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Girardis M, Coloretti I, Antonelli M, Berlot G, Busani S, Cortegiani A, De Pascale G, De Rosa FG, De Rosa S, Donadello K, Donati A, Forfori F, Giannella M, Grasselli G, Montrucchio G, Oliva A, Pasero D, Piazza O, Romagnoli S, Tascini C, Viaggi B, Tumbarello M, Viale P. Adjunctive immunotherapeutic agents in patients with sepsis and septic shock: a multidisciplinary consensus of 23. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:28. [PMID: 38689337 PMCID: PMC11059820 DOI: 10.1186/s44158-024-00165-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 04/18/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND In the last decades, several adjunctive treatments have been proposed to reduce mortality in septic shock patients. Unfortunately, mortality due to sepsis and septic shock remains elevated and NO trials evaluating adjunctive therapies were able to demonstrate any clear benefit. In light of the lack of evidence and conflicting results from previous studies, in this multidisciplinary consensus, the authors considered the rational, recent investigations and potential clinical benefits of targeted adjunctive therapies. METHODS A panel of multidisciplinary experts defined clinical phenotypes, treatments and outcomes of greater interest in the field of adjunctive therapies for sepsis and septic shock. After an extensive systematic literature review, the appropriateness of each treatment for each clinical phenotype was determined using the modified RAND/UCLA appropriateness method. RESULTS The consensus identified two distinct clinical phenotypes: patients with overwhelming shock and patients with immune paralysis. Six different adjunctive treatments were considered the most frequently used and promising: (i) corticosteroids, (ii) blood purification, (iii) immunoglobulins, (iv) granulocyte/monocyte colony-stimulating factor and (v) specific immune therapy (i.e. interferon-gamma, IL7 and AntiPD1). Agreement was achieved in 70% of the 25 clinical questions. CONCLUSIONS Although clinical evidence is lacking, adjunctive therapies are often employed in the treatment of sepsis. To address this gap in knowledge, a panel of national experts has provided a structured consensus on the appropriate use of these treatments in clinical practice.
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Affiliation(s)
- Massimo Girardis
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy.
| | - Irene Coloretti
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Massimo Antonelli
- Dipartimento Di Scienze Biotecnologiche Di Base, Cliniche Intensivologiche E Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento Di Scienze Dell'Emergenza, Anestesiologiche E Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giorgio Berlot
- Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Stefano Busani
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
- Department of Anaesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - Gennaro De Pascale
- Dipartimento Di Scienze Biotecnologiche Di Base, Cliniche Intensivologiche E Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento Di Scienze Dell'Emergenza, Anestesiologiche E Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Silvia De Rosa
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS, Trento, Italy
| | - Katia Donadello
- Department of Surgery, Dentistry, Ginaecology and Paediatrics, University of Verona, and Anesthesia and Intensive Care Unit B, University Hospital Integrated Trust of Verona, Verona, Italy
| | - Abele Donati
- Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Delle Marche, Ancona, Italy
| | - Francesco Forfori
- Anesthesia and Intensive Care, Anesthesia and Resuscitation Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Maddalena Giannella
- Department of Medical and Surgical Sciences Infectious Diseases Unit, IRCCS Azienda Ospedaliero Universitaria Di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giorgia Montrucchio
- Department of Surgical Sciences, Departement of Anesthesia, Resuscitation and Emergency Torino, University of Turin, Turin, Italy
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Daniela Pasero
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Ornella Piazza
- University Hospital "San Giovanni Di Dio E Ruggi d'Aragona", Salerno, Italy
| | - Stefano Romagnoli
- Department of Health Science, Department of Anesthesia and Intensive Care, University of Florence, Careggi University Hospital, Florence, Italy
| | - Carlo Tascini
- Department of Medicine (DAME), Infectious Diseases Clinic, University of Udine, Udine, Italy
| | - Bruno Viaggi
- Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Mario Tumbarello
- Infectious and Tropical Diseases Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences Infectious Diseases Unit, IRCCS Azienda Ospedaliero Universitaria Di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
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2
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Slim MA, Turgman O, van Vught LA, van der Poll T, Wiersinga WJ. Non-conventional immunomodulation in the management of sepsis. Eur J Intern Med 2024; 121:9-16. [PMID: 37919123 DOI: 10.1016/j.ejim.2023.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 10/24/2023] [Indexed: 11/04/2023]
Abstract
