Ruling In and Ruling Out Sepsis Using Likelihood Ratios of a Host Response Assay

Abstract

Overview: SeptiCyte RAPID is an FDA-cleared gene expression test that quantifies host immune response to aid in the diagnosis of sepsis. The test yields a score (the SeptiScore) ranging from 0–15, distributed across four bands (1–4) based on increased likelihood of sepsis. Each band can be characterized by average positive and negative likelihood ratios (LR+ and LR−, respectively) for the discrimination of sepsis versus the non-infectious systemic inflammatory response syndrome (SIRS). Methods: A retrospective analysis of prospectively collected data from a combined cohort of critically ill patients suspected of sepsis (n = 889), recruited across 19 hospitals in the USA and Europe. The analysis quantified the LR+ and LR− parameters as a function of SeptiScore, for discrimination of sepsis vs. SIRS in patients admitted to ICU. Hypotheses: (1) The likelihood ratio (LR) framework provides a clinically useful interpretive approach that complements the previously used SeptiScore banding scheme; (2) Low Band 1 SeptiScores are associated with sufficiently small LR− to support the use of SeptiCyte RAPID as a rule-out test for sepsis; (3) High Band 4 SeptiScores are associated with sufficiently large LR+ to support the use of SeptiCyte RAPID as a rule-in test for sepsis; and (4) SeptiScore-derived LR+ and LR− values can be combined with estimates of pre-test probability (derived from patient characteristics and/or other diagnostic tests) to generate individualized, patient-specific post-test probabilities of sepsis. Results: The SeptiCyte RAPID test demonstrates strong diagnostic performance in distinguishing sepsis from SIRS. The likelihood ratios across different score bands provide clear clinical utility: the median LR+ was 3.26 (range 2.57–4.24) for Band 3, and 6.97 (range 4.35–15.57) for Band 4, providing evidence toward ruling in sepsis at high SeptiScores. Conversely, the median LR− was 0.16 (range 0.14–0.20) for Band 2 and 0.085 (range 0.014–0.16) for Band 1, providing evidence toward ruling out sepsis at low SeptiScores. A higher-resolution analysis of SeptiCyte RAPID performance confirmed these trends by evaluating LR+ and LR− at specific values within each band. The sepsis group was further stratified according to whether patients were classified as blood culture positive (BC+) or blood culture negative (BC−), and the detailed LR+ and LR− analyses were repeated. A monotonic increase in likelihood ratio with increasing SeptiScore was consistently observed, independent of whether sepsis patients were culture-positive, culture-negative, or unstratified with respect to blood culture status. Conclusions: High SeptiScores have correspondingly high LR+ values, and low SeptiScores have correspondingly low LR− values, both of which may have clinical utility. High likelihood ratios for Band 4 SeptiScores, which precede traditional microbiology results, may provide clinicians with early confidence of a sepsis diagnosis and microbiology diagnostic stewardship. Low likelihood ratios for Band 1 SeptiScores may prompt clinicians to consider an alternate diagnosis to sepsis. These are diagnostic-performance-based observations; whether they translate into fewer missed diagnoses or more efficient use of hospital resources has not been directly assessed in this study and will require dedicated clinical outcome studies.