PRO-ADM-Based Antibiotic Therapy Guidance

Abstract

The present invention relates to a method for guiding, stratifying, and / or controlling antibiotic therapy in a patient suspected of having an infection. Specifically, the method includes providing a sample from the patient, determining the level of proADM or one or more fragments thereof in the sample, and wherein the level of proADM or one or more fragments thereof in the sample indicates whether antibiotic treatment needs to be initiated or changed. In a preferred embodiment of the present invention, the method further includes determining the level of PCT or one or more fragments thereof in a sample from the patient. In addition, the present invention also relates to a kit for performing the method of the present invention.

Description

Technical Field

[0001] The present invention relates to a method for guiding, stratifying, and / or controlling antibiotic therapy in a patient suspected of having an infection. Specifically, the method includes providing a sample from the patient, determining the level of proADM or one or more fragments thereof in the sample, and wherein the level of proADM or one or more fragments thereof in the sample indicates whether antibiotic treatment needs to be initiated or changed. In a preferred embodiment of the present invention, the method includes additionally determining the level of PCT or one or more fragments thereof in a sample from the patient. Furthermore, the present invention also relates to a kit for performing the method of the present invention. Background Art

[0002] Early diagnosis and accurate assessment of the disease severity in septic patients are considered crucial in improving survival rate and efficacy through targeted therapy guidance. However, this is complicated by the non-specific signs and symptoms of the disease and exacerbated by the aging population, resistance to antibiotics, and increased use of immunosuppressants and foreign materials in the body. 1 Moreover, in cases showing a higher mortality rate in response to delayed therapeutic intervention, the timely use of antibiotics is crucial. Since most sepsis episodes initially occur in the community, the incidence of sepsis episodes may even be greatly underestimated. 2,3 The earliest opportunity for targeted clinical intervention is, for example, at the starting point of hospitalization - the emergency department (ED). 4 ;

[0003] Therefore, although many biomarkers have been established in the field of sepsis diagnosis, such as C-reactive protein (CRP) and procalcitonin (PCT), 5-8 and various algorithms have been incorporated into clinical practice, 9 there is still a need for a more accurate and rapid assessment of disease severity. This "missing link" was further emphasized in the recently revised sepsis definition, 10 wherein the assessment of life-threatening organ dysfunction using clinical severity scores such as the Sequential Organ Failure Assessment (SOFA) score and the quick SOFA (qSOFA) score was proposed. Unfortunately, time constraints and complexity issues make it particularly complex to calculate SOFA in the ED, where many constitutive parameters are not immediately available when they occur. The second severity score, qSOFA, which was constructed to address these issues, has shown extremely low sensitivity in terms of disease severity. 10,11Thus, a biomarker that is significantly elevated in the early stages of sepsis development and has high sensitivity for accurately differentiating disease severity can prove clinically useful in facilitating early treatment decisions and tailoring personalized treatment strategies. 12,13 。

[0004] One such biomarker can include mid-regional proadrenomedullin (MR-proADM), which has been shown to contribute to stabilizing the integrity of the microcirculation and microvasculature. 14-18 and can thus play a significant role in the early pathophysiological response to sepsis. Indeed, many studies have been conducted on patients in the emergency room with 19-21 lower respiratory tract 22 infections and urinary tract infections. However, few studies have investigated the disease severity in an undifferentiated group of sepsis patients in such settings.

[0005] Proadrenomedullin, specifically mid-regional proadrenomedullin (MR-proADM), has been described as a marker for infection and poor outcome 42 and has been shown to decrease with successful progression of therapy. 40，41 By taking multiple proADM measurements during antibiotic therapy, changes in ADM levels can be monitored. 40，41 However, methods such as these as described in the prior art require multiple measurements of ADM and close monitoring of changes in ADM levels, thus requiring time-intensive assessments and resulting in significant uncertainty in disease progression and treatment efficacy until additional samples can be obtained during later stages of comparable therapies. These methods do not directly enable early therapy decisions, such as changing or initiating antibiotic therapy at an early time point before the patient's condition deteriorates, as usually any changes are detected too late.

[0006] Furthermore, until the present invention, ADM has not been considered a reliable prognostic marker for disease progression or for making decisions regarding therapy. 42 。

[0007] The biomarker PCT has been used to guide antibiotic therapy 43 (EP2320237). However, a combined assessment using a specific combination of proADM and biomarker values has not been previously identified for making early and reliable decisions regarding initiating or adjusting antibiotic therapy.

[0008] In view of the prior art, there is an urgent need for additional means for antibiotic therapy selection, guidance, stratification, and / or control in the field of treating patients suspected of having an infection, specifically sepsis. SUMMARY OF THE INVENTION

[0009] In view of the difficulties in the prior art, the technical problem addressed by the present invention is to provide alternative and / or improved means for guiding, stratifying and / or controlling antibiotic therapy in patients suspected of having an infection / or presenting symptoms of an infection, specifically sepsis.

[0010] Accordingly, the present invention seeks to provide a method, a kit and further means for guiding, stratifying and / or controlling antibiotic therapy in patients suspected of having an infection, as well as a pharmaceutical composition comprising one or more antibiotic agents for treating patients suspected of having an infection. Thus, an object of the present invention is to use biomarkers or a combination of biomarkers and possibly one or more clinical scores to identify patients in need of initiating or changing antibiotic treatment.

[0011] Solutions to the technical problems of the present invention are provided in the independent claims. Preferred embodiments of the present invention are provided in the dependent claims.

[0012] Accordingly, the present invention relates to a method for guiding, stratifying and / or controlling antibiotic therapy in a patient suspected of having an infection, the method comprising:

[0013] - providing a sample from the patient, and

[0014] - determining the level of proADM or one or more fragments thereof in the sample,

[0015] - wherein the level of proADM or one or more fragments thereof in the sample indicates whether antibiotic treatment needs to be initiated or changed.

[0016] The method of the present invention provides very useful measures for medical staff treating patients suspected of having an infection due to the presence of symptoms of an infectious disease or sepsis to decide whether (immediate) antibiotic treatment is needed. The method is objective and rapid, thus providing a high degree of safety to the person responsible for the treatment measures to make the correct treatment decision. Completely unexpectedly, proADM can provide such information as the sole biomarker to be employed in a diagnostic method or in a method for treatment guidance and stratification that can be performed when first encountering a patient presenting symptoms of an infectious disease. Thus, MR-proADM can be used as a tool to facilitate early decision-making regarding antibiotic treatment.

[0017] The present invention potentially employs a series of biomarkers (proADM, PCT, lactate, C-reactive protein (CRP), and clinical severity scores (SOFA and qSOFA)) in order to assess (i) the initial need for initiation or change of antibiotic therapy, (ii) the prediction of positive blood cultures, (iii) the development of severe sepsis, and / or (iv) the disease severity as evaluated by 28-day mortality.

[0018] In some embodiments, a physician or medical staff member who encounters a patient suspected of having an infection, for example in an emergency room or primary care department but also in any other setting (such as during a house call by a doctor or medical staff, or in an ambulance or at the site of an emergency), can employ the method of the present invention in a point-of-care format, preferably in the emergency room of a primary care department. This presents a significant advantage over other biomarker tests, which require sample analysis in a laboratory, thus taking more time and enabling biomarker-based treatment decisions to be made only after several hours or even days. In contrast, the method of the present invention can be performed on-site, at the location where the patient is first encountered by the person responsible for taking the first treatment measure, such as in an emergency room, primary care department, or even an ambulance vehicle.

[0019] The method can be used to decide whether a patient suspected of having an infection should receive antibiotic therapy or whether ongoing antibiotic therapy should be continued or changed or stopped. Additionally, based on the level of proADM or a fragment thereof, it can be determined whether the patient is a high-risk patient who should be under intensive medical observation, in which case antibiotic therapy should be initiated or modified, or whether the patient is a low-risk patient with a stable or even improving health condition who may not require antibiotic therapy or a change in antibiotic therapy.

[0020] Accordingly, the method of the present invention can contribute to improving the treatment decisions to be taken when medical staff encounters a patient. The method of the present invention can distinguish high-risk patients who are more likely to require initiation or change of antibiotic therapy from low-risk patients whose health condition is stable or even improved even without initiation or change of antibiotic therapy.

[0021] In some embodiments, the method comprises or consists of a single measurement of the proADM level in a sample from the patient. This represents an improvement over methods of the prior art.

[0022] In the methods of the prior art, it is necessary to make multiple measurements over time and compare these values to determine changes in ADM levels to evaluate the efficacy of a therapy. Thus, the present invention preferably employs a single measurement of ADM and / or multiple measurements in a single sample and / or in multiple samples obtained at substantially the same time point in order to make a therapy decision regarding the initiation or change of antibiotic therapy. Until the present invention, it was not known that proADM, optionally in combination with additional markers such as PCT, could provide therapy guidance by evaluating proADM levels at a single time point.

[0023] In a further embodiment of the present invention, a level of proADM or one or more fragments thereof in a sample that is equal to or higher than 1 nmol / L, preferably equal to or greater than 1.2 nmol / L, more preferably equal to or higher than 1.27 nmol / L indicates a need to initiate or change antibiotic therapy. In an embodiment of the present invention, in the case where the level of proADM or its fragment does not indicate a need to initiate or change antibiotic therapy, the patient may be discharged, leave the ICU or any hospital or clinical setting or not be hospitalized. In an alternative embodiment, in the case where the level of proADM or its fragment indicates a need to initiate or change antibiotic therapy, the patient may be hospitalized or admitted to the ICU. In particular, in the case where the patient is already hospitalized, ICU admission may be considered. In another alternative embodiment, in the case where the level of proADM or its fragment indicates no need to initiate or change antibiotic therapy, the patient may leave the hospital or hospital setting in the case where non-intravenous antibiotics (oral antibiotics) are needed or no antibiotics are needed.

[0024] A particular advantage of the method of the present invention is that patients suspected of having an infection can be stratified with respect to the therapy required. The stratified patient groups can include patients who need to initiate or change antibiotic therapy and patients who do not need antibiotic therapy or a change in the ongoing therapy.

[0025] In addition, it may be possible to decide, based on the level of proADM or its fragment, which type of antibiotic therapy may be needed, e.g., regarding the antibiotic agent or combination of antibiotic agents to be administered, one or more administration routes of the respective antibiotic agent, and the treatment regimen, such as single or repeated or multiple administrations and potentially the administration intervals.

[0026] Accordingly, the method of the present invention can help avoid unnecessary use of antibiotics. This can enable more efficient use of antibiotics, which will not only avoid unnecessary costs but also avoid the development of antibiotic resistance or physiological side effects caused by unnecessary use of antibiotic agents. In addition, it can be easily determined which patients should be monitored during antibiotic treatment and possibly hospitalized after being encountered by medical staff, for example, in the emergency room of a hospital, and which patients can be discharged because they do not require strict monitoring. Thus, the corresponding hospital or medical institution can be managed more efficiently because only patients in need of antibiotic therapy may have to stay in the hospital for further treatment, while other patients can be discharged. This also brings significant benefits resulting from avoiding the costs of unnecessary measures that would otherwise be applied to low-risk patients who do not require antibiotic treatment.

[0027] Importantly, in a preferred embodiment, the patient of the method of the present invention has not been diagnosed with an infection or an infectious disease. However, when a patient may exhibit symptoms or signs of an infection, the patient is suspected of having an infection.

[0028] In addition, although the patient has not been diagnosed with an infectious disease or sepsis, the patient may have received antibiotic treatment, such as oral antibiotic agents.

[0029] Accordingly, the method of the present invention can be used to determine whether a subject presenting symptoms or signs of an infection should receive antibiotic treatment. The symptoms of an infection vary widely depending on the organ system that may be affected by the infection. However, such symptoms are well-defined and are well-known to persons skilled in the art, such as medical staff working in an emergency room, primary care department, hospital, or similar institution. General signs of infectious diseases and sepsis include but are not limited to fever, elevated body temperature, body temperature above 38 °C, runny nose, cough, headache, fatigue, body aches, nausea, vomiting, diarrhea, fever, chills, abdominal pain, heart rate above 90 beats per minute, respiratory rate above 20 breaths per minute, significantly reduced urine output, sudden change in mental state, decreased platelet count, difficulty breathing, abnormal heart pumping function, or low blood pressure.

[0030] In another embodiment of the present invention, the subject exhibits symptoms of sepsis.

[0031] The measured level of proADM or a fragment thereof indicates whether antibiotic treatment should be initiated or an ongoing antibiotic treatment should be changed. In other words, the level of proADM or a fragment thereof can be used as an indicator of the likelihood of the presence of an infectious disease that may require antibiotic treatment. Based on the method of the present invention, it can be determined whether treatment should be initiated, changed, or continued or whether antibiotic treatment is not required.

[0032] In the context of the present invention, a change in a patient's antibiotic treatment can involve a change in the dosage, route of administration or regimen of the antibiotic treatment or other parameters, while the changed treatment can still cover the same one or more antibiotic agents initially used. Additionally, a change in the antibiotic treatment can also and potentially additionally involve a change in the one or more antibiotic agents used to treat the patient. In some embodiments, the change can thus involve adding additional antibiotic agents or replacing one or more antibiotic agents with one or more other agents.

[0033] In a preferred embodiment, a change in the antibiotic treatment refers to starting antibiotic treatment for a patient who has not received antibiotic treatment. Further, a change in the antibiotic treatment can involve an escalation of the antibiotic treatment, for example, in terms of the route of administration, such as starting intravenous antibiotic treatment for a patient receiving oral and / or topical antibiotic treatment, where, conversely or in addition to the previous antibiotic treatment, intravenous antibiotic treatment can also be administered. Additionally, a change in the antibiotic treatment can involve a de-escalation of the antibiotic treatment in terms of the route of administration, such as replacing intravenous antibiotic treatment with oral and / or topical administration of the antibiotic treatment or discontinuing the antibiotic treatment. Moreover, a change in the antibiotic treatment can also involve a change in the administration setting of the antibiotic treatment. For example, a change in the antibiotic treatment in the sense of escalation can involve administering antibiotic treatment to a patient who was not hospitalized prior to the change in antibiotic treatment in a hospital setting, or administering antibiotic treatment to a patient who was not an ICU patient prior to the antibiotic change in an ICU setting. Herein, the terms antibiotic treatment and antibiotic therapy are used interchangeably. In some embodiments, a change in the antibiotic treatment can include administering additional or fewer antibiotic agents, depending on the results of the proADM measurement.

[0034] In some embodiments, antibiotic therapy guidance, stratification and / or control preferably involves prognosticating the success or efficacy of an ongoing antibiotic therapy, also with respect to the likelihood of future adverse events.

[0035] According to the present invention, in the context of "indicating whether antibiotic treatment needs to be started or changed", the term "indicating" is intended to serve as a measure of the likelihood that antibiotic treatment may need to be started or an ongoing antibiotic treatment may need to be changed. Preferably, an "indication" that antibiotic treatment needs to be started or changed is intended to refer to an increased likelihood that a patient suffering from an infection can be successfully treated by administering a suitable antibiotic agent so as to improve the patient's health status. On the other hand, the level of proADM or a fragment thereof can indicate the fact that, although a patient is suspected of having an infection, antibiotic treatment may not help improve the patient's condition because administering antibiotics may not result in an improvement in the health status.