Sepsis remains a critical global health issue, demanding novel therapeutic strategies. Traditional immunomodulation treatments such as corticosteroids, specific modifiers of cytokines, complement or coagulation, growth factors or immunoglobulins, have so far fallen short. Meanwhile the number of studies investigating non-conventional immunomodulatory strategies is expanding. This review provides an overview of adjunctive treatments with herbal-based medicine, immunonutrition, vasopressors, sedative treatments and targeted temperature management, used to modulate the immune response in patients with sepsis. Herbal-based medicine, notably within traditional Chinese medicine, shows promise. Xuebijing injection and Shenfu injection exhibit anti-inflammatory and immune-modulatory effects, and the potential to lower 28-day mortality in sepsis. Selenium supplementation has been reported to reduce the occurrence of ventilator-associated pneumonia among sepsis patients, but study results are conflicting. Likewise, the immune-suppressive effects of omega-3 fatty acids have been associated with improved clinical outcomes in sepsis. The immunomodulating properties of supportive treatments also gain interest. Vasopressors like norepinephrine exhibit dual dosage-dependent roles, potentially promoting both pro- and anti-inflammatory effects. Dexmedetomidine, a sedative, demonstrates anti-inflammatory properties, reducing sepsis mortality rates in some studies. Temperature management, particularly maintaining higher body temperature, has also been associated with improved outcomes in small scale human trials. In conclusion, emerging non-conventional immunomodulatory approaches, including herbal medicine, immunonutrition, and targeted supportive therapies, hold potential for sepsis treatment, but their possible implementation into everyday clinical practice necessitates further research and stringent clinical validation in different settings.
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Affiliation(s)
- M A Slim
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands; Department of Intensive Care, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands.
| | - O Turgman
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - L A van Vught
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands; Department of Intensive Care, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - T van der Poll
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands; Department of Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - W J Wiersinga
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands; Department of Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, the Netherlands
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3
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Gao Q, Yang L, Teng F, Cheng XY, Guo SB. The tissue factor expression on CD14++CD16-monocytes is a new markers in the Chinese Han older adult population with sepsis: A prospective study. Exp Gerontol 2023; 171:112012. [PMID: 36347361 DOI: 10.1016/j.exger.2022.112012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/27/2022] [Accepted: 10/31/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate the tissue factor (TF) expression on different subsets of monocyte and tissue factor secretion of peripheral blood and evaluate their association with the prognosis of sepsis in the Chinese older adult population. METHODS Monocyte subsets and TF expression on different subsets of monocyte were measured using flow cytometry in 80 older adult sepsis patients and 40 age and sex matched healthy controls. Plasma level of TF was measured using ELISA (enzyme-linked immunosorbent assay) method. RESULTS TF expression on CD14++CD16- (MO1) monocyte was lower in death (28-day non-survivor) group compared with survival (28-day survivor) groups [1.01 % (0.58 %, 1.62 %) vs. 3.66 % (1.32 %, 6.93 %), p = 0.001]. The plasma level of TF was increased in death group compared to survival group according to the 28-day mortality [109.2 (67.3, 154.2) vs. 62.1 (44.7, 115.5) pg/mL, p = 0.031]. Logistic regression analysis showed TF expression on MO1 monocyte (β = -0.776, OR = 0.460, CI: 0.251, 0.843, p = 0.012) was independently associated with the 28-day mortality. The ROC (receiver operating characteristic) curve showed that the AUC (area under the curve) of the TF expression on MO1 monocyte for predicting 28-day mortality was 0.846 (p < 0.001). CONCLUSION The TF expression on CD14++CD16- monocyte is a new marker for the prognosis of older adult sepsis.
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Affiliation(s)
- Qian Gao
- Emergency Department, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tieyi Road, Yangfangdian, Haidian District, Beijing 100038, China
| | - Li Yang
- Emergency Department, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tieyi Road, Yangfangdian, Haidian District, Beijing 100038, China
| | - Fei Teng
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, No. 8, South Road of Worker's Stadium, Chaoyang District, Beijing 100020, China
| | - Xiao-Yan Cheng
- Institute of Analysis and Testing, Beijing Academy of Science and Technology (Beijing Center for Physical and Chemical Analysis), No. 27 Xisanhuan North Road, Beijing 100094, China
| | - Shu-Bin Guo
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, No. 8, South Road of Worker's Stadium, Chaoyang District, Beijing 100020, China.
