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Munley JA, Kelly LS, Park G, Drury SK, Gillies GS, Coldwell PS, Kannan KB, Bible LE, Efron PA, Nagpal R, Mohr AM. Acute emergence of the intestinal pathobiome after postinjury pneumonia. J Trauma Acute Care Surg 2024; 97:65-72. [PMID: 38480488 PMCID: PMC11199099 DOI: 10.1097/ta.0000000000004300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
BACKGROUND Previous preclinical studies have demonstrated sex-specific alterations in the gut microbiome following traumatic injury or sepsis alone; however, the impact of host sex on dysbiosis in the setting of postinjury sepsis acutely is unknown. We hypothesized that multicompartmental injury with subsequent pneumonia would result in host sex-specific dysbiosis. METHODS Male and proestrus female Sprague-Dawley rats (n = 8/group) were subjected to either multicompartmental trauma (PT) (lung contusion, hemorrhagic shock, cecectomy, bifemoral pseudofracture), PT plus 2-hour daily restraint stress (PT/RS), PT with postinjury day 1 Pseudomonas aeruginosa pneumonia (PT-PNA), PT/RS with pneumonia (PT/RS-PNA), or naive controls. Fecal microbiome was measured on days 0 and 2 using high-throughput 16S rRNA sequencing and Quantitative Insights Into Microbial Ecology 2 bioinformatics analyses. Microbial α-diversity was assessed using Chao1 (number of different unique species) and Shannon (species richness and evenness) indices. β-diversity was assessed using principal coordinate analysis. Significance was defined as p < 0.05. RESULTS All groups had drastic declines in the Chao1 (α-diversity) index compared with naive controls ( p < 0.05). Groups PT-PNA and PT/RS-PNA resulted in different β-diversity arrays compared with uninfected counterparts (PT, PT/RS) ( p = 0.001). Postinjury sepsis cohorts showed a loss of commensal bacteria along with emergence of pathogenic bacteria, with blooms of Proteus in PT-PNA and Escherichia-Shigella group in PT/RS-PNA compared with other cohorts. At day 2, PT-PNA resulted in β-diversity, which was unique between males and females ( p = 0.004). Microbiome composition in PT-PNA males was dominated by Anaerostipes and Parasuterella , whereas females had increased Barnesiella and Oscillibacter . The PT/RS males had an abundance of Gastranaerophilales and Muribaculaceae . CONCLUSION Multicompartmental trauma complicated by sepsis significantly diminishes diversity and alters microbial composition toward a severely dysbiotic state early after injury, which varies between males and females. These findings highlight the role of sex in postinjury sepsis and the pathobiome, which may influence outcomes after severe trauma and sepsis.
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Affiliation(s)
- Jennifer A. Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Lauren S. Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Gwoncheol Park
- Department of Nutrition and Integrative Physiology, Florida State University, Tallahassee, Florida
| | - Stacey K. Drury
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Gwendolyn S. Gillies
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Preston S. Coldwell
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Letitia E. Bible
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Ravinder Nagpal
- Department of Nutrition and Integrative Physiology, Florida State University, Tallahassee, Florida
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
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Kelly LS, Munley JA, Pons EE, Kannan KB, Whitley EM, Bible LE, Efron PA, Mohr AM. A rat model of multicompartmental traumatic injury and hemorrhagic shock induces bone marrow dysfunction and profound anemia. Animal Model Exp Med 2024; 7:367-376. [PMID: 38860566 PMCID: PMC11228100 DOI: 10.1002/ame2.12447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 05/06/2024] [Accepted: 05/25/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Severe trauma is associated with systemic inflammation and organ dysfunction. Preclinical rodent trauma models are the mainstay of postinjury research but have been criticized for not fully replicating severe human trauma. The aim of this study was to create a rat model of multicompartmental injury which recreates profound traumatic injury. METHODS Male Sprague-Dawley rats were subjected to unilateral lung contusion and hemorrhagic shock (LCHS), multicompartmental polytrauma (PT) (unilateral lung contusion, hemorrhagic shock, cecectomy, bifemoral pseudofracture), or naïve controls. Weight, plasma toll-like receptor 4 (TLR4), hemoglobin, spleen to body weight ratio, bone marrow (BM) erythroid progenitor (CFU-GEMM, BFU-E, and CFU-E) growth, plasma granulocyte colony-stimulating factor (G-CSF) and right lung histologic injury were assessed on day 7, with significance defined as p values <0.05 (*). RESULTS Polytrauma resulted in markedly more profound inhibition of weight gain compared to LCHS (p = 0.0002) along with elevated plasma TLR4 (p < 0.0001), lower hemoglobin (p < 0.0001), and enlarged spleen to body weight ratios (p = 0.004). Both LCHS and PT demonstrated suppression of CFU-E and BFU-E growth compared to naïve (p < 0.03, p < 0.01). Plasma G-CSF was elevated in PT compared to both naïve and LCHS (p < 0.0001, p = 0.02). LCHS and PT demonstrated significant histologic right lung injury with poor alveolar wall integrity and interstitial edema. CONCLUSIONS Multicompartmental injury as described here establishes a reproducible model of multicompartmental injury with worsened anemia, splenic tissue enlargement, weight loss, and increased inflammatory activity compared to a less severe model. This may serve as a more effective model to recreate profound traumatic injury to replicate the human inflammatory response postinjury.
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Affiliation(s)
- Lauren S. Kelly
- Department of Surgery and Sepsis and Critical Illness Research CenterUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Jennifer A. Munley
- Department of Surgery and Sepsis and Critical Illness Research CenterUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Erick E. Pons
- Department of Surgery and Sepsis and Critical Illness Research CenterUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research CenterUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | | | - Letitia E. Bible
- Department of Surgery and Sepsis and Critical Illness Research CenterUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research CenterUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research CenterUniversity of Florida College of MedicineGainesvilleFloridaUSA
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Barth H, Worek F, Steinritz D, Papatheodorou P, Huber-Lang M. Trauma-toxicology: concepts, causes, complications. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:2935-2948. [PMID: 37999755 PMCID: PMC11074020 DOI: 10.1007/s00210-023-02845-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/09/2023] [Indexed: 11/25/2023]
Abstract
Trauma and toxic substances are connected in several aspects. On the one hand, toxic substances can be the reason for traumatic injuries in the context of accidental or violent and criminal circumstances. Examples for the first scenario is the release of toxic gases, chemicals, and particles during house fires, and for the second scenario, the use of chemical or biological weapons in the context of terroristic activities. Toxic substances can cause or enhance severe, life-threatening trauma, as described in this review for various chemical warfare, by inducing a tissue trauma accompanied by break down of important barriers in the body, such as the blood-air or the blood-gut barriers. This in turn initiates a "vicious circle" as the contribution of inflammatory responses to the traumatic damage enhances the macro- and micro-barrier breakdown and often results in fatal outcome. The development of sophisticated methods for detection and identification of toxic substances as well as the special treatment of the intoxicated trauma patient is summarized in this review. Moreover, some highly toxic substances, such as the protein toxins from the pathogenic bacterium Clostridioides (C.) difficile, cause severe post-traumatic complications which significantly worsens the outcome of hospitalized patients, in particular in multiply injured trauma patients. Therefore, novel pharmacological options for the treatment of such patients are necessarily needed and one promising strategy might be the neutralization of the toxins that cause the disease. This review summarizes recent findings on the molecular and cellular mechanisms of toxic chemicals and bacterial toxins that contribute to barrier breakdown in the human body as wells pharmacological options for treatment, in particular in the context of intoxicated trauma patients. "trauma-toxicology" comprises concepts regrading basic research, development of novel pharmacological/therapeutic options and clinical aspects in the complex interplay and "vicious circle" of severe tissue trauma, barrier breakdown, pathogen and toxin exposure, tissue damage, and subsequent clinical complications.