[0036] In the context of the present invention, an indication to initiate or change antibiotic therapy (such as, for example, changing one or more antibiotic agents used in the antibiotic therapy of a patient suffering from an infectious disease) may be associated with an increased likelihood of the occurrence of future adverse events in the health of the patient. An indication to initiate or change antibiotic therapy may be intended as an assessment of the expected efficacy of the antibiotic treatment and will generally not be construed in a restrictive manner as definitively indicating the absolute success or failure of the antibiotic treatment, the absolute success of which may be manifested by a continued improvement in the health status of the patient.

[0037] Keeping the above in mind, the method of the present invention demonstrates a very reliable process for determining whether an initiation or change of antibiotic therapy is needed, especially when using the cut-off values disclosed herein. Surprisingly, based on the level of proADM or a fragment thereof, it may be possible to predict with confidence the likelihood of success of the antibiotic therapy to be initiated.

[0038] According to a preferred embodiment of the method of the present invention, the sample provided is isolated from the patient within 12 hours, preferably 6 hours, 2 hours, 1 hour or more preferably within 30 minutes from the first contact with a medical staff member.

[0039] In a preferred embodiment of the present invention, the sample provided is within 12 hours after the presentation of symptoms of infection and / or sepsis to a medical staff member,

[0040] preferably 6 hours, 2 hours, 1 hour or more preferably within 30 minutes after the presentation of said symptoms to a medical staff member, isolated from the patient.

[0041] The time point of the first contact between the patient and the medical staff member is defined as the time when the medical staff member first examines a patient who has contacted or has visited the medical staff member. This time point may also be a time point at which symptoms of infection or sepsis may be presented. The examination may involve a physical examination, a medical examination or a clinical examination, which may be a process in which a medical professional investigates the patient's body for signs of a disease. The examination generally involves taking a medical history, evaluating the ongoing treatment and describing symptoms as experienced by the patient. The physical examination, together with the medical history, helps to determine the correct diagnosis and envision a treatment plan.

[0042] The time point at which a medical professional becomes aware of a patient's symptoms can also be the time point at which the patient is identified as a suspected infected patient. This time point can also be referred to as the reference time point or time point 0 with respect to the time span mentioned in the context of the method of the present invention. Ideally, the sample in which the level of proADM or a fragment thereof should be measured should be isolated as soon as possible after the patient is identified as a suspected infected patient, so that the results of the sample analysis can be received very quickly and thus a proADM-based treatment decision can be taken very quickly. Starting the correct treatment very quickly after the patient's symptoms are identified is crucial for the successful efficacy of the treatment of a patient suspected of having an infection or sepsis. Therefore, preferably, in the context of the present invention, the sample is isolated within 12 hours, preferably 11 hours, 10 hours, 9 hours, 8 hours, 7 hours, 6 hours, 5 hours, 4 hours, 3 hours, 2.5 hours, 2 hours, 1.5 hours, 1 hour, 0.9 hour, 0.8 hour, 0.7 hour, 0.6 hour, 0.5 hour, 0.4 hour, 0.3 hour, 0.2 hour, 0.1 hour or immediately after the first contact with a medical staff member and / or the presentation of symptoms to a medical staff member. Preferably, the sample can be analyzed directly at the location where the sample is isolated, such as in an emergency room, a point-of-care unit or an ambulance, by using a point-of-care assay, which can be automated or semi-automated and provides results to the medical professional responsible for making the treatment decision in a very short time. In this way, the time required to obtain the information needed to make a treatment decision based on the present invention can be significantly reduced, which is crucial for the success of the possible antibiotic treatment.

[0043] In a preferred embodiment, the antibiotic treatment is started or changed immediately when the results of the sample analysis are provided, which indicate the level of proADM or a fragment thereof in the sample. In a further embodiment, the treatment can be started within 12 hours, preferably 11 hours, 10 hours, 9 hours, 8 hours, 7 hours, 6 hours, 5 hours, 4 hours, 3 hours, 2.5 hours, 2 hours, 1.5 hours, 1 hour, 0.9 hour, 0.8 hour, 0.7 hour, 0.6 hour, 0.5 hour, 0.4 hour, 0.3 hour, 0.2 hour, 0.1 hour or immediately after receiving the results of the sample analysis.

[0044] In another embodiment of the present invention, the decision to start, change or stop antibiotic treatment can be supported by quantifying proADM or one or more fragments thereof to predict 28-day mortality, predict the development of severe sepsis within 48 hours and predict positive bacterial cultures (blood cultures).

[0045] Preferably, the patient presents at an emergency room or a primary care unit.

[0046] A great advantage of the method of the present invention is that the method can be performed at the location where the patient is encountered and does not necessarily require a designated laboratory, which may consume time due to the transmission and provision of results. In addition, treatment decisions based on the method of the present invention can be taken very quickly after the patient is encountered in the ED or primary care department.

[0047] According to a preferred embodiment of the present invention, the method of the present invention comprises determining the level of: the N-terminal peptide of proADM (PAMP) or the mid-region peptide of proADM (MR-proADM) or mature adrenomedullin (comprising bioactive ADM) or the C-terminal peptide of proADM (CT-proADM). Measuring MR-proADM is preferred for any given embodiment described herein and can thus be considered in the context of each embodiment. In a preferred embodiment, the "proADM fragment" can be considered to be MR-proADM.

[0048] In a preferred embodiment of the present invention, a level of proADM or one or more of its fragments in the sample being determined to be greater than the level of proADM or one or more of its fragments in one or more control samples, such as a group of healthy individuals, indicates the need to initiate or change antibiotic treatment.

[0049] In such preferred embodiments, control samples or control values generated from testing control samples can be used, such as preferably, a group of subjects suffering from any given disease or other larger number of such subjects or control groups. Appropriate statistical means for analyzing and comparing such data sets are known to those skilled in the art. Control samples for a positive control group (such as disease patients) or a negative control group (from healthy subjects) can be used as reference values in simultaneous or non-simultaneous comparisons.

[0050] In some embodiments, the antibiotic treatment that needs to be initiated or changed includes initiating or changing intravenous antibiotic treatment. Thus, the present invention presents a method that enables a decision on whether intravenous antibiotic administration is needed and / or intensified by means of proADM measurement, optionally in combination with PCT measurement.

[0051] According to a preferred embodiment of the present invention, a level of proADM or one or more of its fragments in the sample that is equal to or higher than 1 nmol / L, preferably equal to or greater than 1.2 nmol / L, more preferably equal to or higher than 1.27 nmol / L indicates the need to initiate or change antibiotic treatment.

[0052] In certain embodiments of the present invention, a level of proADM or one or more fragments thereof in a sample that is equal to or higher than 0.5, 0.55, 0.6, 0.65, 0.7, 0.75, 0.8, 0.85, 0.9, 0.95, 1.0, 1.05, 1.1, 1.15, 1.2, 1.25, 1.27, 1.3, 1.35, 1.4, 1.45, 1.5, 1.55, 1.6, 1.65, 1.7, 1.75, 1.8, 1.85, 1.9, 1.95, 2.0, 2.05, 2.1, 2.15, 2.2, 2.25, 2.3, 2.35, 2.4, 2.45, 2.5, 2.55, 2.6, 2.65, 2.7, 2.75, 2.8, 2.85, 2.9, 2.95, 3.0, 3.05, 3.1, 3.15, 3.2, 3.25, 3.3, 3.35, 3.4, 3.45, 3.5, 3.55, 3.6, 3.65, 3.7, 3.75, 3.8, 3.85, 3.9, 3.95, 4.0 nmol / L indicates a need to initiate or change antibiotic therapy.

[0053] The threshold value of the protein level of proADM or its fragment preferably refers to the measurement result in a plasma sample obtained from a patient. Thus, the values disclosed herein may vary to some extent depending on the detection / measurement method employed, and the specific values disclosed herein are intended to be read in relation to the corresponding values determined by other methods.

[0054] All threshold values disclosed herein in relation to a marker or biomarker such as proADM or PCT should be understood as "equal to or higher than" a certain threshold or "equal to or lower than" a certain threshold. For example, an embodiment related to a level of proADM or one or more fragments thereof higher than 1 nmol / L should be understood as related to a level of proADM or one or more fragments thereof equal to or higher than 1 nmol / L. Conversely, an embodiment related to a level of proADM or one or more fragments thereof lower than 1 nmol / L should be understood as related to a level of proADM or one or more fragments thereof equal to or lower than 1 nmol / L.

[0055] In one embodiment, the present invention further includes informing the patient of the results of the method described herein. In additional embodiments, the present invention further includes initiating antibiotic therapy. Additionally, the method may include the steps of stratifying the patient into specific therapy groups associated with specific treatment regimens and optionally informing the patient of the results of the treatment stratification.

[0056] According to a further preferred embodiment of the invention, a level of proADM or one or more fragments thereof in a sample that is equal to or higher than 1 nmol / L, preferably equal to or higher than 1.2 nmol / L, more preferably equal to or higher than 1.27 nmol / L indicates transfer of the patient to the intensive care unit, or a level of proADM or one or more fragments thereof in the sample that is lower than 1 nmol / L, preferably lower than 1.2 nmol / L, more preferably lower than 1.27 nmol / L indicates discharge of the patient.

[0057] A great advantage of the method of the invention is that further treatment steps and decisions can be taken based on the level of proADM or the fragment. If the level of proADM is equal to or higher than 1 nmol / L, preferably equal to or higher than 1.2 nmol / L, more preferably equal to or higher than 1.27 nmol / L, this indicates that antibiotic treatment should be initiated or the ongoing antibiotic treatment should be improved or changed. In addition, it can be determined that the patient is a high-risk patient who requires strict medical supervision and potentially additional therapeutic measures. On the other hand, if the level of proADM or its fragment in the sample is lower than 1 nmol / L, preferably lower than 1.2 nmol / L, more preferably lower than 1.27 nmol / L, this indicates that the patient is not a high-risk patient with an infectious disease that requires antibiotic treatment and strict medical supervision. The patient can recover without further measures that require medical supervision and can leave the medical facility.

[0058] In a preferred embodiment of the method of the invention, the antibiotic treatment is administered in combination with one or more medical treatments or therapeutic measures, such as, for example, organ therapy, supplemental oxygen, intravenous fluids, corticosteroids, vasopressors, mechanical ventilation, non-invasive ventilation, renal replacement therapy or continuous positive airway pressure (CPAP).

[0059] In a preferred embodiment of the invention, the patient is suspected of having or has a systemic infection (associated with a positive blood culture), a pulmonary infection, an upper respiratory tract infection, a urinary tract infection, a bone or joint infection, a skin infection, a soft tissue infection, a CNS infection, an abdominal infection or an infection of unknown origin.

[0060] The method is advantageous if it further comprises determining the level of PCT or one or more fragments thereof in a sample from the patient.

[0061] It is believed that PCT is a marker for infectious diseases such as sepsis. Thus, a low PCT value is considered to indicate the absence of infection or sepsis and may not require antibiotic treatment. However, as disclosed herein, it has become apparent that if the level of proADM or a fragment thereof is elevated, such as above a control value (the control value can be a defined cut-off value) or the average value of proADM or a fragment thereof in a relevant reference group, then despite a low PCT value (the low PCT value can be lower than the average PCT of patients with infection and / or can be lower than a defined cut-off value), the patient still needs to initiate or change antibiotic therapy. Thus, a treating physician or other medical staff can adjust antibiotic therapy for such patients who would not otherwise be identified as needing to initiate or change antibiotic treatment based solely on PCT. Quite surprisingly, even when the PCT level is low, the level of proADM or a fragment thereof can be associated with the need to initiate or change antibiotic treatment.

[0062] Particularly preferred is to measure the level of PCT or one or more fragments thereof in the same sample as the level of proADM or one or more fragments thereof in the context of the method of the present invention. In this embodiment, both biomarker PCT and proADM can be measured in the same sample simultaneously in a multiplex assay format or at different time points in a multiplex assay format or a single assay format. The multiplex assay can be a dual assay for measuring the two biomarkers, where the assay can be a point-of-care assay that can be performed immediately after sample separation at the same place where the patient is encountered.

[0063] In some embodiments that include an assessment of proADM and PCT, the two values can be evaluated in substantially a single measurement of each biomarker and / or in multiple measurements in a single sample and / or in multiple samples obtained at substantially the same time point in order to make a therapy decision regarding initiating or changing antibiotic therapy. Until the present invention, it was not known that proADM in combination with PCT can provide therapy guidance by evaluating the levels of the two biomarkers at a single time point. This presents a significant advantage over prior art methods that require multiple measurements to observe changes before a therapy decision can be made.

[0064] In a preferred embodiment of the method of the present invention, a level of PCT or one or more fragments thereof equal to or higher than 0.05 ng / ml, preferably equal to or higher than 0.1 ng / ml, more preferably equal to or higher than 0.12 ng / ml indicates the need to initiate or change antibiotic therapy.

[0065] In a preferred embodiment, a level of PCT or a fragment thereof equal to or higher than 0.01, 0.02, 0.03, 0.04, 0.05, 0.06, 0.07, 0.08, 0.09, 0.10, 0.11, 0.12, 0.13, 0.14, 0.15, 0.16, 0.17, 0.18, 0.19 or 0.2 ng / ml indicates the need to initiate or change antibiotic therapy.

[0066] In a further preferred embodiment of the present invention, the sample for determining proADM or one or more fragments thereof and / or the sample for determining PCT or one or more fragments thereof is a body fluid, which is preferably selected from the group consisting of a blood sample, a serum sample, a plasma sample and / or a urine sample. Particularly preferably, the body fluid used is one that is easily separated in an emergency room or at point-of-care, such as a blood or blood-derived sample or a urine or saliva sample.

[0067] The sample for determining proADM or one or more fragments thereof and the sample for determining PCT or one or more fragments thereof may be the same sample or different samples.

[0068] According to another preferred embodiment of the method of the present invention,

[0069] - a level of proADM or one or more fragments thereof in the sample equal to or higher than 1 nmol / L, preferably equal to or higher than 1.2 nmol / L, more preferably equal to or higher than 1.27 nmol / L, and

[0070] - a level of PCT or one or more fragments thereof lower than 0.05 ng / ml, preferably lower than 0.1 ng / ml, more preferably lower than 0.12 ng / ml

[0071] - indicate the need to initiate or change antibiotic therapy.

[0072] The above embodiments exhibit surprising and unexpected advantages over the prior art methods. What has not been proposed in the art previously is that for patients in whom antibiotic treatment needs to be changed or initiated, the PCT level in the patient remains relatively low, such as below 0.05 ng / ml, preferably below 0.1 ng / ml, more preferably below 0.12 ng / ml, but the ADM level increases, such as the level of proADM or one or more of its fragments in the sample being equal to or higher than 1 nmol / L, preferably equal to or higher than 1.2 nmol / L, more preferably equal to or higher than 1.27 nmol / L. Generally, in cases where the risk is significantly increased and a change in therapy is required, a practitioner would expect both of these biomarkers to increase. Contrary to this expectation, the present invention enables therapy decisions based on the combined PCT and proADM measurements, where PCT remains low but proADM is high. This represents a novel group of patients for whom effective and early therapy decisions can be made. In some embodiments, these therapy decisions can be made after evaluating these biomarkers at substantially a single time point and / or from a single sample.

