The Elecsys BRAHMS PCT assay is intended for use to determine the change of PCT over time as an aid in assessing the cumulative 28-day risk of all-cause mortality for patients diagnosed with severe sepsis or septic shock in the Intensive Care Unit (ICU) or when obtained in the emergency department or other medical wards prior to ICU admission. The electrochemiluminescence immunoassay "ECLIA" is intended for use on Elecsys and cobas e immunoassay analyzers.

Procalcitonin (PCT) is a biomarker associated with the inflammatory response to bacterial infection that aids in the risk assessment of critically ill patients on their first day of Intensive Care Unit (ICU) admission for progression to severe sepsis and septic shock. The percent change in PCT level over time aids in the prediction of cumulative 28-day mortality in patients with severe sepsis and septic shock.

A PCT level that declines ≤ 80 % from the day that severe sepsis or septic shock was clinically diagnosed (Day 0) to four days after clinical diagnosis (Day 4) is associated with higher cumulative 28-day risk of all-cause mortality than a decline > 80 %.

The combination of the first PCT level (≤ 2.0 ng/mL or > 2.0 ng/mL) at initial diagnosis of severe sepsis or septic shock with the patient's clinical course and the change in PCT level over time until Day 4 provides important additional information about the mortality risk.

The PCT level on Day 1 (the day after severe septic shock is first clinically diagnosed) can be used to calculate the percent change in PCT level at Day 4 if the Day 0 measurement is unavailable.

Device Description

The Elecsys BRAHMS PCT assay is a two-step sandwich immunoassay with streptavidin microparticles and an electrochemiluminescence detection system. PCT in the sample reacts with these labeled antibodies to form a sandwich complex. This complex binds to streptavidin coated magnetic microparticles, which are magnetically captured onto an electrode. Application of voltage to the electrode induces chemiluminescence which is measured by a photomultiplier tube. Results are determined via a calibration curve which is instrument-specifically generated by 2-point calibration and a master curve provided via the reagent barcode. An optional Procalcitonin CalCheck product is also available.

AI/ML Overview

The provided text describes the Elecsys BRAHMS PCT assay, an immunoassay for the quantitative determination of procalcitonin (PCT) in human serum and plasma, intended to aid in assessing the 28-day risk of all-cause mortality for patients with severe sepsis or septic shock. The document outlines the performance characteristics and a clinical study conducted to support its indications for use.

Here's an analysis of the acceptance criteria and the study that proves the device meets them, based on the provided text:

1. Table of Acceptance Criteria and Reported Device Performance

The document does not explicitly present a table of acceptance criteria with numerical targets for clinical performance endpoints (e.g., specific sensitivity, specificity, or predictive values that the device needed to meet to be considered "accepted"). Instead, it presents the results of the clinical study and infers substantial equivalence to a predicate.

However, the non-clinical performance evaluation sections (analytical sensitivity, precision, linearity, etc.) implicitly have acceptance criteria, as the reported performance values are deemed satisfactory to demonstrate substantial equivalence. The document states: "The information provided in this 510(k) Premarket Notification will support a determination of substantial equivalence for the Elecsys BRAHMS PCT test system. The data supports a safe, effective device which performs as well as or better than the predicate device." This strongly suggests that the reported values met internal or regulatory expectations for substantial equivalence.

Here's a table summarizing the reported device performance from the provided text, derived from the non-clinical and clinical performance evaluations:

Performance Metric	Acceptance Criteria (Inferred from Substantial Equivalence and Study Design)	Reported Device Performance (Elecsys BRAHMS PCT)
Non-Clinical Performance
Precision (cobas e 411 Analyzer)	Expected to be within acceptable variability for a diagnostic immunoassay.	Repeatability:- HS1: 5.03% CV @ 0.079 ng/mL- HS2: 1.71% CV @ 0.442 ng/mL- HS3: 2.35% CV @ 1.49 ng/mL- HS4: 1.38% CV @ 27.5 ng/mL- HS5: 2.23% CV @ 71.4 ng/mL- HS6: 1.35% CV @ 88.1 ng/mL- PC1: 1.91% CV @ 0.456 ng/mL- PC2: 1.83% CV @ 9.07 ng/mLIntermediate Precision:- HS1: 6.44% CV @ 0.079 ng/mL- HS2: 3.14% CV @ 0.442 ng/mL- HS3: 3.40% CV @ 1.49 ng/mL- HS4: 3.24% CV @ 27.5 ng/mL- HS5: 3.66% CV @ 71.4 ng/mL- HS6: 3.18% CV @ 88.1 ng/mL- PC1: 3.21% CV @ 0.456 ng/mL- PC2: 3.35% CV @ 9.07 ng/mL
Limit of Blank (LoB)	Determined as the 95th percentile of blank-sample measurements.	0.015 ng/mL
Limit of Detection (LoD)	Smallest amount of analyte detectable with 95% probability.	0.02 ng/mL
Limit of Quantitation (LoQ)	Lowest concentration quantifiable with intermediate precision ≤ 20%.	0.06 ng/mL
Measuring Range	Needs to cover clinically relevant range.	0.02 – 100 ng/mL
Hook Effect	No hook effect within tested concentration.	No hook effect up to 1000 ng/mL
Interferences	Recovery within ± 15% of initial value for endogenous and exogenous substances.	Unaffected by icterus (< 428 µmol/L), hemolysis (Hb < 0.559 mmol/L), lipemia (Intralipid < 1500 mg/dL), biotin (< 123 nmol/L). No interference from rheumatoid factors (up to 1500 IU/mL) and 27 pharmaceutical compounds. No HAMA interference.
Method Comparison (vs. BRAHMS PCT sensitive KRYPTOR®)	Linear correlation, with slope and intercept close to 1 and 0, respectively.	N=2617 samples on Cobas e411 and predicate.Passing Bablok:- Slope: 0.959 (95% CI: 0.947; 0.972)- Intercept: -0.023 (95% CI: -0.028; -0.018)- Coefficient: 0.989 (95% CI: 0.988; 0.990)
Clinical Performance
Association with 28-day Mortality (ΔPCT)	Significant association (p < 0.05) with 28-day cumulative mortality.	Binary test result (ΔPCT > 80% or ≤ 80%) significantly associated with 28-day cumulative mortality (Two-sided Fisher's Exact Test p-value = 0.002). Adjusted for ICU vs. non-ICU: p-value = 0.020.
Prognostic Accuracy (Day 0-4 interval)	Sensitivity and Specificity values demonstrating utility in risk assessment.	ICU Patients:- Sensitivity: 73.4% (62.9-83.8)- Specificity: 35.0% (28.2-41.8)Non-ICU Patients:- Sensitivity: 72.3% (55.9-88.6)- Specificity: 44.4% (38.4-50.3)
Hazard Ratio for 28-day all-cause mortality (ΔPCT)	Hazard Ratio (HR) significantly > 1.0 for positive ΔPCT (≤ 80%).	Univariate Model (Per-Protocol):- ΔPCT4.0 (≤ 80% vs. > 80%): HR = 1.80 (1.15-2.82); p=0.011- ΔPCT4.1 (≤ 80% vs. > 80%): HR = 1.61 (1.04-2.49); p=0.034

2. Sample Size Used for the Test Set and Data Provenance

Test Set Sample Size:
- Method Comparison: 2617 samples were used to compare the Elecsys BRAHMS PCT assay with the predicate device (BRAHMS PCT sensitive KRYPTOR®).
- Clinical Performance Evaluation: 858 adult patients were enrolled. The "per protocol analysis population" was 598 subjects.
- Reference Range: 282 self-reported healthy individuals.
Data Provenance:
- Clinical Performance Evaluation: The clinical trial was a prospective study conducted across 13 investigational sites in the US. This indicates prospective data from multiple US sites.
- Reference Range: Implied to be from healthy individuals, likely domestic (US) given the submission context.
- Non-Clinical Studies: The text does not explicitly state the country of origin for all non-clinical samples or specific data provenance for each analytical study, but it implies internal testing by Roche Diagnostics, which has sites in Germany and the United States (as per Establishment Registration).

3. Number of Experts Used to Establish the Ground Truth for the Test Set and Qualifications of Those Experts

The document describes a clinical study for an in vitro diagnostic (IVD) device that measures a biomarker (PCT) to aid in risk assessment for mortality. For IVD devices, "ground truth" for clinical performance is typically defined by the clinical outcome itself, not by expert consensus on interpreting images or other subjective data.

For the clinical performance study: The ground truth was cumulative 28-day all-cause mortality. This is an objective clinical outcome. It does not involve expert interpretation or adjudication in the way that, for example, a radiology AI model might. The diagnosis of "severe sepsis or septic shock" would have been established by clinicians based on recognized medical criteria at each investigational site. The "experts" in this context would be the attending clinicians who managed the patients and determined their clinical status and outcomes, but their role was in providing the clinical data, not in acting as a ground truth panel for the PCT assay results themselves.
For the reference range study: The ground truth was "self-reported healthy individuals," which implies a general population considered free from disease, not requiring expert adjudication of individual cases.

4. Adjudication Method for the Test Set

As mentioned above, the primary clinical endpoint was objective (28-day all-cause mortality). There is no indication of an "adjudication method" in the sense of a panel of experts reviewing the outcome or interpreting the device's results. Outcomes like mortality are typically recorded facts. The diagnosis of severe sepsis or septic shock would have been made by the local clinicians at each site.

5. If a Multi-Reader Multi-Case (MRMC) Comparative Effectiveness Study was done

No, an MRMC comparative effectiveness study was not done. This type of study is typically associated with imaging devices where multiple human readers interpret cases and their performance is compared with and without AI assistance. The Elecsys BRAHMS PCT assay is an in vitro diagnostic (blood test) device quantifying a biomarker, not an imaging device.

6. If a Standalone (i.e., algorithm only without human-in-the-loop performance) was done

Yes, the very nature of an in vitro diagnostic (IVD) test like the Elecsys BRAHMS PCT assay is that it operates as a standalone algorithm/device. It quantitatively measures PCT levels from a human specimen. The "algorithm" in this context is the immunochemical reaction and the analyzer's detection system, which then calculates a numerical PCT value. The clinical performance study evaluates this standalone measurement in relation to a clinical outcome (mortality risk) and how its results can be integrated into clinical decision-making by human clinicians, but the device itself functions independently to produce the PCT value.

