Immunotherapy of endotoxemia and septicemia

Invited review: A critical appraisal of mastitis vaccines for dairy cows

Infections of the mammary gland remain a frequent disease of dairy ruminants that negatively affect animal welfare, milk quality, farmer serenity, and farming profitability and cause an increase in use of antimicrobials. There is a need for efficacious vaccines to alleviate the burden of mastitis in dairy farming, but this need has not been satisfactorily fulfilled despite decades of research. A careful appraisal of past and current research on mastitis vaccines reveals the peculiarities but also the commonalities among mammary gland infections associated with the major mastitis pathogens Escherichia coli, Staphylococcus aureus, Streptococcus uberis, Streptococcus agalactiae, or Streptococcus dysgalactiae. A major pitfall is that the immune mechanisms of effective protection have not been fully identified. Until now, vaccine development has been directed toward the generation of antibodies. In this review, we drew up an inventory of the main approaches used to design vaccines that aim at the major pathogens for the mammary gland, and we critically appraised the current and tentative vaccines. In particular, we sought to relate efficacy to vaccine-induced defense mechanisms to shed light on some possible reasons for current vaccine shortcomings. Based on the lessons learned from past attempts and the recent results of current research, the design of effective vaccines may take a new turn in the years to come.

Shielding Effect of Escherichia coli O-Antigen Polysaccharide on J5-Induced Cross-Reactive Antibodies

Despite intensive research, mastitis remains an important disease in dairy cattle with a significant impact on animal welfare, use of antibiotics, and, in the end, the economy of dairy farms. Although vaccines available so far have shown limited efficacy against coliform mastitis, vaccination is considered one of the measures that could limit the consequences of mastitis.

Escherichia coli is the leading cause of severe mastitis in dairy farms. As E. coli mastitis is refractory to the hygienic control measures adapted to contagious mastitis, efficient vaccines are in demand. Existing mastitis vaccines, based on the use of killed rough E. coli J5 as the antigen, aim at inducing phagocytosis by neutrophils. We assessed the binding of J5-induced antibodies to isogenic rough and smooth strains along with a panel of mastitis-associated E. coli. Analysis by enzyme-linked immunosorbent assay revealed that antibodies to OmpA or killed J5 bind readily to rough E. coli but poorly to smooth strains. Flow cytometry analysis indicated that immunization with J5 induced antibodies that cross-reacted with rough E. coli strains but with only a small subpopulation of smooth strains. We identified type 1 fimbriae as the target of most antibodies cross-reacting with the smooth strains. These results suggest that the O-polysaccharide of lipopolysaccharide shields the outer membrane antigens and that only fiber antigens protruding at the bacterial surface can elicit antibodies reacting with mastitis-associated E. coli. We evaluated J5-induced antibodies in an opsonophagocytic killing assay with bovine neutrophils. J5 immune serum was not more efficient than preimmune serum, showing that immunization did not improve on the already high efficiency of naturally acquired antibodies to E. coli. In conclusion, it is unlikely that the efficiency of J5 vaccines is related to the induction of opsonic antibodies. Consequently, other research directions, such as cell-mediated immunity, should be explored to improve E. coli mastitis vaccines.

IMPORTANCE Despite intensive research, mastitis remains an important disease in dairy cattle with a significant impact on animal welfare, use of antibiotics, and, in the end, the economy of dairy farms. Although vaccines available so far have shown limited efficacy against coliform mastitis, vaccination is considered one of the measures that could limit the consequences of mastitis. One reason for the lack of efficiency of current vaccines likely stems from the current evaluation of vaccines that relies mostly on measuring antibody production against vaccine antigens. This report clearly shows that vaccine-induced antibodies fail to bind to most mastitis-associated E. coli strains because of the presence of an O-antigen and, thus, do not allow for improved phagocytosis of pathogens. As a consequence, this report calls for revised criteria for the evaluation of vaccines and suggests that cell-mediated immunity should be targeted by new vaccinal strategies. More generally, these results could be extended to other vaccine development strategies targeting coliform bacteria.

