MxA to Drive Increased Specificity and Augment Sensitivity of Bacterial Biomarkers

REFERENCE TO RELATED APPLICATIONS

This application claims priority from U.S. Application Serial Number 15/012,897, filed February 2, 2016, entitled "IMPROVED METHODS AND DEVICES FOR

ACCURATE DIAGNOSIS OF INFECTIONS". This application also claims one or more inventions which were disclosed in Provisional Application Number 62/245,431, filed October 23, 2015, entitled "MxA TO DRIVE INCREASED SPECIFICITY AND

AUGMENT SENSITIVITY OF BACTERIAL BIOMARKERS". The benefit under 35 USC § 119(e) of the United States provisional application is hereby claimed, and the aforementioned applications are hereby incorporated herein by reference.

BACKGROUND OF THE INVENTION

FIELD OF THE INVENTION

The invention pertains to the field of identifying infection. More particularly, the invention pertains to increasing the specificity and sensitivity in identifying and diagnosing viral and bacterial infections.

DESCRIPTION OF RELATED ART

Mx proteins are members of the superfamily of high molecular weight GTPases. Accordingly, these GTPases are upregulated by type I alpha/beta or type II interferons (IFN). The Mx GTPases are expressed exclusively in IFN alpha/beta but not IFN gamma treated cells. Type I interferons play important roles in innate immune responses and have immunomodulatory, antiproliferative, and antiviral functions. Human MxA, a 78 kDa protein, accumulates in the cytoplasm of IFN α/β treated cells and inhibits the replication of a wide range of viruses. MxA protein may offer certain advantages as a biomarker for viral infection over the other induced proteins such as 2', 5'- oligoadenylate synthetase, because of its lower basal concentration, longer half-life (2.3 days) and fast induction. MxA mRNA is detectable in isolated peripheral blood white blood cells stimulated with IFN within 1 to 2 h of IFN induction, and MxA protein begins to accumulate shortly thereafter.

Studies have shown that MxA protein expression in peripheral blood is a sensitive and specific marker for viral infection. The higher MxA levels in the viral infection group compared with the bacterial infection group can be explained by the fact that the MxA protein is induced exclusively by type I IFN and not by IFN-gamma, IL-1, TNF-alpha, or any of the other cyotokines by bacterial infection. Serum type I IFN levels remain within normal limits, even in patients with severe bacterial infections.

Similarly, most viral infections have been reported to cause little acute phase response, and low C-Reactive Protein (CRP) concentrations have been used to distinguish illnesses of viral origin from those of bacterial etiology. Because the plasma concentration of CRP increases rapidly after stimulation and decreases rapidly with a short half-life, CRP can be a useful tool in diagnosing and monitoring infections and inflammatory diseases. Often the diagnostic value of CRP is found to be superior to that of the erythrocyte sedimentation rate (ESR) and superior or equal to that of the white blood cell count (WBC).

Procalcitonin (PCT) is another marker of bacterial infection. While procalcitonin has no known hormonal activity, it is an 116 amino acid peptide precursor of the hormone calcitonin which is involved with calcium homeostais. When a patient is healthy, procalcitonin is only present in the parafollicular cells (C cells) of the thyroid gland and by the neuroendocrine cells of the lung and the intestine. If a bacterial infection is present, however, intact procalcitonin is found in the blood. The level of procalcitonin is related to the proinflammatory stimulus by severity of bacterial infection and sepsis. Procalcitonin levels do not rise significantly with viral or non-infectious inflammations. Interestingly, the high procalcitonin levels produced during infections are not followed by a

simultaneous increase in calcitonin levels or a decrease in serum calcium levels.

Clinically, it can be challenging to differentiate certain systemic viral and bacterial infections. Bacterial cultures are usually performed in cases of severe infection such as pneumonia, or when the consequence of missing a diagnosis can lead to severe complications, such as with Strep throat. Often times, cultures are difficult to obtain. Unfortunately, viral cultures are not routinely performed due to the significant time delay in receiving results. Viral screening PCR panels are useful, but they are expensive and do not provide information at the point of care. Thus, there remains a need for diagnostic tests that are capable of confidently identifying viral and bacterial infections in a point of care setting.

SUMMARY OF THE INVENTION

In one embodiment, a method of increasing the specificity of detection of a bacterial host biomarker without compromising sensitivity comprises the step of assaying for at least one viral host biomarker and at least one bacterial host biomarker.