7. The Type of Ground Truth Used

Clinical Performance Evaluation: The ground truth was outcomes data, specifically cumulative 28-day all-cause mortality for patients diagnosed with severe sepsis or septic shock.
Reference Range: The ground truth was based on a population of self-reported healthy individuals.
Non-Clinical Studies (e.g., Linearity, Dilution): Ground truth would be the known concentration of spiked PCT or reference materials.

8. The Sample Size for the Training Set

The document does not explicitly mention a "training set" in the context of machine learning or AI models. For an IVD assay like this, "training" usually refers to the development and optimization process (e.g., optimizing reagent concentrations, reaction times), rather than a distinct dataset used for machine learning. The clinical performance data presented serves as a validation dataset to demonstrate the assay's utility when used according to its indications.

If "training set" refers to the data used to initially establish the assay's performance characteristics or calibrate it, then:

Calibrator Value Assignment: The calibrators are run in duplicate on at least six cobas e 411 analyzers and least three cobas e 601/cobas e 602/MODULAR ANALYTICS E170 analyzers with "all Elecsys BRAHMS PCT reagent lots available."
PreciControl Value Assignment: Controls are run in duplicate on at least six analyzers of the master analyzer platform and compared to a master calibration curve.

However, these are more akin to standardization and quality control procedures rather than a machine learning training set for an "algorithm."

9. How the Ground Truth for the Training Set Was Established

Since an explicit "training set" for an AI/ML algorithm is not described, the concept of establishing its ground truth isn't directly applicable in that sense.

For the assay's development and analytical performance:

Calibrators: Recombinant PCT in a human serum matrix (PCT CalSet). Their assigned values are determined through multiple runs on multiple analyzers using a Master Calibration Curve and must meet pre-defined acceptance criteria for associated controls (PreciControl PCT).
Controls: Recombinant PCT in human plasma (PreciControl PCT). Their assigned values are read from the master calibration curve and must meet pre-defined acceptance criteria.
Analytical Specificity/Interference: Ground truth is established by spiking known concentrations of interferents into known PCT samples.

In essence, the "ground truth" for the analytical performance characteristics is established by using controlled, manufactured materials with known properties or by challenging the assay with known substances at defined concentrations.

Summary

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Image /page/0/Picture/1 description: The image shows the logo for the U.S. Department of Health & Human Services. The logo consists of a stylized image of an eagle with three human profiles incorporated into its design. The words "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" are arranged in a circular pattern around the eagle.

Food and Drug Administration 10903 New Hampshire Avenue Document Control Center - WO66-G609 Silver Spring, MD 20993-0002

August 3, 2016

Roche Diagnostics Mr. Adam Clark Regulatory Affairs Consultant 9115 Hague Road Indianapolis, IN 46250

Re: K160729

Trade/Device Name: Elecys BRAHMS PCT, Elecys BRAHMS PCT CalCheck 5 Regulation Number: 21 CFR 866.3215 Regulation Name: Device to detect and measure non-microbial analyte(s) in human clinical specimens to aid in assessment of patients with suspected sepsis Regulatory Class: II Product Code: PMT, JJX Dated: March 15, 2016 Received: March 16, 2016

Dear Mr. Clark:

This letter corrects our substantially equivalent letter of June 13, 2016.

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food. Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21

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CFR Part 807); labeling (21 CFR Parts 801 and 809); medical device reporting (reporting of medical device-related adverse events) (21 CFR 803); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

If you desire specific advice for your device on our labeling regulations (21 CFR Parts 801 and 809), please contact the Division of Industry and Consumer Education at its toll-free number (800) 638 2041 or (301) 796-7100 or at its Internet address

http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21 CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to

http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm for the CDRH's Office of Surveillance and Biometrics/Division of Postmarket Surveillance.

You may obtain other general information on your responsibilities under the Act from the Division of Industry and Consumer Education at its toll-free number (800) 638-2041 or (301) 796-7100 or at its Internet address

http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm.

Sincerely yours,

Kristian M.Roth -S

For : Uwe Scherf, M.Sc., Ph.D. Director Division of Microbiology Devices Office of In Vitro Diagnostics and Radiological Health Center for Devices and Radiological Health

Enclosure

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Indications for Use

510(k) Number (if known) K160729

Device Name Elecsys BRAHMS PCT

Indications for Use (Describe)

Immunoassay for the in vitro quantitative determination of PCT (procalcitonin) in human serum and plasma (K2 and K3 EDTA, Li-Heparin).

A PCT level that declines $[ \le ]$ 80 % from the day that severe sepsis or septic shock was clinically diagnosed (Day 0) to four days after clinical diagnosis (Day 4) is associated with higher cumulative 28-day risk of all-cause mortality than a decline > 80 %.

The combination of the first PCT level ($[ \le ]$ 2.0 ng/mL or > 2.0 ng/mL) at initial diagnosis of severe sepsis or septic shock with the patient's clinical course and the change in PCT level over time until Day 4 provides important additional information about the mortality risk.

The PCT level on Day 1 (the day after severe septic shock is first clinically diagnosed) can be used to calculate the percent change in PCT level at Day 4 if the Day 0 measurement is unavailable.

Type of Use (Select one or both, as applicable)

Prescription Use (Part 21 CFR 801 Subpart D)	Over-The-Counter Use (21 CFR 801 Subpart C)
----------------------------------------------	---------------------------------------------

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Indications for Use

Form Approved: OMB No. 0910-0120 Expiration Date: January 31, 2017 See PRA Statement below.

510(k) Number (if known) K160729

Device Name Elecsys BRAHMS PCT CalCheck 5

Indications for Use (Describe)

The Elecsys BRAHMS PCT Calcheck 5 is an assayed control for use in calibration verification and for use in verification of the assay range established for the Elecsys BRAHMS PCT assay on the Elecsys and cobas e analyzers,

CARACHER COLUMN COLLEGIONand the many of the county of the county of the county ofType of Use (Select one or both, as applicable)
	ACALCOM

Prescription Use (Part 21 CFR 801 Subpart D)

Over-The-Counter Use (21 CFR 801 Subpart C)

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DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL ADDRESS BELOW.

Department of Health and Human Services Food and Drug Administration Office of Chief Information Officer Paperwork Reduction Act (PRA) Staff PRAStaff(@fda.hhs.gov

"An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB number."

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510(k) Summary

This summary of 510(k) safety and effectiveness information is being submitted in accordance with the requirements of 21 CFR 807.92.

Submitter Name	Roche Diagnostics
Address	9115 Hague RoadIndianapolis, IN 46250
Contact	Adam ClarkPhone: (317) 521-4371FAX: (317) 521-2324Email: adam.clark@roche.com
Date Prepared	March 15, 2016
Proprietary Name	1) Elecsys BRAHMS PCT2) Elecsys BRAHMS PCT CalCheck 5
Common Name	1) PCT Test System (test system contains both controls and calibrators)2) PCT CalCheck 5
Classification Name	1) Device to detect and measure non-microbial analyte(s) in human clinicalspecimens to aid in assessment of patients with suspected sepsis2) Secondary, calibrator3) Multi-Analyte Control, All Kinds (Assayed)4) Single (specified) analyte Controls (assayed and unassayed)
Product Codes	1) PMT; 866.32152) JIT; 862.11503) JJY; 862.16604) JJX; 862.1660
Predicate Devices	1) BRAHMS PCT sensitive KRYPTOR® test system2) Elecsys Progesterone III CalSet3) Elecsys Progesterone III CalCheck 54) BRAHMS PCT sensitive KRYPTOR® QC Kit
Establishment Registration	Roche Diagnostics GmbH in Mannheim, Germany: 9610126Roche Diagnostics GmbH in Penzberg, Germany: 9610529Roche Diagnostics in the United States: 1823260

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1. DEVICE DESCRIPTION

Reagents 1.1.

The reagent working solutions include:

Rackpack (kit placed on analyzer)

M: Streptavidin-coated microparticles, ●
R1: Anti-PCT-Ab~biotin
R2: Anti-PCT – Ab~Ru(bpy)$\overline{2}$

1.2. Calibrator

PCT CalSet is a 2-level PCT calibrator consisting of lyophilized recombinant PCT in a human serum matrix. The CalSet includes:

PCT Call: approximately 0.10 ng/mL, 1 bottle, containing 4 mL ●
. PCT Cal2: approximately 54 ng/mL, 1 bottle, containing 4 mL

1.3. Control

PreciControl PCT is a single analyte control that is used for quality control of the Elecsys BRAHMS PCT assay. The PreciControl PCT includes:

PC PCT 1: approximately 0.5 ng/mL, 2 bottles each for 4 mL
PC PCT 2: approximately 10 ng/mL, 2 bottles each for 4 mL ●

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1.4. CalCheck

PCT CalCheck 5 is a lyophilized Human serum matrix with added PCT in five concentration ranges. The CalCheck includes:

PCT CalCheck 1: approximately <0.06 ng/mL
PCT CalCheck 2: approximately 0.5 ng/mL ●
PCT CalCheck 3: approximately 40 ng/mL
PCT CalCheck 4: approximately 80 ng/mL
PCT CalCheck 5: approximately 100 ng/mL

INDICATIONS FOR USE 2.

Immunoassay for the in vitro quantitative determination of PCT (procalcitonin) in human serum and plasma (K2 and K3 EDTA, Li-Heparin).

The electrochemiluminescence immunoassay "ECLIA" is intended for use on Elecsys and cobas e immunoassay analyzers.

A PCT level that declines < 80 % from the day that severe sepsis or septic shock was clinically diagnosed (Day 0) to four days after clinical diagnosis (Day 4) is associated with higher cumulative 28-day risk of all-cause mortality than a decline > 80 %.

The PCT level on Day 1 (the day after severe sepsis or septic shock is first clinically diagnosed) can be used to calculate the percent change in PCT level at Day 4 if the Day 0 measurement is unavailable.

DISCUSSION OF ANALYZER PLATFORMS 3.

The following summary of the Elecsys platforms is provided.

The cobas e 411 analyzer is an updated version of the Elecsys 2010 analyzer. Roche Diagnostics pursued a conservative course and submitted a 510(k) for the analyzer under K062279. The submission was closed out under 'exempt' since the submission was only for the analyzer and the 'Joint Risk Assessment' performed internally identified no potential impact on reagent performance. However, to be on the conservative side. Roche Diagnostics conducted recovery and reproducibility testing with representative Elecsys assays, and those data are documented

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internally. The modifications did not alter the measurement components of the analyzer or the means by which results are calculated. The systems are analytically identical. The majority of the hardware changes, outside of the obvious name change, were cosmetic (e.g., change to color scheme, an external PC versus an internal PC) or related to safety (e.g., protective shields added over moving parts), or were made to improve customer satisfaction (e.g., a larger external waste container, flash drive replacement of floppy drive). The user-interface changes were made for aesthetics, customer satisfaction, or to bring the 'old' 2010 analyzer up to parity with those features already designed into the cobas 6000 series system.