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Affiliation(s)
- Holger Barth
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Center, Ulm, Germany.
| | - Franz Worek
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
| | - Dirk Steinritz
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
| | - Panagiotis Papatheodorou
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Center, Ulm, Germany
| | - Markus Huber-Lang
- Institute of Clinical and Experimental Trauma Immunology, University of Ulm Medical Center, Ulm, Germany.
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Munley JA, Kelly LS, Park G, Gillies GS, Pons EE, Kannan KB, Bible LE, Efron PA, Nagpal R, Mohr AM. Sex-specific intestinal dysbiosis persists after multicompartmental injury. Surgery 2023; 174:1453-1462. [PMID: 37833155 DOI: 10.1016/j.surg.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/02/2023] [Accepted: 08/17/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Preclinical studies of the gut microbiome after severe traumatic injury have demonstrated severe dysbiosis in males, with sex-specific microbial differences up to 2 days after injury. However, the impact of host sex on injury-driven dysbiosis over time remains unknown. We hypothesized that sex-specific differences in intestinal microbiome diversity and composition after traumatic injury with and without stress would persist after 7 days. METHODS Male and proestrus female Sprague-Dawley rats (n = 8/group) were subjected to either polytrauma (lung contusion, hemorrhagic shock, cecectomy, bifemoral pseudofractures), polytrauma plus chronic restraint stress, or naïve controls. The fecal microbiome was measured on days 0, 3, and 7 using 16S rRNA sequencing and Quantitative Insights into Microbial Ecology bioinformatics analyses. Microbial alpha-diversity (Chao1 and Shannon indices) and beta-diversity were assessed. Analyses were performed in GraphPad and "R," with significance defined as P < .05. RESULTS Polytrauma and polytrauma plus chronic restraint stress reduced alpha-diversity (Chao1, Shannon) within 3 days postinjury, which persisted up to day 7 in both sexes; polytrauma and polytrauma plus chronic restraint stress females had significantly decreased Chao1 compared to male counterparts at day 7 (P = .02). At day 7, the microbiome composition in polytrauma females had higher proportion of Mucispirillum, whereas polytrauma plus chronic restraint stress males demonstrated elevated abundance of Ruminococcus and Akkermansia. CONCLUSION Multicompartmental trauma induces intestinal dysbiosis that is sex-specific with persistence of decreased diversity and unique "pathobiome" signatures in females after 1 week. These findings underline sex as an important biological variable that may influence variable host-specific responses and outcomes after severe trauma and critical illness. This underscores the need to consider precision medicine strategies to ameliorate these outcomes.
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Affiliation(s)
- Jennifer A Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL. https://twitter.com/jen_munley
| | - Lauren S Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL. https://twitter.com/LaurenKelly_MD
| | - Gwoncheol Park
- Department of Nutrition and Integrative Physiology, Florida State University College of Health and Human Sciences, Tallahassee, FL
| | - Gwendolyn S Gillies
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL. https://twitter.com/gee_gills
| | - Erick E Pons
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL
| | - Kolenkode B Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL
| | - Letitia E Bible
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL. https://twitter.com/LBibleMD
| | - Philip A Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL
| | - Ravinder Nagpal
- Department of Nutrition and Integrative Physiology, Florida State University College of Health and Human Sciences, Tallahassee, FL
| | - Alicia M Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL.
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Munley JA, Kirkpatrick SL, Gillies GS, Bible LE, Efron PA, Nagpal R, Mohr AM. The Intestinal Microbiome after Traumatic Injury. Microorganisms 2023; 11:1990. [PMID: 37630549 PMCID: PMC10459834 DOI: 10.3390/microorganisms11081990] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 07/29/2023] [Accepted: 07/30/2023] [Indexed: 08/27/2023] Open
Abstract
The intestinal microbiome plays a critical role in host immune function and homeostasis. Patients suffering from-as well as models representing-multiple traumatic injuries, isolated organ system trauma, and various severities of traumatic injury have been studied as an area of interest in the dysregulation of immune function and systemic inflammation which occur after trauma. These studies also demonstrate changes in gut microbiome diversity and even microbial composition, with a transition to a pathobiome state. In addition, sex has been identified as a biological variable influencing alterations in the microbiome after trauma. Therapeutics such as fecal transplantation have been utilized to ameliorate not only these microbiome changes but may also play a role in recovery postinjury. This review summarizes the alterations in the gut microbiome that occur postinjury, either in isolated injury or multiple injuries, along with proposed mechanisms for these changes and future directions for the field.
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Affiliation(s)
- Jennifer A. Munley
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (J.A.M.); (S.L.K.); (G.S.G.); (L.E.B.); (P.A.E.)
| | - Stacey L. Kirkpatrick
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (J.A.M.); (S.L.K.); (G.S.G.); (L.E.B.); (P.A.E.)
| | - Gwendolyn S. Gillies
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (J.A.M.); (S.L.K.); (G.S.G.); (L.E.B.); (P.A.E.)
| | - Letitia E. Bible
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (J.A.M.); (S.L.K.); (G.S.G.); (L.E.B.); (P.A.E.)
| | - Philip A. Efron
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (J.A.M.); (S.L.K.); (G.S.G.); (L.E.B.); (P.A.E.)
| | - Ravinder Nagpal
- Department of Nutrition & Integrative Physiology, Florida State University College of Health and Human Sciences, Tallahassee, FL 32306, USA;
| | - Alicia M. Mohr
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (J.A.M.); (S.L.K.); (G.S.G.); (L.E.B.); (P.A.E.)