In another embodiment, a method of increasing the specificity of detection of C- reactive protein without compromising sensitivity in an assay comprises the step of testing for a presence of MxA and C-reactive protein.

In another embodiment, a method of increasing the specificity of detection of procalcitonin without compromising sensitivity in an assay comprises the step of testing for a presence of MxA and procalcitonin.

In yet another embodiment, a method of using MxA in combination with at least one bacterial biomarker to increase specificity of host bacterial biomarkers comprises the step of testing for a presence of MxA and a host bacterial biomarker.

BRIEF DESCRIPTION OF THE DRAWINGS

Fig. 1 shows a CRP receiver-operator curve and its shift upon the addition of MxA.

Fig. 2 shows a PCT receiver-operator curve and its shift upon the addition of MxA.

Fig. 3A shows a fully open sample analysis device with dual test strips, as well as a

conjugate zone and a sample application zone on a sample compressor in a plane separate from the test strips in an embodiment of the present invention.

Fig. 3B shows the sample analysis device of Fig. 3A with part of the housing closed, but the conjugate zone still visible on the left side of the device. Fig. 3C shows the sample analysis device of Fig. 3A after the test has been initiated.

Fig. 4A shows a fully open sample analysis device with dual test strips and a conjugate zone on a sample compressor in a plane separate from the test strips in an embodiment of the present invention.

Fig. 4B shows the sample analysis device of Fig. 4A with part of the housing closed, but the conjugate zone still visible on the left side of the device.

Fig. 4C shows the sample analysis device of Fig. 4A after the test has been initiated.

DETAILED DESCRIPTION OF THE INVENTION

Several viral infections such as influenza A/B, adenovirus, Epstein-Barr Virus, cause mild to moderate elevations in the acute phase response, leading to elevations of both C-Reactive Protein (CRP) and procalcitonin (PCT). Historically, CRP and PCT have been used independently in an effort to distinguish illnesses of viral origin from those of bacterial etiology. At lower concentrations, CRP has high sensitivity but very low specificity for a bacterial infection and at very high concentrations, the reverse is true and the sensitivity is poor but the specificity is significantly improved. In Scandinavia, point of care CRP testing is part of the routine evaluation of patients with respiratory infections in general practice, and its use has proved cost-effective, despite the significant overlap in viral and bacterial signs and symptoms at moderate CRP levels. In general practice, CRP is found to be valuable aid in reducing unnecessary antibiotics even if it is of modest value at differentiating viral from bacterial disease independently.

Similar to CRP, at low concentrations, PCT has high sensitivity and low specificity at differentiating a viral from bacterial infection yet at high concentrations, the reverse is true, and sensitivity falls and specificity is increased.

While the host biomarkers of bacterial infection C-reactive protein and

procalcitonin are bacterial markers used in the art, they are known for their lack of sensitivity and specificity when used alone. MxA is a biomarker that is specific for viral infection. The Applicant has found that testing for the presence of MxA, a host biomarker of viral infection, combined together with either C-reactive protein or procalcitonin creates an unexpected synergy, greater than an additive phenomenon, and increases both the specificity and sensitivity of both of the bacterial markers. Typically, a bacterial biomarker has an ability to detect bacterial infection with an optimized point that maximizes sensitivity and specificity to identify a bacterial infection. The presence of MxA allows the curve to shift to maximal sensitivity (a lower CRP or PCT cutoff concentration) without sacrificing the specificity because the MxA identifies the viral patients that have elevated CRP or PCT (leading to reduced specificity), and correctly recategorizes these patients as viral. Thus, any patient with an elevated CRP or PCT in the presence of MxA is a viral disease and any elevation of CRP or PCT (now at a much lower cutoff concentration) in the absence of MxA is bacterial. Furthermore, the lack of elevation of CRP, PCT, or MxA has an extremely high negative predictive value for the presence of a clinically significant infection. Other host biomarkers of viral infection, for example IFITs (interferon-induced proteins with tetratricopeptide repeats) may alternatively be used to increase sensitivity and specificity of any of the bacterial biomarkers tested alone.