The cobas e 601 analyzer is an updated version of the MODULAR ANALYTICS E170 analyzer. The MODULAR ANALYTICS E170 analyzer was acknowledged by FDA under Addto-File K961481/A003 on May 23, 2001. The cobas e 601 analyzer was reviewed and cleared as a component of the cobas 6000 series system submission K060373. The submission was required to introduce the other component of the cobas 6000 series system: the cobas c 501 analyzer, a new clinical-chemistry analyzer.

The cobas e 602 analyzer, part of the cobas 8000 analyzer series, was cleared via Internal Documentation, in keeping with the Reagent Replacement and Instrument Family Policy, as a new member of the Roche/Elecsys family of analyzers. The cobas e 602 is analytically identical to the cobas e 601 analyzer, part of the cobas 6000 analyzer series cleared in K060373.

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TECHNOLOGICAL CHARACTERISTICS 4.

Feature	Candidate Device: ElecsysBRAHMS PCT (K160729)	Predicate Device: BRAHMS PCT sensitiveKRYPTOR®(DEN150009)
Intended Use/Indications for Use	Immunoassay for the in vitroquantitative determination of PCT(procalcitonin) in human serum andplasma.The Elecsys BRAHMS PCT assay isintended for use to determine thechange of PCT over time as an aidin assessing the cumulative 28 dayrisk of all-cause mortality for patientsdiagnosed with severe sepsis orseptic shock in the Intensive CareUnit (ICU) or when obtained in theemergency department or othermedical wards prior to ICUadmission.The electrochemiluminescenceimmunoassay "ECLIA" is intendedfor use on Elecsys and cobas eimmunoassay analyzers.A PCT level that declines ≤ 80%from the day that severe sepsis orseptic shock was clinicallydiagnosed (Day 0) to four days afterclinical diagnosis (Day 4) isassociated with higher cumulative28-day risk of all-cause mortalitythan a decline > 80%.The combination of the first PCTlevel (≤ 2.0 ng/mL or > 2.0 ng/mL) atinitial diagnosis of severe sepsis orseptic shock with the patient'sclinical course and the change inPCT level over time until Day 4provides important additionalinformation about the mortality risk.The PCT level on Day 1 (the dayafter severe sepsis or septic shockis first clinically diagnosed) can beused to calculate the percentchange in PCT level at Day 4 if theDay 0 measurement is unavailable.	The BRAHMS PCT sensitive KRYPTOR® is intended foruse in conjunction with other laboratory findings andclinical assessments to aid in the risk assessment ofcritically ill patients on their first day of ICU admission forprogression to severe sepsis and septic shock.The BRAHMS PCT sensitive KRYPTOR® test is alsointended for use to determine the change of PCT overtime as an aid in assessing the cumulative 28-day risk ofall-cause mortality for patients diagnosed with severesepsis or septic shock in the Intensive Care Unit (ICU)or when obtained in the emergency department or othermedical wards prior to the ICU admission.
Assay Protocol	The Elecsys BRAHMS PCT assay isa two-step sandwich immunoassaywith streptavidin microparticles andan electrochemiluminescencedetection system. The test systemreagents contain a biotinylatedmonoclonal PCT-specific antibodyand a ruthenium labeled monoclonalPCT-specific antibody.	The BRAHMS PCT sensitive KRYPTOR® assay is ahomogeneous sandwich immunoassay for detection ofPCT in human serum or plasma. The measuringprinciple is based on Time-Resolved Amplified CryptateEmission (TRACE®) technology, which measures thesignal that is emitted from an immunocomplex with timedelay.
Detection Protocol	Electrochemiluminescent Assay	Time-Resolved Amplified Cryptate Emission (TRACE®)
Applications	18-minute application	19-minute incubation
Feature	Candidate Device: ElecsysBRAHMS PCT (K160729)	Predicate Device: BRAHMS PCT sensitiveKRYPTOR®(DEN150009)
InstrumentPlatform	cobas e 411 analyzer	BRAHMS KRYPTOR® analyzer
Sample Volume	30 μL	50 μL
Sample Type	Human serum and plasma (Li-Heparin, K2/K3 EDTA)	Human serum and plasma (EDTA, heparin)
Reagents	M: Streptavidin-coatedmicroparticles: Steptavidin-coatedmicroparticles; preservativeR1: Anti-PCT-Ab~~biotin: Biotinylatedmonoclonal anti-PCT antibody(mouse), phosphate buffer,preservativeR2: Anti-PCT – Ab~~Ru(bpy) 2/3+ amonoclonal anti-PCT antibody(mouse) labeled with rutheniumcomplex, phosphate buffer,preservative	Cryptate conjugate, cryptate labeled, anti-PCTantibody (polyclonal, sheep), 3.2mL afterreconstitution with KRYPTOR® Solution 2XL665 conjugate, XL665 labeled, anti-PCTantibody (monoclonal, mouse), 3.95 mL afterreconstitution with KRYPTOR® Solution 1 andKRYPTOR® Solution 2Defibrinated human plasma, for diluting samplesabove 50µg/L, ready for use
Calibrator	Elecsys PCT CalSet	BRAHMS PCT sensitive KRYPTOR® Calibrator
Calibration Interval	Calibration must be performed onceper reagent lot using fresh reagent(i.e. not more than 24 hours sincethe reagent kit was registered onthe analyzer). Renewed calibrationis recommended as follows:after 8 weeks when using thesame reagent lotafter 7 days (when using thesame reagent kit on theanalyzer) as required: e.g.quality control findings outsidethe specified limits	Before first use of each new BRAHMS PCT sensitiveKRYPTOR® assay lot, then repeated on a regular basisautomatically managed by the BRAHMS PCT sensitiveKRYPTOR®.
Controls	Elecsys Precicontrol PCT	BRAHMS PCT sensitive KRYPTOR® Controls
Traceability/Standardization	This method has been standardizedagainst the BRAHMS PCT LIAassay.	N/P
Reagent Stability	Store at 2-8 °C. Do not freeze.Store the Elecsys reagent kitupright in order to ensurecomplete availability of themicroparticles during automaticmixing prior to use. Stability:unopened at 2-8 °C: up to thestated expiration dateafter opening at 2-8 °C: 12weekson the analyzers: 4 weeks	In original shipping containers unopened at 2-8 °C:up to the stated expiration dateafter opening, onboard at 2-8 °C: 29 days
Feature	Candidate Device: ElecsysBRAHMS PCT (K160729)	Predicate Device: BRAHMS PCT sensitiveKRYPTOR®(DEN150009)
Measuring Range	0.02 – 100ng/mL	0.02-50000µg/L
Precision	cobas e 411RepeatabilityHS1: 5.03% CV @ 0.079 ng/mLHS2: 1.71% CV @ 0.442 ng/mLHS3: 2.35% CV @ 1.49 ng/mLHS4: 1.38% CV @ 27.5 ng/mLHS5: 2.23% CV @ 71.4 ng/mLHS6: 1.35% CV @ 88.1 ng/mLPC1: 1.91% CV @ 0.456 ng/mLPC2: 1.83% CV @ 9.07 ng/mLIntermediate PrecisionHS1: 6.44% CV @ 0.079 ng/mLHS2: 3.14% CV @ 0.442 ng/mLHS3: 3.40% CV @ 1.49 ng/mLHS4: 3.24% CV @ 27.5 ng/mLHS5: 3.66% CV @ 71.4 ng/mLHS6: 3.18% CV @ 88.1 ng/mLPC1: 3.21% CV @ 0.456 ng/mLPC2: 3.35% CV @ 9.07 ng/mL	Not Provided (N/P)
LoB	0.015 ng/mL	N/P
LoD	0.02 ng/mL	N/P
LoQ	0.06 ng/mL	0.075 µg/L
Lower DetectionLimit	0.015 ng/mL	N/P
Hook Effect	No hook effect up to 1000ng/mL	N/A
Feature	Candidate Device: ElecsysBRAHMS PCT (K160729)	Predicate Device: BRAHMS PCT sensitiveKRYPTOR®(DEN150009)
Limitations	The assay is unaffected by icterus(bilirubin < 428 µmol/L or < 25 mg/dL), hemolysis (Hb < 0.559mmol/L or < 0.900 g/dL), lipemia(Intralipid < 1500 mg/dL) and biotin(< 123 nmol/L or < 30 ng/mL).Criterion: Recovery within ± 15% ofinitial value.Samples should not be taken frompatients receiving therapy with highbiotin doses (i.e. > 5 mg/day) until atleast 8 hours following the last biotinadministration.No interference was observed fromrheumatoid factors up to aconcentration of 1500 IU/mL.In vitro tests were performed on 27pharmaceuticals compounds. Nointerference with the assay wasfound.Human Anti Mouse Antibody (HAMA)interference testing was completedwith three PCT analyteconcentrations using a high HAMAhuman serum pool. No interferencewas detected.Samples from patients routinelyexposed to animals or animal serumproducts may contain heterophilicantibodies causing an atypical result.This assay has been formulated tomitigate the risk of this type ofinterference. However, potentialinteractions between rare sera andtest components can occur.In rare cases, interference due toextremely high titers of antibodies toanalyte specific antibodies,streptavidin or ruthenium can occur.These effects are minimized bysuitable test design.For diagnostic purposes, the resultsshould always be assessed inconjunction with the patient's medicalhistory, clinical examination andother findings.	Citrate plasma tubes should not be used as PCTconcentrations are underestimated.• The prognostic value of PCT in the setting of sepsishas not been validated in US patients younger than 18.• Carefully follow the manufacturer's instructions.Improper handling of the reagents may falsify the testresults.• Increased PCT levels may not always be related tosystemic infection4, 11, 12, 13. These conditions include,but are not limited to:• Patients experiencing major trauma and/or recentsurgical procedure including extracorporeal circulation orburns;• Patients under treatment with OKT3 antibodies, OK-432, interleukins, TNF-alpha and other drugs stimulatingthe release of pro-inflammatory cytokines or resulting inanaphylaxis;• Patients diagnosed with active medullary C-cellcarcinoma, small cell lung carcinoma, or bronchialcarcinoid;• Patients with acute or chronic viral hepatitis and/ordecompensated severe liver cirrhosis (Child-Pugh ClassC);• Patients with prolonged or severe cardiogenic shock,prolonged severe organ perfusion anomalies or afterresuscitation from cardiac arrest;• Patients receiving peritoneal dialysis or hemodialysistreatment;• Patients with biliary pancreatitis, chemical pneumonitisor heat stroke;• Patients with invasive fungal infections (e.g.candidiasis, aspergillosis ) or acute attacks ofplasmodium falciparum malaria; and• Neonates during the first 2 days of life.The results of the B-R-A-H-M-S PCT sensitiveKRYPTOR® should be evaluated in context of alllaboratory findings and the total clinical status of thepatient. In cases where the laboratory results do notagree with the clinical picture or history, additional testsshould be performed.
Feature	Candidate Device: ElecsysBRAHMS PCT (K160729)	Predicate Device: BRAHMS PCT sensitiveKRYPTOR® (DEN150009)
LimitationsContinued	Increased PCT levels may notalways be related to systemicinfection. These include, but are notlimited to:•Patients experiencing major traumaand/or recent surgical procedureincluding extracorporeal circulationor burns.•Patients undergoing treatment withOKT3 antibodies, OK 432,interleukins, TNF alpha and otherdrugs that stimulate the release ofpro inflammatory cytokines or resultin anaphylaxis.•Patients diagnosed with activemedullary C cell carcinoma, smallcell lung carcinoma, or bronchialcarcinoid.•Patients with acute or chronic viralhepatitis and/or decompensatedsevere liver cirrhosis (Child PughClass C).•Patients with prolonged or severecardiogenic shock, prolonged severeorgan perfusion anomalies, or afterresuscitation from cardiac arrest.•Patients receiving peritoneal dialysisor hemodialysis treatment.•Patients with biliary pancreatitis,chemical pneumonitis, or heatstroke.•Patients with invasive fungalinfections (e.g. candidiasis,aspergillosis) or acute attacks ofplasmodium falciparum malaria.•Neonates during the first 2 days oflife.The results of the Elecsys BRAHMSPCT assay should be evaluated inthe context of all laboratory findingsand the total clinical status of thepatient. In cases where laboratoryresults do not agree with the clinicalpicture or history, additional testsshould be performed.
MethodComparison	2617 samples were run on the Cobas e411 and the predicate device (BRAHMS PCTsensitive KRYPTOR®).Passing BablokSlope: 0.959 (95% CI: 0.947; 0.972)Intercept: -0.023 (95% CI: -0.028; -0.018)Coefficient: 0.989 (95% CI: 0.988; 0.990)

