Improved reverse screening algorithm for Treponema pallidum antibody using signal-to-cutoff ratios from chemiluminescence microparticle immunoassay.

Background The widespread reverse syphilis screening algorithm involves 1 more treponemal test than the traditional screening algorithm, resulting in increased medical costs. In the first screening step of the algorithm, a chemiluminescence microparticle immunoassay is used to detect Treponema pallidum (TP) antibody on the basis of signal-to-cutoff (S/CO) ratios. We hypothesized that by analyzing S/CO ratios, we could determine a strategy to reduce unnecessary confirmatory testing. Methods The ARCHITECT Syphilis TP assay using the chemiluminescence microparticle immunoassay was used as a syphilis screening test, and all reactive results were followed up with a toluidine red unheated serum test (TRUST) and a TP particle agglutination (TPPA) assay. We evaluated the S/CO ratios of 319 reactive samples of a total of 8980 that were included in the screening tests. A receiver operating characteristic curve was used to determine the optimal S/CO ratio to predict confirmatory TPPA results. Results When the S/CO ratio was 9.9 or greater, the specificity and positive predictive value were both determined to be 100.0%. All samples (194/194) with S/CO ratios of 9.9 or greater, even with negative results for TRUST, were confirmed to be positive for treponemal antibody. Conclusions A sample with an S/CO ratio of 9.9 or greater in initial screening does not need an extra confirmatory TPPA test, although the sample has a negative result for TRUST. We propose a potentially cost-effective reverse screening algorithm, obviating the need for the secondary treponemal testing in 65.2% of the screening-reactive samples.