[0073] In another preferred embodiment of the method according to the invention,

[0074] - the level of proADM or one or more of its fragments in the sample being equal to or higher than 1 nmol / L, preferably equal to or higher than 1.2 nmol / L, more preferably equal to or higher than 1.27 nmol / L, and

[0075] - the level of PCT or one or more of its fragments being equal to or higher than 0.05 ng / ml, preferably equal to or higher than 0.1 ng / ml, more preferably equal to or higher than 0.12 ng / ml

[0076] - indicates the need to initiate or change antibiotic treatment.

[0077] In another preferred embodiment of the method according to the invention,

[0078] - the level of proADM or one or more of its fragments in the sample being lower than 1 nmol / l, preferably lower than 1.2 nmol / L, more preferably lower than 1.27 nmol / L, and

[0079] - the level of PCT or one or more of its fragments being equal to or higher than 0.05 ng / ml, preferably equal to or higher than 0.1 ng / ml, more preferably equal to or higher than 0.12 ng / ml

[0080] - indicates the need to initiate or change antibiotic treatment.

[0081] In another preferred embodiment of the method according to the invention,

[0082] - The level of proADM or one or more fragments thereof in the sample that is equal to or higher than 1 nmol / L, preferably equal to or higher than 1.1 nmol / L, more preferably equal to or higher than 1.2 nmol / L,

[0083] - Indicates the development of severe sepsis within the next 48 hours.

[0084] In another preferred embodiment of the method according to the invention,

[0085] - The level of proADM or one or more fragments thereof in the sample that is equal to or higher than 1.2 nmol / L, preferably equal to or higher than 1.5 nmol / L, more preferably equal to or higher than 1.78 nmol / L,

[0086] - Indicates a positive bacterial culture.

[0087] In the context of the method of the invention, the method is preferred if the patient has not yet received antibiotic treatment for a suspected infection.

[0088] According to a further preferred embodiment of the invention, the patient is receiving antibiotic treatment and the change in antibiotic treatment comprises or consists of a change in the route of administration of the antibiotic treatment. Preferably, the patient is receiving topical or oral antibiotic treatment. Furthermore, the route of administration after changing the antibiotic treatment is preferably intravenous application of an antibiotic.

[0089] This embodiment demonstrates a surprising and beneficial aspect of the invention, whereby, through proADM measurement preferably of a single sample and / or at a single time point, antibiotic therapy can be intensified, for example by intravenous administration of an antibiotic, thus achieving an effective enhancement of the therapy at an earlier time point without prolonging the observation period or incurring risks. The practical benefit to a practitioner who evaluates proADM levels based on a single marker value and initiates, for example, intravenous therapy is significant. Conversely, being able to determine when intensified therapy is unnecessary, for example by measuring lower levels of ADM as described herein, represents an effective means of avoiding more cost-intensive and difficult procedures.

[0090] In a further preferred embodiment of the invention, the change in antibiotic treatment comprises a change in the route of administration of the ongoing antibiotic treatment.

[0091] In a further preferred embodiment of the invention, the change in antibiotic treatment consists of a change in the route of administration of the ongoing antibiotic treatment.

[0092] The method of the invention preferably further comprises determining one or more risk factors such as age, gender, comorbidities and / or organ dysfunction.

[0093] Preferably, the present invention preferably includes additionally determining one or more comorbidities, which are preferably selected from the group consisting of: cardiovascular diseases, atrial fibrillation, flutter, congestive heart failure, COPD, asthma, pulmonary fibrosis, asbestosis, lung diseases, immunodeficiency, diabetes, kidney diseases, hypertension, stroke, transient ischemic attack (TIA), dementia, anemia, thrombosis, rheumatic diseases, neuromuscular diseases, malignancies or cancers.

[0094] Preferred organ dysfunctions that can be determined in the context of the method of the present invention relate to, but are not limited to, one or more of the following: neurological dysfunction, cardiovascular dysfunction, respiratory dysfunction, renal dysfunction, hepatic dysfunction, blood dysfunction, and / or metabolic acidosis.

[0095] According to a further preferred embodiment, the method of the present invention further includes

[0096] - determining the level of at least one additional biomarker or one or more fragments thereof in a sample from the patient, and / or

[0097] - determining at least one clinical score,

[0098] - wherein the level of the at least one additional biomarker and / or the at least one clinical score and the level of proADM or one or more fragments thereof, and preferably PCT or one or more fragments thereof, indicate whether antibiotic treatment needs to be initiated or changed.

[0099] According to a further preferred embodiment, the method of the present invention further includes

[0100] - determining the level of at least one additional biomarker or one or more fragments thereof in a sample from the patient, wherein the at least one additional biomarker is preferably lactate and / or C-reactive protein, and / or

[0101] - determining at least one clinical score, wherein the at least one clinical score is preferably SOFA and / or qSOFA,

[0102] - wherein the level of the at least one additional biomarker and / or the at least one clinical score and the level of proADM or one or more fragments thereof indicate whether antibiotic treatment needs to be initiated or changed.

[0103] In a further embodiment of the method described herein, the method further comprises performing a molecular analysis of a sample from the patient to detect an infection. The sample for performing the molecular analysis to detect an infection is preferably a blood sample. In a preferred embodiment, the molecular analysis is a method aimed at detecting one or more biomolecules derived from a pathogen. The one or more biomolecules may be nucleic acids, proteins, sugars, carbohydrates, lipids, and / or combinations thereof, such as glycoproteins, preferably nucleic acids. The biomolecules are preferably specific for one or more pathogens. According to a preferred embodiment, such biomolecules are detected by one or more methods for analyzing biomolecules, the one or more methods selected from the group comprising nucleic acid amplification methods (such as PCR, qPCR, RT-PCR, qRT-PCR, or isothermal amplification), mass spectrometry, enzyme activity detection methods, and immunoassay-based detection methods. Additional molecular analysis methods are known to those skilled in the art and are included in the method of the present invention.

[0104] The present invention further relates to a pharmaceutical composition comprising one or more antibiotic agents for treating a patient suspected of having an infection, wherein the patient is administered the composition after being identified by the method of the present invention as in need of starting or changing antibiotic treatment due to the level of proADM or one or more of its fragments in a sample obtained from the patient.

[0105] Preferably, the administration of the pharmaceutical composition of the present invention is initiated within 180 minutes, preferably within 120 minutes, more preferably within 60 minutes, or immediately after determining the level of proADM or one or more of its fragments in the sample.

[0106] In a preferred embodiment of the pharmaceutical composition of the present invention, the composition of the present invention is administered repeatedly to the patient over a certain treatment period. For example, the antibiotic treatment may last for several hours, days, or weeks, wherein the antibiotic may be administered continuously, for example, by i.v. infusion or repeatedly, for example, by oral administration, injection, or topical application, wherein the administration intervals may vary between one or more hours, one or more days, or one or more weeks, depending on the condition of the patient and / or the one or more antibiotic agents and formulations to be administered.

[0107] In addition, proADM and / or one or more of its fragments and preferably PCT and / or one or more of its fragments are measured one or more times during the treatment period using the composition of the present invention. proADM and / or one or more of its fragments and preferably PCT and / or one or more of its fragments may be measured during treatment with the pharmaceutical composition of the present invention for monitoring treatment success and / or disease progression.

[0108] Preferably, the pharmaceutical composition of the present invention is administered in combination with other treatments, such as, for example, the treatment of comorbidities or the treatment of symptoms different from antibiotic treatment. Specifically, the pharmaceutical composition of the present invention is administered in combination with the symptomatic treatment of local infections, skin infections, urinary tract infections, etc. or in combination with the symptomatic treatment of inflammatory events.

[0109] Preferably, the patient receives intravenous administration of the composition of the present invention. Alternatively, the patient may receive intravenous administration and oral administration of one or more compositions.

[0110] The present invention further relates to a kit for performing the method of the present invention, which comprises:

[0111] - a detection reagent for determining the level of proADM or one or more of its fragments in a sample from a subject and optionally also for determining the level of PCT or one or more of its fragments in a sample from a subject, and

[0112] - reference data corresponding to the level of proADM or one or more of its fragments in the sample, such as a reference level, wherein the level of proADM or one or more of its fragments in the sample is equal to or higher than 1 nmol / L, preferably equal to or higher than 1.2 nmol / L, more preferably equal to or higher than 1.27 nmol / L, and wherein the reference data is preferably stored on a computer-readable medium and / or used in the form of computer-executable code configured to compare the determined level of proADM or one or more of its fragments and optionally also the determined level of PCT or one or more of its fragments with the reference data.

[0113] The detection reagent for determining the level of proADM or one or more of its fragments and optionally for determining the level of PCT or one or more of its fragments is preferably selected from those necessary for performing the method, for example, an antibody against proADM, a suitable label (such as a fluorescent label, preferably two separate fluorescent labels suitable for application in a KRYPTOR assay), a sample collection tube.

[0114] In one embodiment of the methods described herein, the levels of proADM or one or more of its fragments and optionally PCT or one or more of its fragments are determined using a method selected from the group consisting of mass spectrometry (MS), luminescence immunoassay (LIA), radioimmunoassay (RIA), chemiluminescence immunoassay and fluorescence immunoassay, enzyme immunoassay (EIA), enzyme-linked immunosorbent assay (ELISA), bead array based on luminescence, magnetic bead-based array, protein microarray assay, rapid test format (such as, for example, immunochromatographic strip test), rare complex assay, and automated systems / analyzers.

[0115] Determining the levels of proADM or one or more of its fragments and optionally PCT or one or more of its fragments and / or other biomarkers can be performed using the detection reagents of the kit of the invention in a multiplex or duplex assay for determining proADM or one or more of its fragments and another biomarker (such as PCT or one or more of its fragments) of the invention.

[0116] The assay can also preferably be defined as a point-of-care assay that can be performed directly at the location where the patient encounters medical staff, such as, for example, in the emergency room or primary care department. In addition, the assay for detecting proADM or one or more of its fragments and optionally PCT or one or more of its fragments and / or other biomarkers can be an automated or semi-automated assay, preferably a duplex assay and / or a point-of-care assay.

[0117] The method according to the invention can further be embodied as a homogeneous method, in which a sandwich complex formed by one / more antibodies and the biomarker to be detected (e.g., proADM or its fragment) remains suspended in the liquid phase. In this case, preferably, when two antibodies are used, the two antibodies are labeled with the respective parts of the detection system, which results in the generation or triggering of a signal when the two antibodies are incorporated into a single sandwich structure.

[0118] Such techniques should be specifically embodied as fluorescence enhancement or fluorescence quenching detection methods. A particularly preferred aspect relates to the use of detection reagents that should be used in pairs, such as, for example, the detection reagents described in US 4882733 A, EP-B1 0180492 or EP-B1 0539477 and the prior art cited therein. In this way, it becomes possible to detect only the measurement of the reaction product of two labeled components directly included in a single immune complex in the reaction mixture.

[0119] For example, such techniques are provided under the trade name (Time Resolved Amplified Cryptate Emission) or to achieve the teachings of the above applications. Thus, in a particularly preferred aspect, a diagnostic device is used to perform the methods provided herein. For example, determining the level of proADM protein or its fragment and / or the level of any additional biomarker of the methods provided herein. In a particularly preferred aspect, the diagnostic device is

[0120] In one embodiment of the method described herein, the method is an immunoassay and wherein the assay is performed in homogeneous or heterogeneous phase and can be run on an automated system.

[0121] In one embodiment of the method described herein, the first antibody and the second antibody are present in a liquid reaction mixture in a dispersed form, and a first labeling component as part of a labeling system based on fluorescence or chemiluminescence quenching or amplification binds to the first antibody and a second labeling component of the labeling system binds to the second antibody such that upon detection of the two antibodies binding to the proADM or a fragment thereof, a measurable signal is generated that permits detection of the resulting sandwich complex in the measurement solution.

[0122] In one embodiment of the method described herein, the labeling system comprises a rare earth cryptate or chelate in combination with a fluorescent or chemiluminescent dye (in particular a cyanine-type dye).

[0123] In one embodiment of the method described herein, the method further comprises comparing the determined level of proADM or one or more of its fragments to a reference level, threshold, and / or population mean corresponding to proADM or its fragment in a patient suspected of having an infection or exhibiting symptoms of sepsis, wherein the comparison is performed in a computer processor using computer-executable code.

[0124] The method of the present invention may be partially computer-implemented. For example, the step of comparing the detected level of a marker (e.g., proADM or a fragment thereof) to a reference level may be performed in a computer system. In the computer system, the determined levels of one or more markers may be combined with other marker levels and / or parameters of the subject in order to calculate a score that indicates a diagnosis, prognosis, risk assessment, and / or risk stratification. For example, the measured values may be input (either manually by a healthcare professional or automatically from one or more devices in which the levels of one or more corresponding markers have been measured) into the computer system. The computer system may be located directly at the point of care (e.g., primary care department or ED), or the computer system may be located at a remote location connected via a computer network (e.g., via the Internet or a dedicated medical cloud system, optionally combinable with other IT systems or platforms such as a hospital information system (HIS)). Generally, the computer system stores values (e.g., marker levels or parameters such as age, blood pressure, weight, gender, etc. or clinical scoring systems such as SOFA, qSOFA, BMI, etc.) on a computer-readable medium and calculates a score based on predefined and / or pre-stored reference levels or reference values. The resulting score will be displayed and / or printed for the user (typically a healthcare professional such as a physician). Alternatively or additionally, associated prognosis, diagnosis, assessment, treatment guidance, patient management guidance, or stratification will be displayed and / or printed for the user (typically a healthcare professional such as a physician).

[0125] In one embodiment of the present invention, a software system may be employed, in which machine learning algorithms are evident, preferably for using data from an electronic health record (EHR) to identify hospitalized patients at risk of sepsis, severe sepsis, and septic shock. Machine learning methods can be trained on a random forest classifier using EHR data from patients, such as laboratory, biomarker expression, vital signs, and demographic characteristics. Machine learning is a type of artificial intelligence that enables a computer to learn complex patterns in data without explicit programming, which is different from systems based on simpler rules. Early studies have used electronic health record data to trigger alerts for detecting overall clinical deterioration. In one embodiment of the present invention, the processing of proADM levels can be incorporated into appropriate software for comparison with existing datasets. For example, proADM levels can also be processed in machine learning software to assist in diagnosing adverse events or predicting the occurrence of adverse events.

[0126] The use of proADM or a fragment thereof in combination with another biomarker such as PCT or CRP or lactate can be achieved in a single multiplex assay or in two separate assays on samples from a patient. The samples can relate to the same sample or different samples. The assays for detecting and measuring proADM and, for example, PCT can also be the same or different. For example, immunoassays can be employed to measure one of the above-mentioned markers. A more detailed description of suitable assays is provided below.

[0127] Cut-off values and other reference levels for proADM or a fragment thereof in patients suspected of having an infection can be determined by the methods described previously. For example, methods for using the coefficient of variation to evaluate the variability of a quantitative assay to establish reference values and / or cut-off values are known to those skilled in the art (George F. Reed et al., Clin Diagn Lab Immunol, 2002; 9(6): 1235-1239).