Table 1: Assay Comparison

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	Table 2. CalSet Comparison

Characteristic	Candidate Device: PCT CalSet(K160729)	CalSet Predicate Device:Progesterone III CalSet (K152526)
Intended Use	PCT CalSet is used for calibratingthe quantitative Elecsys BRAHMSPCT assay on the Elecsys andcobas e analyzers.	The Progesterone III CalSet is usedfor calibrating the quantitativeElecsys Progesterone III assay onthe Elecsys and cobas eimmunoassayanalyzers.
Analyte	Recombinant PCT	Progesterone (plant-derived)
Matrix	Human serum matrix	Human serum matrix
Levels	Two	Two
Target Ranges	PCT Cal 1: 0.10 ng/mLPCT Cal 2: 54 ng/mL	Cal 1: 0.80 ng/mLCal 2: 53 ng/mL
Format	Lyophilized	Lyophilized
Handling	Carefully dissolve the contents ofone bottle by adding exactly 4 mL ofdistilled or deionized water andallow to stand closed for 15 minutesto reconstitute. Mix carefully,avoiding the foam formation.Transfer aliquots of thereconstituted calibrators intoempty labeled snap-cap bottles(CalSet Vials). Attach thesupplied labels to the additionalbottles. Store the aliquotsimmediately at .15 to -25°C.Perform only one calibrationprocedure per aliquot.	Carefully dissolve the contents ofone bottle by adding exactly 1.0mLof distilled or deionized water andallow to stand closed for 15 minutesto reconstitute. Mix carefully,avoiding the foam formation.Transfer aliquots of thereconstituted calibrators intoempty labeled snap-cap bottles(CalSet Vials). Attach thesupplied labels to the additionalbottles. Store the aliquotsimmediately at -20°C.Perform only one calibrationprocedure per aliquot.

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Table 3. Control Comparison

Characteristic	Candidate Device: PreciControlPCT (K160729)	Predicate Device: BRAHMS PCTsensitive KRYPTOR® QC Kit(DEN150009)
Intended Use	PreciControl PCT is a single analytecontrol that is used for qualitycontrol of the Elecsys BRAHMSPCT assay.	The B-R-A-H-M-S PCT sensitiveKRYPTOR® QC is designed forquality control on board theB-R-A-H-M-S KRYPTOR® analyzerfor the B-R・A・H・M・S PCT sensitiveKRYPTOR® assay.
Analyte	Recombinant PCT	Recombinant PCT
Matrix	Human plasma	Human plasma
Levels	Two	Two
Target Ranges	PC1: 0.5 ng/mLPC2: 10 ng/mL	PC1: 0.2-0.4 µg/LPC2: 8-12 µg/L
Format	Lyophilized	Lyophilized
Handling	Carefully dissolve the contents ofone bottle by adding exactly 4 mL ofdistilled or deionized water andallow to stand closed for 15 minutesto reconstitute. Mix carefully,avoiding foam formation.Transfer the reconstituted controlsinto the empty labeled snap capbottles supplied or into additionalsnapcap bottles (ControlSet Vials).Attach the supplied labels to theseadditional bottles. Aliquots intendedfor storage at 15 to -25°C shouldbe frozen immediately.Perform only one control procedureper aliquot.	Reconstitute a vial with de-ionizedwater (2.0mL) as indicated on thevial label. Use de-ionized water withconductivity of less than 50 µS/cm.☐dissolution of the lyophilisate.☐ the control sampleusing a Vortex.☐ tubes.☐ immediate measurements. Freezethe other tubes immediately at < -16 °C and store up to one month.☐ using a Vortex and use immediatelyfor measurement. A control tube willbe processed like a sample tube.

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Table 4. CalCheck Comparison

Characteristic	Candidate Device: Elecsys PCTCalCheck 5 (K160729)	Predicate Device: ElecsysProgesterone III CalCheck 5(K150955)
Intended Use	The BRAHMS PCT CalCheck 5 isan assayed control for use incalibration verification and for use inthe verification of the assay rangeestablished by the ElecsysBRAHMS PCT reagent on theindicated Elecsys and cobas eimmunoassay analyzers.	The Elecsys Progesterone IIICalCheck 5 is an assayed control foruse in calibration verification and foruse in the verification of the assayrange established by the ElecsysProgesterone III reagent on theindicated Elecsys and cobas eimmunoassay analyzers.
Analyte	Recombinant PCT	Progesterone (plant material)
Matrix	Human plasma	Human serum matrix
Levels	Five	Five
Assay measuring range	0.02 - 100 ng/mL	0.05 - 60 ng/mL
Target Ranges	Check 1: ≤ 0.06 ng/mLCheck 2: 0.5 ng/mLCheck 3: 40.0 ng/mLCheck 4: 80.0 ng/mLCheck 5: 100.0 ng/mL	Check 1: ≤ 0.15 ng/mLCheck 2: 2.0 ng/mLCheck 3: 30.0 ng/mLCheck 4: 45.0 ng/mLCheck 5: 60.0 ng/mL
Format	Lyophilized	Lyophilized
Handling	Reconstitute the contents of Check1, Check 2, Check 3, Check 4 andCheck 5 with exactly 1.0 mL distilledor deionized water.Allow the bottles to stand closed for15 minutes. Mix gently by inversionto ensure homogeneity.	Reconstitute Check 1, Check 2,Check 3, Check 4, and Check 5 withexactly 1.0mL distilled or deionizedwater.Allow to stand closed for 15 minutes,then mix gently by inversion to ensurehomogeneity.
Stability	Unopened:· Store at 2-8°C until expiration dateOpened:· 20-25°C: 2 hours	Unopened:· Store at 2-8°C until expiration dateOpened:· 20-25°C: 4 hours

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5. NON-CLINICAL PERFORMANCE EVALUATION

Non-clinical performance evaluations for the Elecsys BRAHMS PCT assay executed with the study briefly summarized.

Precision (Human Sera) 5.1.

Precision of the Elecsys BRAHMS PCT assay was evaluated on one cobas e 411 analyzer according to CLSI EP5-A3 guideline. One reagent lot was evaluated.

The protocol consisted of testing two replicates of each control (PC PCT 1 and PC PCT 2) and six human serum samples per run, two runs per day for 21 days. The samples were run in randomized order on the analyzer.

Repeatability and Intermediate precision were calculated according to CLSI EP5-A3.

5.2. Limit of Blank (LoB)

For the analytical sensitivity studies, the Limit of Blank was determined according to CLSI EP17-A2. The LoB was determined as the 95th percentile of blank-sample measurements. The distribution of values for five analyte-free serum samples was determined with one reagent lot on one cobas e 411 anavlzer over three days for six runs total.

The samples were measured in two-fold determination for each run. A total of 60 measuring points were collected.

5.3. Limit of Detection (LoD)

For the analytical sensitivity studies, the Limit of Detection was determined according is the smallest amount of analyte that can be detected with 95% probability. The distribution of values for five low-level human serum samples was determined with one reagent lot on one cobas e 411 anaylzer over three days for six runs total.

The samples were measured in two-fold determination for each run. A total of 60 measuring points were collected.

Limit of Quantitation (LoQ) 5.4.

The Limit of Quantitation was determined according to CLSI EP17-A2. The LoO represents the lowest amount of analyte that can be quantitatively determined with stated accuracy, precision, and experimental conditions. For Procalcitonin, no reference material or reference method is available, thus bias cannot be calculated. Therefore, the LoO was calculated based on intermediate precision according to CLSI EP17-A2. The LoQ was determined as the lowest concentration of analyte that can be quantified with an intermediate precision of no more than 20%.

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A five-day precision experiment was carried out with one reagent lot on one cobas e 411 analyzer. Samples tested included five human serum (HS) samples with concentrations from LoB to two times the LoQ. Samples were measured in five-fold determination for each run. A total of 125 measuring points were collected.

The mean values and the intermediate precision (coefficient of variation and standard deviation) for each LoO sample were calculated. To determine the LoQ, samples were sorted according to the concentration of their measured mean value. The LoQ is defined as the mean value of the sample that is first to fulfill the specification for intermediate precision, and for which there is no lower-concentration sample that exceeds the specification.