On a receiver-operator curve, there is a point of optimization of specificity and one for sensitivity for detection of each biomarker. Using MxA as a second biomarker in combination, increases the specificity of both procalcitonin and C-reactive protein and also shifts their curves to allow higher optimized sensitivity. A C-reactive protein receiver-operator curve is shown in Figure 1 and a procalcitonin receiver-operator curve is shown in Figure 2. The sensitivities and specificities for C-reactive protein from various studies (and the respective references) are shown in Table 1.

As shown in Figure 1, the optimized ROC value of CRP alone is 40 mg/L (74% sensitivity and 73% specificity). Testing for a combination of 20 mg/L CRP and 40 ng/ml of MxA increases sensitivity and specificity to 95% and 90%, respectively. Testing for a combination of 40 mg/L CRP and 40 ng/ml of MxA (not shown in the figures) increases sensitivity and specificity to 100% and 90%, respectively. Thus, the use of MxA in combination with CRP permits a more accurate interpretation with detection of lower levels of CRP and relying on MxA to provide the specificity. As shown in Figure 2, the optimized ROC of PCT alone is 0.4 ng/ml (95% sensitivity and 57% specificity). Testing for a combination of 0.4 ng/ml PCT and 40 ng/ml of MxA increases sensitivity and specificity to 100% and 90%, respectively. Thus, a combination of MxA and PCT allows not only higher sensitivity but also a dramatic increase in specificity.

Table 1

CRP

Sensitivity Specificity Article

Cut-off

Putto A, Ruuskanen 0, Meurman 0. Arch Dis

20 mg/L 100% 75%

Child. 1986 Jan: 61(l):24-9.

Hatherill M, Tibby SM, Sykes K et al. Arch Dis

20 mg/L 100% 54%

Child 1999: 81: 417-21.

Berger RM, Berger MY, van Steensel-Moll HA,

20 mg/L 83% 67%

Eur J Pediatr 1996; 155: 468-73.

Lala S, Madhi S, Pettifor J. Ann Trop Pediatr.

40 mg/L 76% 60%

2002; 22: 271-279.

Andreola G, Bressan S, Callegaro S. Pediatr

40 mg/L 71% 81%

Infect Dis J 2007; (8): 672-7.

Liu A, Bui T, Van Nguyen H. Age Ageing 2010:

40 mg/L 83% 88%

559-65.

Stolz, D, Christ-Crain M, Gencey MM et al.

50 mg/L 94% 72%

Swiss Med Wkly. 2006;136(27-28):434-440.

Liu A, Bui T, Van Nguyen H. Age Ageing 2010:

60 mg/L 81% 96%

559-65.

Moulin F, Raymond J, Lorrot M et al., Arch Dis

60 mg/L 70% 52%

Child. 2001; 84: 332-336.

Liu A, Bui T, Van Nguyen H. Age Ageing 2010:

80 mg/L 72% 97%

559-65.

Korppi M, Kroger L. Scand J Infect Dis J 1992;

80 mg/L 15% 95%

207-213.

Andreola G, Bressan S, Callegaro S. Pediatr

80 mg/L 46% 95%

Infect Dis J 2007; (8): 672-7. There is a challenge to define true infection from bacterial colonization or a local viral infection without a systemic host response. There needs to be a change in definition of infection, which will change the diagnostic parameters and reported performance of a test. The new definition that should be adopted and standardized for a clinically significant respiratory infection requires confirmation of the presence of a pathogen via antigen, culture, or molecular detection in association with a systemic host response.

As newly defined herein, a clinically significant infection is the local

microbiological confirmation of a pathogen by cell culture, molecular techniques, and antigen in association with a systemic immune response (CRP, PCT, MxA, or serological response).

The Applicant also discovered that a positive low CRP result plus a positive MxA result does not indicate viral-bacterial co-infection. Instead, a patient with that result has a viral infection only. In fact, the Applicant believes that viral-bacterial co-infection only infrequently exists. True infections are either solely bacterial or solely viral. A diagnosis of "co-infection" is the product of the erroneous definitions of infection. The presence of a true infection (versus colonization of a virus or bacteria) requires both the presence of a pathogen and a host response (systemic response) to that infection. In prior art methods, technicians and doctors would culture a sample and ignore whether or not there was a simultaneous presence of a host response. When they saw both a bacterial and viral culture growing together, they would define that as co-infection. In a study of over 300 patients, the Applicant saw no occurrences of co-infection in their patients. Low CRP and elevated MxA were actually only viral infections.