On the translocation of bacteria and their lipopolysaccharides between blood and peripheral locations in chronic, inflammatory diseases: the central roles of LPS and LPS-induced cell death

We have recently highlighted (and added to) the considerable evidence that blood can contain dormant bacteria. By definition, such bacteria may be resuscitated (and thus proliferate). This may occur under conditions that lead to or exacerbate chronic, inflammatory diseases that are normally considered to lack a microbial component. Bacterial cell wall components, such as the endotoxin lipopolysaccharide (LPS) of Gram-negative strains, are well known as potent inflammatory agents, but should normally be cleared. Thus, their continuing production and replenishment from dormant bacterial reservoirs provides an easy explanation for the continuing, low-grade inflammation (and inflammatory cytokine production) that is characteristic of many such diseases. Although experimental conditions and determinants have varied considerably between investigators, we summarise the evidence that in a great many circumstances LPS can play a central role in all of these processes, including in particular cell death processes that permit translocation between the gut, blood and other tissues. Such localised cell death processes might also contribute strongly to the specific diseases of interest. The bacterial requirement for free iron explains the strong co-existence in these diseases of iron dysregulation, LPS production, and inflammation. Overall this analysis provides an integrative picture, with significant predictive power, that is able to link these processes via the centrality of a dormant blood microbiome that can resuscitate and shed cell wall components.

Review: Bacterial endotoxin and the human monoclonal antibody HA-IA: specificity, potential mechanisms of action, and limits to its effectiveness

Bacterial endotoxins are lipopolysaccharides present in the outer membrane of all Gram-negative bacteria (GNB). Endotoxins consist of a lipid moiety, lipid A, that is covalently linked to highly variable, serotype O-specific polysaccharide lateral chains. In contrast, the endotoxin core, which includes lipid A, is better conserved and can be recognized by antibodies showing cross-reactivity among various GNB. Such polyclonal and monoclonal antibodies have been developed in an attempt to neutralize the biological and dele. terious effects of endotoxin, thus preventing lipid A from binding to macrophages. In fact, almost all the biological activities of endotoxin are elicited by lipid A, and there is substantial evidence to the effect that the monocyte-macrophage is the principal mediator of endotoxicity. Antiserum against LPS isolated from rough mutants of GNB (expressing virtually only the central core-lipid A), has been shown to counteract the lethal effects of endotoxin in animals and humans. However, such serum or plasma contains antibodies of different specificities and isotypes which represent different effector functions, insofar as LPS is a very complex and highly heterogenous macromolecule. Because of the difficulties encountered in investigating the nature and specificity of the protection afforded by these antisera, and their limited capacity of production for therapeutic use, specific anti-lipid A monoclonal antibodies have been produced in their stead. A variety of mouse and human monoclonal antibodies against LPS have been generated and selected for their ability to cross-react with many GNB species. The most recent clinical trials involving the treatment of septic patients with human HA-IA (Centoxin) or with murine (E5) anti-lipid A monoclonal antibody showed no difference in survival rates, as compared to treatment with a placebo. However, statistical significance was demonstrated in subsets of patients suffering from documented Gram-negative septicemia or Gram-negative sepsis without refractory shock. The usefulness of anti-lipid A antibodies will undoubtedly remain controversial, since they appear to benefit only a minority of all patients treated, and also because no consensus exists regarding their specificity and modes of action. The aim of this review is to describe results which demonstrate the requirements for, difficulties in and limits to, elucidating the ability of certain antibodies to recognize structural elements present in the lipid A domain of LPS. A clear demonstration of antibody cross-reactivity was obtained only when rough LPS bacteria were used, and was markedly enhanced when smooth bacteria had been pretreated with cell wall active antibiotics. Further, new data have recently demonstrated the specific involvement of HA-IA in the immunocytoadherence assay in the presence of human complement and human red blood cells. Such phenomena may form part of the potential role for natural or monoclonal human IgM anti-lipid A antibodies, which will be to remove IgM-lipid A immune complexes through transhepatic clearance via C3b binding to the CR1 present on circulating human erythrocytes. Insofar as immunocytoadherence is a multiparameter phenomenon, various limiting factors probably interfere with its mechanism of clearance. These factors may be absent in various subsets of septic patients under treatment, thus explaining therapeutic failures with HA-IA in humans or preclinical animal studies. Several clinical settings involving defects to CR1 expression, C3b production, LPS recognition and hepatic clearance dysfunction are described. Long term, however, it will impossible to specify the patient subsets suitable for monoclonal therapy without first defining their characteristics. HA-IA may be able to inhibit one of the earliest stages in activation of the cytokine cascade by sequestrating and eliminating biologically active lipid A. The major problem today in terms of using anti-lipid A antibodies is an efficiently early detection of specific pathway defects which detract from or nullify the HA-IA therapeutic effect.