[0128] In addition, the functional assay sensitivity can be determined so that statistically significant values can be used as reference levels or cut-off values according to established technical guidelines. Laboratories can independently establish the functional sensitivity of an assay according to clinically relevant protocols. "Functional sensitivity" can be considered as the concentration that produces a 20% coefficient of variation (CV) (or some other predetermined CV%) and is thus a measure of the precision of the assay at low analyte levels. Therefore, the CV is a normalization of the standard deviation (SD) that allows comparison of variability estimates at least within most of the working range of the assay, regardless of the magnitude of the analyte concentration.

[0129] In addition, a method based on ROC analysis can be used to determine a statistically significant difference between two clinical patient groups. The Receiver Operating Characteristic (ROC) curve measures the sorting efficiency of the fitting probability of a model to sort the response levels. The ROC curve can also help set the criterion point in a diagnostic test. The higher the diagonal curve, the better the fit. If the logistic fit has more than two response levels, a generalized ROC curve is generated. In such a plot, there is a curve for each response level, and the curve is the ROC curve of that level relative to all other levels. Software capable of performing this analysis to establish appropriate reference levels and cut-off values is available from, for example, JMP 12, JMP 13, Statistical Discovery of SAS.

[0130] The cut-off value of PCT can be determined similarly. Literature is available for the skilled person to determine appropriate cut-off values. For example, Philipp Schuetz et al. (BMC Medicine 2011; 9:107) describe that at a cut-off value of 0.1 ng / mL, PCT has a high sensitivity to exclude infection. Terence Chan et al. (Expert Rev. Mol. Diagn 2011; 11(5), 487.496) describe that indices calculated based on sensitivity and specificity (such as positive likelihood ratio and negative likelihood ratio) can also be used to evaluate the strength of a diagnostic test. The values are usually plotted as multiple cut-off values (CV) as the Receiver Operating Characteristic curve. The area under the curve value is used to determine the optimal diagnostic-related CV. This literature describes the variation of CV (cut-off value, which depends on the assay and study design) and suitable methods for determining the cut-off value.

[0131] The population mean level of proADM or its fragment can also be used as a reference value, such as the mean proADM population value, whereby patients suspected of having an infection or showing symptoms of sepsis can be compared with a control population, where the control group preferably includes more than 10, 20, 30, 40, 50 or more subjects.

[0132] In one embodiment of the present invention, when using, for example, a BRAHMS PCT-Kryptor assay or an automated system such as, for example, the Cobas system of Roche, the Vidas system of BioMerieux, or the Architect system of Abbott, the critical level of PCT in a serum sample can be a value in the range of 0.01 ng / mL to 100.00 ng / mL. In a preferred embodiment, the critical level of PCT can be in the range of 0.01 ng / mL to 100 ng / mL, 0.05 ng / mL to 50 ng / mL, 0.1 ng / mL to 20 ng / mL, or 0.1 ng / mL to 2 ng / mL, and most preferably, in the range of >0.05 ng / mL to 0.5 ng / mL. Any value within these ranges can be considered an appropriate critical value. For example, 0.01, 0.05, 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1.0, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2.0, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, or 100 ng / mL can be employed. In some embodiments, the PCT level in healthy subjects is approximately 0.05 ng / mL.

[0133] All preferred embodiments and advantages of the methods of the present invention disclosed herein also apply to the pharmaceutical compositions and kits of the present invention. Conversely, this also applies to the preferred embodiments and advantages of the pharmaceutical compositions and kits of the present invention. Detailed Description

[0134] The present invention relates to a method for guiding, stratifying, and / or controlling antibiotic therapy in a patient suspected of having an infection. As is evident from the data presented herein, starting or changing antibiotic treatment is indicated by the level of proADM or one or more of its fragments, which provides information regarding the possible initiation or change of antibiotic treatment.

[0135] In another embodiment of the present invention, the decision to start, change, or stop antibiotic treatment can be supported by quantifying proADM or one or more of its fragments to predict 28-day mortality, predict the development of severe sepsis within 48 hours, and predict positive bacterial cultures (blood cultures).

[0136] Compared with traditional methods, the present invention has the following advantages: The methods and kits of the present invention are rapid, objective, easy to use and accurate for guiding, stratifying and / or controlling therapies in patients suspected of having an infection. The methods and kits of the present invention relate to markers and clinical scores that are readily measurable in routine hospital methods, since the levels of proADM, PCT, lactate, C-reactive protein, SOFA, qSOFA, APACHE II, SAPS II can be determined in routinely obtained blood samples or additional biological fluids or samples obtained from a subject.

[0137] As used herein, "patient" or "subject" can be a vertebrate. In the context of the present invention, the term "subject" encompasses both humans and animals, particularly mammals and other organisms.

[0138] In the context of the present invention, "adverse event in the health of a patient" relates to an event indicating a complication of the patient or a deterioration in the health status of the patient. Such adverse events include, but are not limited to, patient death, death of the patient within 28 - 90 days after the start of diagnosis and treatment, occurrence of an infection or a new infection, organ failure, and deterioration of the general clinical signs or symptoms of the patient, such as hypotension or hypertension, tachycardia or bradycardia. In addition, examples of adverse events include situations where the worsening of clinical symptoms indicates the need for therapeutic measures, such as debridement, infusion of blood products, infusion of colloids, invasive mechanical ventilation, non-invasive mechanical ventilation, emergency surgery, organ replacement therapy (such as kidney or liver replacement), and vasopressor therapy.

[0139] As used herein, the primary care unit is a doctor's consulting room or a healthcare center where routine primary healthcare can be provided to patients by healthcare providers. Typically, the provider acts as the first point of contact and the main point of ongoing care for the patient within the healthcare system, and coordinates other specialized care that the patient may require. Patients typically receive primary care from professionals such as primary care physicians (e.g., general practitioners or family physicians), advanced practice nurses (such as adult - gerontology nurse practitioners, family nurse practitioners or pediatric nurse practitioners), or physician assistants. Such professionals can also be registered nurses, pharmacists, clinical military physicians.

[0140] In the context of the present invention, the emergency department (ED) (also known as the emergency accident and emergency department, emergency room (ER), emergency ward (EW) or casualty department) is a medical treatment facility specializing in emergency medicine, which involves providing acute care to patients who come to the department on their own or by ambulance without prior appointment. The emergency department is usually found in a hospital or other primary care center.

[0141] As used herein, "diagnosis" in the context of the present invention relates to the identification and (early) detection of the clinical symptoms of a subject related to an infectious disease. The term "diagnosis" can also cover the assessment of the severity of an infectious disease.

[0142] "Prognosis" relates to the prediction of the efficacy or specific risks of a subject based on an infectious disease. This can also include an estimate of the likelihood of recovery or the likelihood of poor efficacy of the subject.

[0143] The methods of the present invention can also be used for monitoring. "Monitoring" involves tracking a diagnosed infectious disease, condition, complication, or risk, for example, to analyze the progression of the disease or the impact of a specific treatment or therapy on the disease progression of a critically ill patient or the infectious disease of a patient.

[0144] In the context of the present invention, the term "therapy monitoring" or "therapy control" refers to monitoring and / or adjusting the therapeutic treatment of the subject, for example, by obtaining feedback on the efficacy of the therapy.

[0145] In the present invention, the terms "risk assessment" and "risk stratification" and "therapy stratification" involve grouping subjects into different risk groups according to the further prognosis of the subject. Risk assessment also involves stratification for the application of preventive measures and / or therapeutic measures. Specifically, the term "therapy stratification" involves grouping or classifying patients into different groups that receive certain differential therapeutic measures depending on their classification, such as risk groups or therapy groups. The term "therapy stratification" also involves grouping or classifying patients with an infection or symptoms of an infectious disease into groups that do not require certain therapeutic measures.

[0146] As used herein, the term "therapy guidance" refers to the application of certain therapies or medical interventions based on the values of one or more biomarkers and / or clinical parameters and / or clinical scores.

[0147] It should be understood that in the context of the present invention, "determining the level of proADM or one or more of its fragments", etc. refers to any means of determining the level of proADM or its fragments. The fragment can have any length, for example, at least about 5, 10, 20, 30, 40, 50, or 100 amino acids, as long as the fragment allows for the unambiguous determination of the level of proADM or its fragment. In a preferred aspect of the present invention, "determining the level of proADM" refers to determining the level of mid-regional proadrenomedullin (MR-proADM). MR-proADM is a fragment and / or region of proADM.

[0148] Peptide adrenomedullin (ADM) was found to be a 52-amino acid hypotensive peptide isolated from a human pheochromocytoma (Kitamura et al., 1993). Adrenomedullin (ADM) is encoded as a precursor peptide consisting of 185 amino acids (“adrenomedullin prepropeptide” or “pre proADM”). An exemplary amino acid sequence of ADM is given in SEQ ID NO:1.

[0149] SEQ ID NO:1: Amino acid sequence of pre-pro-ADM:

[0150] 1 MKLVSVALMY LGSLAFLGAD TARLDVASEF RKKWNKWALS RGKRELRMSS

[0151] 51 SYPTGLADVK AGPAQTLIRP QDMKGASRSP EDSSPDAARI RVKRYRQSMN

[0152] 101 NFQGLRSFGC RFGTCTVQKL AHQIYQFTDK DKDNVAPRSK ISPQGYGRRR

[0153] 151 RRSLPEAGPG RTLVSSKPQA HGAPAPPSGS APHFL

[0154] ADM comprises amino acid positions 95 - 146 of the pre-proADM amino acid sequence and is a spliced product thereof. “Adrenomedullin precursor” (“proADM”) refers to pre-proADM without the signal sequence (amino acids 1 to 21), i.e., amino acid residues 22 to 185 of pre-proADM.

[0155] “Mid-region adrenomedullin precursor” (“MR-proADM”) refers to amino acids 45 to 95 of pre-proADM. An exemplary amino acid sequence of MR-proADM is given in SEQ ID NO:2.

[0156] SEQ ID NO:2: Amino acid sequence of MR-pro-ADM (AS 45 - 92 of pre-pro-ADM):

[0157] ELRMSSSYPT GLADVKAGPA QTLIRPQDMK GASRSPEDSS PDAARIRV

[0158] Also contemplated herein is that peptides and fragments thereof of pre-proADM or MR-proADM can be used in the methods described herein. For example, the peptide or fragment thereof can include amino acids 22-41 of pre-proADM (PAMP peptide) or amino acids 95-146 of pre-proADM (mature adrenomedullin, including the bioactive form, also referred to as bio-ADM). The C-terminal fragment of proADM (amino acids 153 to 185 of proADM) is called adrenotensin. Fragments of proADM peptides or fragments of MR-proADM can include, for example, at least about 5, 10, 20, 30 or more amino acids. Thus, fragments of ADM can, for example, be selected from the group consisting of MR-proADM, PAMP, adrenotensin, and mature adrenomedullin, and preferably, herein, the fragment is MR-proADM.

[0159] The determination of these different forms of ADM or proADM and their fragments also encompasses measuring and / or detecting specific sub-regions of these molecules, for example, by employing antibodies or other affinity reagents directed against specific parts of the molecule, or by measuring the presence and / or amount of the molecule by means of measuring a portion of the protein using mass spectrometry.

[0160] The methods and kits of the invention can also include determining at least one additional biomarker, marker, clinical score, and / or parameter other than proADM or its fragments.

[0161] As used herein, a parameter is a characteristic, feature, or measurable factor that can contribute to defining a particular system. Parameters are important elements for health and physiology-related assessments, such as disease / condition / clinical state risk, preferably one or more organ dysfunctions. Additionally, a parameter is defined as a characteristic that is objectively measured and evaluated as an indicator of a normal biological process, a pathogenic process, or a pharmacological response to a therapeutic intervention. Exemplary parameters can 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), Sequential Organ Failure Assessment Score (SOFA), Body Mass Index, body weight, age, sex, IGS II, fluid intake, white blood cell count, sodium, potassium, temperature, blood pressure, dopamine, bilirubin, respiratory rate, partial pressure of oxygen, World Federation of Neurosurgical Societies (WFNS) grade, and Glasgow Coma Index (GCS).

[0162] As used herein, terms such as "marker", "surrogate", "prognostic marker", "factor", or "biomarker" or "biological marker" are used interchangeably and refer to a measurable and quantifiable biological marker (e.g., the concentration of a specific protein or enzyme or a fragment thereof, the concentration of a specific hormone or a fragment thereof, or the presence of a biological substance or a fragment thereof), which biological marker serves as an index for health and physiology-related assessments, such as the risk of a disease / condition / clinical state, preferably an adverse event. 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 the pharmacological response to a therapeutic intervention. Biomarkers can be measured in samples such as blood, plasma, urine, or tissue tests.

[0163] The at least one additional biomarker and / or parameter of the subject may be selected from the group consisting of: the lactate level in the sample, the procalcitonin (PCT) level in the sample, the sequential organ failure assessment score (SOFA score) of the subject, the simplified acute physiology score (SAPSII) of the subject, the acute physiology and chronic health evaluation II (APACHE II) score of the subject, and the levels of the following or fragments thereof: 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 ILs, presepsin (sCD14-ST), lipopolysaccharide-binding protein (LBP), alpha-1-antitrypsin, matrix metalloproteinase 2 (MMP2), metalloproteinase 2 (MMP8), matrix metalloproteinase 9 (MMP9), matrix metalloproteinase 7 (MMP7), placental growth factor (PIGF), chromogranin A, S100A protein, S100B protein, and tumor necrosis factor alpha (TNFα), neopterin, alpha-1-antitrypsin, proarginine vasopressin (AVP, proAVP or copeptin), procalcitonin, atrial natriuretic peptide (ANP, pro-ANP), endothelin-1, 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, CCL6, 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, 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.

[0164] As used herein, "procalcitonin" or "PCT" refers to a peptide spanning amino acid residues 1 - 116, 2 - 116, or 3 - 116 of the procalcitonin peptide or a fragment thereof. PCT is the peptide precursor of the hormone calcitonin. Thus, the length of the procalcitonin fragment is at least 12 amino acids, preferably more than 50 amino acids, more preferably more than 110 amino acids. PCT may include post-translational modifications such as glycosylation, lipidation, or derivatization. Procalcitonin is the precursor of calcitonin and procalcitonin antagonist. Thus, under normal conditions, the level of PCT in the circulation is very low (< about 0.05 ng / ml).

[0165] The PCT level in a sample of a subject can be determined by immunoassays as described herein. As used herein, the level of ribonucleic acid or deoxyribonucleic acid encoding "procalcitonin" or "PCT" can also be determined. Methods for determining PCT are known to those skilled in the art, for example, by using products obtained from Thermo Fisher Scientific / BRAHMS GmbH.

[0166] Lactate or lactic acid is an organic compound with the molecular formula CH3CH(OH)COOH, which appears in body fluids including blood. Blood tests for lactate are performed to determine the state of the acid-base balance in the body. Lactic acid is a cellular metabolite that accumulates when cells lack sufficient oxygen (hypoxia) and must turn to less efficient means of energy production, or when medical conditions cause overproduction of lactate or impaired clearance. Lactic acidosis can be caused by insufficient oxygen levels (hypoxia) in cells and tissues. For example, if a person has a medical condition (such as shock, septic shock, or congestive heart failure) that can lead to a reduced amount of oxygen delivered to cells and tissues, lactate testing can be used to help detect and assess the severity of hypoxia and lactic acidosis.