A rapid lateral flow test aids the primary and urgent care physicians in the outpatient setting to make a rapid assessment of the clinical significance of an acute respiratory infection. Further, the test helps to differentiate infections with a systemic host response from local infections or colonization as well as identify patients as having a viral or bacterial infection versus those with a microbiologically unconfirmed respiratory illness (MURI). The test uses a combination of two biomarkers, including myxovirus resistance protein A (MxA), a novel viral biomarker, and C-reactive protein (CRP). MxA is an intracellular blood protein that is induced by type 1 interferon and is therefore specific for true viral infections (as opposed to viral carriage). The biomarker is normally very low in the blood but has fast induction in case of a viral infection, a long half-life, and stays elevated in the presence of elevated interferon. The test is preferably a single use disposable test that uses a fingerstick blood (5ul) sample near the bedside. The time to result is approximately 15 minutes and no additional sample processing is required. The readout of the test is interpreted either as a viral infection when MxA is elevated (MxA positive, CRP positive or negative) or as a bacterial infection whenever CRP is elevated in the presence of normal MxA (MxA negative, low or high CRP positive).

Dual strip formats for a lateral flow test that detects the presence of MxA and CRP are shown in Figs. 3A-3C and 4A-4C, and described in US Patent No. 8,962,260, entitled "METHOD AND DEVICE FOR COMBINED DETECTION OF VIRAL AND

BACTERIAL INFECTIONS", issued February 24, 2015, and US Patent Publication No. 2013/0196310, entitled "METHOD AND DEVICE FOR COMBINED DETECTION OF VIRAL AND BACTERIAL INFECTIONS", published August 1, 2013, both incorporated herein by reference.

One preferred configuration for a bimodal dual test strip sample analysis device is shown in Figures 3A through 3C. The sample analysis device or test card (800) includes a closable housing (835) with two sides (836), (837) and a spine or hinged portion (831). In one preferred embodiment, the test card (800) is approximately 11.5 cm long (L) x 7 cm wide (W) when the two sides (836), (837) are closed. However, any size test card (800) that accommodates all of the components may be used. Within the first side (836) of the housing (835), there are two test strips (815), (825), each including a receiving pad (845), a diverting zone (850), a transfer pad (855) and a detection zone (805). The first side (836) also includes an absorbent pad (840) and preferably a waste pad (860). The first test strip (815) preferably includes a detection zone (805) with an MxA test line (802), a low CRP test line (803) and a control line (804). The second test strip (825) preferably includes a detection zone (805) with a high CRP test line (823) and a control line (804). All of the test lines are visible through the windows (865) on the second side (837) of the housing

(835) when the housing (835) is closed. The absorbent pad (840) is preferably a single pad that the running buffer is added to start lateral flow. Similarly, the waste pad (860) is preferably a single pad that collects excess running buffer at the end of the test. However, in other embodiments, each strip could have a separate absorbent pad (840) and/or waste pad (860). The second side (837) of the housing (835) includes three separate sections (838),

(839) and (870). The middle portion, a sample compressor or flap (870), preferably includes two conjugate zones (872), (874), each including a labeled binding partner for at least one analyte, and a labeled control. A window (843) is located in the lower portion (838) of the second side (837) of the housing so that the buffer can be added to the absorbent pad (840) when the housing (835) is closed. The viewing windows (865) for the detection zones (805) are on the upper portion (839) of the second side (837) of the housing (835).

The upper portion (839) and the lower portion (838) of the second side (837) of the housing (835) also preferably each include at least one knob, peg or protrusion (875) that mates with one or more holes (895) so that the upper and lower portions (838), (839) may be easily fastened onto the first side (836) of the housing (835). In a preferred

embodiment, there are two pegs (875) on the lower portion (838) that mate with two holes (895) flanking the absorbent pad (840) on the first side (836) of the housing (835) and two pegs (875) on the upper portion (839) that mate with two holes (895) flanking the waste pad (860) on the first side (836) of the housing (835). In other embodiments, the holes (895) are on the second side (837) of the housing (835) and the pegs (875) are on the first side (836) of the housing (835). In yet other embodiments, other reversible fastening mechanisms could be used to secure the upper portion (838) and/or lower portion (839) of the second side (837) of the housing (835) to the first side (836) of the housing (835). In other embodiments, the upper and lower sections (838), (839) are permanently closed, for example using an adhesive, before use.