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4
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Groff E, Orzechowski M, Schuetz C, Steger F. Ethical Aspects of Personalized Research and Management of Systemic Inflammatory Response Syndrome (SIRS) in Children. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:470. [PMID: 36612792 PMCID: PMC9819223 DOI: 10.3390/ijerph20010470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 06/17/2023]
Abstract
Systemic inflammatory response syndrome (SIRS) is a life-threatening condition with nonspecific symptoms. Because of that, defining a targeted therapy against SIRS in children and adults remains a challenge. The identification of diagnostic patterns from individualized immuneprofiling can lead to development of a personalized therapy. The aim of this study was to identify and analyze ethical issues associated with personalized research and therapy for SIRS in pediatric populations. We conducted an ethical analysis based on a principled approach according to Beauchamp and Childress' four bioethical principles. Relevant information for the research objectives was extracted from a systematic literature review conducted in the scientific databases PubMed, Embase and Web of Science. We searched for pertinent themes dealing with at least one of the four bioethical principles: "autonomy", "non-maleficence", "beneficence" and "justice". 48 publications that met the research objectives were included in the thorough analysis, structured and discussed in a narrative synthesis. From the analysis of the results, it has emerged that traditional paradigms of patient's autonomy and physician paternalism need to be reexamined in pediatric research. Standard information procedures and models of informed consent should be reconsidered as they do not accommodate the complexities of pediatric omics research.
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Affiliation(s)
- Elisa Groff
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, 89073 Ulm, Germany
| | - Marcin Orzechowski
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, 89073 Ulm, Germany
| | - Catharina Schuetz
- Paediatric Immunology, Medical Faculty “Carl Gustav Carus”, Technic University Dresden, 01307 Dresden, Germany
| | - Florian Steger
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, 89073 Ulm, Germany
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5
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Dash SP, Chakraborty P, Sarangi PP. Inflammatory Monocytes and Subsets of Macrophages with Distinct Surface Phenotype Correlate with Specific Integrin Expression Profile during Murine Sepsis. THE JOURNAL OF IMMUNOLOGY 2021; 207:2841-2855. [PMID: 34732468 DOI: 10.4049/jimmunol.2000821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/27/2021] [Indexed: 01/15/2023]
Abstract
Monocytes and macrophages participate in both pro- and anti-inflammatory responses during sepsis. Integrins are the cell adhesion receptors that mediate leukocyte migration and functions. To date, it is not known whether integrin profiles correlate with their trafficking, differentiation, and polarization during sepsis. In this study, using endotoxemia and cecal ligation and puncture model of murine sepsis, we have analyzed the role of surface integrins in tissue-specific infiltration, distribution of monocytes and macrophages, and their association with inflammation-induced phenotypic and functional alterations postinduction (p.i.) of sepsis. Our data show that Ly-6Chi inflammatory monocytes infiltrated into the peritoneum from blood and bone marrow within a few hours p.i. of sepsis, with differential distribution of small (Ly-6CloCD11bloF4/80lo) and large peritoneal macrophages (Ly-6CloCD11bhiF4/80hi) in both models. The results from flow cytometry studies demonstrated a higher expression of integrin α4β1 on the Ly-6Chi monocytes in different tissues, whereas macrophages in the peritoneum and lungs expressed higher levels of integrin α5β1 and αvβ3 in both models. Additionally, F4/80+ cells with CD206hiMHCIIlo phenotype increased in the lungs of both models by six hours p.i. and expressed higher levels of integrin αvβ3 in both lungs and peritoneum. The presence of such cells correlated with higher levels of IL-10 and lower levels of IL-6 and IL-1β transcripts within six hours p.i. in the lungs compared with the mesentery. Furthermore, bioinformatic analysis with its experimental validation revealed an association of integrin α4 and α5 with inflammatory (e.g., p-SRC) and integrin αv with regulatory molecules (e.g., TGFBR1) in macrophages during sepsis.