[0167] C-reactive protein (CRP) is a pentameric protein that can be found in body fluids such as plasma. CRP levels can increase in response to inflammation. Measuring and plotting CRP values can prove useful in determining disease progression or the effectiveness of treatment.

[0168] As used herein, "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 degree of organ function or failure rate in a person. The score is based on six different scores, each used for the respiratory system, cardiovascular system, hepatic system, coagulation system, renal system, and nervous system. Both the mean SOFA score and the highest SOFA score are predictors of outcome. An increase in the SOFA score during the first 24 to 48 hours in the ICU predicts a mortality rate of at least 50% and up to 95%. A score below 9 gives a predicted mortality rate of 33%, while a score above 14 approaches or exceeds 95%.

[0169] As used herein, the quick SOFA score (qSOFA) is a scoring system that indicates the risk of organ dysfunction or mortality in a patient. The score is based on three criteria: 1) change in mental status, 2) systolic blood pressure reduced to less than 100 mm Hg, and 3) respiratory rate greater than 22 breaths per minute. Patients with two or more of these conditions are at greater risk of organ dysfunction or death.

[0170] As used herein, "APACHE II" or "Acute Physiology and Chronic Health Evaluation II" is a disease severity classification scoring system (Knaus et al., 1985). It can be applied to the intensive care unit (ICU) within 24 hours after patient admission 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 Index.

[0171] As used herein, "SAPS II" or "Simplified Acute Physiology Score II" refers to a system for classifying the severity of a disease or disorder (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 based on 12 routine physiological measurements, information about the previous health status, and some information obtained at the time of admission 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 measure associated with the highest score. The range of the SAPS II score is from 0 to 163 points. The classification system includes the following parameters: age, heart rate, systolic blood pressure, temperature, Glasgow Coma Index, mechanical ventilation or CPAP, PaO2, FiO2, urine output, blood urea nitrogen, sodium, potassium, bicarbonate, bilirubin, white blood cells, chronic disease, and type of admission. There is an S - shaped relationship between the mortality rate and the total SAPS II score. The mortality rate of the subjects is 10% when the SAPS II score is 29, 25% when the SAPS II score is 40, 50% when the SAPS II score is 52, 75% when the SAPS II score is 64, and 90% when the SAPS II score is 77 (Le Gall, in the above - cited reference).

[0172] As used herein, the term "sample" is a biological sample obtained or isolated from a patient or subject. A "sample" as used herein can be, for example, a sample of a body fluid or tissue obtained for the purpose of diagnosing, prognosticating, or evaluating a subject of interest (such as a patient). Preferably herein, the sample is a sample of a body fluid, such as blood, serum, plasma, cerebrospinal fluid, urine, saliva, sputum, pleural effusion, cells, cell extracts, tissue samples, tissue biopsies, fecal samples, and the like. Specifically, the sample is blood, plasma, serum, or urine.

[0173] In the context of the present invention, "plasma" is an almost cell-free blood supernatant obtained after centrifugation and containing an anticoagulant. Exemplary anticoagulants include calcium ion-binding compounds (such as EDTA or citrate) and thrombin inhibitors (such as heparin salts or hirudin). Cell-free plasma can be obtained by centrifuging anticoagulated blood (e.g., citrate blood, EDTA blood, or heparinized blood) at, for example, 2000 to 3000 g for at least 15 minutes.

[0174] In the context of the present invention, "serum" is the liquid portion of whole blood collected after allowing the blood to clot. When the clotted blood (coagulated blood) is centrifuged, serum can be obtained as the supernatant.

[0175] As used herein, "urine" is the liquid product of the body secreted by the kidneys through a process called urination (or micturition) and excreted through the urethra.

[0176] In the context of the present invention, "sepsis" refers to the systemic response to infection. Alternatively, sepsis can be considered as a combination of SIRS and a confirmed infectious process or infection. Sepsis can be characterized as a clinical syndrome defined by the presence of both infection and a systemic inflammatory response (Levy MM et al., 2001 SCCM / ESICM / ACCP / ATS / SIS International Sepsis Definitions Conference, Crit Care Med. 2003 Apr;31(4):1250 - 6). The term "sepsis" as used herein includes but is not limited to sepsis, severe sepsis, septic shock.

[0177] As used herein, the term "sepsis" encompasses, but is not limited to, sepsis, severe sepsis, and septic shock. Severe sepsis refers to sepsis associated with organ dysfunction, abnormal hypoperfusion, or sepsis-induced hypotension. Abnormal hypoperfusion includes lactic acidosis, oliguria, and acute change in mental status. Sepsis-induced hypotension is defined by a systolic blood pressure of less than 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, along with the presence of abnormal hypoperfusion or organ dysfunction (Bone et al., CHEST 101(6):1644-55, 1992).

[0178] Alternatively, the term sepsis can also be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can preferably be indicated by an increase in the Sequential Organ Failure Assessment (SOFA) score by 2 points or more, which is associated with a hospital mortality of greater than 10%. Septic shock can be defined as a subgroup of sepsis in which particularly severe circulatory, cellular, and metabolic abnormalities are associated with a greater risk of death than sepsis alone. Clinically, patients with septic shock can be identified by the need for vasopressors to maintain a mean arterial pressure of 65 mm Hg or greater and a serum lactate level of greater than 2 mmol / L (>18 mg / dL) in the absence of hypovolemia.

[0179] As used herein, the term "sepsis" refers to all possible stages in the development of sepsis.

[0180] The term "sepsis" also encompasses severe sepsis or septic shock based on the Sepsis-2 (SEPSIS-2) definition (Bone et al., 2009). The term "sepsis" also encompasses subjects falling within the Sepsis-3 (SEPSIS-3) definition (Singer et al., 2016). As used herein, the term "sepsis" refers to all possible stages in the development of sepsis.

[0181] As used herein, "infection" within the scope of the present invention means a pathological process caused by the invasion of normal sterile tissue or fluid by a pathogenic agent or potential pathogenic agent / pathogen, organism, and / or microorganism and preferably involves infection by one or more of bacteria, viruses, fungi, and / or parasites. Thus, an infection can be a bacterial infection, a viral infection, and / or a fungal infection. An infection can be local or systemic. For the purposes of the present invention, a viral infection can be considered an infection by a microorganism.

[0182] Furthermore, a subject suffering from an infection can have more than one source of infection simultaneously. For example, a subject suffering from an infection can have a bacterial infection and a viral infection; a viral infection and a fungal infection; a bacterial and a fungal infection; and a bacterial infection, a fungal infection, and a viral infection or a mixed infection, the mixed infection including one or more of the infections listed herein and potentially including repeated infections, such as one or more bacterial infections in addition to one or more viral infections and / or one or more fungal infections.

[0183] As used herein, "infectious disease" includes all diseases or disorders associated with bacterial and / or viral and / or fungal infections.

[0184] According to the present invention, critically ill patients such as sepsis patients may require strict control of vital functions and / or monitoring of organ protection and may be undergoing medical treatment.

[0185] In the context of the present invention, the term "medical treatment" or "treatment" includes various treatments and treatment strategies, which include but are not limited to anti-inflammatory strategies, administration of ADM antagonists such as therapeutic antibodies, si-RNA, or DNA, extracorporeal blood purification or removal of harmful substances by apheresis, dialysis, absorbers to prevent cytokine storms, removal of inflammatory mediators, plasmapheresis, administration of vitamins such as vitamin C, antibiotic treatment, fluid therapy, apheresis, and organ protection measures.

[0186] In a preferred embodiment, the term "medical treatment" or "treatment" includes antibiotic treatment, such as intravenous antibiotics, oral antibiotics, or topical antibiotics.

[0187] In a more preferred embodiment, the term "medical treatment" or "treatment" includes antibiotic treatment administered intravenously.

[0188] In addition, the medical treatment of the present invention includes but is not limited to stabilization of blood coagulation, iNOS inhibitors, anti-inflammatory agents such as hydrocortisone, sedatives and analgesics, and insulin.

[0189] "Fluid management" refers to monitoring and controlling the fluid status of a subject and administering fluids, such as by oral, enteral, or intravenous fluid administration, to stabilize circulation or organ viability. Fluid management includes stabilizing fluid and electrolyte balance or preventing or correcting hypervolemia or hypovolemia and supplying blood products.

[0190] In the context of a major disease such as sepsis or severe infection, it is very important to make an early diagnosis of the patient and to perform prognosis and risk assessment of the patient's therapeutic efficacy in order to find the best therapy and management. The therapeutic approach needs to be very unique and vary according to the situation. Therapeutic monitoring is required for best practice therapy and is affected by the timing of treatment, the use of combination therapy, and the optimization of drug administration. An incorrect or neglected therapy or management will increase the mortality rate hourly.

[0191] In the context of the present invention, the term "comorbidity" refers to any additional pathology or disease of the patient of the method of the present invention that may be present in addition to the suspected infection or sepsis. Such comorbidities can include, but are not limited to, cardiovascular disease, atrial fibrillation, flutter, congestive heart failure, COPD, asthma, pulmonary fibrosis, asbestosis, lung disease, immunodeficiency, diabetes, kidney disease, hypertension, stroke, transient ischemic attack (TIA), dementia, anemia, thrombosis, rheumatic disease, neuromuscular disease, malignancy or cancer.

[0192] The medical treatment of the present invention can be antibiotic treatment, wherein if an infection has been diagnosed or the symptoms of an infectious disease have been identified, one or more "antibiotics" or "antibiotic agents" can be administered.

[0193] The antibiotics or antibiotic agents according to the present invention also potentially cover antifungal compounds or antiviral compounds for the treatment of a diagnosed infection or sepsis. The antibiotic agents commonly applied to treat any given infection are classified into the following pathogen categories:

[0194] Gram-positive coverage: Penicillins (ampicillin, amoxicillin), penicillinase resistant (Dicloxacillin, Oxacillin), Cephalosporins (1st and 2nd generations), Macrolides (Erythromycin, Clarithromycin, Azithromycin), Quinolones (gatifloxacin, moxifloxacin, levofloxacin), Vancomycin, Sulfonamide / trimethoprim, Clindamycin, Tetracyclines, Chloramphenicol, Linezolid, Synercid.

[0195] Gram-negative coverage: Broad spectrum penicillins (Ticarcillin, clavulanate, piperacillin, tazobactam), Cephalosporins (2nd, 3rd and 4th generations), Aminoglycosides, Macrolides, Azithromycin, Quinolones (Ciprofloxacin), Monobactams (Azetreonam), Sulfonamide / trimethoprim, Carbapenems (Imipenem), Chloramphenicol.

[0196] Pseudomonas coverage: Ciprofloxacin, Aminoglycosides, some 3rd generation Cephalosporins, 4th generation Cephalosporins, Broad spectrum penicillins, Carbapenems.

[0197] Additional antibiotic agents include, for example, Bensylpenicillin, Cefotaxim, Klaxacillin, Klindamycin, aminoglycosides, Metronidazol, Piperacillin-Tazobactam, Meropenem, Imipenem, Erythromycin, Quinolones, Trimethoprim, and Vancomycin.

[0198] Fungal treatment: Allyamines, Amphotericin B, Fluconazole and other Azoles, itraconazole, voriconazole, posaconazole, ravuconazole, echinocandins, Flucytosine, sordarins, chitin synthase inhibitors, topoisomerase inhibitors, lipopeptides, pradimycins, Liposomal nystatin, voriconazole, echinocandins, imidazoles, triazoles, thiazoles, polyenes.

[0199] Antiviral Therapy: Abacavir, Acyclovir (Aciclovir), Activated Caspase Oligomerizer, Adefovir, Amantadine, Amprenavir (Agenerase), Ampligen, Arbidol, Atazanavir, Atripla, Balavir, Cidofovir, Combivir, Dolutegravir, Darunavir, Delavirdine, Didanosine, Double-stranded RNA, Behenyl Alcohol, Edoxudine, Efavirenz, Emtricitabine, Enfuvirtide, Entecavir, Ecoliever, Famciclovir, Fixed-dose Combination (for Antiretrovirals), Fomivirsen, Fosamprenavir, Foscarnet, Fosfonet, Fusion Inhibitor, Ganciclovir, Ibacitabine, Imunovir, Idoxuridine, Imiquimod, Indinavir, Inosine, Integrase Inhibitor, Type III Interferon, Type II Interferon, Type I Interferon, Interferon, Lamivudine, Lopinavir, Loviride, Maraviroc, Moroxydine, Methisazone, Morpholinos, Nelfinavir, Nevirapine, Nexavir, Nitazoxanide, Nucleoside Analogue, Novir, Oseltamivir (Tamiflu), Peginterferon alfa-2a, Penciclovir, Peramivir, Pleconaril, Podophyllotoxin, Protease Inhibitor (Pharmacology), RaltegravirReverse transcriptase inhibitors, Ribavirin, ribozymes, Rifampicin, Rimantadine, Ritonavir, Ribonuclease H (RNase H), protease inhibitors, pyrimidines, Saquinavir, Sofosbuvir, Stavudine, co - enhancers (for antiretrovirals), Telaprevir, Tenofovir, Tenofovir disoproxil, Tipranavir, Trifluridine, Trizivir, Tromantadine, Truvada, Valaciclovir (Valtrex), Valganciclovir, Vicriviroc, Vidarabine, Viramidine, Zalcitabine, Zanamivir (Relenza), Zidovudine.

[0200] In addition, antibiotic agents include bacteriophages for treating bacterial infections, synthetic antimicrobial peptides, or iron antagonists / iron chelators that can be used. Further, therapeutic antibodies or antagonists administered against pathogenic structures (such as anti - VAP - antibodies), anti - anti - clone vaccinations, immune cells (such as in vitro - sensitized or regulated T - effector cells) are antibiotic agents that represent treatment options for critically ill patients such as sepsis patients. Additional antibiotic agents / treatments or therapeutic strategies for treating infections or preventing new infections include the use of antiseptics, decontamination products, anti - toxicity agents such as liposomes, environmental hygiene, wound care, and surgery.

[0201] Several of the above - mentioned antibiotic agents or treatment strategies can also be combined.

[0202] According to the present invention, proADM and optionally PCT and / or other markers or clinical scores are used as markers for guiding, stratifying, and / or controlling antibiotic therapy in patients suspected of having an infection.

[0203] Those skilled in the art can obtain or develop means for identifying, measuring, assaying, and / or quantifying the above - mentioned proADM molecule or its fragments or variants, as well as other markers of the present invention, according to standard molecular biology practices.

[0204] The levels of proADM or its fragments, as well as the levels of other markers of the present invention, can be determined by a determination that reliably measures the concentration of the marker. Specifically, mass spectrometry (MS) and / or immunoassays can be employed, as exemplified in the appended examples. As used herein, an immunoassay is a biochemical test that measures the presence or concentration of a macromolecule / polypeptide in solution by using an antibody or an antibody-binding fragment or an immunoglobulin.