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6
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Munley JA, Kelly LS, Park G, Gillies GS, Pons EE, Kannan KB, Whitley EM, Bible LE, Efron PA, Nagpal R, Mohr AM. Multicompartmental traumatic injury induces sex-specific alterations in the gut microbiome. J Trauma Acute Care Surg 2023; 95:30-38. [PMID: 36872509 PMCID: PMC10293079 DOI: 10.1097/ta.0000000000003939] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND Previous preclinical studies have demonstrated an altered gut microbiome after traumatic injury; however, the impact of sex on dysbiosis remains unknown. We hypothesized that the "pathobiome" phenotype induced by multicompartmental injuries and chronic stress is host sex specific with unique microbiome signatures. METHODS Male and proestrus female Sprague-Dawley rats (n = 8/group) aged 9 weeks to 11 weeks were subjected to either multicompartmental injury (PT) (lung contusion, hemorrhagic shock, cecectomy, bifemoral pseudofractures), PT plus 2 hours daily chronic restraint stress (PT/CS) or naive controls. Fecal microbiome was measured on Days 0 and 2 using high-throughput 16S rRNA sequencing and Quantitative Insights Into Microbial Ecology bioinformatics analyses. Microbial alpha-diversity was assessed using Chao1 (number of different unique species) and Shannon (species richness and evenness) indices. Beta-diversity was assessed using principle coordinate analysis. Intestinal permeability was evaluated by plasma occludin and lipopolysaccharide binding protein. Histologic evaluation of ileum and colon tissues was scored for injury by a blinded pathologist. Analyses were performed in GraphPad and R, with significance defined as p < 0.05 between males versus females. RESULTS At baseline, females had significantly elevated alpha-diversity (Chao1, Shannon indices) compared with males ( p < 0.05) which was no longer present 2 days postinjury in PT and PT/CS. Beta-diversity also differed significantly between males and females after PT ( p = 0.01). At Day 2, the microbial composition in PT/CS females was dominated by Bifidobacterium , whereas PT males demonstrated elevated levels of Roseburia ( p < 0.01). The PT/CS males had significantly elevated ileum injury scores compared with females ( p = 0.0002). Plasma occludin was higher in PT males compared with females ( p = 0.004); plasma lipopolysaccharide binding protein was elevated in PT/CS males ( p = 0.03). CONCLUSION Multicompartmental trauma induces significant alterations in microbiome diversity and taxa, but these signatures differ by host sex. These findings suggest that sex is an important biological variable that may influence outcomes after severe trauma and critical illness.
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Affiliation(s)
- Jennifer A. Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Lauren S. Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Gwoncheol Park
- Department of Nutrition & Integrative Physiology, Florida State University College of Health and Human Sciences, Tallahassee, Florida
| | - Gwendolyn S. Gillies
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Erick E. Pons
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | | | - Letitia E. Bible
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Ravinder Nagpal
- Department of Nutrition & Integrative Physiology, Florida State University College of Health and Human Sciences, Tallahassee, Florida
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
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Munley JA, Kelly LS, Pons EE, Kannan KB, Coldwell PS, Whitley EM, Gillies GS, Efron PA, Nagpal R, Mohr AM. Multicompartmental traumatic injury and the microbiome: Shift to a pathobiome. J Trauma Acute Care Surg 2023; 94:15-22. [PMID: 36203239 PMCID: PMC9805505 DOI: 10.1097/ta.0000000000003803] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous animal models have demonstrated altered gut microbiome after mild traumatic injury; however, the impact of injury severity and critical illness is unknown. We hypothesized that a rodent model of severe multicompartmental injuries and chronic stress would demonstrate microbiome alterations toward a "pathobiome" characterized by an overabundance of pathogenic organisms, which would persist 1 week after injury. METHODS Male Sprague-Dawley rats (n = 8 per group) were subjected to either multiple injuries (PT) (lung contusion, hemorrhagic shock, cecectomy, and bifemoral pseudofractures), PT plus daily chronic restraint stress for 2 hours (PT/CS), or naive controls. Fecal microbiome was measured on days 0, 3, and 7 using high-throughput 16S rRNA sequencing and Quantitative Insights Into Microbial Ecology 2 bioinformatics analysis. Microbial α diversity was assessed using Chao1 and Shannon indices, and β diversity with principle coordinate analysis. Intestinal permeability was evaluated by plasma occludin; ileum and descending colon tissues were reviewed for injury. Analyses were performed in GraphPad (GraphPad Software, La Jolla, CA) and R (R Foundation for Statistical Computing, Vienna, Austria), with significance defined as p < 0.05. RESULTS There were significant alterations in β diversity at day 3 and between all groups. By day 3, both PT and PT/CS demonstrated significantly depleted bacterial diversity (Chao1) ( p = 0.01 and p = 0.001, respectively) versus naive, which persisted up to day 7 in PT/CS only ( p = 0.001). Anaerostipes and Rothia dominated PT and Lactobacillus bloomed in PT/CS cohorts by day 7. Plasma occludin was significantly elevated in PT/CS compared with naive ( p = 0.04), and descending colon of both PT and PT/CS showed significantly higher injury compared with naive ( p = 0.005, p = 0.006). CONCLUSIONS Multiple injuries with and without chronic stress induces significant alterations in microbiome diversity and composition within 3 days; these changes are more prominent and persist for 1 week postinjury with stress. This rapid and persistent transition to a "pathobiome" phenotype represents a critical phenomenon that may influence outcomes after severe trauma and critical illness.
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Affiliation(s)
- Jennifer A. Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Lauren S. Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Erick E. Pons
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Preston S. Coldwell
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | | | - Gwendolyn S. Gillies
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Ravinder Nagpal
- Department of Nutrition & Integrative Physiology, Florida State University College of Health and Human Sciences, Tallahassee, Florida
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
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Ayoub C, Arroyo LG, MacNicol JL, Renaud D, Weese JS, Gomez DE. Fecal microbiota of horses with colitis and its association with laminitis and survival during hospitalization. J Vet Intern Med 2022; 36:2213-2223. [PMID: 36271677 DOI: 10.1111/jvim.16562] [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: 04/05/2022] [Accepted: 09/21/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The association of microbiota with clinical outcomes and the taxa associated with colitis in horses remains generally unknown. OBJECTIVES Describe the fecal microbiota of horses with colitis and investigate the association of the fecal microbiota with the development of laminitis and survival. ANIMALS Thirty-six healthy and 55 colitis horses subdivided into laminitis (n = 15) and non-laminitis (n = 39, 1 horse with chronic laminitis was removed from this comparison) and survivors (n = 27) and nonsurvivors (n = 28). METHODS Unmatched case-control study. The Illumina MiSeq platform targeting the V4 region of the 16S ribosomal RNA gene was used to assess the microbiota. RESULTS The community membership (Jaccard index) and structure (Yue and Clayton index) were different (analysis of molecular variance [AMOVA]; P < .001) between healthy and colitis horses. The linear discriminant analysis effect size (LEfSe; linear discriminant analysis [LDA] >3; P < .05) and random forest analyses found Enterobacteriaceae, Lactobacillus, Streptococcus, and Enterococcus enriched in colitis horses, whereas Treponema, Faecalibacterium, Ruminococcaceae, and Lachnospiraceae were enriched in healthy horses. The community membership and structure of colitis horses with or without laminitis was (AMOVA; P > .05). Enterobacteriaceae, Streptococcus, and Lactobacillus were enriched in horses with laminitis (LDA > 3; P < .05). The community membership (AMOVA; P = .008) of surviving and nonsurviving horses was different. Nonsurviving horses had an enrichment of Enterobacteriaceae, Pseudomonas, Streptococcus, and Enterococcus (LDA >3; P < .05). CONCLUSION AND CLINICAL IMPORTANCE Differences in the microbiota of horses with colitis that survive or do not survive are minor and, similarly, the microbiota differences in horses with colitis that do or do not develop laminitis are minor.