5.5. Linearity

The linearity results were obtained with serum samples on one cobas e 411 analyzer. Three spiked human plasma samples and three spiked human serum samples were diluted into six dilution series with each series containing at least 14 dilutions. Samples were assayed in threefold determination within a single run.

The linearity data were analyzed with regards to linear, quadratic, and cubic polynomials, according to CLSI EP6-A. In the first step, a linearity check was performed with a first order (linear) regression, and then with high order models (quadratic and cubic).

5.6. Dilution Study

To demonstrate the Elecsys BRAHMS PCT assay dilution study, three different dilutions with dilution factors between 1:1 and 1:5 were prepared. Three serum samples and one plasma sample were spiked with PCT to concentrations exceeding the measuring range. The samples were diluted with serum (low PCT concentrations) and recovery was investigated on the cobas e 411.

5.7. Analytical Specificity

The specificity of the Elecsys BRAHMS PCT assay was determined using native human serum samples spiked with potential cross-reacting compounds. The spiked and unspiked reference samples were measured in duplicate on one Elecsys 2010 analyzer. Specificity was determined using two human serum sample pools spiked with potential cross-reactant compounds at four different concentrations each. The analyte concentration of the samples was at approximately 0.4 and 1.5 ng/mL PCT. Cross-reactivity results will be reported in the method sheet.

5.8. Endogenous Interferences

The effect on quantitation of PCT in the presence of five endogenous interfering substances (Hemoglobin, Biotin, Intralipid, Bilirubin, and Rheumatoid Factor) was tested using one Elecsys 2010 analyzer. Spiked serum pools were used for testing.

For each potential interferent, three human serum samples (containing low, mid, and high concentrations of PCT) were tested.

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5.9. HAMA Effect

The effect of the presence of human anti-mouse antibodies (HAMA) on the Elecsys BRAHMS PCT assay was assessed on the Elecsys 2010 analyzer.

A suitable HAMA serum was spiked with PCT analyte at multiple concentrations covering the clinically relevant range. In parallel, a control (human serum) sample was spiked with the same levels of analyte. For each analyte concentration, a series of 11 dilutions of the HAMA sample

and control sample were each prepared and measured in duplicate. The recovery for each sample was calculated by comparison to the reference (no HAMA) sample.

5.10. High-Dose Hook Effect

The high-dose hook effect of the Elecsys BRAHMS PCT assay was assessed on the Elecsys 2010 analyzer. Human serum pools were spiked with analyte up to a concentration of 2,500 ng/mL. These samples were subsequently diluted with negative human serum.

The expected values for the diluted samples were calculated using the known spiked PCT analyte concentration of the undiluted sample and the appropriate dilution factor.

The hook concentration reported corresponds to the analyte concentration that generates a signal >10% above the upper limit of the measuring range

5.11. Exogenous Interferences - Drugs

The effect on quantitation of analyte in the presence of drugs was determined by comparing values obtained from samples spiked with 27 pharmaceutical compounds into two human serum samples at differing analyte concentrations and tested on the Elecsys 2010 analyzer.

The PCT concentration of the spiked aliquots was tested in two-fold determination and compared to the PCT concentration for the reference aliquot (also tested in two-fold determination).

5.12. Serum/Plasma Comparison

The effect on quantitation of analyte in the presence of anticoagulants with the Elecsys BRAHMS PCT assay was determined by comparing values obtained from samples drawn into Serum Separator Tubes (SST), Serum, Li-Heparin Plasma, K2-, K3-EDTA and Plasma primary tubes and Plasma Separation Tubes (PST). Ten human serum samples were tested in duplicate on one Elecsys 2010 analyzer at three time points for SST. For remaining Serum/Plasma comparison studies, a minimum of 50 serum/plasma pairs were tested with one reagent lot on one cobas e 411 analyzer. Potential effects were assessed by Passing/Bablok regression analysis.

5.13. Method Comparison

A method comparison study was performed to compare the Elecsys BRAHMS PCT assay on the cobas e 601 analyzer with the Elecsys BRAHMS PCT assay on the cobas e 411 analyzer. A total of 137 human serum samples with PCT values from 0.0681 ng/mL to 99.1 ng/mL were measured.

The results were calculated using Passing/Bablok and Linear Regression analyses.

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5.14. Reagent Stability

To test reagent stability, three studies were executed.

5.14.1. Study 1. Reagent Stability (On Board)

Reagent on-board stability for the Elecsys BRAHMS PCT assay was tested on one Elecsys 2010 analyzer.

A fresh reagent Rack Pack was placed on the analyzer and calibrated. Reference values for the samples tested were determined. On day 7 and day 28 the same samples were determined with the same reagent kit (kept on board the instrument) using the calibration curve of day 0 and day 21 respectively.

Samples tested in duplicate include five human serum samples and two controls.

5.14.2. Study 2. Reagent Stability (After Opening)

Reagent stability after first opening for the Elecsys BRAHMS PCt assay was tested on one Elecsys 2010 analyzer.

A fresh reagent Rack Pack was placed on the analyzer and calibrated. Reference values for the samples tested were determined. After measurement, the kit was removed from the analyzer and stored at 2-8°C for 12 weeks. The kit was again placed on the analyzer, calibrated, and the samples were tested.

Samples tested included five human serum samples and two controls.

5.14.3. Study 3. Reagent Stability (Real-Time Shelf Life)

In the real-time, shelf-life stability study, the Elecsys BRAHMS PCT assay reagent was stored at 2-8°C. The stored reagent was tested at time point 0 (at manufacture), then again at specified intervals over the shelf life of the device (up to the planned shelf life plus one month).

Samples tested in duplicate include human serum samples from three reagent lots and two controls.

5.15. Sample Stability

To test reagent stability, four studies were executed.

5.15.1. Study 1. Sample Stability (Freeze/Thaw Cycles)

Ten samples of each human serum and plasma types were aliquoted and measured fresh (reference value) and after one freeze/thaw cycle with the Elecsys BRAHMS PCT assay.

Measurements were performed in three-fold determination on one cobas e 601 analyzer, and recovery was calculated as percent of the reference value or as deviation in ne/mL.

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5.15.2. Study 2. Sample Stability (at -20°C)

Ten samples of each human serum and plasma types were aliquoted and measured fresh (reference value) and after storage for up to 13 months at -20°C with the Elecsys BRAHMS PCT assay.

Measurement were performed in three-fold determination on one cobas e 601 analyzer, and recovery was calculated as percent of the reference value or as deviation in ng/mL.

5.15.3. Study 3. Sample Stability (at 2-8°C)

Ten samples of each human serum and plasma types were aliquoted and measured fresh (reference value) and after storage for up to 72 hours at 2-8°C with the Elecsys BRAHMS PCT assav.

Measurement were performed in three-fold determination on one cobas e 601 analyzer, and recovery was calculated as percent of the reference value or as a deviation in ng/mL.

5.15.4. Study 4. Sample Stability (at 15-25°C)

Ten samples of each human serum and plasma types were aliquoted and measured fresh (reference value) and after storage for up to 48 hours at 15-25℃ with the Elecsys BRAHMS PCT assay.

Measurement were performed in three-fold determination on one cobas e 601 analyzer, and recovery was calculated as percent of the reference value or as a deviation in ne/mL.

5.16. Calibration Stability

To test calibration stability, two studies were executed.

5.16.1. Study 1. Calibration (Lot) Stability

Calibration of an Elecsys BRAHMS PCT reagent lot is recommended every 4 weeks. During that time period, fresh reagent kits of the same lot can be used in conjunction with the calibration curve established at Day 0 for that reagent kit lot.

The Elecsys BRAHMS PCT assay was calibrated with a fresh reagent kit on Day 0 using one Elecsys 2010 analyzer. After 4, 8, and 12 weeks, a new reagent kit of the same lot was used, with recovery of samples being determined using the calibration curve established on Day 0 for that reagent kit lot.

Five human serum (HS) samples and two controls were tested in duplicate. Recovery compared to the reference value was calculated as either deviation (in ng/mL).

5.16.2. Study 2. Calibration (On Board) Stability

A fresh Elecsys BRAHMS PCT test kit was placed on an Elecsys 2010 analyzer and calibrated. Five native human serum (HS) sample pools and two control samples were tested with the fresh reagent kit; each sample was tested with 2-fold determination. On day 7 and day 28 the same samples were determined with the same reagent kit (kept on board of the instruments) using the

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calibration curve of day 0 and day 21 respectively. Each sample was tested with 2-fold determination.

5.16. Calibrator Stability

The PCT CalSet was evaluated for value assignment and stability; three studies were executed.

5.17.1. Calibrator Value Assignment

Value assignment tested was conducted and passed pre-defined acceptance criteria. The target values for the two levels of the PCT Calset are chosen to obtain the best fit with the Master Calibration Curve, together with the Rodbard curve parameters encoded in the reagent barcode. For each Elecsys PCT CalSet lot manufactured, the calibrators are run in duplicate on at least six cobas e 411 analyzers and least three cobas e 601/cobas e 602/MODULAR ANALYTICS E170 analyzers with all Elecsys BRAHMS PCT reagent lots available. The assigned value of each calibrator is defined as the mean value obtained over at least six runs on at least three analyzers of the respective calibrator.

Measurement values for PreciControl PCT (Levels 1 and 2), a single-analyte control recommended for use to monitor accuracy and precision of the PCT analyte, are read from the calibration curves generated. The pre-defined acceptance criteria for PreciControl PCT have to be met to release the Assigned Values for the PCT CalSet.

5.17.2. Study 1. Calibrator Stability (Post Reconstitution at −20°C)

Reconstituted calibrators were stored for 3 months at -20°C.

The freshly reconstituted calibrators, and the reconstituted calibrators stored for 3 months at -20℃, were measured in one run on one Elecsys 2010 analyzer.

Recoveries of the stressed calibrators versus the freshly reconstituted calibrators were calculated.

5.17.3. Study 2. Calibrator Stability (Post Reconstitution at 20-25°C)

Reconstituted calibrators were stored for 5 hours at 20-25°C.

The freshly reconstituted calibrators, and the reconstituted calibrators stored for 5 hours at 20-25°C, were measured in one run on one Elecsys 2010.

Recoveries of the stressed calibrators versus the freshly reconstituted calibrators were calculated.

5.17.4. Study 3. Calibrator Stability (Real-Time Shelf Life part of Assay Testing)

In the real-time, shelf-life stability study, the PCT CalSet was stored at 2-8°C. The stored calibrator was tested at time point 0 (at manufacture), then again at specified intervals over the shelf life of the device (up to the planned shelf life plus one month).