Zwitterionic chitosan for the systemic treatment of sepsis

Severe sepsis and septic shock are life-threatening conditions, with Gram-negative organisms responsible for most sepsis mortality. Systemic administration of compounds that block the action of lipopolysaccharide (LPS), a constituent of the Gram-negative outer cell membrane, is hampered by their hydrophobicity and cationic charge, the very properties responsible for their interactions with LPS. We hypothesize that a chitosan derivative zwitterionic chitosan (ZWC), previously shown to suppress the production of pro-inflammatory cellular mediators in LPS-challenged macrophages, will have protective effects in an animal model of sepsis induced by systemic injection of LPS. In this study, we evaluate whether ZWC attenuates the fatal effect of LPS in C57BL/6 mice and investigate the mechanism by which ZWC counteracts the LPS effect using a PMJ2-PC peritoneal macrophage cell line. Unlike its parent compound with low water solubility, intraperitoneally administered ZWC is readily absorbed with no local residue or adverse tissue reaction at the injection site. Whether administered at or prior to the LPS challenge, ZWC more than doubles the animals' median survival time. ZWC appears to protect the LPS-challenged organisms by forming a complex with LPS and thus attenuating pro-inflammatory signaling pathways. These findings suggest that ZWC have utility as a systemic anti-LPS agent.

A Dormant Microbial Component in the Development of Preeclampsia

Preeclampsia (PE) is a complex, multisystem disorder that remains a leading cause of morbidity and mortality in pregnancy. Four main classes of dysregulation accompany PE and are widely considered to contribute to its severity. These are abnormal trophoblast invasion of the placenta, anti-angiogenic responses, oxidative stress, and inflammation. What is lacking, however, is an explanation of how these themselves are caused. We here develop the unifying idea, and the considerable evidence for it, that the originating cause of PE (and of the four classes of dysregulation) is, in fact, microbial infection, that most such microbes are dormant and hence resist detection by conventional (replication-dependent) microbiology, and that by occasional resuscitation and growth it is they that are responsible for all the observable sequelae, including the continuing, chronic inflammation. In particular, bacterial products such as lipopolysaccharide (LPS), also known as endotoxin, are well known as highly inflammagenic and stimulate an innate (and possibly trained) immune response that exacerbates the inflammation further. The known need of microbes for free iron can explain the iron dysregulation that accompanies PE. We describe the main routes of infection (gut, oral, and urinary tract infection) and the regularly observed presence of microbes in placental and other tissues in PE. Every known proteomic biomarker of "preeclampsia" that we assessed has, in fact, also been shown to be raised in response to infection. An infectious component to PE fulfills the Bradford Hill criteria for ascribing a disease to an environmental cause and suggests a number of treatments, some of which have, in fact, been shown to be successful. PE was classically referred to as endotoxemia or toxemia of pregnancy, and it is ironic that it seems that LPS and other microbial endotoxins really are involved. Overall, the recognition of an infectious component in the etiology of PE mirrors that for ulcers and other diseases that were previously considered to lack one.

Perinatal immunomodulation

The fetus and the neonate are particularly vulnerable to injury caused directly by immunologic mechanisms or inflicted by infectious agents that take advantage of their relatively immature and inexperienced immune system. With increasing survival of high-risk neonates in the surfactant era, prevention/treatment of sepsis and chronic lung disease (CLD) has emerged as an area of priority in neonatal research. Considering the role of inflammatory mediators in the pathogenesis of sepsis and CLD, the clinical application of immunomodulator therapy to neonatology is perhaps more important at present than ever. Advances in molecular biology and immunology have led to development of newer immune modulator therapies that are directed towards specific cells or cytokines rather than resulting in a general suppression of the immune response. Failure of promising, newer immunomodulator therapies in sepsis trials in adults has, however, clearly documented the difficulties in diagnosing/correcting the imbalance between pro- and anti-inflammatory responses. As in the case of sepsis, development of a single magic bullet for prevention/management of a multi-factorial illness like CLD may be difficult, as prevention of prematurity - the single most important high-risk factor for CLD - is an unachievable goal at present. As new frontiers are being explored, older, well-established therapies like antenatal anti-D immunoglobulin prophylaxis continue to emphasize the tremendous potential of immunomodulator therapy in neonatology/perinatology. The current immunomodulators/immunotherapeutic agents with established/potential clinical applications in the perinatal period are reviewed.