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Affiliation(s)
- Cosette Ayoub
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Luis G Arroyo
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Jennifer L MacNicol
- Department of Animal Biosciences, Ontario Agricultural College, University of Guelph, Guelph, Ontario, Canada
| | - David Renaud
- Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - J Scott Weese
- Department of Pathobiology, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Diego E Gomez
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
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Integrated Transcriptome and 16S rDNA Analyses Reveal That Transport Stress Induces Oxidative Stress and Immune and Metabolic Disorders in the Intestine of Hybrid Yellow Catfish (Tachysurus fulvidraco♀ × Pseudobagrus vachellii♂). Antioxidants (Basel) 2022; 11:antiox11091737. [PMID: 36139809 PMCID: PMC9496016 DOI: 10.3390/antiox11091737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/21/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Live fish are often transported in aquaculture. To explore the effects of transport stress, hybrid yellow catfish (Tachysurus fulvidraco♀ × Pseudobagrus vachellii♂) were subjected to simulated transport treatments (0–16 h) with 96 h of recovery after the 16-h transport treatment, and intestinal biochemical parameters, the transcriptome, and gut microbiota were analyzed. Transportation affected the number of mucus cells and led to oxidative stress in the intestine, which activated immune responses. Changes in lipid metabolism reflected metabolic adaptation to oxidative stress. Toll-like receptor signaling, peroxisome proliferator-activated receptor signaling, and steroid biosynthesis pathways were involved in the transport stress response. Gene expression analyses indicated that transport-induced local immune damage was reversible, whereas disordered metabolism recovered more slowly. A 16S rDNA analysis revealed that transport stress decreased the alpha diversity of the gut microbiota and disrupted its homeostasis. The dominant phyla (Fusobacteria, Bacteroidetes) and genera (Cetobacterium, Barnesiellaceae) were involved in the antioxidant, immune, and metabolic responses of the host to transportation stress. Correlation analyses suggested that gut microbes participate in the transport stress response and the host–microbiota interaction may trigger multiple events in antioxidant, immune, and metabolic pathways. Our results will be useful for optimizing transport processes.
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Guidry CA, Medvecz AJ, Adams RC, Dennis BM, Eastham SC, Guillamondegui OD, Gunter OL, Peetz AB, Thompson CM, Gondek SP, Nunez TC, Sawyer RG, May AK, Patel MB. Prior Antibiotic Exposure Is Associated With Reoperation After Elective Non-colorectal Surgery. Am Surg 2022; 88:2752-2759. [PMID: 35722722 DOI: 10.1177/00031348221109812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent antibiotic exposure has previously been associated with poor outcomes following elective surgery. The purpose of this study is to evaluate the impact of prior recent antibiotic exposure in a multicenter cohort of Veterans Affairs patients undergoing elective non-colorectal surgery. METHODS This is a retrospective cohort study of the Veterans Affairs Surgical Quality Improvement Program, including elective, non-cardiovascular, non-colorectal surgery from 2013 to 2017. Outpatient antibiotic exposure within 90 days prior to surgery was identified from the Veterans Affairs outpatient pharmacy database and matched with each case. Primary outcomes included serious complication, any complication, any infection, or surgical site infection. Secondary outcomes included 30-day mortality, length of stay, and Clostridioides difficile infection. RESULTS Of 21,112 eligible patients, 2885 (13.7%) were exposed to antibiotics within 90 days prior to surgery with a duration of 7 (IQR: 5-10) days and prescribed 42 (IQR: 21-64) days prior to surgical intervention. Compared to non-exposed patients, exposed patients had higher unadjusted complication rates, increased length of stay, and rates of return to the operating. Exposure was independently associated with return to the operating room (OR: 1.39; 99% CI: 1.05-1.84). CONCLUSIONS Among Veterans, recent antibiotic exposure within 90 days of elective surgery was associated with a 39% increase in the odds of return to the operating room. Further work is needed to evaluate the effects of antibiotic exposure and dysbiosis on surgical outcomes.
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Affiliation(s)
- Christopher A Guidry
- Division of Trauma, Acute Care Surgery and Critical Care; Department of Surgery, 21638The University of Kansas Medical Center, Kansas City, KS, USA
| | - Andrew J Medvecz
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Raeanna C Adams
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bradley M Dennis
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shannon C Eastham
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Oscar D Guillamondegui
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Oliver L Gunter
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Allan B Peetz
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Surgical Services, Nashville Veterans Affairs Medical Center; Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Callie M Thompson
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephen P Gondek
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy C Nunez
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Surgical Services, Nashville Veterans Affairs Medical Center; Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Robert G Sawyer
- Department of Surgery, 51374Western Michigan University Homer Stryker School of Medicine, Kalamazoo, MI, USA
| | - Addison K May
- Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Mayur B Patel
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Surgical Services, Nashville Veterans Affairs Medical Center; Tennessee Valley Healthcare System, Nashville, TN, USA
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11
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Rogers MB, Simon D, Firek B, Silfies L, Fabio A, Bell MJ, Yeh A, Azar J, Cheek R, Kochanek PM, Peddada SD, Morowitz MJ. Temporal and Spatial Changes in the Microbiome Following Pediatric Severe Traumatic Brain Injury. Pediatr Crit Care Med 2022; 23:425-434. [PMID: 35283451 PMCID: PMC9203870 DOI: 10.1097/pcc.0000000000002929] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The microbiome may be affected by trauma and critical illness. Many studies of the microbiome in critical illness are restricted to a single body site or time point and confounded by preexisting conditions. We report temporal and spatial alterations in the microbiome of previously healthy children with severe traumatic brain injury (TBI). DESIGN We collected oral, rectal, and skin swabs within 72 hours of admission and then twice weekly until ICU discharge. Samples were analyzed by 16S rRNA gene amplicon sequencing. Children undergoing elective outpatient surgery served as controls. Alpha and beta diversity comparisons were performed with Phyloseq, and differentially abundant taxa were predicted using Analysis of Composition of Microbiomes. SETTING Five quaternary-care PICUs. PATIENTS Patients less than 18 years with severe TBI requiring placement of an intracranial pressure monitor. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three hundred twenty-seven samples were analyzed from 23 children with severe TBI and 35 controls. The community composition of initial oral (F = 3.2756, R2 = 0.0535, p = 0.012) and rectal (F = 3.0702, R2 = 0.0649, p = 0.007) samples differed between TBI and control patients. Rectal samples were depleted of commensal bacteria from Ruminococcaceae, Bacteroidaceae, and Lachnospiraceae families and enriched in Staphylococcaceae after TBI (p < 0.05). In exploratory analyses, antibiotic exposure, presence of an endotracheal tube, and occurrence of an infection were associated with greater differences of the rectal and oral microbiomes between TBI patients and healthy controls, whereas enteral nutrition was associated with smaller differences (p < 0.05). CONCLUSIONS The microbiome of children with severe TBI is characterized by early depletion of commensal bacteria, loss of site specificity, and an enrichment of potential pathogens. Additional studies are needed to determine the impact of these changes on clinical outcomes.