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5.18. PreciControl PCT

PreciControl PCT was evaluated for value assignment and stability; three studies were executed.

5.18.1. PreciControl Value Assignment

The PreciControl PCT assigned values are determined with the Elecsys BRAHMS PCT assay. A human serum sample panel (Master Calibrators) covering the entire measuring range is available, which is traceable to the PCT.

The assigned values for PreciControl PCT are read from the master calibration curve. Values are assigned for each lot of PreciControl PCT in combination with each Elecsys PCT assay reagent lot available. The controls are run in duplicate on at least six analyzers of the master analyzer platform. The assigned value of each control level is defined as the median value obtained over at least six determinations of the respective control level. For additional analyzer platforms, the same value assignment procedure is performed. The assigned values obtained on the additional analyzer are compared to those obtained on the master platform.

5.18.2. Study 1. PreciControl Stability (Post Reconstitution at -20°C)

Reconstituted calibrators were stored for 3 months at -20°C.

The freshly reconstituted calibrators, and the reconstituted calibrators stored for 3 months at -20°C, were measured in one run on one Elecsys 2010 analyzer. Recovery of the stressed PreciControl PCT compared to the freshly reconstituted PreciControl PCT was calculated.

5.18.3. Study 2. PreciControl Stability (Post Reconstitution at 20-25°C)

Reconstituted controls were stored for 5 hours at 20-25°C.

The freshly reconstituted controls, and the reconstituted controls stored for 5 hours at 20-25°C, were measured in one run on one Elecsys 2010.

Recoveries of the stressed controls versus the freshly reconstituted controls.

5.18.4. Study 3. PreciControl Stability (Real-Time Shelf Life part of Assay Testing)

In the real-time, shelf-PCT samples were tested at time point 0 (at manufacture), then again at specified intervals over the shelf life of the device (up to the planned shelf life plus one month).

5.19. PCT CalCheck 5 Stability

PCT CalCheck 5 was evaluated for value assignment and stability; two studies were executed.

5.19.1. PCT CalCheck 5 Value Assignment

Value assignment testing was conducted and passed pre-defined acceptance criteria. For each Elecsys BRAHMS PCT CalCheck 5 lot manufactured, each CalCheck is run in duplicate on at

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least six analyzers of the master analyzer platform. The assigned yalued of each CalCheck level is defined as the mean value obtained over at least six determinations (duplicate runs on at least three analyzers) of the respective CalCheck level.

The CalCheck assigned range is calculated as ±30% of the assigned value for levels two through five. The label states that each laboratory should establish appropriate acceptance criteria when using this product for its intended use.

The same value assignment procedure is performed on the cobas e 601 analyzer. The assigned values obtained are compared to those obtained on the cobas e 411 analyzer. The mean value obtained on the additional analyzer must be within 10% of the master platform assigned value. After this acceptance criterion is met, the assigned values from the master platform are deemed valid for the Elecsys 2010. MODULAR ANALYTICS E170, cobas e 411, cobas e 601, and cobas e 602 analyzers.

5.19.2. Study 1. PCT CalCheck 5 Accelerated and Open Vial Stability

One PCT CalCheck 5 lot was evaluated, in duplicate, on one cobas e 411 analyzer. A set of PCT CalCheck 5 was stored for 3 weeks at 35℃. After the three week period the test material was reconstituted and stored for 3 hours at 25℃ (in an open vial).

The reference material used was a freshly reconstituted set of PCT CalCheck 5. Recovery of the stressed PCT CalCheck 5 compared to the freshly reconstituted PCT CalCheck 5 was calculated.

5.19.3. Study 2. PCT CalCheck 5 Stability (Real-Time Shelf Life)

In the real-time shelf-life stability study (which is ongoing), the PCT CalCheck 5 will be stored at 2-8°C. The stored PCT CalCheck 5 will be tested at time point 0 (at manufacture), then again at specified intervals over the shelf life of the device (up to the planned shelf life plus one month).

Samples tested in duplicate include five CalCheck levels.

5.19.4. Study 3. PCT CalCheck 5* Stability (Real-Time Shelf Life)

In another real-time shelf-life stability study, a PCT CalCheck 5 lot (*with slightly different level 2 and 3 concentrations) was stored at 2-8°C for up to 37 months. The stored PCT CalCheck 5 was tested at time point 0 (at manufacture), then again at specified internals up to 37 months.

Samples tested in duplicate include five CalCheck levels.

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CLINICAL PERFORMANCE EVALUATION 6.

6.1 Reference Range

In a population of 282 self-reported healthy individuals, the 95th percentile, upper reference range limit was calculated at 0.08 ng/mL.

			assay
			PCT study
			unit
			ng/mL
			ResultStudyUnit
		NMiss	N	Min	Median	P95	Mean	StdDev	CV	Max
total (all)		0	282	0.02	0.02	0.08	0.03	0.03	100.25	0.39
gender		0	139	0.02	0.02	0.04	0.03	0.01	46.86	0.12
female	total (all)
male	total (all)	0	143	0.02	0.03	0.11	0.04	0.04	105.30	0.39
smoking		0	210	0.02	0.02	0.08	0.03	0.03	99.49	0.39
	no total (all)
yes	total (all)	0	40	0.02	0.02	0.11	0.04	0.05	122.89	0.29
unknown	total (all)	0	32	0.02	0.03	0.08	0.04	0.02	67.85	0.13
race		0	101	0.02	0.02	0.09	0.03	0.02	81.44	0.16
	African/black total (all)
Alaska Native/American Indian	total (all)	0	1	0.03	0.03	0.03	0.03	.		0.03
Asian	total (all)	0	4	0.02	0.03	0.15	0.06	0.06	99.45	0.15
Caucasian/white	total (all)	0	169	0.02	0.03	0.07	0.04	0.04	108.24	0.39
other	total (all)	0	7	0.02	0.02	0.05	0.03	0.01	42.75	0.05
age class		0	113	0.02	0.02	0.09	0.04	0.05	129.22	0.39
	20-<30 years total (all)
30-<40 years	total (all)	0	97	0.02	0.02	0.08	0.03	0.02	65.56	0.15
40-<50 years	total (all)	0	43	0.02	0.02	0.11	0.03	0.02	71.93	0.11
50-<60 years	total (all)	0	23	0.02	0.03	0.08	0.04	0.03	72.37	0.12
60-<70 years	total (all)	0	4	0.02	0.02	0.04	0.02	0.01	38.38	0.04
70 years or older	total (all)	0	2	0.03	0.03	0.04	0.03	0.01	34.28	0.04

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6.2 Clinical Performance

The Elecsys BRAHMS PCT assay was evaluated for the prediction of cumulative 28-day all-cause mortality in a prospective clinical trial $ study of 858 adult patients diagnosed with severe sepsis or septic shock admitted to ICU care in which PCT levels were measured on Days 0, 1, and 4 across 13 investigational sites in the US. The per protocol analysis population (598 subjects) was comprised of 44 % female and 56 % male patients with a mean age of 64 years. About half of the patients had severe sepsis (51 %) versus septic shock (49 %). Infections were mainly community acquired (91%).

The binary test result (ΔPCT > 80 % or ≤ 80 %) was significantly associated with 28-day cumulative mortality (vital status on day 28) (Two-sided Fisher's Exact Test p-value = 0.002). Adjusted for ICU vs. non-ICU patient subgroups (based on hospital location at day 4 after initial diagnosis), the association remained significant (Cochran-Mantel-Haenszel Test p-value = 0.020). In each binary △PCT subgroup, the 28-day cumulative mortality rate was stratified by need to continue ICU care on day 4 and/or the selection of Day 1 as the baseline measurement day for the △PCT calculation. The data are as follows:

28-day mortality risk stratified by patient location on Day 4: ΔРСТ > 80 % = Test Negative;ΔРCT ≤ 80 % = Test Positive per-protocol population
Day 4patientlocation	Measurementinterval	28-day mortality risk (%)	Prognostic accuracyb)
		ΔРСТ > 80 %	ΔРCT ≤ 80 %	Sensitivity	Specificity
ICU	ΔРСТ 0-4	22.1 (13.3-31.0)	29.6 (22.9-36.4)	73.4 (62.9-83.8)	35.0 (28.2-41.8)
	ΔРСТ 1-4	21.5 (13.0-29.9)	30.4 (23.4-37.3)	71.6 (60.8-82.3)	38.7 (31.7-45.7)
Non-ICU	ΔРСТ 0-4	5.6 (1.8-9.4)	11.0 (6.6-15.5)	72.3 (55.9-88.6)	44.4 (38.4-50.3)
	ΔРСТ 1-4	7.1 (2.8-11.3)	9.9 (5.7-14.2)	65.4 (48.0-82.7)	43.3 (37.3-49.2)

Prediction performances of binary ΔPCT stratified by ICU care on Day 4

b) Prognostic accuracy refers to how accurate the ΔΡCT (> 80 %) can predict mortality risk using 28-day mortality as the clinical reference.

Kaplan Meier survival curves show that patients with a positive ΔPCT result (≤ 80 %) had a clearly lower survival probability from study Day 4 till the end of follow up time compared to ΔΡCT negative (> 80 %) patients.

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Image /page/26/Figure/0 description: The image is a survival plot comparing two groups of patients based on their delta PCT values. The y-axis represents the proportion of patients surviving, ranging from 0% to 100%. The x-axis represents time in days, ranging from 0 to 28. The green line represents patients with a negative delta PCT (n=229, deaths=27), while the red line represents patients with a positive delta PCT (n=369, deaths=74).

Image /page/26/Figure/1 description: The image shows the text "Time (days)". The text is in a sans-serif font and is black. The background is white.

Additional stratification of patients based on absolute initial PCT levels (> or ≤ 2.0 µg/L) at Day 0 (or Day 1) revealed subgroups with particularly reduced or elevated mortality risk considering their hospital disposition on Day 4. Mortality rates and prognostic performance are given for the following subgroups in the table below:

1. Patients with PCT ≤ 2.0 µg/L at Day 0 (or Day 1) receiving ICU care on Day 4.
1. Patients with PCT > 2.0 µg/L at Day 0 (or Day 1) receiving ICU care on Day 4.
1. Patients with PCT ≤ 2.0 µg/L at Day 0 (or Day 1) without ICU care on Day 4.
1. Patients with PCT > 2.0 µg/L at Day 0 (or Day 1) without ICU care on Day 4.