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Affiliation(s)
- Shiba Prasad Dash
- Department of Biosciences and Bioengineering, Indian Institute of Technology Roorkee, Roorkee, Uttarakhand, India
| | - Papiya Chakraborty
- Department of Biosciences and Bioengineering, Indian Institute of Technology Roorkee, Roorkee, Uttarakhand, India
| | - Pranita P Sarangi
- Department of Biosciences and Bioengineering, Indian Institute of Technology Roorkee, Roorkee, Uttarakhand, India
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6
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Vázquez AC, Arriaga-Pizano L, Ferat-Osorio E. Cellular Markers of Immunosuppression in Sepsis. Arch Med Res 2021; 52:828-835. [PMID: 34702587 DOI: 10.1016/j.arcmed.2021.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/27/2021] [Accepted: 10/04/2021] [Indexed: 12/16/2022]
Abstract
Sepsis is a pathological condition frequently caused by invasion of a pathogen and the subsequent unregulated response that threatens the patient's life through diverse organ failure. The incidence of sepsis is increasing, and there is no specific therapy. Despite technological contributions to treat sepsis or increased knowledge of its molecular pathophysiology, mortality remains high, and sepsis is a global health problem. Knowledge of the role of the cells involved in the host response through the synthesis of inflammatory mediators and their different effects on cells, tissues or systems is key to the development of medical treatments that regulate systems involved in such responses to pathogens. This review addresses new insights into the role of cells, their mediators, and the interaction between them that lead to the development of a state of immunosuppression.
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Affiliation(s)
- Arturo Cérbulo Vázquez
- Servicio de Medicina Genómica, Hospital General de México, Dr Eduardo Liceaga, Ciudad de México, México
| | - Lourdes Arriaga-Pizano
- Unidad de Investigación Médica en Inmunoquímica de la Unidad de Investigación en Epidemiología Clínica, Hospital de Especialidades, Dr. Bernardo Sepúlveda Gutiérrez, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Eduardo Ferat-Osorio
- División de Investigación en Salud, Unidad de Investigación en Epidemiología Clínica, Hospital de Especialidades, Dr. Bernardo Sepúlveda Gutiérrez, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México.
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7
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Cheng Z, Abrams ST, Toh J, Wang SS, Wang Z, Yu Q, Yu W, Toh CH, Wang G. The Critical Roles and Mechanisms of Immune Cell Death in Sepsis. Front Immunol 2020; 11:1918. [PMID: 32983116 PMCID: PMC7477075 DOI: 10.3389/fimmu.2020.01918] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 07/16/2020] [Indexed: 12/23/2022] Open
Abstract
Sepsis was first described by the ancient Greek physicians over 2000 years ago. The pathophysiology of the disease, however, is still not fully understood and hence the mortality rate is still unacceptably high due to lack of specific therapies. In the last decade, great progress has been made by shifting the focus of research from systemic inflammatory response syndrome (SIRS) to multiple organ dysfunction syndrome (MODS). Sepsis has been re-defined as infection-induced MODS in 2016. How infection leads to MODS is not clear, but what mediates MODS becomes the major topic in understanding the molecular mechanisms and developing specific therapies. Recently, the mechanism of infection-induced extensive immune cell death which releases a large quantity of damage-associated molecular patterns (DAMPs) and their roles in the development of MODS as well as immunosuppression during sepsis have attracted much attention. Growing evidence supports the hypothesis that DAMPs, including high-mobility group box 1 protein (HMGB1), cell-free DNA (cfDNA) and histones as well as neutrophil extracellular traps (NETs), may directly or indirectly contribute significantly to the development of MODS. Here, we provide an overview of the mechanisms and consequences of infection-induced extensive immune cell death during the development of sepsis. We also propose a pivotal pathway from a local infection to eventual sepsis and a potential combined therapeutic strategy for targeting sepsis.