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Affiliation(s)
- Matthew B. Rogers
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dennis Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Children’s Hospital of Pittsburgh Neuroscience Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Brian Firek
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Laurie Silfies
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Anthony Fabio
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Michael J. Bell
- Division of Critical Care Medicine, Children’s National Medical Center, Washington, DC, USA
| | - Andrew Yeh
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Justin Azar
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Richard Cheek
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Children’s Hospital of Pittsburgh Neuroscience Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shyamal D. Peddada
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Michael J. Morowitz
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Center for Microbiome and Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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12
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Abstract
Burns are a severe form of trauma that account for 1.1 million cases necessitating medical attention and 4500 mortalities annually in the United States alone. Importantly, the initial trauma is succeeded by extensive, prolonged physiological alterations that detrimentally impact multiple organ systems. Given the complexity of post-burn pathophysiology, in vitro experiments are insufficient to model thermal injuries. Therefore, compatible animal burn models are essential for studying burn-related phenomena. In this chapter, we discuss commonly employed small animal burn models and their comparability and applicability to human studies. In particular, we compare post-burn wound healing between the species as well as relevant hypermetabolic and inflammatory characteristics, providing a better understanding of the pros and cons of utilizing a small animal surrogate for human burns. We further provide an overview of the rodent scald burn model methodology as well as a comparison between elderly, aged and young animals, providing a guide for tailoring animal model choice based on the relevant research question.
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13
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Yracheta J, Muraoka W, Wu X, Burmeister D, Darlington D, Zhao D, Lai Z, Sayyadioskoie S, Cap AP, Bynum J, Nicholson SE. Whole blood resuscitation restores intestinal perfusion and influences gut microbiome diversity. J Trauma Acute Care Surg 2021; 91:1002-1009. [PMID: 34407003 DOI: 10.1097/ta.0000000000003381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Gut dysbiosis, an imbalance in the gut microbiome, occurs after trauma, which may be ameliorated with transfusion. We hypothesized that gut hypoperfusion following trauma causes dysbiosis and that whole blood (WB) resuscitation mitigates these effects. METHODS Anesthetized rats underwent sham (S; laparotomy only, n = 6); multiple injuries (T; laparotomy, liver and skeletal muscle crush injuries, and femur fracture, n = 5); multiple injuries and 40% hemorrhage (H; n = 7); and multiple injuries, hemorrhage, and WB resuscitation (R; n = 7), which was given as 20% estimated blood volume from donor rats 1 hour posttrauma. Baseline cecal mesenteric tissue oxygen (O2) concentration was measured following laparotomy and at 1 hour and 2 hours posttrauma. Fecal samples were collected preinjury and at euthanasia (2 hours). 16S rRNA sequencing was performed on purified DNA, and diversity and phylogeny were analyzed with QIIME (Knight Lab, La Jolla, CA; Caporaso Lab, Flagstaff, AZ) using the Greengenes 16S rRNA database (operational taxonomic units; 97% similarity). α and β diversities were estimated using observed species metrics. Permutational analysis of variance was performed for overall significance. RESULTS In H rats, an average decline of 36% ± 3.6% was seen in the mesenteric O2 concentration at 1 hour without improvement by 2 hours postinjury, which was reversed following resuscitation at 2 hours postinjury (4.1% ± 3.1% difference from baseline). There was no change in tissue O2 concentration in the S or T rats. β Diversity differed among groups for all measured indices except Bray-Curtis, with the spatial median of the S and R rats more similar compared with S and H rats (p < 0.05). While there was no difference in α diversity found among the groups, indices were significantly correlated with mesenteric O2 concentration. Members of the family Enterobacteriaceae were significantly enriched in only 2 hours. CONCLUSION Mesenteric perfusion after trauma and hemorrhage is restored with WB resuscitation, which influences β diversity of the gut microbiome. Whole blood resuscitation may also mitigate the effects of hemorrhage on intestinal dysbiosis, thereby influencing outcomes.
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Affiliation(s)
- Jaclyn Yracheta
- From the Department of Surgery (J.Y., S.S., S.E.N.), UT Health San Antonio, San Antonio; Coagulation and Blood Research, US Army Institute of Surgical Research (W.M., X.W., D.D., D.Z., A.P.C., J.B., S.E.N.), Fort Sam Houston, Texas; Department of Medicine, Uniformed Services University of the Health Sciences (D.B.), Bethesda, Maryland; and Department of Molecular Medicine (Z.L.), Greehey Children's Cancer Research Institute, UT Health San Antonio, San Antonio, Texas
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Bornbusch SL, Harris RL, Grebe NM, Roche K, Dimac-Stohl K, Drea CM. Antibiotics and fecal transfaunation differentially affect microbiota recovery, associations, and antibiotic resistance in lemur guts. Anim Microbiome 2021; 3:65. [PMID: 34598739 PMCID: PMC8485508 DOI: 10.1186/s42523-021-00126-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 09/19/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Antibiotics alter the diversity, structure, and dynamics of host-associated microbial consortia, including via development of antibiotic resistance; however, patterns of recovery from microbial imbalances and methods to mitigate associated negative effects remain poorly understood, particularly outside of human-clinical and model-rodent studies that focus on outcome over process. To improve conceptual understanding of host-microbe symbiosis in more naturalistic contexts, we applied an ecological framework to a non-traditional, strepsirrhine primate model via long-term, multi-faceted study of microbial community structure before, during, and following two experimental manipulations. Specifically, we administered a broad-spectrum antibiotic, either alone or with subsequent fecal transfaunation, to healthy, male ring-tailed lemurs (Lemur catta), then used 16S rRNA and shotgun metagenomic sequencing to longitudinally track the diversity, composition, associations, and resistomes of their gut microbiota both within and across baseline, treatment, and recovery phases. RESULTS Antibiotic treatment resulted in a drastic decline in microbial diversity and a dramatic alteration in community composition. Whereas microbial diversity recovered rapidly regardless of experimental group, patterns of microbial community composition reflected long-term instability following treatment with antibiotics alone, a pattern that was attenuated by fecal transfaunation. Covariation analysis revealed that certain taxa dominated bacterial associations, representing potential keystone species in lemur gut microbiota. Antibiotic resistance genes, which were universally present, including in lemurs that had never been administered antibiotics, varied across individuals and treatment groups. CONCLUSIONS Long-term, integrated study post antibiotic-induced microbial imbalance revealed differential, metric-dependent evidence of recovery, with beneficial effects of fecal transfaunation on recovering community composition, and potentially negative consequences to lemur resistomes. Beyond providing new perspectives on the dynamics that govern host-associated communities, particularly in the Anthropocene era, our holistic study in an endangered species is a first step in addressing the recent, interdisciplinary calls for greater integration of microbiome science into animal care and conservation.