Endotoxin removal by affinity sorbents

Affinity sorbents and detoxification strategies are described to remove different amounts of endotoxin. Advantages and disadvantages of the employed ligands are discussed and it is shown that both electrostatic and hydrophobic interactions contribute to the association of ligands and endotoxins. Furthermore, the flexibility of the ligand is more important than an exact structural match between ligand and ligate. Owing to the formation of endotoxin micelles and vesicles, microfiltration membrane adsorbers are particularly effective since mass transfer restrictions are almost absent in the flow-through pores.

What are the microbial components implicated in the pathogenesis of sepsis? Report on a symposium

Despite considerable efforts in the past quarter century to improve therapy for sepsis, mortality rates remain unacceptably high. Microbe-derived constituents can induce the host to produce many mediators that can contribute to immune dysregulation, tissue damage, and death. Although endotoxin-mediated events are clearly important in gram-negative infections, gram-positive bacteria can also play a dominant role. Understanding the interplay of microbial constituents and host immune or inflammatory responses prompted a meeting at Rockefeller University in May 1998. Participants discussed the relative merits of a "2-hit" hypothesis to explain the course of lethal septic shock and a "multihit" synergistic threshold hypothesis. Recommendations include the following: (1) developing animal models that closely mimic human sepsis; (2) further investigating antibiotic effects on bacteria; (3) assessing the relationships between endotoxin, prokaryotic DNA, and peptidoglycan (i.e., independent, additive, or synergistic) in inducing host responses; and (4) developing new strategies to improve outcomes. Studies are needed to better define which and how different microbial constituents lead to sepsis and to provide critical leads for therapeutic intervention.

Clinical trials of antibody therapy

Much of the 25 years since Kohler and Milstein first described making monoclonal antibodies (mAbs) has been spent trying to develop these reagents to treat human disease. Until recently, progress has been frustratingly slow and by 1994 only one mAb, anti-CD3 (OKT3), had been licensed for clinical use. In the past five years, however, the situation has changed dramatically, with numerous mAbs now showing clinical potential, and a further seven approved for human treatment. Furthermore, all indications are that this upward trend will continue, with a quarter of all new biological products currently undergoing clinical development being antibody based.

Extracellular Ca(2+) suppresses endotoxin-inducible tissue factor activation in monocytic THP-1 cells

BACKGROUND

Monocytic tissue factor (TF), an initiator of extrinsic blood coagulation, is often activated under various inflammatory conditions including endotoxemia. This activation could be a contributing factor to the manifestation of disseminated intravascular coagulation following septic shock.

HYPOTHESIS

We herein determine if extracellular Ca(2+) ([Ca(2+)](ex)) regulates bacterial endotoxin (LPS)-inducible monocytic TF activation.

METHODS

We have employed a model monocytic cell line (THP-1) to explore the mode of action of [Ca(2+)](ex) on the modulation of LPS-induced TF activation. TF activity was measured by a single stage clotting assay, while TF expression as well as LPS recognition and its receptor expression were studied in immunofluorescent approaches.

RESULTS

LPS-induced TF activation was inversely correlated to [Ca(2+)](ex). Upon exposure of THP-1 cells to LPS (1.5 microg ml(-1)) for 6 h in the Hanks' medium without CaCl(2), TF was activated by nearly 10-fold. TF activation appreciably decreased with the increasing [Ca(2+)](ex). No more than 3.5-fold TF activation was detected at 5 mM [Ca(2+)](ex). Consistent with the significantly lower degree of TF activation, LPS-induced TF expression at 5 mM [Ca(2+)](ex) was 60 per cent less than that without [Ca(2+)](ex). FACScan analysis showed that LPS recognition was significantly blocked at 5 mM [Ca(2+)](ex) which however had no effect on the expression of CD14 and CD11b, the proposed major LPS receptors. Moreover, LPS binding in vitro was significantly inhibited by 5 mM CaCl(2).

CONCLUSION

Our results demonstrate that [Ca(2+)](ex) blocked LPS recognition without affecting its receptor expression on THP-1 monocytes. This insensitivity to LPS thereby resulted in the depressed inducible monocytic TF expression and activation.

Blockade by polyunsaturated n-3 fatty acids of endotoxin-induced monocytic tissue factor activation is mediated by the depressed receptor expression in THP-1 cells

BACKGROUND

Monocytic hypercoagulation often occurs in inflammatory conditions. We have previously reported that polyunsaturated n-3 fatty acids (n-3 FA) including eicosapentaenoic acid (20:5) and docosahexaenoic acid (22:6) prevent the activation of monocytic tissue factor (TF) induced by bacterial endotoxin [lipopolysaccharide (LPS)] in cell cultures and animals.