The flap (870), also known as a sample compressor, on the second side (837) of the housing includes two conjugate zones (872), (874) and two sample application zones (873), (876), and can be easily opened and closed. The flap (870) also preferably includes at least one knob, peg or protrusion (875) that mates with one or more holes (895) so that the flap (870) is easily correctly closed onto the first side (836) of the housing (835) after sample has been added to the sample application zones (873), (876). In other

embodiments, the holes (895) are on the second side (837) of the housing (835) and the pegs (875) are on the first side (836) of the housing (835). In yet other embodiments, other reversible fastening mechanisms could be used to secure the flap (870) to the first side (836) of the housing (835).

The conjugate zones (872), (874) and the sample application zones (873), (876) preferably overlap. In preferred embodiments, the conjugate zones (872), (874) are colored due to the dyes in the sample conjugates and control conjugates, and the sample is placed directly on the colored portion of the flap (870). In one preferred embodiment, the conjugate zone (872) that is used for the first test strip (815) contains an MxA binding partner that is labeled with a red dye, a low CRP binding partner that is labeled with a black dye, and a control binding partner that is labeled with a blue dye. In this embodiment, the conjugate zone (872) appears purplish. The other conjugate zone (874) contains a high CRP binding partner that is labeled with a black dye and a control binding partner that is labeled with a blue dye. In this embodiment, the conjugate zone (874) appears bluish.

The diverting zone (850) preferably includes a gap or barrier that interrupts lateral flow, diverting the running buffer up into the flap (870) that includes the conjugate zones (872), (874) and the sample application zones (873), (876). In operation, the upper and lower portions (838), (839) of the second side (837) of the housing (835) are preferably snapped closed before use by securing the pegs (875) to the holes (895). The sample analysis device, or test card (800) is preferably placed on a flat surface. If the flap (870) is not already open, the user opens it to access the sample application zones (873), (876). A blood sample to be tested is taken from the patient. The sample may be taken by any procedure known in the art. In a preferred embodiment, a sample of 5μ1 of blood is added to each of the sample application zones (873), (876) and then the flap (870) is closed. Each of the 5 μΐ samples is preferably collected

independently of each other. The blood samples are preferably added directly to the device (800), without any pretreatment. To ensure that the sample compressor or flap (870) has been closed correctly, pressure is preferably applied to the housing (835) above the pegs (875) to snap the pegs (875) closed. The top of the flap (870) needs to be flush with the top of the rest of the second side (837) of the housing (835) for the test to run properly. Running buffer is added to the absorbent pad (840), which initiates lateral flow (885). In preferred embodiments, the running buffer includes one or more lysis agents, for example detergents, to lyse the blood sample and expose the intracellular MxA in the sample. When the running buffer reaches the diverting zone (850), it is diverted up into the flap (870). It travels through the conjugate zones (872), (874), collecting any complexes formed between the MxA binding partner and MxA in the sample, the low CRP binding partner and low levels of CRP in the sample, the high CRP binding partner and high levels of CRP in the sample, as well as the control conjugate.

Since the conjugate zones (872), (874) bridge the diverting zone (850) on the lateral flow test strips (815), (825), the running buffer, which now contains sample, conjugate, and the complexes described above, then travels into the transfer pad (855), and to the detection zones (805) on each of the test strips (815), (825). If MxA is present in the sample, the MxA test line (802) on the first test strip (815) will be red. If a threshold low level of CRP is present in the sample, the low CRP test line (803) on the first test strip (815) will be black. If a threshold high level of CRP is present in the sample, the high CRP test line (823) on the second test strip (825) will be black. If the test is run correctly, the control lines (804) on both the first strip (815) and the second test strip (825) will be blue. In preferred embodiments, the levels of detection are 40 ng/ml for MxA, 10 mg/L for low CRP on the first test strip (815) and 80 mg/L for high CRP on the second test strip (825). The results of the test should be visible after approximately 5-20 minutes, preferably within about 10 minutes.