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Affiliation(s)
- Zhenxing Cheng
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom.,Medical School, Southeast University, Nanjing, China
| | - Simon T Abrams
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Julien Toh
- Wirral University Teaching Hospitals NHS Foundation Trust, Wirral, United Kingdom
| | | | - Zhi Wang
- Medical School, Southeast University, Nanjing, China
| | - Qian Yu
- Medical School, Southeast University, Nanjing, China
| | - Weiping Yu
- Medical School, Southeast University, Nanjing, China
| | - Cheng-Hock Toh
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Guozheng Wang
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom.,Medical School, Southeast University, Nanjing, China
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8
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Shang S, Wu J, Li X, Liu X, Li P, Zheng C, Wang Y, Liu S, Zheng J, Zhou H. Artesunate interacts with the vitamin D receptor to reverse sepsis-induced immunosuppression in a mouse model via enhancing autophagy. Br J Pharmacol 2020; 177:4147-4165. [PMID: 32520399 DOI: 10.1111/bph.15158] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 05/25/2020] [Accepted: 05/28/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND PURPOSE Immunosuppression is the predominant cause of mortality for sepsis because of failure to eradicate pathogens. No effective and specific drugs capable of reversing immunosuppression are clinically available. Evidences implicate the involvement of the vitamin D receptor (NR1I1) in sepsis-induced immunosuppression. The anti-malarial artesunate was investigated to determine action on sepsis-induced immunosuppression. EXPERIMENTAL APPROACH The effect of artesunate on sepsis-induced immunosuppression was investigated in mice and human and mice cell lines. Bioinformatics predicted vitamin D receptor as a candidate target for artesunate, which was then identified using PCR and immunoblotting. Vdr, Atg16l1 and NF-κB p65 were modified to investigate artesunate 's effect on pro-inflammatory cytokines release, bacterial clearance and autophagy activities in sepsis-induced immunosuppression. KEY RESULTS Artesunate significantly reduced the mortality of caecal ligation and puncture (CLP)-induced sepsis immunosuppression mice challenged with Pseudomonas aeruginosa and enhanced pro-inflammatory cytokine release and bacterial clearance to reverse sepsis-induced immunosuppression in vivo and in vitro. Mechanistically, artesunate interacted with vitamin D receptor, inhibiting its nuclear translocation, which influenced ATG16L1 transcription and subsequent autophagy activity. Artesunate inhibited the physical interaction between vitamin D receptor and NF-κB p65 in LPS-tolerant macrophages and then promoted the nuclear translocation of NF-κB p65, which activated the transcription of NF-κB p65 target genes such as pro-inflammatory cytokines. CONCLUSION AND IMPLICATIONS Our findings provide evidence that artesunate interacted with vitamin D receptor to reverse sepsis-induced immunosuppression in an autophagy and NF-κB-dependent manner, highlighting a novel approach for sepsis treatment and drug repurposing of artesunate has a bidirectional immunomodulator.
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Affiliation(s)
- Shenglan Shang
- Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Pharmacy, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jiaqi Wu
- Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xiaoli Li
- Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xin Liu
- Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Pan Li
- Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Chongqing municipal Enterprise Technology Center, Chongqing Shenghuaxi Pharmaceutical Co., Ltd., Chongqing, China
| | - Chunli Zheng
- Key Laboratory of Basic Pharmacology of Ministry of Education and Joint International Research Laboratory of Ethnomedicine of Ministry of Education, Zunyi Medical University, Zunyi, Guizhou, China
| | - Yonghua Wang
- Key Laboratory of Basic Pharmacology of Ministry of Education and Joint International Research Laboratory of Ethnomedicine of Ministry of Education, Zunyi Medical University, Zunyi, Guizhou, China
| | - Songqing Liu
- Department of Pharmacy, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jiang Zheng
- Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Hong Zhou
- Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Chongqing municipal Enterprise Technology Center, Chongqing Shenghuaxi Pharmaceutical Co., Ltd., Chongqing, China.,Key Laboratory of Resource Biology and Biotechnology in Western China, Ministry of Education, School of Life Sciences, Northwest University, Xi'an, Shanxi, China
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9
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Jarneborn A, Mohammad M, Engdahl C, Hu Z, Na M, Ali A, Jin T. Tofacitinib treatment aggravates Staphylococcus aureus septic arthritis, but attenuates sepsis and enterotoxin induced shock in mice. Sci Rep 2020; 10:10891. [PMID: 32616791 PMCID: PMC7331611 DOI: 10.1038/s41598-020-67928-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/16/2020] [Indexed: 12/30/2022] Open
Abstract
Tofacitinib, a janus kinase inhibitor, is a novel immunosuppressive drug for treatment of rheumatoid arthritis (RA). Septic arthritis (SA) and sepsis caused by Staphylococcus aureus (S. aureus), for which RA patients are at risk, are infections with high mortality. The aim of this study was to investigate the effect of tofacitinib on S. aureus infections using mouse models. In vitro tofacitinib treated mouse splenocytes were stimulated with S. aureus derived stimuli. Mice pre-treated with tofacitinib were inoculated intravenously with either arthritogenic- or septic doses of S. aureus. Arthritis severity and mortality were compared between groups. Additionally, pre-treated mice were challenged with staphylococcal toxin TSST-1 to induce shock. Tofacitinib inhibited splenocyte proliferation and IFN-γ production in response to TSST-1 and dead S. aureus. In SA, tofacitinib treatment aggravated arthritis with more severe bone erosions. However, in sepsis, treated mice displayed significantly prolonged survival compared to controls. Similarly, in staphylococcal enterotoxin-induced shock tofacitinib pre-treatment, but not late treatment dramatically reduced mortality, which was accompanied by decreased levels of TNF-α and IFN-γ. Our findings show that tofacitinib treatment increase susceptibility of SA in mice, but has a positive effect on survival in S. aureus-induced sepsis and a strong protective effect in toxin-induced shock.
