules in the preparation of a kit for assessing the severity of an infection in a subject, wherein the capture molecules are used to: (a) determine the level of procalcitonin PCT, and (b) determine the level of mid-region proadrenomedullin MR-proADM, wherein the kit is configured to compare the determined levels of (a) PCT and (b) MR-proADM with threshold values ​​of (a) PCT and (b) MR-proADM contained in the kit, wherein the threshold is selected from the values ​​in the following features (iv) to (xiii), The kit is prepared as follows: (i) determining the level of PCT in a body fluid sample from the subject, and (ii) determining the level of MR-proADM in a body fluid sample from the subject, and (iii) determining the severity of infection in a subject suspected of infection or having infection by comparing said determined PCT level and MR-proADM level with a threshold level, (iv) wherein a PCT below a threshold level of 0.1 ng / ml and a MR-proADM below a threshold level of 0.88 nmol / L indicates that the subject has a non-severe infection, and / or (v) wherein a threshold level of PCT below 0.1 ng / ml and a threshold level of MR-proADM equal to or above 0.88 nmol / L and not equal to or above 1.28 nmol / L indicates that the subject has a mostly non-serious infection, and / or (vi) wherein a threshold level of PCT below 0.1 ng / ml and a threshold level of MR-proADM equal to or above 1.28 nmol / L indicates that the subject has a low severity infection, and / or (vii) wherein a PCT equal to or above a threshold level of 0.1 ng / ml and a MR-proADM below a threshold level of 0.88 nmol / L indicates that the subject has a very low severity infection, and / or (viii) wherein a threshold level of PCT equal to or above 0.1 ng / ml and a threshold level of MR-proADM equal to or above 0.88 nmol / L and not equal to or above 1.28 nmol / L indicates that the subject has a low severity infection, and / or (ix) wherein a PCT equal to or above a threshold level of 0.1 ng / ml and a MR-proADM equal to or above a threshold level of 1.28 nmol / L indicates that the subject has a severe infection, and / or (x) wherein a threshold level of PCT below 0.1 ng / ml and a threshold level of MR-proADM equal to or above 1.50 nmol / L indicates that the subject has a severe infection, and / or (xi) wherein a threshold level of PCT below 0.1 ng / ml and a threshold level of MR-proADM equal to or above 2.75 nmol / L indicates that the subject has a severe infection, and / or (xii) wherein a PCT equal to or above a threshold level of 0.1 ng / ml and a MR-proADM equal to or above a threshold level of 1.50 nmol / L indicates that the subject has a high severity infection, and / or (xiii) wherein a PCT equal to or above a threshold level of 0.1 ng / ml and a MR-proADM equal to or above a threshold level of 2.75 nmol / L indicates that the subject has a very high severity infection.

2. The use according to claim 1, wherein the determined PCT level and MR-proADM level are compared with the PCT and MR-proADM threshold levels of at least two of features (iv) to (xiii).

3. The use according to claim 1, wherein the determined PCT level and MR-proADM level are compared with the PCT and MR-proADM threshold levels of at least one of features (v), (vi), (x) and (xi).

4. The use according to claim 1, wherein a threshold level of MR-proADM equal to or above 1.28 nmol / L indicates that one or more of the following measures i)-iv) are applicable: i) blood culture testing from a central venous line and / or different sources and samples, ii) oral or intravenous administration of antibiotics, iii) if the test result in i) is negative and the PCT is less than 0.1 ng / ml, stop administering antibiotics, or iv) Monitor blood test results.

5. The use according to claim 1, wherein If (iv) is applicable, no antibiotics are administered to the subject, If (v) is applicable, antibiotics are not administered to the subject and a further PCT measurement should be performed on the subject's sample within at least 6-12 hours or 24 hours for clarification or investigation. If (vi) is applicable, administering an antibiotic to the subject, If (vii) applies, it is possible not to administer antibiotics to the subject, If (viii) is applicable, antibiotics may be administered to the subject and a further PCT measurement should be performed on the subject's sample within at least 6-12 hours or 24 hours for clarification or investigation. If one of (ix), (x), (xi), (xii), (xiii) is applicable, the subject is immediately administered an antibiotic.

6. The use according to claim 1, wherein If one of (v), (vi), (viii), (ix), (x), (xi), (xii), (xiii) is applicable, hospitalizing the subject, and / or If (iv) or (vii) is applicable, the subject is discharged from the hospital.

7. Use of a detection reagent for determining the level of mid-region pro-adrenomedullin MR-proADM in the preparation of a kit for assessing the severity of infection in a subject, wherein the kit is configured to compare the determined level of MR-proADM with a threshold value contained in the kit, The threshold is selected from the value in feature (ii) below: The kit is prepared as follows: (i) determining the level of MR-proADM in a body fluid sample from the subject independently of the PCT level, and (ii) determining the severity of the infection in the subject by comparing said determined MR-proADM level with a threshold level, a) where the threshold level of MR-proADM equal to or greater than 0.88 nmol / L refers to the clinical decision to assess the subject for hospital admission, or b) wherein the threshold level of the assay of MR-proADM equal to or above 1.50 nmol / L is intended to identify subjects at high risk of infection with an approximate mortality rate of at least 25%, or c) wherein the threshold level of the assay of MR-proADM equal to or above 2.75 nmol / L is intended to identify subjects at very high risk of infection with an approximate mortality rate of at least 35%, or d) wherein the threshold level of the assay where MR-proADM is equal to or greater than 2.75 nmol / L refers to a clinical decision to assess the subject for admission to the ICU.