Since the control binding partner is on the sample compressor or flap (870) and not on either of the test strips (815), (825), there is a true procedural control to this configuration. If the flap (870) is not closed properly, nothing will show up in the detection zone (805), indicating that the test was run improperly. Another preferred configuration for a bimodal dual test strip sample analysis device (1000) is shown in Figures 4A through 4C. This configuration is similar to the configuration (800) shown in Figures 3A through 3C, but the sample application zones (1073), (1076) are located on each of the test strips (1015), (1025), downstream of the diverting zone (850). The sample analysis device or test card (1000) includes a closable housing (835) with two sides (836), (837) and a spine or hinged portion (831). In one preferred embodiment, the test card (1000) is approximately 11.5 cm long (L) x 7 cm wide (W) when the two sides (836), (837) are closed. However, any size test card (1000) that accommodates all of the components may be used. Within the first side (836) of the housing (835), there are two test strips (1015), (1025), each including a receiving pad (845), a diverting zone (850), a transfer pad (1055) and a detection zone (805). The first side (836) also includes an absorbent pad (840) and preferably a waste pad (860). The first test strip (1015) preferably includes a detection zone (805) with an MxA test line (802), a low CRP test line (803) and a control line (804). The second test strip (1025) preferably includes a detection zone (805) with a high CRP test line (823) and a control line (804). All of the test lines are visible through the windows (865) on the second side (837) of the housing (835) when the housing (835) is closed. The absorbent pad (840) is preferably a single pad to which the running buffer is added to start lateral flow. Similarly, the waste pad (860) is preferably a single pad that collects excess running buffer at the end of the test. However, in other embodiments, each strip could have a separate absorbent pad (840) and/or waste pad (860). The second side (837) of the housing (835) includes three separate sections (838),

(839) and (1070). The middle portion, or flap (1070), also known as a sample compressor, preferably includes two conjugate zones (872), (874), each including a labeled binding partner for at least one analyte, and a labeled control. A window (843) is located in the lower portion (838) of the second side (837) of the housing so that the buffer can be added when the housing (835) is closed. The viewing windows (865) for the detection zones (805) are on the upper portion (839) of the second side (837) of the housing (835).

The upper portion (839) and the lower portion (838) of the second side (837) of the housing (835) also preferably each include at least one knob, peg or protrusion (875) that mates with one or more holes (895) so that the upper and lower portions (838), (839) may be easily fastened onto the first side (836) of the housing (835). In a preferred

embodiment, there are two pegs (875) on the lower portion (838) that mate with two holes (895) flanking the absorbent pad (840) on the first side (836) of the housing (835) and two pegs (875) on the upper portion (839) that mate with two holes (895) flanking the waste pad (860) on the first side (836) of the housing (835). In other embodiments, the holes (895) are on the second side (837) of the housing (835) and the pegs (875) are on the first side (836) of the housing (835). In yet other embodiments, other reversible fastening mechanisms could be used to secure the upper portion (838) and/or lower portion (839) of the second side (837) of the housing (835) to the first side (836) of the housing (835). In other embodiments, the upper and lower sections (838), (839) are permanently closed, for example using an adhesive, before use. The flap (1070) on the second side (837) of the housing includes two conjugate zones (872), (874) and can be easily opened and closed. The flap (1070) also preferably includes at least one knob, peg or protrusion (875) that mates with one or more holes (895) so that the flap (1070) is easily correctly closed onto the first side (836) of the housing (835) after sample has been added to the sample application zones (1073), (1076) on the test strips (1015), (1025). In other embodiments, the holes (895) are on the second side (837) of the housing (835) and the pegs (875) are on the first side (836) of the housing (835). In yet other embodiments, other reversible fastening mechanisms could be used to secure the flap (1070) to the first side (836) of the housing (835).

In preferred embodiments, the conjugate zones (872), (874) are colored due to the dyes in the sample conjugates and control conjugates. In one preferred embodiment, the conjugate zone (872) that is used for the first test strip (1015) contains an MxA binding partner that is labeled with a red dye, a low CRP binding partner that is labeled with a black dye, and a control binding partner that is labeled with a blue dye. In this embodiment, the conjugate zone (872) appears purplish. The other conjugate zone (874) contains a high CRP binding partner that is labeled with a black dye and a control binding partner that is labeled with a blue dye. In this embodiment, the conjugate zone (874) appears bluish.