HYPOTHESIS

We herein explore the mode of inhibitory action of n-3 FA to determine if LPS transmembrane signaling is blocked, exerting such antagonism.

RESULTS

Exposure of human leukemia monocytic THP-1 cells to bacterial endotoxin (Escherichia coli 0111:B04, 1.5 microg/ml) for 6 h significantly activated TF activity and the production of nitric oxide (NO), tumor necrosis factor alpha (TNF-alpha), and interleukin (IL)-1beta in conditioned medium. Pretreatment with n-3 FA, 20:5 and 22:6 at 10 microM, resulted in time-dependent suppression of not only TF activation but also the elicitation of NO, TNF-alpha, and IL-1beta. These LPS responses were substantially depressed by more than 50% after a 72-h pretreatment. FACScan analysis showed that n-3 FA readily prevented fluorescein isothiocyanate (FITC)-conjugated LPS from binding to THP-1 cells by approximately 70%. The observation that anti-CD14 mAb diminished FITC-LPS binding in a dose-dependent fashion has revealed CD14 dependency in LPS recognition. LPS upregulated CD14 expression, which was significantly arrested by n-3 FA. Similarly, the upregulation of the expression of CD11b, another proposed LPS receptor, was also minimally but significantly depressed by n-3 FA.

CONCLUSION

The present study demonstrates that n-3 FA are able to block LPS transmembrane signaling via suppression of the receptor upregulation, mediating a variety of significant antagonisms against LPS action.

Protective capacity of a IgM/IgA-enriched polyclonal immunoglobulin-G preparation in endotoxemia

Animal experiments were carried out to investigate whether a protective effect can be achieved in endotoxemia by intravenous (i.v.) application of a polyclonal immunoglobulin preparation (IVIG-IgG/A/M) enriched with 12% IgM and 12% IgA. Following administration of IVIG-IgG/A/M (500 mg/kg), endotoxemia was induced by intraperitoneal inoculation of a sublethal dose (5x10(8) CFU/kg) of Escherichia coli (E. coli) and subsequent i.v. administration of an antimicrobial agent (Imipenem). Plasma endotoxin activity, IL-6 activity, mean arterial pressure, and skeletal muscle oxygen pressure (tpO2) were measured at regular intervals over a total observation period of 7 h. Prophylactic administration of IVIG-IgG/A/M was found to significantly attenuate (P<0.01) the antibiotic-induced increase in endotoxin activity as compared to the albumin control group. Limited endotoxemia in the IgG/A/M group was associated with reduced levels of circulating IL-6 (P<0.01). Both lipopolysaccharide-induced hypotension and depression of tissue oxygenation were attenuated (P<0.01) by pre-treatment with IVIG-IgG/A/M. The experimental results suggest that in endotoxemia the polyclonal immunoglobulin preparation has a prophylactic protective effect on the acute phase responses and reduces the cardiodepressant effects of E. coli septicaemia.

Isolation and structural analysis of phosphorylated oligosaccharides obtained from Escherichia coli J-5 lipopolysaccharide

The chemical structure of the phosphorylated lipopolysaccharide (LPS) of Escherichia coli J-5 was investigated because it is of biomedical interest in the context of septic shock, a syndrome often encountered in nosocomial infections with gram-negative pathogens. The successive de-O-acylation and de-N-acylation of J-5 LPS yielded phosphorylated oligosaccharides which represent the complete carbohydrate backbone. Five compounds were separated by high-performance anion-exchange chromatography and analysed by one-dimensional and two-dimensional homonuclear and heteronuclear 1H-NMR, 13C-NMR and 31P-NMR spectroscopy. The main product was a nonasaccharide of the structure alpha-D-Glcp-(1-->3)-[alpha-D-GlcpN- (1-->7)-alpha-L,D-Hepp-(1-->7)]-alpha-L,D-Hepp-(1-->3)-alpha -L, D-Hepp-4P-(1-->5)-[alpha-Kdop-(2-->4)]-alpha-Kdop-(2-- >6)-beta-D-GlcpN-4p- (1-->6)-alpha-D-GlcN-1P wherein all sugars are present as D-pyranoses. Hep and Kdo represent L-glycero-D-manno-heptose and 3-deoxy-D-manno-oct-2-ulosonic acid, respectively. In addition, two octasaccharides and two heptasaccharides were isolated that were partial structures of the nonasaccharide. In one octasaccharide the terminal alpha-D-GlcpN was missing and an additional phosphate group linked to O4 of the branched heptose was present, whereas in the other octasaccharide the side-chain Kdo was missing. In both heptasaccharides the side-chain alpha-D-GlcpN-(1-->7)-L-alpha-D-Hepp-disaccharide was absent; they differed in their phosphate substitution. Whereas both heptasaccharides contained two phosphates in the lipid-A backbone (beta-1,6-linked GlcpN-disaccharide at the reducing end) and one phosphate group at O4 of the first heptose, only one of them was additionally substituted with phosphate at O4 of the second heptose.