[0205] Methods for determining proADM or other markers (such as PCT) used in the context of the present invention are contemplated in the present invention. By way of example, methods selected from the group consisting of: mass spectrometry (MS), luminescence immunoassay (LIA), radioimmunoassay (RIA), chemiluminescence immunoassay and fluorescence immunoassay, enzyme immunoassay (EIA), enzyme-linked immunoassay (ELISA), bead arrays based on luminescence, magnetic bead-based arrays, protein microarray assays, rapid test formats (such as, for example, immunochromatographic strip tests), rare earth complex assays, and automated systems / analyzers can be employed.

[0206] Determining proADM and optionally other markers based on antibody recognition is a preferred embodiment of the present invention. As used herein, the term "antibody" refers to an immunoglobulin molecule and the immunologically active portion of an immunoglobulin (Ig) molecule,

[0207] i.e., a molecule containing an antigen-binding site that specifically binds to an antigen (immunologically reacts with the antigen). According to the present invention, the antibody can be a monoclonal antibody as well as a polyclonal antibody. Specifically, an antibody that specifically binds to at least proADM or its fragment is used.

[0208] An antibody is considered specific if its affinity for the molecule of interest (e.g., proADM) or its fragment is at least 50-fold, preferably 100-fold, most preferably at least 1000-fold higher than that of other molecules included in a sample containing the molecule of interest. How to develop and select antibodies with a given specificity is well known in the art. In the context of the present invention, monoclonal antibodies are preferred. The antibody or antibody-binding fragment specifically binds to the marker or its fragment as defined herein. Specifically, the antibody or antibody-binding fragment binds to the proADM peptide as defined herein. Thus, the peptide as defined herein can also be an epitope to which the antibody specifically binds. Further, an antibody or antibody-binding fragment that specifically binds to ADM or proADM, particularly MR-proADM, is used in the methods and kits of the present invention.

[0209] Furthermore, the methods and kits of the present invention use antibodies or antibody-binding fragments that specifically bind to proADM or fragments thereof and optionally other markers of the present invention (such as PCT). Exemplary immunoassays can be luminescence immunoassay (LIA), radioimmunoassay (RIA), chemiluminescence immunoassay, and fluorescence immunoassay, enzyme immunoassay (EIA), enzyme-linked immunosorbent assay (ELISA), bead arrays based on luminescence, magnetic bead-based arrays, protein microarray assays, rapid test formats, rare complex assays. Further, assays suitable for point-of-care testing and rapid test formats (such as, for example, immunochromatographic strip tests) can also be employed. Automated immunoassays are also contemplated, such as the KRYPTOR assay.

[0210] Alternatively, the scope of the present invention can cover other capture molecules or molecular scaffolds that specifically and / or selectively recognize proADM or fragments thereof rather than antibodies. As used herein, the term "capture molecule" or "molecular scaffold" includes molecules that can be used to bind to a target molecule or molecule of interest (i.e., analyte) from a sample (e.g., ADM, proADM, MR-proADM, and PCT). Thus, the capture molecule must be sufficiently shaped both spatially and in terms of surface characteristics (such as surface charge, hydrophobicity, hydrophilicity, presence or absence of Lewis donors and / or acceptors) to specifically bind to the target molecule or molecule of interest. Thus, the binding can be mediated, for example, by ionic interactions, van der Waals interactions, π-π interactions, σ-π interactions, hydrophobic interactions, or hydrogen bond interactions or a combination of two or more of the above interactions or a covalent interaction between the capture molecule or molecular scaffold and the target molecule or molecule of interest. In the context of the present invention, the capture molecule or molecular scaffold can be selected, for example, from the group consisting of nucleic acid molecules, carbohydrate molecules, PNA molecules, proteins, peptides, and glycoproteins. The capture molecule or molecular scaffold includes, for example, aptamers, DARPins (designed ankyrin repeat proteins), Affimers, and the like.

[0211] In certain aspects of the present invention, the method is an immunoassay comprising the steps of:

[0212] a) contacting a sample with:

[0213] i. a first antibody or an antigen-binding fragment or derivative thereof that is specific for a first epitope of the proADM, and

[0214] ii. a second antibody or an antigen-binding fragment or derivative thereof that is specific for a second epitope of the proADM; and

[0215] b) Detect the binding of the two antibodies or their antigen-binding fragments or derivatives to the proADM.

[0216] Preferably, one of the antibodies can be labeled, while the other antibody can be bound to a solid phase or can be selectively bound to a solid phase. In a particularly preferred aspect of the assay, one of the labeled antibodies is labeled, while the other antibody is bound to a solid phase or can be selectively bound to a solid phase. The first and second antibodies can be present in the form of a dispersion in a liquid reaction mixture, and a first labeling component as part of a labeling system based on fluorescence or chemiluminescence quenching or amplification is bound to the first antibody, and a second labeling component of the labeling system is bound to the second antibody, such that after detecting the binding of the two antibodies to the proADM or its fragment, a measurable signal is generated that allows for the detection of the resulting sandwich complex in the measurement solution. The labeling system can include a rare earth cryptate or chelate in combination with a fluorescent or chemiluminescent dye (especially a cyanine-type dye).

[0217] In a preferred embodiment, the method is performed as a heterogeneous sandwich immunoassay, wherein one of the antibodies is immobilized on an arbitrarily selected solid phase, such as on the wall of a coated test tube (e.g., a polystyrene test tube; a coated tube; CT) or a microtiter plate (e.g., composed of polystyrene), or immobilized on particles, such as magnetic particles, whereby the other antibody has a group similar to a detectable label or enables selective attachment to a label, and the group is used to detect the formed sandwich structure. It is also possible to temporarily delay the immobilization or perform subsequent immobilization by using a suitable solid phase.

[0218] The method according to the invention can further be embodied as a homogeneous method, wherein the sandwich complex formed by one antibody / two antibodies and the marker to be detected, i.e., proADM or its fragment, remains suspended in the liquid phase. In this case, preferably, when using two antibodies, the two antibodies are labeled with the respective parts of the detection system, which results in the generation or triggering of a signal when the two antibodies are incorporated into a single sandwich structure. Such techniques should be specifically embodied as fluorescence enhancement or fluorescence quenching detection methods. A particularly preferred aspect relates to the use of detection reagents that should be used in pairs, such as those described in US4882733, EP0180492 or EP0539477 and the prior art cited therein. In this way, it becomes possible to detect only the reaction product of the two labeling components directly included in a single immune complex in the reaction mixture. For example, such techniques are sold under the trade name (Time Resolved Amplified Cryptate Emission) or Provided, thus implementing the teachings of the above applications. Thus, in particularly preferred aspects, a diagnostic device is used to perform the methods provided herein. For example, determining the level of proADM or a fragment thereof and / or the level of any additional biomarker (such as PCT) of the methods provided herein. In particularly preferred aspects, the diagnostic device is

[0219] The biomarkers of the present invention can also be determined by mass spectrometry (MS)-based methods, such as the levels of proADM or a fragment thereof, PCT or a fragment thereof, or other biomarkers. Such methods can include detecting the presence, amount, or concentration of one or more modified or unmodified fragment peptides, such as proADM or PCT, or from a protein digest (e.g., tryptic digest) of the sample in the biological sample, and optionally separating the sample by chromatography, and performing MS analysis on the prepared and optionally separated sample. For example, selected reaction monitoring (SRM), multiple reaction monitoring (MRM), or parallel reaction monitoring (PRM) mass spectrometry can be used for MS analysis, particularly to determine the amount of proADM or a fragment thereof.

[0220] As used herein, the term "mass spectrometry" or "MS" refers to an analytical technique for identifying compounds by their mass. To enhance the mass resolution and mass determination capabilities of mass spectrometry, the sample can be processed prior to MS analysis. Thus, the present invention relates to MS detection methods that can be associated with immunoenrichment techniques, and sample preparation and / or chromatography methods, preferably in combination with liquid chromatography (LC), more preferably with high performance liquid chromatography (HPLC) or ultra-high performance liquid chromatography (UHPLC).

[0221] Sample preparation methods include techniques for lysing, fractionating, digesting the sample into peptides, depleting, enriching, dialyzing, desalting, alkylating, and / or reducing peptides. However, these steps are optional. Selective detection of analyte ions can be performed by tandem mass spectrometry (MS / MS). Tandem mass spectrometry is characterized by a mass selection step (as used herein, the term "mass selection" means the separation of ions having a specified m / z or narrow m / z range), followed by fragmentation of the selected ions and mass analysis of the resulting product (fragment) ions.

[0222] Those skilled in the art will recognize how to quantify the level of biomarkers in a sample by mass spectrometry. For example, as described above, relative quantification "rSRM" or absolute quantification can be employed.

[0223] Furthermore, the levels (including reference levels) can be determined by mass spectrometry-based methods, such as methods for determining the relative quantification or absolute quantification of a protein of interest or a fragment thereof.

[0224] Relative quantification "rSRM" can be achieved as follows:

[0225] 1. The increased or decreased presence of a target protein is determined by comparing the SRM (selected reaction monitoring) characteristic peak area of a given target fragment peptide detected in a sample with the same SRM characteristic peak areas of the target fragment peptide in at least a second, third, fourth, or more biological samples.

[0226] 2. The increased or decreased presence of a target protein is determined by comparing the SRM characteristic peak area of a given target peptide detected in a sample with the SRM characteristic peak areas generated from fragment peptides of other proteins in other samples derived from different individual biological sources, wherein the comparison of the SRM characteristic peak areas between the two samples of peptide fragments is normalized relative to, for example, the amount of protein analyzed in each sample.

[0227] 3. The increased or decreased presence of a target protein is determined by comparing the SRM characteristic peak area of a given target peptide with the SRM characteristic peak areas of other fragment peptides of different proteins within the same biological sample in order to normalize the changing level of histone relative to the levels of other proteins that do not change their expression levels under various cellular conditions.

[0228] 4. These determinations can be applied to both unmodified and modified fragment peptides of the target protein, wherein the modifications include but are not limited to phosphorylation and / or glycosylation, acetylation, methylation (monomethylation, dimethylation, trimethylation), citrullination, ubiquitination, and wherein the relative levels of the modified peptides are determined in the same manner as the relative amounts of the unmodified peptides are determined.

[0229] Absolute quantification of a given peptide can be achieved as follows:

[0230] 1. The SRM / MRM characteristic peak area of a given fragment peptide of a target protein in a separate biological sample is compared with the SRM / MRM characteristic peak area of an internal fragment peptide standard incorporated into the protein lysate of the biological sample. The internal standard can be a labeled synthetic version of a fragment peptide from the target protein being interrogated or a labeled recombinant protein. This standard is incorporated into the sample in a known amount before digestion (mandatory for recombinant proteins) or after, and the SRM / MRM characteristic peak areas of both the internal fragment peptide standard and the native fragment peptide in the biological sample can be determined separately and then the two peak areas are compared. This can be applied to both unmodified and modified fragment peptides, wherein the modifications include but are not limited to phosphorylation and / or glycosylation, acetylation, methylation (e.g., monomethylation, dimethylation, trimethylation), citrullination, ubiquitination, and wherein the absolute levels of the modified peptides are determined in the same manner as the absolute levels of the unmodified peptides are determined.

[0231] 2. Peptides can also be quantified using an external calibration curve. The normal curve method uses a constant amount of heavy peptide as an internal standard and different amounts of light synthetic peptides incorporated into the sample. A representative matrix similar to the test sample is required to construct the standard curve to account for matrix effects. Additionally, the reverse curve method circumvents the problem of endogenous analytes in the matrix, where a constant amount of light peptide is incorporated on top of the endogenous analyte to generate an internal standard and different amounts of heavy peptide are incorporated to generate a set of concentrated standards. The test sample to be compared to the normal or reverse curve is spiked with the same amount of standard peptide as the internal standard incorporated into the matrix used to generate the calibration curve.

[0232] The present invention further relates to kits, the use of the kits, and methods in which such kits are used. The present invention relates to kits for performing the methods provided above and below herein. The definitions provided herein, such as those provided with respect to the methods, also apply to the kits of the present invention. Specifically, the present invention relates to kits for therapy guidance, stratification, and / or control of patients suspected of having an infection, wherein the kits comprise:

[0233] - a detection reagent for determining the level of proADM or one or more of its fragments in a sample from a subject and optionally additionally for determining the level of PCT, lactate, and / or C-reactive protein or one or more of its fragments, and

[0234] - reference data corresponding to the level of proADM or one or more of its fragments and optionally the levels of PCT, lactate, and / or C-reactive protein in the sample, such as reference levels, wherein the level of proADM or one or more of its fragments in the sample is equal to or higher than 1 nmol / L, preferably equal to or higher than 1.2 nmol / l, more preferably equal to or higher than 1.27 nmol / L, and wherein the reference data is preferably stored on a computer-readable medium and / or used in the form of computer-executable code configured to compare the measured level of proADM or one or more of its fragments and optionally additionally the measured level of PCT, lactate, and / or C-reactive protein or one or more of its fragments with the reference data.

[0235] As used herein, "reference data" includes one or more reference levels of proADM and optionally PCT, lactate, and / or C-reactive protein. The levels of proADM and optionally PCT, lactate, and / or C-reactive protein in a sample from a subject can be compared to the reference levels included in the reference data of the kit. The reference levels are described above and are also exemplified in the attached examples. The reference data can also include reference samples to which the levels of proADM and optionally PCT, lactate, and / or C-reactive protein are compared. The reference data can also include an instruction manual on how to use the kit of the present invention.

[0236] The kit can additionally include items useful for obtaining a sample such as a blood sample (e.g., the kit can include a container, where the container includes means for attaching the container to a cannula or syringe), a syringe suitable for blood separation, having an internal pressure below atmospheric pressure (such as suitable for drawing a predetermined volume of sample into the container), and / or additionally includes a cleaning agent, chaotropic salts, ribonuclease inhibitors, chelating agents (such as guanidinium isothiocyanate, guanidine hydrochloride, sodium dodecyl sulfate, polyoxyethylene sorbitan monolaurate, RNAse inhibitor protein, and mixtures thereof), and / or a filtration system containing: nitrocellulose, silica matrix, ferromagnetic spheres, a cup retrieves spillover, trehalose, fructose, lactose, mannose, polyethylene glycol, glycerol, EDTA, TRIS, limonene, xylene, benzoyl, phenol, mineral oil, aniline, pyrrole, citrate, and mixtures thereof.

[0237] As used herein, "detection reagent" and the like are reagents suitable for assaying markers such as proADM, PCT, lactate, and / or C-reactive protein described herein. Such exemplary detection reagents are, for example, ligands such as antibodies or fragments thereof that specifically bind to a peptide or epitope of one or more of the markers described herein. Such ligands can be used in immunoassays as described above. Additional reagents for assaying the levels of the one or more markers in an immunoassay can also be included in the kit and are considered detection reagents herein. The detection reagent can also relate to a reagent for detecting a marker or a fragment thereof by an MS-based method. Thus, such a detection reagent can also be a reagent for preparing a sample for MS analysis, such as an enzyme, a chemical, a buffer, etc. A mass spectrometer can also be considered a detection reagent. The detection reagent according to the present invention can also be one or more calibration solutions, for example, the one or more calibration solutions can be used to assay and compare the levels of the one or more markers.