The diverting zone (850), which preferably includes a gap or barrier, interrupts lateral flow, diverting the running buffer up into the flap (1070) that includes the conjugate zones (872), (874). In operation, the upper and lower portions (838), (839) of the second side (837) of the housing (835) are preferably snapped closed before use by securing the pegs (875) to the holes (895). The sample analysis device, or test card (1000) is preferably placed on a flat surface. If the flap (1070) is not already open, the user opens it to access the sample application zones (1073), (1076). The sample application zones (1073), (1076) may be located in any portion of the transfer pad (1055). A blood sample to be tested is taken from the patient. The sample may be taken by any procedure known in the art. In a preferred embodiment, a sample of 5μ1 of blood is added to each of the sample application zones (1073), (1076) zones and then the flap (1070) is closed. Each of the 5 μΐ samples is preferably collected independently of each other. The blood is preferably added directly to the device (1000), without any pretreatment. In preferred embodiments, an arrow (1002) or other indication (shown in Figure 4A), for example the words "add sample here" shows the user where to place the sample on the test strips (1015), (1025).

To ensure that the flap (1070) has been closed correctly, pressure is preferably applied to the housing (835) above the pegs (875) to snap the pegs (875) closed. The top of the flap (1070) needs to be flush with the top of the rest of the second side (837) of the housing (835) for the test to run properly. Running buffer is added to the absorbent pad (840), which initiates lateral flow (885). In preferred embodiments, the running buffer includes one or more lysis agents, for example detergents, to lyse the blood sample and expose the intracellular MxA in the sample. When the running buffer reaches the diverting zone (850), it is diverted up into the flap (1070). It travels through the conjugate zones (872), (874), collecting the MxA binding partners, the low CRP binding partners, and the high CRP binding partners, as well as the control conjugate.

Since the conjugate zones (872), (874) bridge the diverting zone (850) on the lateral flow test strips (1015), (1025), the running buffer, which now contains conjugate, then travels into the transfer pad (1055), which includes the sample application zones (1073), (1076), and to the detection zones (805) on each of the test strips (1015), (1025). If MxA is present in the sample, the MxA test line (802) on the first test strip (1015) will be red. If a threshold low level of CRP is present in the sample, the low CRP test line (803) on the first test strip (1015) will be black. If a threshold high level of CRP is present in the sample, the high CRP test line (823) on the second test strip (1025) will be black. In preferred embodiments, the levels of detection are 40 ng/ml for MxA, 10 mg/L for low CRP on the first test strip (1015) and 80 mg/L for high CRP on the second test strip (1025). The results of the test should be visible after approximately 5-20 minutes, preferably within about 10 minutes. If the test was run correctly, the control lines (804) on both the first strip (815) and the second test strip (825) will be blue.

Since the control binding partner is on the flap (1070) and not on either of the test strips (1015), (1025), there is a true procedural control to this configuration. If the flap (1070) is not closed properly, nothing will show up in the detection zone (805), indicating that the test was run improperly. In an alternative embodiment, the sample application zones (1073), (1076) are located on the receiving pad (845), before the diverting zone (850). In this embodiment, the running buffer travels through the sample application zones (1073), (1076), and then is diverted into the flap (1070).

In preferred embodiments of the configurations shown in Figures 3A through 3C and 4 A through 4C, greater than approximately 1.2 ml of running buffer is placed on the absorbent pad (840). If less than 1.0 ml is added in embodiments where the diverting zone (850) is a gap, the buffer gets stalled at the gap because the gap holds approximately 1.0 ml.

In data from a prospective, multicenter clinical trial in the USA using the format shown in Figs. 3A through 3C, the lateral flow test demonstrated a sensitivity and specificity of 80% and 96%, respectively, to identify a bacterial infection, and a sensitivity and specificity of 86% and 94%, respectively for detecting a viral infection. The patients in this study with positive CRP (low and/or high CRP) and positive MxA were identified as having a viral infection. For five patients, the test lines for low CRP, high CRP and MxA were all positive, and these patients were all identified as having a viral infection. "Unconfirmed" results are preferably interpreted as "negative".

The test may alternatively be in an even simpler format with only one strip that includes MxA and CRP (preferably low CRP). In alternative embodiments, MxA is the viral host biomarker and the bacterial host biomarker is PCT.

All of the patent and nonpatent references described herein (and in the figures) are herein incorporated by reference. Accordingly, it is to be understood that the embodiments of the invention herein described are merely illustrative of the application of the principles of the invention. Reference herein to details of the illustrated embodiments is not intended to limit the scope of the claims, which themselves recite those features regarded as essential to the invention.