8. Use according to claim 1 or 7, wherein the kit comprises capture molecules for determining the level of MR-proADM.

9. The use according to claim 1 or 7, wherein a threshold level of MR-proADM equal to or above 1.50 nmol / L indicates that one or more of the following measures i)-vi) are applicable: i) oxygen is provided through a mask, ii) administer fluid bolus therapy, iii) blood culture testing from a central venous line and / or different sources and samples, iv) oral or intravenous administration of antibiotics, v) monitoring blood test results, vi) monitoring urine output, or Where MR-proADM is equal to or above a threshold level of 2.75 nmol / L, it is indicated that the following measures vii) should additionally apply: vii) Monitoring of organ dysfunction, including review of clinical parameters and other life-sustaining measures.

10. The use according to claim 1 or 7, wherein the body fluid sample is selected from the group consisting of a blood sample, a serum sample and a plasma sample.

11. The use according to claim 1 or 7, wherein the subject has a bacterial infection, or wherein the subject has a suspected infection, or wherein the subject is at increased risk of getting an infection, or wherein the subject is a patient after discharge from a hospital, or wherein the subject presents at a clinical setting.

12. The use according to claim 11, wherein the subject presents to primary care or an ambulance.

13. The use according to claim 1 or 7, wherein the kit is formulated to determine at least one other marker, clinical score and / or parameter in addition to PCT and MR-proADM.

14. The use according to claim 13, wherein the marker is a biomarker.

15. The use according to claim 13, wherein the other parameters are selected from the group consisting of: Acute Physiology and Chronic Health Evaluation II, simplified acute physiology score, rapid sequential organ failure assessment score, sequential organ failure assessment score, body mass index, weight, age, sex, IGSII, fluid intake, white blood cell count, red blood cell count, platelet count, hemoglobin, hematocrit, sodium, potassium, body temperature, blood pressure, dopamine, bilirubin, respiratory rate, oxygen partial pressure, World Federation of Neurosurgical Societies grade and Glasgow Coma Scale.

16. Use according to claim 13, wherein the other parameter is the cell count of neutrophil bands, segmented neutrophils, eosinophils, basophils, monocytes or lymphocytes.

17. The use according to claim 13, wherein the other markers and / or parameters are selected from the group consisting of: lactate level, the subject's Sequential Organ Failure Assessment score, the subject's Simplified Acute Physiology Score, the subject's Acute Physiology and Chronic Health Evaluation II score, and the levels of: soluble fms-like tyrosine kinase-1, histone H2A, histone H2B, histone H3, histone H4, calcitonin, endothelin-1, neutrophil gelatinase-associated lipocalin NGAL, troponin, brain natriuretic peptide BNP, C-reactive protein CRP, pancreatic stone protein PSP, triggering receptor expressed on myeloid cells 1, interleukin-6, interleukin-1, interleukin-24, interleukin- 22. Interleukin-20, Presepsin, Lipopolysaccharide binding protein, α-1-antitrypsin, Matrix metalloproteinase 2, Matrix metalloproteinase 8, Matrix metalloproteinase 9, Matrix metalloproteinase 7, Placental growth factor, Chromogranin A, S100A protein, S100B protein and tumor necrosis factor α, Neopterin, Arginine vasopressin AVP, proAVP or Copeptin, Atrial natriuretic peptide ANP, pro-ANP, E-selectin, ICAM-1, VCAM-1, IP-10, CCL1 / TCA3, CCL11, CCL12 / MCP-5, CCL13 / MCP-4, CCL14, CCL15, CCL16, CCL17 / TARC, CCL18, CCL19, CCL2 / MCP-1, CCL20, CCL21, CCL22 / MDC, CCL23, CCL24, CCL25, CCL26, CCL27, CCL28, CCL3, CCL3L3, CCL4, CCL4L1 / LAG-1, CCL5, CCL 6. CCL7, CCL8, CCL9, CX3CL1, CXCL1, CXCL10, CXCL11, CXCL12, CXCL13, CXCL14, CXCL15, CXCL16, CXCL17, CXCL2 / MIP-2, CXCL3, CXCL4, CXCL5, CXCL6, CXC L7 / Ppbp, CXCL9, IL8 / CXCL8, XCL1, IFNA13, IFNA14, IFNA2, IFNA4, IFNA7, IFNB1, IFNE, IFNG, IFNZ, IFNA8, IFNA5 / IFNaG, IFNω / IFNW1, BAFF, 4-1BBL, TNFSF8, CD40LG, CD70, CD95L / CD178,<h2 style=";text-align:left;direction:ltr">EDA-A1, TNFSF14, LTA / TNFB, LTB, TNFa, TNFSF10, TNFSF11, TNFSF12, TNFSF13, TNFSF15, TNFSF4, IL18, IL18BP, IL1A, IL1B, IL1F10, IL1F3 / IL1RA, IL1F5, IL1F6, IL1F7, IL1F8, IL1RL2, IL1F9, IL33, etc.

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