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Affiliation(s)
| | - Rachel L. Harris
- Department of Evolutionary Anthropology, Duke University, Durham, USA
| | - Nicholas M. Grebe
- Department of Evolutionary Anthropology, Duke University, Durham, USA
| | - Kimberly Roche
- Program in Computational Biology & Bioinformatics, Duke University, Durham, USA
| | | | - Christine M. Drea
- Department of Evolutionary Anthropology, Duke University, Durham, USA
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15
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Abstract
INTRODUCTION While recent reports underscore the significance of the gut microbiome (GM) in health and disease, its importance in burn outcomes remains unclear. Moreover, aggressive intravenous (IV) fluid resuscitation of patients may alter intestinal flora. Herein, we describe GM changes following a large burn in swine randomized to different volumes of IV Lactated Ringers' (LR). METHODS Anesthetized Yorkshire swine sustained 40% total body surface area full-thickness burns and were randomized to different volumes of IV LR: none (n = 5), 15 mL/kg/d (low; n = 6), or 80 mL/kg/d (high; n = 6). At baseline and days 1 and 2, fecal swabs were collected for 16s rDNA sequencing. Proximal jejunum was collected immediately after euthanasia (day 2) for western blot, histopathology, and cytokine analyses. RESULTS Burns produced significant shifts in β-diversity and non-significant reductions in α-diversity that did not recover regardless of treatment group. Burn-induced increases in Proteobacteria and decreases in Firmicutes were attenuated by IV fluids in a dose-dependent manner, and also correlated with α-diversity. IV fluids caused a dose-dependent increase in Bacteroides and prevented a transient increase in the opportunistic pathogen Haemophilus parainfluenzae. While high volumes of IV fluids increased intestinal Hsp70 levels (P = 0.0464), they reduced SGLT1 (P = 0.0213) and caspase3 (P = 0.0139) levels. IV fluids elicited a non-specific cytokine response; however, Bacteroidetes levels correlated with intestinal IL18 levels (P = 0.0166, R = 0.4201). CONCLUSIONS We present the first report on the gut microbiome in a porcine burn model, and present data to suggest that IV fluids may influence GM and gut functional proteins following a burn. Overall, burn-induced GM diversity shifts may expose diagnostic and/or therapeutic targets to improve outcomes.
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16
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Kelly LS, Apple CG, Gharaibeh R, Pons EE, Thompson CW, Kannan KB, Darden DB, Efron PA, Thomas RM, Mohr AM. Stress-related changes in the gut microbiome after trauma. J Trauma Acute Care Surg 2021; 91:192-199. [PMID: 34144563 PMCID: PMC8243873 DOI: 10.1097/ta.0000000000003209] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The gut microbiome protects the host from infection by promoting epithelial integrity and providing basal immunologic stimulation. Disruption of this delicate ecosystem is linked to morbidity and mortality among critically ill patients, but the impact of traumatic injury on the gut microbiome is poorly understood. This study sought to identify alterations in gut microbiota following trauma and persistent stress in rodents without confounding antibiotics. METHODS Male Sprague-Dawley rats aged 9 weeks to 11 weeks were randomized to naive, lung contusion with hemorrhagic shock (LCHS), and LCHS plus either 7 (LCHS/CS 7/7) or 14 days (LCHS/CS 14) of restraint cylinder stress for 2 hours daily. Stool was collected on Days 0, 3, 7, and 14 for bacterial whole genome DNA isolation. Alpha diversity, or the number and relative abundance of unique bacterial species within each cohort, was assessed using Chao1 indices. Beta diversity, or the measure of differences in biodiversity across cohorts, was assessed by principle coordinate analysis. False discovery rate correction was applied to all statistical analyses and corrected for cohousing effects. RESULTS Rodent groups subject to restraint stress demonstrated a progressive increase in alpha diversity over time. These microbiota changes resolved after cessation of stress (LCHS/CS 7/7) but continued to increase among rats subjected to ongoing stress (LCHS/CS 14). The LCHS/CS 7/7 also demonstrated reductions in class Actinobacteria and increased abundance of the genus Bacteroides by Day 7, which resolved by Day 14. Increased abundance of Bacteroides was also noted in the LCHS/CS 14 cohort, suggesting the role of chronic stress in its destabilization. CONCLUSION This study points to persistent stress as a potential source of the destabilization of microbial diversity seen after trauma. This lack of microbiota stability could be associated with worse long-term outcomes in critically ill trauma patients. Further studies are warranted to elucidate mechanistic pathways and potential therapeutic modalities.
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Affiliation(s)
- Lauren S. Kelly
- University of Florida College of Medicine, Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Camille G. Apple
- University of Florida College of Medicine, Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Raad Gharaibeh
- University of Florida College of Medicine, Department of Medicine, Gainesville, Florida
| | - Erick E. Pons
- University of Florida College of Medicine, Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Chase W. Thompson
- University of Florida College of Medicine, Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Kolenkode B. Kannan
- University of Florida College of Medicine, Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Dijoia B. Darden
- University of Florida College of Medicine, Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Philip A. Efron
- University of Florida College of Medicine, Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Ryan M. Thomas
- University of Florida College of Medicine, Department of Surgery, Gainesville, Florida
- University of Florida College of Medicine, Department of Molecular Genetics and Microbiology, Gainesville, Florida
| | - Alicia M. Mohr
- University of Florida College of Medicine, Department of Surgery and Sepsis and Critical Illness Research Center, Gainesville, Florida
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17
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Appiah SA, Foxx CL, Langgartner D, Palmer A, Zambrano CA, Braumüller S, Schaefer EJ, Wachter U, Elam BL, Radermacher P, Stamper CE, Heinze JD, Salazar SN, Luthens AK, Arnold AL, Reber SO, Huber-Lang M, Lowry CA, Halbgebauer R. Evaluation of the gut microbiome in association with biological signatures of inflammation in murine polytrauma and shock. Sci Rep 2021; 11:6665. [PMID: 33758228 PMCID: PMC7988149 DOI: 10.1038/s41598-021-85897-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 03/05/2021] [Indexed: 12/03/2022] Open
Abstract
Severe injuries are frequently accompanied by hemorrhagic shock and harbor an increased risk for complications. Local or systemic inflammation after trauma/hemorrhage may lead to a leaky intestinal epithelial barrier and subsequent translocation of gut microbiota, potentially worsening outcomes. To evaluate the extent with which trauma affects the gut microbiota composition, we performed a post hoc analysis of a murine model of polytrauma and hemorrhage. Four hours after injury, organs and plasma samples were collected, and the diversity and composition of the cecal microbiome were evaluated using 16S rRNA gene sequencing. Although cecal microbial alpha diversity and microbial community composition were not found to be different between experimental groups, norepinephrine support in shock animals resulted in increased alpha diversity, as indicated by higher numbers of distinct microbial features. We observed that the concentrations of proinflammatory mediators in plasma and intestinal tissue were associated with measures of microbial alpha and beta diversity and the presence of specific microbial drivers of inflammation, suggesting that the composition of the gut microbiome at the time of trauma, or shortly after trauma exposure, may play an important role in determining physiological outcomes. In conclusion, we found associations between measures of gut microbial alpha and beta diversity and the severity of systemic and local gut inflammation. Furthermore, our data suggest that four hours following injury is too early for development of global changes in the alpha diversity or community composition of the intestinal microbiome. Future investigations with increased temporal-spatial resolution are needed in order to fully elucidate the effects of trauma and shock on the gut microbiome, biological signatures of inflammation, and proximal and distal outcomes.