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28-day mortality risk stratified by patient location on Day 4, absolute PCT value on Day 0:ΔPCT > 80 % = Test Negative; ΔPCT ≤ 80 % = Test Positive
Per-Protocol Population: ΔPCT 0-4 stratified PCT at Day 0
Day 4patientlocation	Measurementinterval	28-day mortality risk (%)		Prognostic accuracy*
		ΔPCT Day 0-4> 80 %	ΔPCT Day 0-4≤ 80 %	Sensitivity (%)	Specificity (%)
ICU	≤ 2.0 μg/L	10.4 (0.0-29.7)	24.9 (15.2-34.6)	94.9 (85.2-100)	13.3 (4.9-21.8)
	> 2.0 μg/L	23.6 (14.0-33.2)	33.2 (24.0-42.4)	65.1 (51.8-78.3)	46.3 (37.5-55.0)
Non-ICU	≤ 2.0 μg/L	5.6 (0.0-16.3)	8.3 (3.6-12.9)	91.7 (76.0-100)	12.3 (6.2-18.4)
	> 2.0 μg/L	5.6 (1.6-9.7)	17.5 (7.5-27.5)	58.6 (35.1-82.1)	71.4 (64.1-78.8)

28-day mortality risk stratified by patient location on Day 4, absolute PCT value on Day 1:$\Delta$ PCT > 80 % = Test Negative; $\Delta$ PCT ≤ 80 % = Test Positive
Per-Protocol Population: $\Delta$ PCT 1-4 stratified PCT at Day 1
Day 4 patient location	Measurement interval	28-day mortality risk (%)		Prognostic accuracy*
		$\Delta$ PCT Day 1-4 > 80 %	$\Delta$ PCT Day 1-4 ≤ 80 %
ICU	≤ 2.0 μg/L	11.8 (0.0-33.6)	25.5 (15.4-35.6)	94.7 (84.6-100.0)	12.7 (3.8-21.7)
	> 2.0 μg/L	22.5 (13.5-31.5)	34.0 (24.4-43.5)	62.9 (49.4-76.5)	51.3 (42.4-59.7)
Non-ICU	≤ 2.0 μg/L	0.0 (0.0-17.6%)c	7.5 (3.0-12.0)	100.0 (69.2-100.0)c	13.4 (7.3-19.5)
	> 2.0 μg/L	8.2 (3.3-13.1)	15.3 (6.0-24.7)	47.2 (24.6-69.7)	69.4 (61.6-77.2)

c) Normality approximation of within-imputation variance not valid, therefore the estimate corresponds to within-imputation variation based on exact confidence intervals [Clopper & Pearson, 1934]

Prognostic accuracy refers to how accurate the ΔΡCT (≤ 80%) can predict mortality risk.

Kaplan-Meier Plots are depicted below to illustrate the time-to-event structure in the extended patient subgroups according to hospital location on Day 4 and initial PCT level.

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Image /page/28/Figure/0 description: This image is a survival plot showing the proportion of patients surviving over time, up to 28 days. The plot compares two groups: those with negative ΔPCT (n=10, deaths=1) and those with positive ΔPCT (n=76, deaths=19). The survival rate is higher for the ΔPCT negative group compared to the ΔPCT positive group. The study includes patients with PCT ≤ 2.0 µg/L at Day 0, ICU Day 4 (n=86).

Image /page/28/Figure/1 description: This image shows a survival analysis until day 28 for patients with PCT > 2.0 ug/L at Day 0 and ICU Day 4 (n=179). The y-axis shows the proportion of patients surviving, and the x-axis shows the time in days. There are two lines on the graph, one for delta PCT negative (n=77, deaths=18) and one for delta PCT positive (n=102, deaths=34).

Image /page/28/Figure/2 description: This image is a survival curve comparing patients with negative and positive delta PCT values. The y-axis represents the proportion of patients surviving, ranging from 0% to 100%. The x-axis represents time in days, up to 28 days. The survival rate is higher for patients with negative delta PCT values, with 18 patients and 1 death, compared to patients with positive delta PCT values, with 133 patients and 11 deaths.

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Image /page/29/Figure/0 description: This image is a survival curve that shows the survival rate of patients until day 28. The title indicates that the patients had PCT > 2.0 µg/L at Day 0, non-ICU Day 4 (n=182). The green line represents patients with negative ΔPCT, where n=125 and deaths=7, while the red line represents patients with positive ΔPCT, where n=57 and deaths=10.

Time-to-event analysis evidently reveals that patients in the ICU or with an initial PCT value > 2.0 µg/L had a lower survival probability from study Day 4 until the end of follow up time (28 days) when the ΔΡCT test result was positive compared to ΔΡCT negative patients as illustrated by the Kaplan-Meier curves above (patient subgroups according to hospital location on Day 4 and initial PCT level).

A generally lower mortality rate was observed in the non-ICU subgroup. The mortality rates for △PCT positive vs. ΔPCT negative patient subgroups were:

Patients with PCT ≤ 2.0 µg/L at Day 0 receiving ICU care on Day 4	10.4 % vs. 24.9 %
Patients with PCT > 2.0 µg/L at Day 0 receiving ICU care on Day 4	23.6 % vs. 33.2 %
Patients with PCT ≤ 2.0 µg/L at Day 0 without ICU care on Day 4	5.6 % vs. 8.3 %
Patients with PCT > 2.0 µg/L at Day 0 without ICU care on Day 4	5.6 % vs. 17.5 %

Based on relative mortality ratios a decrease by more than 80 % from Day 0 (or Day 4 constitutes a lower risk for mortality within 28 days compared to smaller declines in each subgroup. For the prediction of absolute mortality risks ICU disposition at Day 4 and initial PCT concentrations should be considered:

1. An initial PCT level < 2.0 ug/L on Day 0 followed by a PCT decline of more than 80 % until Day 4 indicates an almost 2-fold lower mortality (10.4 %) for patients with severe sepsis or septic shock who are still in the ICU by Day 4 compared to those patients with an initial PCT level > 2.0 µg/L (23.6 %). Regardless of the initial PCT level, patients in the ICU on Day 4 that do not decline by more than 80 % in PCT plasma concentration from Day 0 to Day 4 have an even higher mortality risk of 24.9-33.2 %.
1. An initial PCT level > 2.0 ug/L that does not decline by more than 80 % until Day 4 signals that such patients remain at high mortality risk (17.5 %) even when they are no longer receiving ICU care on Day 4. Mortality was otherwise observed between 5.6 to 8.3 % for patients discharged from the ICU by Day 4.

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In conclusion, hazard ratios for binary APCT for both subgroups enrolled show an increase in mortality with △PCT. The mortality risk stratification using ΔPCT is valid when calculated from the day severe sepsis or septic shock is first diagnosed (Day 0) or the day thereafter (Day 1) and compared to the fourth day (Day 4) after diagnosis. The APCT at Day 4 combined with the patient's clinical course provides important information for the 28-day all-cause mortality risk prediction after a diagnosis of severe sepsis or septic shock.

The prognostic value of APCT was quantified by pooled p values of Wald statistics (Rubin's rule). The hazard ratio of binary ΔPCT4.0 in the univariate model is 1.80 (p = 0.011) for patients of the Per-Protocol population and similarly of the Intention to diagnose group (1.81; p = 0.008). That means the risk of death is increased 1.8-fold if an individual has a positive test result for APCT.

Univariate hazard ratios for 28-day all-cause mortality of ΔPCT and clinical covariates
Factor	Comparison	Hazard ratio	p-Value
ΔPCT4.0	≤ 80 % vs. > 80 %	1.80 (1.15-2.82)	0.011
ΔPCT4.1	≤ 80 % vs. > 80 %	1.61 (1.04-2.49)	0.034
APACHE	Difference of 5 units	1.36 (1.22-1.53)	< 0.001
Max SOFA	Difference of 3 units	1.73 (1.50-2.00)	< 0.001
Antibiotic adequacy	No vs. yes	1.59 (1.00-2.53)	0.051
Sepsis severity	Septic shock vs. severesepsis	1.19 (0.80-1.76)	0.386
Biologic infection type	Gram pos vs. gram neg	0.83 (0.48-1.45)	0.522
Biologic infection type	Other vs. gram neg	0.99 (0.63-1.54)	0.960
Biologic infection type	Fungal vs. gram neg	2.44 (0.87-6.84)	0.090
Clinical infection type	Nosocomial vs.community	0.76 (0.35-1.64)	0.481
Positive blood culture	Yes vs. no	1.05 (0.69-1.58)	0.834
Baseline PCT	> 2 µg/L vs. ≤ 2 µg/L	1.43 (0.94-2.17)	0.095
Age	Difference of 5 years	1.16 (1.08-1.24)	< 0.001
Gender	Male vs. female	0.95 (0.64-1.40)	0.782
ICU care on Day 4	Yes vs. no	3.45 (2.24-5.31)	< 0.001

As a comparison, the table below lists the univariate hazard ratios for other clinical factors evaluated as separate predictors of mortality in the per protocol study population.

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ΔPCT from Day 0 (or Day 1) to Day 4 remains a prognostic parameter for the risk of cumulative 28-day mortality in patients diagnosed with severe sepsis or septic shock even when hazard ratios are adjusted for other mortality predictors in multivariate models. The relative mortality risk estimates for △PCT and selected predictors are given below with 95 % confidence intervals. For continuous predictors, the hazard ratio (HR) was calculated for one standard deviation (SD) change in the predictor. For binary predictors, the risk estimate compares the hazards for the two binary results.

Hazard ratios for APCT were calculated for each group as univariate and when applying certain covariates and are tabulated below.