[0238] The sensitivity and specificity of a diagnostic and / or prognostic test depend not only on the analytical "quality" of the test, but also on the definition of the characteristics that constitute an abnormal result. In fact, a receiver operating characteristic curve (ROC curve) is typically calculated by plotting the values of a variable for a "normal" population (i.e., apparently healthy individuals without the infection) and a "diseased" population (e.g., subjects with the infection) against their relative frequencies. For any particular biomarker (such as proADM), the distributions of biomarker levels in subjects with and without the disease / condition may overlap. Under such conditions, the test does not absolutely distinguish between normal and disease with 100% accuracy, and the overlapping region can indicate cases where the test fails to distinguish between normal and disease. A threshold is selected below which the test is considered abnormal and above which the test is considered normal, or below or above which the test indicates a specific condition, such as an infection. The area under the ROC curve is a measure of the likelihood that a perceived measurement will allow correct discrimination of the condition. Even if the test results do not necessarily give exact numbers, an ROC curve can be used. As long as the results can be ranked, an ROC curve can be generated. For example, the test results for "disease" samples can be ranked according to degree (e.g., 1 = low, 2 = normal, and 3 = high). This ranking can be related to the results in the "normal" population and an ROC curve is generated. 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 an ROC curve area greater than about 0.5, more preferably greater than about 0.7, still more preferably greater than about 0.8, even more preferably greater than about 0.85, and most preferably greater than about 0.9. In this context, the term "about" means + / - 5% of a given measurement result.

[0239] 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. Thus, for a particular cut-off value selected, 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 likelihood that the measured biomarker level will allow correct discrimination of the disease or condition. Thus, the area under the ROC curve can be used to determine the effectiveness of the test.

[0240] Accordingly, the present invention includes administering an antibiotic suitable for treatment based on the information obtained by the methods described herein.

[0241] The present invention encompasses the administration of the pharmaceutical compositions of the present invention to a subject. As used herein, "administration" or "administering" shall include, but not be limited to, introducing the composition by oral administration. Such administration can also be carried out, for example, once, multiple times, and / or for one or more extended periods of time. A single administration is preferred, but in some cases repeated administrations over time may be required (e.g., hourly, daily, weekly, monthly, quarterly, semi-annually, or annually). Such administrations are also preferably carried out using mixtures and pharmaceutically acceptable carriers. Pharmaceutically acceptable carriers are well known to those skilled in the art.

[0242] Administration can also occur locally, for example, by injection at a site where one or more antibiotic agents should be active, for example, by endoscopic or minimally invasive means.

[0243] The compositions described herein can include different types of carriers, depending on whether the composition is to be administered in solid, liquid, or aerosol form and whether the composition requires sterility for an administration route such as injection. The compositions of the present invention can be administered intravenously, intradermally, intraarterially, intraperitoneally, intralesionally, intracranially, intraarticularly, intraprostatically, intrapleurally, intratracheally, intranasally, intravitreally, intravaginally, rectally, topically, intratumorally, intramuscularly, intraperitoneally, subcutaneously, subconjunctivally, intravascularly, mucosally, pericardially, intraumbilically, intraocularly, orally, locally, locally, by inhalation (e.g., nebulized inhalation), by injection, by infusion, by continuous infusion, by direct local perfusion bathing of target cells, via a catheter, by lavage, in the form of a cream, in the form of a lipid composition (e.g., liposome), or by any combination of other methods or the above methods known to those of ordinary skill in the art (see, for example, Remington's Pharmaceutical Sciences, 18th Edition, Mack Printing Company, 1990, which is incorporated herein by reference).

[0244] In addition, such compositions may include pharmaceutically acceptable carriers, which may be aqueous or non-aqueous solutions, suspensions, and emulsions, and most preferably various types of aqueous solutions or solid formulations known in the art. Aqueous carriers include water, alcoholic solutions / aqueous solutions, emulsions, and suspensions, and the suspensions include saline and buffered media. Parenteral vehicles include sodium chloride solution, Ringer's dextrose, dextrose, and sodium chloride, lactated Ringer's solution, and fixed oils. Intravenous vehicles include fluids and nutrient supplements, electrolyte supplements (such as Ringer's dextrose, those based on Ringer's glucose), and the like. Fluids commonly used for i.v. administration can be found, for example, in Remington: The Science and Practice of Pharmacy, 20th Edition, page 808, Lippincott Williams & Wilkins (2000). Preservatives and other additives may also be present, such as, for example, antibacterial agents, antioxidants, chelating agents, inert gases, and the like.

[0245] As used herein, the terms "comprising" and "including" or grammatical variants thereof shall be regarded as specifying the stated feature, integer, step, or component, but not precluding the addition of one or more further features, integers, steps, components, or groups thereof. This term encompasses the terms "consisting of" and "consisting essentially of".

[0246] Thus, the terms "comprising" / "including" / "having" mean that any additional component (or likewise, feature, integer, step, etc.) can / may be present. The term "consisting of" means that no additional component (or likewise, feature, integer, step, etc.) is present.

[0247] When used herein, the term "consisting essentially of" or grammatical variants thereof shall be regarded as specifying the stated feature, integer, step, or component, but not precluding the addition of one or more further features, integers, steps, components, or groups thereof, provided that the additional features, integers, steps, components, or groups thereof do not materially alter the basic and novel characteristics of the claimed composition, apparatus, or method.

[0248] Thus, the term "consisting essentially of" means those specific additional components (or likewise, features, integers, steps, etc.) that may be present, i.e., those that do not substantially affect the essential characteristics of the composition, device, or method. In other words, the term "consisting essentially of" (which may be used interchangeably herein with "essentially comprising") allows for the presence of other components in the composition, device, or method in addition to the mandatory components (or likewise, features, integers, steps, etc.), provided that the presence of the other components does not substantially affect the essential characteristics of the device or method.

[0249] The term "method" refers to the manner, means, technique, and procedure for accomplishing a given task, including but not limited to those manner, means, technique, and procedure known to or readily developed from known manner, means, technique, and procedure by practitioners in the fields of chemistry, biology, and biophysics.

[0250] The present invention is further described by reference to the following non-limiting examples.

[0251] Examples

[0252] The present invention is further described in the following examples. These examples 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.

[0253] Methods of the examples:

[0254] Study design and setting:

[0255] This study was conducted in the emergency department of Skane University Hospital, Malmo, Sweden. Between December 2013 and February 2015, adult patients with clinically suspected infections were prospectively enrolled. The inclusion criteria were suspected infection as judged by the charge nurse and >2 SIRS criteria. SIRS was defined as follows: temperature >38°C or <36°C or self-reported fever / chills within the past 24 hours, respiratory rate >20 breaths / minute, and heart rate >90 beats / minute. White blood cell count (WBC count) was not used as an inclusion criterion due to lack of measurement upon arrival. This study was approved by the Regional Ethical Review Board at Lund University, Sweden (2013 / 635) and conducted in accordance with the Helsinki Declaration. Informed consent was obtained from all patients or their next of kin.

[0256] Data collection and biomarker measurement:

[0257] Patients were enrolled by the principal research nurse between 6 a.m. and 6 p.m., and the medical records were systematically examined to obtain demographic characteristics, comorbidities, and concomitant medications. Routine laboratory tests were performed by a certified laboratory in the Department of Clinical Chemistry at Skåne University Hospital, and microbiological tests and radiological examinations were also recorded. Additionally, the time from emergency department visit to first antibiotic administration and other treatments was registered, as well as information on organ support therapies (such as supplemental oxygen, intravenous fluids) and the need for vasopressors, mechanical ventilation, and renal replacement therapy. The length of hospital stay, ICU admission information, 28-day mortality information, and overall in-hospital mortality information were also registered. EDTA plasma samples were frozen within 2 hours after sample collection, stored at -80 °C, and never thawed before analysis. PCT and MR-proADM were measured in all 213 samples using a commercially available sandwich immunoassay on the KRYPTOR platform (Thermo Fisher Scientific, Germany).

[0258] Definition of outcomes

[0259] The presence of organ dysfunction and infection status was determined for each patient by the study physician. For patients who did not clearly meet the criteria for organ dysfunction or infection, two infectious disease specialists reviewed the data and determined the final classification. The primary outcomes were intravenous antibiotic requirement, treatment duration, development of infection-related organ dysfunction (severe sepsis) within 48 hours after enrollment, presence of bacteremia, and 28-day all-cause mortality.

[0260] The criteria for organ dysfunction were adapted from consensus criteria and current SSC guidelines 23,24 Accordingly, severe sepsis was defined as an infectious disease with at least 2 SIRS criteria and the presence or development of hypotension, hypoperfusion, and / or organ failure within 48 hours after admission. Septic shock was defined as sepsis plus hypotension (systolic blood pressure < 90 mmHg, or mean arterial pressure < 70 mmHg), requiring fluid resuscitation or administration of vasopressors.

[0261] Statistical analysis:

[0262] Use x for categorical variables 2Examine and use the Student's t-test or Mann-Whitney U test for continuous variables to assess differences in clinical characteristics regarding 28-day mortality according to normal distribution. Normal distribution variables and non-normal distribution variables are expressed as mean (standard deviation) and median [first quartile - third quartile], respectively. The area under the receiver operating characteristic curve (AUROC), logistic, and Cox regression analyses are used to evaluate the associations between antibiotic requirement, bacteremia prediction, development of severe sepsis, and prediction of mortality within 28 days and each biomarker and clinical score. Logistic regression models are created separately using the biomarker or score, or adjusted for sex and age variables, and the logistic regression models are expressed as odds ratio (OR) and 95% confidence interval [95% CI]. A two-sided p < 0.05 is considered statistically significant. All data are analyzed using statistical software R (version 3.1.2).

[0263] Example 1: Patient characteristics

[0264] A total of 213 patients were enrolled in this study, of whom 113 (53.1%) developed severe sepsis within the first 48 hours after presentation, while 7 (6.9%) presented with septic shock. The mean age of the total population was 67.8 years, with no significant difference between genders (50.2% male). The patients showed a high degree of comorbidity, including cases of hypertension (42.2%), anemia (35.4%), coronary heart disease (22.3%), chronic obstructive pulmonary disease (18.4%), and diabetes (17.0%). The source of infection could be identified in 190 (89.2%) patients, among which pulmonary infection (N = 85; 39.9%), urinary tract infection (N = 53; 24.9%), and soft tissue or skin infection (N = 21; 9.9%) were the most common. The overall 28-day mortality rate of the total population was 8.9%, and the SOFA score of 203 (95.3%) patients was < 6. Compared with survivors, all biomarkers and clinical scores of non-surviving patients were significantly higher. Non-survivors were also more likely to develop severe sepsis (p < 0.01), have a higher number of organ failures (p < 0.001), or be admitted to the intensive care unit (p < 0.05).

[0265] Patient characteristics regarding 28-day mortality are summarized in Table 1.

[0266] Example 2: Using biomarkers to assist in assessing antibiotic requirement

[0267] Antibiotics were administered to a total of 187 (87.8%) patients in the study population. Among these patients, 164 (77.0%) were treated with intravenous antibiotics only, 6 (2.8%) were given a combination of intravenous and oral antibiotics, and 17 (8.0%) were treated with oral antibiotics only. A comprehensive overview of the use of intravenous antibiotics can be found in Supplementary Table 2. The median time to initial intravenous antibiotic treatment was 93 [28 - 160] minutes, and 71 (43.8%) patients received initial antibiotic therapy within 60 minutes.

[0268] Logistic regression analysis showed that in both regression models, MR-proADM was most strongly associated with the need for intravenous antibiotics (Table 3). Similar results were found for PCT, where the odds ratios for both markers were greater than those for CRP or lactate. Adding PCT or MR-proADM to each other in the multivariable model significantly improved the prediction of antibiotic need (p < 0.05).

[0269] Subsequently, the optimal cut-off values for all biomarkers were calculated based on AUROC analysis, resulting in cut-off values for PCT and MR-proADM of 0.12 ng / ml and 1.27 nmol / L, respectively (Table 4). Subgroup analysis showed a significant difference in the need for intravenous antibiotics based on the combination of these biomarker cut-off values (Table 5). Interestingly, the median time to antibiotic administration in patients with MR-proADM values < 1.27 nmol / L was 139 [81 - 209] minutes, which was significantly longer than the median time in patients with values ≥ 1.27 nmol / L (43 [26 - 134] minutes; p < 0.001). In contrast, there was no significant difference in PCT values.

[0270] Finally, it was found that 26 (12.6%) patients had been prescribed antibiotics less than 48 hours before entering the ED. Although this had little impact on the performance of MR-proADM, when these patients were excluded from the analysis, the predicted value of PCT for antibiotic need increased from OR [95% CI]: 4.22 [2.21 - 8.04] to 5.45 [2.49 - 11.93].

[0271] Example 3: Added value of the combination of PCT and MR-proADM for predicting the need for intravenous antibiotics

[0272] Compared with performing logistic regression analysis only on individual biomarkers and on multivariate models including the patient's age and gender, adding PCT to the MR-proADM multivariate model (age + gender) (Table 6) and adding MR-proADM to the PCT multivariate model (age + gender) (Table 7) showed that MR-proADM added more value to predicting intravenous antibiotic requirements for PCT than PCT did for MR-proADM (as demonstrated by the higher added LR 2 numbers and lower significance p-values). However, both combinations were significant.

[0273] Similarities were also found when patients who had previously received antibiotic treatment (and thus had artificially reduced PCT concentrations upon arrival at the ED) were excluded from the analysis, as shown for individual markers only in Table 8 and for multivariate models including age and gender in Table 9. Adding PCT to the MR-proADM multivariate model (age + gender) (Table 10) and adding MR-proADM to the PCT multivariate model (age + gender) (Table 11) showed that both combinations were significant.

[0274] Example 4: Prediction of bacteremia and development of severe sepsis

[0275] Positive blood cultures were obtained in 34 (16.1%) patients, with Escherichia coli (n = 9), Staphylococcus aureus (n = 4), and Klebsiella pneumoniae (n = 4) being the most common pathogens. The use of PCT had the strongest predictive value for bacteremia (OR [95% CI]: 3.73 [2.14 - 6.51]), although in the multivariate model, the largest predictive value was found with MR-proADM (OR [95% CI]: 4.24 [2.31 - 7.76]; Table 12). Interestingly, adding MR-proADM to the multivariate model containing PCT significantly increased the predictive value (p < 0.05), while PCT was not added to the corresponding model containing MR-proADM. Additional AUROC analysis is reported in Table 13.

[0276] Similar results were also found for the development of severe sepsis within 48 hours of ED admission, where MR-proADM had the greatest predictive value (OR [95% CI]: 5.79 [3.30 - 10.16]), followed by PCT (OR [95% CI]: 4.33 [2.58 - 7.27]; Tables 14 and 15). The use of lactate and CRP were relatively poor predictors of the development of severe sepsis (OR [95% CI]: 2.31 [1.48 - 3.61] and 1.94 [1.28 - 2.95], respectively).