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Affiliation(s)
- Sandra A Appiah
- Department of Integrative Physiology and Center for Microbial Exploration, University of Colorado Boulder, Boulder, CO, 80309, USA
| | - Christine L Foxx
- Department of Integrative Physiology and Center for Microbial Exploration, University of Colorado Boulder, Boulder, CO, 80309, USA
| | - Dominik Langgartner
- Laboratory for Molecular Psychosomatics, Department of Psychosomatic Medicine and Psychotherapy, University Ulm, 89081, Ulm, Germany
| | - Annette Palmer
- Institute of Clinical and Experimental Trauma Immunology, Centre for Biomedical Research, University Hospital Ulm, University Ulm, Helmholtzstr. 8/1, 89081, Ulm, Germany
| | - Cristian A Zambrano
- Department of Integrative Physiology and Center for Microbial Exploration, University of Colorado Boulder, Boulder, CO, 80309, USA
- Center for Neuroscience, University of Colorado Boulder, Boulder, CO, 80309, USA
| | - Sonja Braumüller
- Institute of Clinical and Experimental Trauma Immunology, Centre for Biomedical Research, University Hospital Ulm, University Ulm, Helmholtzstr. 8/1, 89081, Ulm, Germany
| | - Evan J Schaefer
- Department of Integrative Physiology and Center for Microbial Exploration, University of Colorado Boulder, Boulder, CO, 80309, USA
| | - Ulrich Wachter
- Institute for Anaesthesiological Pathophysiology and Process Development, University of Ulm, Ulm, Germany
| | - Brooke L Elam
- Department of Integrative Physiology and Center for Microbial Exploration, University of Colorado Boulder, Boulder, CO, 80309, USA
| | - Peter Radermacher
- Institute for Anaesthesiological Pathophysiology and Process Development, University of Ulm, Ulm, Germany
| | - Christopher E Stamper
- Department of Integrative Physiology and Center for Microbial Exploration, University of Colorado Boulder, Boulder, CO, 80309, USA
| | - Jared D Heinze
- Department of Integrative Physiology and Center for Microbial Exploration, University of Colorado Boulder, Boulder, CO, 80309, USA
| | - Stephanie N Salazar
- Department of Integrative Physiology and Center for Microbial Exploration, University of Colorado Boulder, Boulder, CO, 80309, USA
| | - Amalia K Luthens
- Department of Integrative Physiology and Center for Microbial Exploration, University of Colorado Boulder, Boulder, CO, 80309, USA
| | - Andrea L Arnold
- Department of Integrative Physiology and Center for Microbial Exploration, University of Colorado Boulder, Boulder, CO, 80309, USA
| | - Stefan O Reber
- Laboratory for Molecular Psychosomatics, Department of Psychosomatic Medicine and Psychotherapy, University Ulm, 89081, Ulm, Germany
| | - Markus Huber-Lang
- Institute of Clinical and Experimental Trauma Immunology, Centre for Biomedical Research, University Hospital Ulm, University Ulm, Helmholtzstr. 8/1, 89081, Ulm, Germany.
| | - Christopher A Lowry
- Department of Integrative Physiology and Center for Microbial Exploration, University of Colorado Boulder, Boulder, CO, 80309, USA
- Center for Neuroscience, University of Colorado Boulder, Boulder, CO, 80309, USA
- Department of Physical Medicine and Rehabilitation and Center for Neuroscience, University of Colorado Anschutz, Medical Campus, Aurora, CO, 80045, USA
- Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, CO, 80045, USA
- Military and Veteran Microbiome Consortium for Research and Education (MVM-CoRE), Aurora, CO, 80045, USA
| | - Rebecca Halbgebauer
- Institute of Clinical and Experimental Trauma Immunology, Centre for Biomedical Research, University Hospital Ulm, University Ulm, Helmholtzstr. 8/1, 89081, Ulm, Germany
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18
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Burn resuscitation strategy influences the gut microbiota-liver axis in swine. Sci Rep 2020; 10:15655. [PMID: 32973266 PMCID: PMC7515893 DOI: 10.1038/s41598-020-72511-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022] Open
Abstract
Fluid resuscitation improves clinical outcomes of burn patients; however, its execution in resource-poor environments may have to be amended with limited-volume strategies. Liver dysfunction is common in burn patients and gut dysbiosis is an understudied aspect of burn sequelae. Here, the swine gut microbiota and liver transcripts were investigated to determine the impact of standard-of-care modified Brooke (MB), limited-volume colloid (LV-Co), and limited-volume crystalloid (LV-Cr) resuscitation on the gut microbiota, and to evaluate its' potential relationship with liver dysfunction. Independent of resuscitation strategy, bacterial diversity was reduced 24 h post-injury, and remained perturbed at 48 h. Changes in community structure were most pronounced with LV-Co, and correlated with biomarkers of hepatocellular damage. Hierarchical clustering revealed a group of samples that was suggestive of dysbiosis, and LV-Co increased the risk of association with this group. Compared with MB, LV-Co and LV-Cr significantly altered cellular stress and ATP pathways, and gene expression of these perturbed pathways was correlated with major dysbiosis-associated bacteria. Taken together, LV-Co resuscitation exacerbated the loss of bacterial diversity and increased the risk of dysbiosis. Moreover, we present evidence of a linkage between liver (dys)function and the gut microbiota in the acute setting of burn injury.
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Lin R, Xu J, Ma Q, Chen M, Wang L, Wen S, Yang C, Ma C, Wang Y, Luo Q, Zhu N. Alterations in the fecal microbiota of patients with spinal cord injury. PLoS One 2020; 15:e0236470. [PMID: 32750057 PMCID: PMC7402510 DOI: 10.1371/journal.pone.0236470] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 07/07/2020] [Indexed: 01/03/2023] Open
Abstract
Objectives Spinal cord injury (SCI) is associated with severe autonomic dysfunction. Patients with SCI often suffer from a lack of central nervous system control over the gastrointestinal system. Therefore, we hypothesized that patients with SCI would cause intestinal flora imbalance. We investigated alterations in the fecal microbiome in a group of patients with SCI. Methods Microbial communities in the feces of 23 patients and 23 healthy controls were investigated using high-throughput Illumina Miseq sequencing targeting the V3-V4 region of the 16S ribosomal RNA (rRNA) gene. The relative abundances between the fecal microbiota at the genus level in patients with SCI and healthy individuals were determined using cluster analysis. Results The structure and quantity of fecal microbiota differed significantly between patients with SCI and healthy controls, but the richness and diversity were not significantly different. A two-dimensional heatmap showed that the relative abundances of forty-five operational taxonomic units (OTUs) were significantly enriched either in SCI or healthy samples. Among these, 18 OTUs were more abundant in healthy controls than in patients with SCI, and 27 OTUs were more abundant in the SCI group than in healthy controls. Conclusion Our study showed that patients with SCI exhibited microbiome dysbiosis.