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Affiliation(s)
- Anders Jarneborn
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Guldhedsgatan 10A, 413 46, Göteborg, Sweden. .,Department of Rheumatology, Sahlgrenska University Hospital, Göteborg, Sweden.
| | - Majd Mohammad
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Guldhedsgatan 10A, 413 46, Göteborg, Sweden
| | - Cecilia Engdahl
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Guldhedsgatan 10A, 413 46, Göteborg, Sweden
| | - Zhicheng Hu
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Guldhedsgatan 10A, 413 46, Göteborg, Sweden.,Department of Microbiology and Immunology, The Affiliated Hospital of GuiZhou Medical University, Guiyang, China
| | - Manli Na
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Guldhedsgatan 10A, 413 46, Göteborg, Sweden
| | - Abukar Ali
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Guldhedsgatan 10A, 413 46, Göteborg, Sweden
| | - Tao Jin
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Guldhedsgatan 10A, 413 46, Göteborg, Sweden.,Department of Rheumatology, Sahlgrenska University Hospital, Göteborg, Sweden
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10
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Abstract
Objectives: To explore the characteristics of cytokine storm in patients with septic shock after abdominal surgery, examine its relationship with clinical data, and determine intervention timings. Materials and Methods: We prospectively observed a cohort of patients with abdominal infection admitted to the surgical intensive care unit (ICU) after surgery (shock group). A control group of healthy individuals was used for comparison. Plasma samples and clinical data recorded at 0, 12, 24, 48, and 72 h after surgery were collected. Cytokines (tumor necrosis factor-α, interleukin [IL]-6, IL-8, IL-10, monocyte chemotactic protein [MCP]-1, IL-1 β, interferon-γ, IL-12p70, MCP-1α, IL-4, IL-2, and IL-13) were detected using the Luminex® technique. Results: Concentrations of most cytokines were significantly higher in the shock group. When a cytokine storm intensity curve was considered with the vasopressor dependency index and a Sequential Organ Failure Assessment (SOFA) score, time point of maximum cytokine storm intensity was earlier than that of the maximum vasopressor dependency index and SOFA score in the shock group. Conclusions: Cytokine storm occurred in patients with septic shock shortly after the abdominal surgery and may be a main mechanism leading to septic shock. Cytokine storm interventions should ideally be initiated within 24 h after surgery and be guided by cytokine storm biomarkers.
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11
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Sungurlu S, Kuppy J, Balk RA. Role of Antithrombin III and Tissue Factor Pathway in the Pathogenesis of Sepsis. Crit Care Clin 2020; 36:255-265. [PMID: 32172812 DOI: 10.1016/j.ccc.2019.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The pathobiology of the septic process includes a complex interrelationship between inflammation and the coagulations system. Antithrombin (AT) and tissue factor are important components of the coagulation system and have potential roles in the production and amplification of sepsis. Sepsis is associated with a decrease in AT levels, and low levels are also associated with the development of multiple organ failure and death. Treatment strategies incorporating AT replacement therapy in sepsis and septic shock have not resulted in an improvement in survival or reversal of disseminated intravascular coagulation.