[0277] Example 5: Prediction of 28-day all-cause mortality

[0278] AUROC and Cox regression analyses showed that MR-proADM had the highest performance in assessing disease severity when measured by 28-day total mortality. Although there was no significant difference between the performance of MR-proADM and SOFA, the values of MR-proADM were consistently higher in AUROC (AUROC [95% CI]: 0.86 [0.79 - 0.92] vs 0.84 [0.77 - 0.91]; Table 16), univariate Cox regression (hazard ratio [95% CI]: 4.29 [2.54 - 7.26] vs 3.29 [2.13 - 5.08]), and multivariate Cox regression (hazard ratio [95% CI]: 3.73 [2.12 - 5.58] vs 2.77 [1.76 - 4.37]) analyses (Table 17).

[0279] In addition, AUROC analysis showed that the optimal sensitivity and specificity cut-off value for MR-proADM was 1.73 nmol / L. When this cut-off value was applied to the total patient population, it was found that 143 (67.1%) patients had values < 1.73 nmol / L, resulting in a 28-day mortality rate of 1.4%, while 70 patients (32.9%) had values > 1.73 nmol / L, corresponding to a 28-day mortality rate of 24.3% (hazard ratio of higher cut-off value vs lower cut-off value [95% CI]: 15.0 [3.2 - 68.0]).

[0280] Finally, it was observed that qSOFA had an extremely high hazard ratio in predicting 28-day mortality (HRIQR [95% CI]: 30.12 [5.56 - 163.24]; Table 16), however, the sensitivity at the cut-off value of 2 points was relatively low (0.58 [0.36 - 0.77]). In fact, among the 19 patients who died within 28 days in this study, 8 patients (42.1%) had a qSOFA score < 2 points. In each case, the MR-proADM value was greater than 1.73 nmol / L.

[0281] Discussion of the example

[0282] This study is the first to introduce the use of MR-proADM as a marker of disease severity in the emergency department and uniquely emphasizes the importance of early and accurate assessment of disease severity in subsequent treatment decisions and the likelihood of disease progression.

[0283] Such an assessment is crucial for providing an appropriate level of treatment as early as possible. In fact, it has been shown that in the most severe cases, for every hour of delay in administering antibiotics, the mortality rate may increase by nearly 8%. 25 . Although the severity of the patient's infectious symptoms has been evaluated, the combination of relatively stable clinical signs and symptoms with low levels of diagnostic biomarkers such as PCT and CRP may lead to treatment delays. In these cases, biomarkers that increase significantly early in the pathophysiological process can provide a rapid tool for assessing the need for immediate intravenous antibiotic treatment as well as the need for specific sepsis therapies.

[0284] Therefore, this study found that the use of mid-regional proadrenomedullin can meet this clinical need. Previous investigations have shown that adrenomedullin increases in response to vascular permeability, endothelial, and microcirculatory injury 14,17,18,26,27 , all of which may precede any subsequent complications of organ function 28,29 .

[0285] Our results show that MR-proADM performs better than all traditional biomarkers at the earliest clinical contact point when assessing disease severity. Similar results were found in previous intensive care sepsis studies 30 , which grouped patients according to existing organ dysfunction and found superior MR-proADM performance in low (SOFA < 6) and moderate (SOFA between 8 - 13) severity groups. The low organ severity group is of particular interest because it not only "represents the earliest manifestation in the clinical course of sepsis and / or less severe disease forms" 30 , but it also represents the largest infected population entering clinical care. In addition, the similarity of the cut-off values between the two study populations (1.73 vs. 1.79 nmol / L) and the high sensitivity values for predicting 28-day mortality (89% vs. 83%) enhance the potential use of this biomarker in the more prevalent ED setting in the early stages of the disease. Additionally, the use of a cut-off value of 1.73 nmol / L found in this study can help identify the high-risk infected patient population for whom potential therapies should be immediately applied.

[0286] Similarities with previous studies can also be found in issues related to the use of qSOFA 11。In these two studies, it was found that the sensitivity for predicting infectious-related mortality was extremely low (58% and 52%), with a significant proportion of non-surviving patients initially having a qSOFA score of 0 or 1. Interestingly, in each of these patients, the MR-proADM value was > 1.73 nmol / L, thus highlighting the use of the marker as an early tool for disease severity assessment - in this case, a significant increase in the marker preceded established clinical signs and symptoms.

[0287] Although a limited number of studies using MR-proADM have focused on the overall mortality of patients presenting to the emergency department 19-21 , the use of MR-proADM in relation to antibiotic administration and antibiotic treatment duration in septic patients has not been investigated previously. Although PCT is generally considered the best biomarker for antibiotic guidance in the ICU 31-33 , many studies have found conflicting results in its use in the emergency department 34,35 。Our results show that PCT was found to be a more accurate biomarker for antibiotic need and bacteremia compared to CRP or lactate, however, MR-proADM was superior compared to all traditionally used biomarkers. This may be due in part to the rapid induction kinetics of the biomarker, which increased significantly earlier than PCT or CRP in response to lipopolysaccharide (LPS) stimulation 36-38 。This was also confirmed in a separate study investigating the development of sepsis in burn patients, where MR-proADM concentrations increased significantly one day prior to the diagnosis of sepsis, while PCT levels increased significantly on the day of infection 39 。

[0288] For this study, detailed information on antibiotic administration, treatment duration, and disease progression for each patient was recorded, as well as a comparison between the current gold standard for disease severity discrimination and the novel biomarker MR-proADM. All patients were thoroughly examined by disease experts to ensure correct diagnosis.

[0289] In summary, MR-proADM can provide a rapid diagnostic alternative to complex clinical scores in assessing disease severity and can provide useful clinical information regarding the immediate need for antibiotics, the likelihood of disease progression, and the need for alternative treatment strategies in order to prevent adverse outcomes. Further studies are needed to confirm and elaborate on these preliminary findings.

[0290] Table

[0291] Table 1. Patient characteristics regarding the 28-day mortality

[0292]

[0293]

[0294] Continuous data are presented as median (interquartile range), except for age (median and standard deviation). Binary variables are presented as count (%). * It refers to the difference between 28-day survivors and non-survivors.

[0295] Table 2. Use of intravenous antibiotics during ED treatment

[0296]

[0297]

[0298] Table 3. Logistic regression analysis of the need for intravenous antibiotics after ED visits

[0299]

[0300] Table 4. AUROC analysis of the need for intravenous antibiotics

[0301]

[0302] Table 5. Subgroup analysis of antibiotic treatment based on PCT and MR-proADM cut-off values

[0303]

[0304] Subgroup analysis: * Group 1 vs. Group 2; ** Group 2 vs. Group 3; *** Group 1 vs. Group 3; **** Group 1 vs. Group 4. PCT: Procalcitonin; MR-proADM: Mid-regional proadrenomedullin; N: Number; OR: Odds ratio; CI: Confidence interval

[0305] Table 6. Adding PCT to the MR-proADM multivariable model (age + sex)

[0306]

[0307] Table 7. Adding MR-proADM to the PCT multivariable model (age + sex)

[0308]

[0309] Table 8. Biomarkers alone

[0310] N Event <![CDATA[LR c 2 > DF p-value C-index OR [95% CI] MR-proADM 187 147 27.71489 1 1.41E-07 0.761139 4.44[2.32-8.49] PCT 187 147 24.8166 1 6.31 E-07 0.751276 4.90[2.35-10.23] Lactate 179 141 9.454986 1 0.002106 0.666013 2.42[1.33-4.40] CRP 181 142 8.233092 1 0.004113 0.656013 2.00[1.24-3.23]

[0311] Table 9. Multivariate model including age and sex

[0312] N Event <![CDATA[LR c 2 > DF p-value C-index OR [95% CI] MR-proADM + age + sex 187 147 27.88646 3 3.84E-06 0.759524 4.84[2.20-10.65] PCT + age + sex 187 147 28.32618 3 3.1E-06 0.771173 4.44[2.13-9.28] Lactate + age + sex 179 141 13.35143 3 0.003935 0.699048 2.04[1.10-3.78] CRP + age + sex 181 142 14.22562 3 0.002614 0.713254 1.92[1.17-3.14]

[0313] Table 10. Adding PCT to the MR-proADM multivariate model (age + sex)

[0314]

[0315] Table 11. Adding MR-proADM to the PCT multivariate model (age + sex)

[0316]

[0317] Table 12. Logistic regression analysis of the prediction of positive bacterial cultures

[0318] N Event <![CDATA[LR c 2 > DF p-value C-index OR [95% CI] MR-proADM 211 34 24.07 1 0.0000 0.750 3.41[2.01-5.78] PCT 211 34 24.29 1 0.0000 0.759 3.73[2.14-6.51] Lactate 202 34 16.47 1 0.0000 0.712 3.14[1.76-5.63] CRP 206 33 2.98 1 0.0845 0.583 1.65[0.91-3.00] MR-proADM + age + sex 211 34 26.86 3 0.0000 0.748 4.24[2.31-7.76] PCT + age + sex 211 34 24.37 3 0.0000 0.759 3.72[2.12-6.54] Lactate + age + sex 202 34 16.60 3 0.0009 0.712 3.25[1.76-6.00] CRP + age + sex 206 33 3.48 3 0.3231 0.589 1.62[0.89-2.97]

[0319] MR-proADM; mid-regional proadrenomedullin; PCT: procalcitonin; CRP: C-reactive protein; N: number; DF: degrees of freedom; OR: odds ratio; CI: confidence interval

[0320] Table 13. AUROC analysis of the prediction of positive blood cultures

[0321]

[0322] Table 14. Logistic regression analysis of the prediction of the development of severe sepsis within 48 hours of arrival at the ED

[0323] N Event <![CDATA[LR c 2 > DF p-value C-index OR [95% CI] MR-proADM 212 113 57.07 1 0.0000 0.782 5.79[3.30-10.16] PCT 212 113 40.82 1 0.0000 0.753 4.33[2.58-7.27] Lactate 203 108 14.90 1 0.0001 0.650 2.31[1.48-3.61] CRP 206 109 10.73 1 0.0011 0.613 1.94[1.28-2.95] MR-proADM + age + sex 212 113 58.57 3 0.0000 0.790 4.95[2.68-9.13] PCT + age + sex 212 113 60.06 3 0.0000 0.801 4.47[2.57-7.79] Lactate + age + sex 203 108 29.53 3 0.0000 0.718 1.97[1.22-3.16] CRP + age + sex 206 109 32.85 3 0.0000 0.727 1.97[1.26-3.07]

[0324] MR-proADM; mid-regional proadrenomedullin; PCT: procalcitonin; CRP: C-reactive protein; N: number; DF: degrees of freedom; OR: odds ratio; CI: confidence interval

[0325] Table 15. AUROC analysis of the prediction of the development of severe sepsis within 48 hours of arrival at the ED

[0326]

[0327] Table 16. AUROC analysis of the prediction of 28-day mortality

[0328]

[0329] Table 17. AUROC and logistic regression analysis of the prediction of 28-day mortality

[0330] N Event <![CDATA[LR c 2 > DF p-value C-index HR IQR [95% CI] MR-proADM 213 19 28.11 1 0.0000 0.841 4.29[2.54-7.26] PCT 213 19 10.05 1 0.0015 0.694 2.65[1.46-4.82] Lactate 204 19 4.46 1 0.0346 0.640 1.99[1.06-3.76] CRP 207 18 4.69 1 0.0303 0.653 2.37[1.00-5.62] SOFA 213 19 22.92 1 0.0000 0.859 3.29[2.13-5.08] qSOFA 213 19 14.63 1 0.0001 0.798 30.12[5.56-163.24] MR-proADM + age 213 19 35.76 2 0.0000 0.864 3.73[2.12-6.58] PCT + age 213 19 27.34 2 0.0000 0.824 2.87[1.51-5.46] Lactate + age 204 19 19.30 2 0.0001 0.767 1.70[0.87-3.31] CRP + age 207 18 20.25 2 0.0000 0.779 2.48[1.01-6.09] SOFA 213 19 32.80 2 0.0000 0.856 2.77[1.76-4.37] qSOFA 213 19 25.85 2 0.0000 0.811 15.55[2.70-89.48]

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[0374] 43. M. Christ-Crain, “Procalcitonin Guidance of Antibiotic Therapy Community-acquired Pneumonia: A Randomized Trial”, American Journal of Respiratory and Critical Care Medicine, Vol. 174, No. 1, January 1, 2006, pp. 84-93. Sequence Listing <110> B.R.A.H.M.S GMBH <120> PRO-ADM-based Antibiotic Therapy Guidance <130> XII 2266 / 17WO <150> EP17209064.9 <151> 2017-12-20 <160> 2 <170> PatentIn version 3.5 <210> 1 <211> 185 <212> PRT <213> Homo sapiens <400> 1 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 <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

Claims

1. Use of a detection reagent for determining the level of MR-proADM in a sample from a patient suspected of having an infection in the preparation of a kit for performing a method for guiding, stratifying, and / or controlling antibiotic therapy for the patient suspected of having an infection, the kit comprising a reference level of MR-proADM of 1.27 nmol / L, wherein the kit is configured to compare the measured level of MR-proADM with the reference level, and the method comprises: - providing a sample from the patient, and - determining the level of MR-proADM in the sample, - wherein a measured level of MR-proADM in the sample that is equal to or higher than the reference level at a single time point indicates whether antibiotic treatment needs to be initiated or changed.

2. The use according to claim 1, wherein the provided sample is isolated from the patient within 12 hours from the first contact with a medical staff member.

3. The use according to claim 1, wherein the patient presents at an emergency department or a primary care unit.

4. The use according to claim 1, wherein the antibiotic treatment that needs to be initiated or changed comprises initiating or changing intravenous antibiotic treatment.

5. The use according to claim 1, wherein the kit is capable of additionally determining the level of PCT in a sample from the patient.

6. The use according to claim 5, wherein the level of PCT and the level of MR-proADM are determined in the same sample.

7. The use according to claim 5, wherein the kit further comprises a reference level of PCT of 0.1 ng / ml, and wherein a measured level of PCT that is equal to or higher than 0.1 ng / ml indicates the need to initiate or change antibiotic treatment.

8. The use according to claim 5, wherein the sample for determining MR-proADM and the sample for determining PCT are body fluids.

9. The use according to claim 5, wherein - a measured level of MR-proADM in the sample that is equal to or higher than 1.27 nmol / L, and - a measured level of PCT that is lower than 0.1 ng / ml, indicate the need to initiate or change antibiotic treatment.

10. The use according to claim 1, wherein the patient has not received antibiotic treatment.

11. The use according to claim 1, wherein the patient has not been diagnosed with an infection and has not received antibiotic treatment, and indicates the initiation of antibiotic treatment.

12. The use according to claim 1, wherein the patient is receiving oral antibiotic treatment and indicates a change in antibiotic treatment, wherein the change in antibiotic treatment comprises a change in the administration route to intravenous antibiotic treatment.

13. A kit for performing the method according to any one of claims 1 to 12, comprising: - a detection reagent for determining the level of MR-proADM in a sample from a patient suspected of having an infection, and - Reference data, said reference data comprising a reference level of MR-proADM of 1.27 nmol / L, wherein the kit is configured to compare the measured level of MR-proADM with said reference level, and said comparison indicates a need to initiate or change antibiotic treatment, wherein when the measured level of MR-proADM is equal to or higher than 1.27 nmol / L, antibiotic treatment needs to be initiated or changed.

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