Hazard ratios for ΔPCT per group
Hazard ratio for ΔPCT ≤ 80 %	Per-protocol
ΔPCT 4.0 (univariate)	1.80 [1.15-2.82]; p=0.0106
ΔPCT 4.0 with binary APACHE + covariatesd)	1.94 [1.14-3.31]; p=0.0140
ΔPCT 4.0 with numeric APACHE + covariatesc)	1.72 [1.00-2.95]; p=0.0487
ΔPCT 4.0 with binary SOFA + covariatesc)	1.76 [1.05-2.96]; p=0.0320
ΔPCT 4.0 with numeric SOFA + covariatesc)	1.46 [0.86-2.48]; p=0.1595
ΔPCT 4.1 (univariate)	1.61 [1.04-2.49]; p=0.0345
ΔPCT 4.1 with binary APACHE + covariatesc)	1.68 [1.03-2.76]; p=0.0392
ΔPCT 4.1 with numeric APACHE + covariatesc)	1.61 [0.98-2.65]; p=0.0625
ΔPCT 4.1 with binary SOFA + covariatesc)	1.64 [1.00-2.69]; p=0.0483
ΔPCT 4.1 with numeric SOFA + covariatesc)	1.47 [0.89-2.42]; p=0.1300

d) Antibiotic adequacy, Sepsis severity, ICU Care on Day 4, Biological infection type, Positive blood culture, PCT on Day 0, Age, Gender

Hazard ratios for ΔPCT and selected predictors from multivariate Cox Regression Models
Model		Hazard ratio (95 % confidence interval)
		Binary predictorse)
ΔPCT interval	Score + Covariatesf)	ΔPCT(≤ 80 % vs > 80 %)	Day 4 patient location(ICU vs. no ICU)
Day 0 untilDay 4	APACHE	1.72 (1.00-2.95)	2.61 (1.63-4.19)
	max SOFA	1.46 (0.86-2.48)	1.71 (1.04-2.81)
Day 1 untilDay 4	APACHE	1.61 (0.98-2.65)	2.63 (1.64-4.21)
	max SOFA	1.47 (0.89-2.42)	1.73 (1.06-2.84)

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e) In the analysis, missing values for predictors were multiple imputed assuming they were Missing at Random (MAR), with the multiple imputations combined according to Rubin D.B.,Wiley New York 1987; Multiple Imputation for Nonresponse in Surveys). f) The models also included the following predictors (HR results not shown): Antibiotic adequacy, Sepsis severity, Biological infection type, Clinical infection type, Positive blood culture, PCT on Day 0, Gender.

Hazard ratios for ΔPCT and selected predictors from multivariate Cox Regression Models
Model	Hazard ratio (95 % confidence interval)
	Continuous predictorsg) (HR per 1 SD)
ΔPCT interval	Score + Covariatesh)	APACHE (1 SD=8.13)	max SOFA (1 SD=3.98)	Age (1 SD=16.18)
Day 0 until Day 4	APACHE	1.25 (0.99-1.57)	----	1.59 (1.27-1.99)
	max SOFA	----	1.97 (1.53-2.53)	1.69 (1.35-2.10)
Day 1 until Day 4	APACHE	1.29 (1.04-1.62)	----	1.57 (1.25-1.96)
	max SOFA	----	2.00 (1.56-2.56)	1.67 (1.33-2.08)

g) In the analysis, missing values for predictors were multiple imputed assuming they were Missing at Random (MAR), with the multiple imputations combined according to Rubin D.B.,Wiley New York 1987; Multiple Imputation for Nonresponse in Surveys).

h) The models also included the following predictors (HR results not shown): Antibiotic adequacy, Sepsis severty, Biological infection type, Clinical infection type, Positive blood culture, PCT on Day 0, Gender.

The change of PCT over time can also be described by the ratio of PCT values from Day 4 and Day 0 (or Day 1):

$$PCT_{ratio} = \frac{PCT_{Day\ 4}}{PCT_{Day\ 0\ (or\ Day\ 1)}}$$

A decline of ΔPCT = 80 % translates into a PCT ratio of 0.2. The PCT ratio has values larger than 0.2 when the APCT decline is below 80 % which is associated with a higher risk for cumulative 28day all-cause mortality in patients diagnosed with severe sepsis or septic shock. Likewise, a PCT ratio below 0.2 indicates a lower risk for mortality within 28 days. On a continuous scale, the relative mortality risk for patients diagnosed with severe sepsis or septic shock is higher the larger the PCT ratio. The following tables list the hazard ratios for an increase by the factor 2 in PCT ratio, i.e. the relative increase in mortality risk for a patient with any given PCT ratio compared to a patient with a 2-fold lower PCT ratio. For comparison, selected predictors are indicated with corresponding equivalents in standard deviation. For the patient location at Day 4, the risk estimate compares the hazards for patients with vs. without ICU care on Day 4.

{33}------------------------------------------------

Hazard ratios for ΔPCT and selected predictors from multivariate Cox Regression Models
ΔPCT interval	Model	Hazard ratio (95 % confidence interval)
	Score + Covariatesj	Binary predictorsjDay 4 patient location (ICU vs. no ICU)
Day 0 until Day 4	APACHE	2.57 (1.59-4.13)
	Max SOFA	1.70 (1.03-2.80)
Day 1 until Day 4	APACHE	2.57 (1.60-4.11)
	Max SOFA	1.74 (1.06-2.86)

i) In the analysis, missing values for predictors were multiple imputed assuming they were Missing at the multiple imputations combined according to Rubin D.B.,Wiley New York 1987; Multiple Imputation for Norresponse in Surveys).

j) The models also included the following predictors (HR results not shown): Antibiotic adequacy, Sepsis severity, Biological infection type, Clinical infection type, Positive blood culture, PCT on Day 0, Gender.

Hazard ratios for ΔPCT and selected predictors from multivariate Cox Regression Models
		Hazard ratio (95 % confidence interval)
ModelContinuous predictorsk)(HR per 2-fold increase in PCT ratio or per equivalent in SD)
ΔPCTinterval	Score +Covarl,m)	PCT ratio(2-foldincrease)	APACHE(SD equivn),o))	Max SOFA(SD equivi),j))	Age(SD equivi),j))
Day 0 untilDay 4	APACHE	1.26 (1.12-1.42)	1.08 (0.96-1.22)	----	1.29 (1.15-1.45)
Day 0 untilDay 4	max SOFA	1.20 (1.07-1.35)	----	1.37 (1.20-1.57)	1.32 (1.18-1.49)
Day 1 untilDay 4	APACHE	1.29 (1.11-1.49)	1.19 (1.02-1.39)	----	1.37 (1.18-1.60)
Day 1 untilDay 4	max SOFA	1.23 (1.06-1.44)	----	1.58 (1.33-1.87)	1.43 (1.23-1.67)

k) In the analysis, missing values for predictors were multiple imputed assuming they were Missing at Random (MAR), with the multiple imputations combined according to Rubin D.B.,Wiley New York 1987; Multiple Imputation for Nonresponse in Surveys).

I) Covar = Covariates

m) The models also included the following predictors (HR results not shown): Antibiotic adequacy, Sepsis severity, Biological infection type, Clinical infection type, Positive blood culture, PCT on Day 0, Gender.

n) Equiv = Equivalent

o) A unit change of ΔPCT on log 2-scale corresponded to 0.52 SD of ΔPCT from Day 0 until Day 4 (0.69 SD for ΔPCT from Day 1 until Day 4). Accordingly, the reported ΔPCT hazard ratios refer to an increase of ΔPCT by a factor of 2. For comparability, hazard ratios of the other continuous predictors were estimated for the same fractional SDs, i.e. 0.52 or 0.69, respectively.

{34}------------------------------------------------

		Per-protocol population (N=598)
Variable	Class	All N	Dead N	Alive N	Mortality %
Gender	Female	264	46	218	17.4
	Male	334	55	279	16.5
	< 30	39	1	38	2.6
	> 30, < 45	45	4	41	8.9
Age, years	> 45, < 55	74	8	66	10.8
(catagorized)	> 55, < 65	149	26	123	17.4
	> 65, < 75	125	21	104	16.8
	> 75	166	41	125	24.7
	African-American	202	32	170	15.8
	Asian	7	0	7	0.0
Ethnicity	Caucasian	362	64	298	17.72
	Hispanic	23	5	18	21.7
	Other	4	0	4	0.0
	< 0.5	125	19	106	15.2
Baseline PCT, ug/L	> 0.5, < 2.0	104	13	91	12.5
	> 2.0	353	69	284	19.5
	Missing	16	0	16	0.0

Cumulative 28-day all-cause mortality did not differ significantly for male vs. female patients (χ2 p-value = 0.84). Demographics with outcome information are shown below :

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7. CONCLUSIONS

The information provided in this 510(k) Premarket Notification will support a determination of substantial equivalence for the Elecsys BRAHMS PCT test system. The data supports a safe, effective device which performs as well as or better than the predicate device.

Regulation Number and Section

§ 866.3215 Device to detect and measure non-microbial analyte(s) in human clinical specimens to aid in assessment of patients with suspected sepsis.

(a)
Identification. A device to detect and measure non-microbial analyte(s) in human clinical specimens to aid in assessment of patients with suspected sepsis is identified as an in vitro device intended for the detection and qualitative and/or quantitative measurement of one or more non-microbial analytes in human clinical specimens to aid in the assessment of patients with suspected sepsis when used in conjunction with clinical signs and symptoms and other clinical and laboratory findings.(b)
Classification. Class II (special controls). The special controls for this device are:(1) Premarket notification submissions must include the device's detailed Indications for Use statement describing what the device detects and measures, the results provided to the user, whether the measure is qualitative and/or quantitative, the clinical indications for which the test is to be used, and the specific population(s) for which the device use is intended.
(2) Premarket notification submissions must include detailed documentation of the device description, including (as applicable), all device components, software, ancillary reagents required but not provided, explanation of the device principle and methodology, and for molecular devices include detailed documentation of the primer/probe sequence, design, and rationale for sequence selection.
(3) Premarket notification submissions must include detailed documentation of applicable analytical studies, such as, analytical sensitivity (Limit of Detection, Limit of Blank, and Limit of Quantitation), precision, reproducibility, analytical measuring range, interference, cross-reactivity, and specimen stability.
(4) Premarket notification submissions must include detailed documentation of a prospective clinical study or, if appropriate, results from an equivalent sample set. This detailed documentation must include the following information:
(i) Results must demonstrate adequate device performance relative to a well-accepted comparator.
(ii) Clinical sample results must demonstrate consistency of device output throughout the device measuring range likely to be encountered in the Intended Use population.
(iii) Clinical study documentation must include the original study protocol (including predefined statistical analysis plan), study report documenting support for the Indications for Use(s), and results of all statistical analyses.
(5) Premarket notification submissions must include evaluation of the level of the non-microbial analyte in asymptomatic patients with demographic characteristics (
e.g., age, racial, ethnic, and gender distribution) similar to the Intended Use population.(6) As part of the risk management activities performed under 21 CFR 820.30 design controls, you must document an appropriate end user device training program that will be offered as part of your efforts to mitigate the risk of failure to correctly operate the instrument.
(7) A detailed explanation of the interpretation of results and acceptance criteria must be included in the device's 21 CFR 809.10(b)(9) compliant labeling, and a detailed explanation of the interpretation of the limitations of the samples (
e.g., collected on day of diagnosis) must be included in the device's 21 CFR 809.10(b)(10) compliant labeling.