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Affiliation(s)
- Sarah Sungurlu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Rush Medical College and Rush University Medical Center, 1725 West Harrison Street, Suite 054, Chicago, IL 606012, USA
| | - Jessica Kuppy
- Division of Pulmonary, Critical Care, and Sleep Medicine, Rush Medical College and Rush University Medical Center, 1725 West Harrison Street, Suite 054, Chicago, IL 606012, USA
| | - Robert A Balk
- Division of Pulmonary, Critical Care, and Sleep Medicine, Rush Medical College and Rush University Medical Center, 1725 West Harrison Street, Suite 054, Chicago, IL 606012, USA.
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12
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Incidence, trends, and outcomes of infection sites among hospitalizations of sepsis: A nationwide study. PLoS One 2020; 15:e0227752. [PMID: 31929577 PMCID: PMC6957188 DOI: 10.1371/journal.pone.0227752] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 12/27/2019] [Indexed: 01/08/2023] Open
Abstract
Purpose To determine the trends of infection sites and outcome of sepsis using a national population-based database. Materials and methods Using the Nationwide Inpatient Sample database of the US, adult sepsis hospitalizations and infection sites were identified using a validated approach that selects admissions with explicit ICD-9-CM codes for sepsis and diagnosis/procedure codes for acute organ dysfunctions. The primary outcome was the trend of incidence and in-hospital mortality of specific infection sites in sepsis patients. The secondary outcome was the impact of specific infection sites on in-hospital mortality. Results During the 9-year period, we identified 7,860,687 admissions of adult sepsis. Genitourinary tract infection (36.7%), lower respiratory tract infection (36.6%), and systemic fungal infection (9.2%) were the leading three sites of infection in patients with sepsis. Intra-abdominal infection (30.7%), lower respiratory tract infection (27.7%), and biliary tract infection (25.5%) were associated with highest mortality rate. The incidences of all sites of infections were trending upward. Musculoskeletal infection (annual increase: 34.2%) and skin and skin structure infection (annual increase: 23.0%) had the steepest increase. Mortality from all sites of infection has decreased significantly (trend p<0.001). Skin and skin structure infection had the fastest declining rate (annual decrease: 5.5%) followed by primary bacteremia (annual decrease: 5.3%) and catheter related bloodstream infection (annual decrease: 4.8%). Conclusions The anatomic site of infection does have a differential impact on the mortality of septic patients. Intra-abdominal infection, lower respiratory tract infection, and biliary tract infection are associated with higher mortality in septic patients.
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13
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Wan R, Li L, Xing C, Peng R, Gao L. Worldwide scientific productions with immunotherapy of sepsis: a bibliometric analysis. PeerJ 2019; 7:e7116. [PMID: 31245180 PMCID: PMC6585897 DOI: 10.7717/peerj.7116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/11/2019] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis represents a significant healthcare problem worldwide and causes a high number of deaths every year but remains to be fully understood. During and after sepsis, the host immune response is complex and involves an initial excessive host inflammatory response to infection that is closely related to tissue damage and leads to organ failure. Over the past three decades, immunotherapy for sepsis has vastly improved, but in this area, the most influential articles, journals, authors, and countries have not yet been completely summarized and analyzed. Objective Performed a bibliometric analysis on all the articles concerning immunotherapy for sepsis from 1962 to 2019 was our objective, and we also explored the potential correlations between publications of different countries and their gross domestic product (GDP). Methods All articles about immunotherapy for sepsis were extracted from the Scopus database and analyzed. We also retrieved GDP data from all the countries that have published information from the World Bank. Results In summary, we have retrieved 1,483 related articles from the Scopus database starting from the first publication on immunotherapy for sepsis in 1962 through March 16, 2019. Over the past decade, the number of the articles published has increased year by year to reach 866 in total, which accounts for about 58% of all publications, with 2017 being the most prolific year when 179 articles were published. The US published 604 articles (41%), followed by China (n = 163, 11%), and Germany (n = 158, 11%). In terms of publishing media, the journal that published the highest number of the articles was Journal of Critical Care Medicine with 65 articles (4%), followed by Shock with 55 articles (4%), and Critical Care with 35 articles (2%). There was a strong correlation between the GDP of the different countries and their publication numbers (r = 0.811, P < 0.001). Conclusions Our present study analyzed all types of articles concerning immunotherapy for sepsis over the past 57 years and countries with high GDP tends to make more contributions to the medical field of this field. In the meantime, these studies highlight the importance of immunotherapy in the treatment of sepsis patients. The recognition of the historical status and development trend of this field can promote inter-agency cooperation, guide future research, and ultimately provide the basis for clinical practice guidelines.
