11411143
0095-1137/97/$04.0010
Copyright q 1997, American Society for Microbiology
The Captia Syphilis IgG enzyme immunoassay (EIA) was evaluated for use in conjunction with the rapid
plasma reagin test (RPR) as a method to test for syphilis. A total of 1,288 serum specimens were tested by the
routine laboratory protocol of the RPR followed by microhemagluttination assay for Treponema pallidum
(MHA-TP) testing of RPR-reactive sera as well as the EIA-RPR protocol in which the automated EIA followed
by a manual RPR test for EIA-positive specimens is used. When using the routine protocol, 131 specimens were
initially reactive by the RPR, and 113 of these were reactive by MHA-TP. When using the EIA-RPR protocol,
170 specimens were initially positive by EIA, and of these, 112 were RPR reactive, indicating active disease.
When compared to the routine protocol, the EIA-RPR protocol had sensitivity, specificity, and positive and
negative predictive values of 96.5, 99.7, 97.3, and 99.7%, respectively. After resolution of discrepancies by
additional testing, the adjusted sensitivity, specificity, and positive and negative predictive values were 100,
99.8, 98.3, and 100%, respectively. This evaluation demonstrates that when used in conjunction with the RPR,
the Captia Syphilis EIA is a reliable method by which to test for syphilis.
Treponema pallidum, the causative agent of syphilis, is very
difficult to culture (1, 6), and specimens for direct detection are
often not available from patients with latent or late stages of
the disease; therefore, serologic testing plays an important role
in the diagnosis of syphilis. The serologic tests most commonly
used in the United States to screen for this disease are the
nontreponemal Venereal Disease Research Laboratory test
and the rapid plasma reagin test (RPR) (4). The nontreponemal tests, in general, are ideal for screening large numbers of
specimens because they are sensitive and technically simple to
perform. However, because they measure the hosts response
to nontreponemal antigens (lipoidal material released from
damaged host cells as well as lipoprotein-like material released
from the treponemes), they are not specific, and in certain test
populations as many as 50% of the RPR-reactive specimens
will be negative in a treponeme-specific test, indicating a falsepositive reaction (3). Because of the problem with specificity, a
positive nontreponemal screening test should be confirmed
with a specific treponemal test such as the fluorescent treponemal antibody-absorption test (FTA-ABS) or microhemagluttination assay for T. pallidum (MHA-TP).
While the nontreponemal screening tests are technically
simple, they are labor-intensive and their results can be difficult
to interpret. For laboratories that screen large numbers of
specimens, an automated method for performing the syphilis
screen is desirable. Recently, the Captia Syphilis IgG enzyme
immunoassay (EIA; Centacore Inc., Malvern, Pa.) became
available as an automated treponemal test for detecting antibodies against T. pallidum. Data from several studies in which
this test was evaluated indicate that the EIA is both sensitive
and specific (2, 5, 79). However, because antibodies to T.
RESULTS
A total of 1,288 serum specimens were included in the evaluation. When the routine laboratory protocol was used (RPR
followed by MHA-TP), 131 specimens were RPR reactive and
1141
1142
REISNER ET AL.
J. CLIN. MICROBIOL.
Nonreactive
Total
Positive
Negative
109
4
3
1,167
112
1,171
Total
113
1,170
1,283
Not diagnostic of
syphilis
Total
Positive
Negative
114
0
2
1,167
116
1,167
Total
114
1,169
1,283
DISCUSSION
We evaluated the ability of the Captia Syphilis IgG EIA in
conjunction with the RPR to accurately diagnose syphilis.
When using the EIA as a preliminary screen to identify those
specimens that required additional testing by the RPR to diagnose active syphilis, 170 specimens required additional testing. When using the RPR as a preliminary screen to identify
those specimens that required additional testing by MHA-TP
to confirm the specificity of the reaction, 131 specimens required additional testing. Although the EIA-RPR protocol
resulted in more specimens that required additional testing
because it detects antibody in sera from patients with a history
of treated syphilis, the reduction in the number of manual
RPR performed by this protocol results in considerable savings
in technical time. On the basis of a time study performed in our
laboratory, the technical time required to perform the EIA is
roughly half that required to perform the manual RPR (approximately 0.5 and 1 min per specimen, respectively). Because
the reagent cost for the EIA is greater than that for the RPR,
each laboratory should determine the potential savings on the
basis of in-house time studies and the volume of tests performed.
The sensitivity and specificity of the EIA in conjunction with
the RPR for the laboratory diagnosis of syphilis were high,
both in the initial testing (96.5 and 99.7%, respectively), which
reflects the performance that can be expected in actual use,
and after resolution of discrepancies (100 and 99.8%, respectively). For the four specimens with discrepant results that
were initially EIA negative but that retested EIA positive, the
reason for the error is unknown; it is likely that technical errors
occurred, but it is not clear whether these were instrument or
operator errors. The high sensitivity and specificity of the EIARPR in this study are similar to the findings of previous studies
in which the EIA was used alone to diagnose syphilis. The
reported sensitivities in those studies were 93.9 and 100% and
the specificities were 98.6 and 98.2% (2, 7). The increased
specificity that we observed is likely a result of including RPR
testing in our protocol to test for active disease.
Resolution of equivocal results is an important consideration when using the EIA. During the evaluation reported
here, 17 of the 1,288 specimens initially had equivocal results
by EIA: the results for 5 specimens could not be resolved by
repeat testing and were subsequently excluded from the analysis; 5 specimens retested EIA negative, agreeing with the
MHA-TP result; 2 specimens retested EIA positive, agreeing
with the FTA-ABS result or the patient history of syphilis; and
5 specimens retested EIA positive, but the results disagreed
with those of the other treponemal serologic tests and chart
review indicated no history of syphilis. All five of the specimens
in this last group were RPR negative; therefore, the EIA result
should not have affected the treatment of the patient. However, this finding suggests that retesting of EIA-equivocal,
RPR-nonreactive specimens is unreliable.
Following the completion of this evaluation, we began using
the EIA-RPR protocol to test for syphilis in our laboratory,
which performs up to 2,600 tests per month. In our protocol,
sera are initially screened for antibodies against T. pallidum by
EIA, with all positive sera subsequently tested by the RPR.
When an equivocal EIA result is obtained, an RPR is performed; if the RPR is nonreactive, no further testing by EIA is
performed on the specimen to resolve the equivocal result. If
the RPR is reactive, the EIA is repeated in duplicate. For
RPR-reactive specimens whose results remain equivocal by
EIA, an MHA-TP is performed to obtain a final result.
Since implementing this protocol in our laboratory, 302
1143