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Affiliation(s)
- Ruizhu Lin
- Department of Rehabilitation Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
- Second Department of Rehabilitation, the Designated Rehabilitation Cooperation Hospital of General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Jianfeng Xu
- Traditional Chinese Medicine and Traumatology, Ningxia Medical University, Yinchuan, Ningxia, China
| | - Qi Ma
- Department of Rehabilitation Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Meihua Chen
- Second Department of Rehabilitation, the Designated Rehabilitation Cooperation Hospital of General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Lei Wang
- Second Department of Rehabilitation, the Designated Rehabilitation Cooperation Hospital of General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Sha Wen
- Department of Rehabilitation Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Caixia Yang
- Second Department of Rehabilitation, the Designated Rehabilitation Cooperation Hospital of General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Chuan Ma
- Second Department of Rehabilitation, the Designated Rehabilitation Cooperation Hospital of General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Yue Wang
- Traditional Chinese Medicine and Traumatology, Ningxia Medical University, Yinchuan, Ningxia, China
| | - Qiang Luo
- Second Department of Rehabilitation, the Designated Rehabilitation Cooperation Hospital of General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Ning Zhu
- Department of Rehabilitation Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
- * E-mail:
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A prospective study in severely injured patients reveals an altered gut microbiome is associated with transfusion volume. J Trauma Acute Care Surg 2020; 86:573-582. [PMID: 30633104 PMCID: PMC6433524 DOI: 10.1097/ta.0000000000002201] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Traumatic injury can lead to a compromised intestinal epithelial barrier and inflammation. While alterations in the gut microbiome of critically injured patients may influence clinical outcomes, the impact of trauma on gut microbial composition is unknown. Our objective was to determine if the gut microbiome is altered in severely injured patients and begin to characterize changes in the gut microbiome due to time and therapeutic intervention. METHODS We conducted a prospective, observational study in adult patients (n = 72) sustaining severe injury admitted to a Level I Trauma Center. Healthy volunteers (n = 13) were also examined. Fecal specimens were collected on admission to the emergency department and at 3, 7, 10, and 13 days (±2 days) following injury. Microbial DNA was isolated for 16s rRNA sequencing, and α and β diversities were estimated, according to taxonomic classification against the Greengenes database. RESULTS The gut microbiome of trauma patients was altered on admission (i.e., within 30 minutes following injury) compared to healthy volunteers. Patients with an unchanged gut microbiome on admission were transfused more RBCs than those with an altered gut microbiome (p < 0.001). Although the gut microbiome started to return to a β-diversity profile similar to that of healthy volunteers over time, it remained different from healthy controls. Alternatively, α diversity initially increased postinjury, but subsequently decreased during the hospitalization. Injured patients on admission had a decreased abundance of traditionally beneficial microbial phyla (e.g., Firmicutes) with a concomitant decrease in opportunistic phyla (e.g., Proteobacteria) compared to healthy controls (p < 0.05). Large amounts of blood products and RBCs were both associated with higher α diversity (p < 0.001) and a β diversity clustering closer to healthy controls. CONCLUSION The human gut microbiome changes early after trauma and may be aided by early massive transfusion. Ultimately, the gut microbiome of trauma patients may provide valuable diagnostic and therapeutic insight for the improvement of outcomes postinjury. LEVEL OF EVIDENCE Prognostic and Epidemiological, level III.
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Burmeister DM, Johnson TR, Lai Z, Scroggins S, DeRosa M, Jonas RB, Zhu C, Scherer E, Stewart RM, Schwacha MG, Jenkins DH, Eastridge BJ, Nicholson SE. The gut microbiome distinguishes mortality in trauma patients upon admission to the emergency department. J Trauma Acute Care Surg 2020; 88:579-587. [PMID: 32039976 PMCID: PMC7905995 DOI: 10.1097/ta.0000000000002612] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Traumatic injury can lead to a compromised intestinal epithelial barrier, decreased gut perfusion, and inflammation. While recent studies indicate that the gut microbiome (GM) is altered early following traumatic injury, the impact of GM changes on clinical outcomes remains unknown. Our objective of this follow-up study was to determine if the GM is associated with clinical outcomes in critically injured patients. METHODS We conducted a prospective, observational study in adult patients (N = 67) sustaining severe injury admitted to a level I trauma center. Fecal specimens were collected on admission to the emergency department, and microbial DNA from all samples was analyzed using the Quantitative Insights Into Microbial Ecology pipeline and compared against the Greengenes database. α-Diversity and β-diversity were estimated using the observed species metrics and analyzed with t tests and permutational analysis of variance for overall significance, with post hoc pairwise analyses. RESULTS Our patient population consisted of 63% males with a mean age of 44 years. Seventy-eight percent of the patients suffered blunt trauma with 22% undergoing penetrating injuries. The mean body mass index was 26.9 kg/m. Significant differences in admission β-diversity were noted by hospital length of stay, intensive care unit hospital length of stay, number of days on the ventilator, infections, and acute respiratory distress syndrome (p < 0.05). β-Diversity on admission differed in patients who died compared with patients who lived (mean time to death, 8 days). There were also significantly less operational taxonomic units in samples from patients who died versus those who survived. A number of species were enriched in the GM of injured patients who died, which included some traditionally probiotic species such as Akkermansia muciniphilia, Oxalobacter formigenes, and Eubacterium biforme (p < 0.05). CONCLUSION Gut microbiome diversity on admission in severely injured patients is predictive of a variety of clinically important outcomes. While our study does not address causality, the GM of trauma patients may provide valuable diagnostic and therapeutic targets for the care of injured patients. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
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Affiliation(s)
- David M. Burmeister
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas
| | | | - Zhao Lai
- Greehey Children’s Cancer Research Institute, UT Health San Antonio, San Antonio, Texas
- Department of Molecular Medicine, UT Health San Antonio, San Antonio, Texas
| | | | - Mark DeRosa
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
| | | | - Caroline Zhu
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
| | | | | | | | | | | | - Susannah E. Nicholson
- Department of Surgery, UT Health San Antonio, San Antonio, Texas
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas
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Ho KM, Kalgudi S, Corbett JM, Litton E. Gut microbiota in surgical and critically ill patients. Anaesth Intensive Care 2020; 48:179-195. [PMID: 32131606 DOI: 10.1177/0310057x20903732] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Microbiota-defined as a collection of microbial organisms colonising different parts of the human body-is now recognised as a pivotal element of human health, and explains a large part of the variance in the phenotypic expression of many diseases. A reduction in microbiota diversity, and replacement of normal microbes with non-commensal, pathogenic or more virulent microbes in the gastrointestinal tract-also known as gut dysbiosis-is now considered to play a causal role in the pathogenesis of many acute and chronic diseases. Results from animal and human studies suggest that dysbiosis is linked to cardiovascular and metabolic disease through changes to microbiota-derived metabolites, including trimethylamine-N-oxide and short-chain fatty acids. Dysbiosis can occur within hours of surgery or the onset of critical illness, even without the administration of antibiotics. These pathological changes in microbiota may contribute to important clinical outcomes, including surgical infection, bowel anastomotic leaks, acute kidney injury, respiratory failure and brain injury. As a strategy to reduce dysbiosis, the use of probiotics (live bacterial cultures that confer health benefits) or synbiotics (probiotic in combination with food that encourages the growth of gut commensal bacteria) in surgical and critically ill patients has been increasingly reported to confer important clinical benefits, including a reduction in ventilator-associated pneumonia, bacteraemia and length of hospital stay, in small randomised controlled trials. However, the best strategy to modulate dysbiosis or counteract its potential harms remains uncertain and requires investigation by a well-designed, adequately powered, randomised controlled trial.
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Affiliation(s)
- Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Australia.,School of Veterinary and Life Sciences, Murdoch University, Perth, Australia.,Medical School, University of Western Australia, Perth, Australia
| | - Shankar Kalgudi
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Australia
| | - Jade-Marie Corbett
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Australia
| | - Edward Litton
- Medical School, University of Western Australia, Perth, Australia.,Department of Intensive Care Medicine, Fiona Stanley Hospital, Murdoch, Australia
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