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Affiliation(s)
- Ronghao Wan
- Department of Neurosurgery, Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Lei Li
- Department of Neurosurgery, Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Chenwei Xing
- Department of Medical Administration, Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Ronggang Peng
- Department of Cardiology, Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Liang Gao
- Department of Neurosurgery, Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
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14
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Zhang S, Tu Y, Sun YM, Li Y, Wang RM, Cao Y, Li L, Zhang LC, Wang ZB. Swiprosin-1 deficiency impairs macrophage immune response of septic mice. JCI Insight 2018; 3:95396. [PMID: 29415882 DOI: 10.1172/jci.insight.95396] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 12/28/2017] [Indexed: 01/05/2023] Open
Abstract
Despite the fact that many therapeutic strategies have been adopted to delay the development of sepsis, sepsis remains one of the leading causes of death in noncoronary intensive care units. Recently, sepsis-3 was defined as life-threatening organ dysfunction due to a dysregulated host response to infection. Here, we report that swiprosin-1 (also known as EFhd2) plays an important role in the macrophage immune response to LPS-induced or cecal ligation and puncture-induced (CLP-induced) sepsis in mice. Swiprosin-1 depletion causes higher mortality, more severe organ dysfunction, restrained macrophage recruitment in the lung and kidney, and attenuated inflammatory cytokine production (including IL-1β, IL-6, TNF-α, IL-10, and IFN-γ). The immunosuppression caused by swiprosin-1 deficiency is manifested by impaired bactericidal capacity and decreased HLA-DR expression in macrophages. Swiprosin-1 affects the activation of the JAK2/STAT1/STAT3 pathway by regulating the expression of IFN-γ receptors in macrophages. Our findings provide a potential target for the regulation of the macrophage immune response in sepsis.
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Affiliation(s)
- Su Zhang
- College of Pharmacy, Second Military Medical University
| | - Ye Tu
- Department of Medicine, Shanghai East Hospital, Tongji University
| | - Yi-Ming Sun
- College of Pharmacy, Second Military Medical University
| | - Ya Li
- College of Pharmacy, Second Military Medical University
| | - Rong-Mei Wang
- College of Pharmacy, Second Military Medical University
| | - Yongbing Cao
- Shanghai Institute of Vascular Disease, Shanghai University of Traditional Chinese Medicine, and
| | - Ling Li
- Shanghai Institute of Vascular Disease, Shanghai University of Traditional Chinese Medicine, and
| | - Li-Chao Zhang
- Department of Pharmacy, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai, China
| | - Zhi-Bin Wang
- College of Pharmacy, Second Military Medical University
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15
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Vitamin C: The next step in sepsis management? J Crit Care 2017; 43:230-234. [PMID: 28934705 DOI: 10.1016/j.jcrc.2017.09.031] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/14/2017] [Accepted: 09/15/2017] [Indexed: 01/20/2023]
Abstract
Sepsis is a life-threatening medical condition, affecting approximately 26 million people worldwide every year. The disease is a continuum, marked by dysregulated inflammation and hemodynamic instability leading to shock, multi-system organ dysfunction, and death. Over the past decades, there has been a focus on the early identification and treatment of sepsis primarily with bundled and goal directed therapy. Despite these advances, morbidity and mortality has remained high, prompting investigation into novel therapies. Vitamin C is a water-soluble vitamin that plays a role in mediating inflammation through antioxidant activities and is also important in the synthesis of cortisol, catecholamines, and vasopressin, which are key mediators in the disease process. Emerging evidence provides cursory data in support of the administration of vitamin C in addition to standard therapy to ameliorate the effects of inflammation and improve hemodynamic stability in patients with sepsis and septic shock; however, further evidence is needed to support this practice. This review discusses the physiologic role of vitamin C as well as the recent literature and evidence for the use of vitamin C in patients presenting with sepsis.
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