A rapid assay of endotoxin in whole blood using autologous neutrophil dependent chemiluminescence

A rapid (30 min) whole blood assay for the detection of lipopolysaccharide (LPS) is described. This chemiluminescent (CL) assay utilizes the CR1 and CR3 receptor-induced oxidant production of polymorphonuclear leucocytes as a detection platform. The differential priming of neutrophils in whole blood by LPS-antibody complexes allows the specificity of the assay to be achieved. Oxidant released in response to complement opsonized zymosan results in luminol oxidation and subsequent light emission. This is dependent on heat labile putative complement proteins in the plasma. The assay consists of a control which measures baseline whole blood neutrophil oxidant production. The test assay contains murine monoclonal IgM antibody against the Lipid A epitope of LPS and measures the enhanced chemiluminescent response of the neutrophils in the presence of LPS-antibody complexes. Maximal sensitivity of the CL assay is dependent upon optimal antigen-antibody equivalence and duration of pre-incubation with the whole blood sample. The quantification of LPS is possible by inclusion of a positive control containing a maximally reactive LPS dose (800 pg/ml Escherichia coli 055:B5 LPS at an antibody concentration of 0.8 microg/assay). The CL assay is insensitive to variations in patient neutrophil concentration over a minimum range of 0.5 to 20 x 10(9) cells/l. The CL assay is widely reactive with the LPS of many strains of gram negative bacteria but not with the cell wall products of gram positive bacteria or Candida and Aspergillus. In comparison to acid extraction chromogenic LAL, the CL assay demonstrates superior recovery precision and accuracy in in vitro studies. This was reproducible over a wide range of LPS concentrations (0.017-1.6 EU/ml or 20-2000 pg/ml). This assay may be a clinically useful tool for the diagnosis of infection or endotoxin in patients.

Anti-lipid A monoclonal antibody centoxin (HA-1A) binds to a wide variety of hydrophobic ligands

This note describes the binding specificities of four lipid A monoclonal antibodies (MAbs) including Centoxin (HA-1A); these MAbs display similar binding properties. MAbs reacted with lipid A and heat-killed smooth bacteria, whereas no reactivity was observed with smooth lipopolysaccharide (LPS). Immunoblotting of bacterial extracts separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis showed that the MAbs bound to many polypeptide bands including the molecular weight markers. Denaturation of bovine serum albumin (BSA) by boiling or dithiothreitol treatment unmasked antibody epitopes. In addition, binding both to a hydrophobic aliphatic C12 chain covalently coupled to BSA and to single-stranded DNA was observed. The polyreactivity of these clones is most likely mediated by a preferential reactivity with hydrophobic molecular patches.

Antagonism by ethanol of endotoxin-induced tissue factor activation in relation to the depressed endotoxin binding to monocyte-like U937 cells

Our previous study has reported that ethanol (ETOH) partially inhibited the endotoxin (LPS)-induced tissue factor (TF)-activation in monocytes including blood peripheral monocytes as well as cultured leukemic U937 and THP-1 cells. The present study shows a strong correlation (r = 0.92; p < 0.01) between TF-activation and depression in LPS binding blocked by ETOH in U937 cells. The antagonism by ETOH of LPS binding was not due to a direct extracellular blockade, since ETOH did not affect the affinity of fluorescein isothiocyanate (FITC)-LPS or -anti CD14 mAb on U937 cells. After U937 cells were treated with 2 per cent (v/v) ETOH for 3 h, LPS binding was however drastically inhibited as shown by immunostaining with FITC-LPS which was viewed on a confocal laser scanning microscope. The results imply that cellular events of the ETOH effect mediate this inhibition of LPS binding. Anti-CD14 mAb (UCHM-1) inhibited LPS binding in a dose-dependent fashion, revealing a competitive specific binding to the LPS receptor. The results suggest that CD14 plays an important role in the recognition of LPS. FITC-UCHM-1 binding was significantly reduced in the cells pretreated with 2 per cent (v/v) ETOH for 3 h, indicating that ETOH modulates the ability to express CD14. CD14 expression was upregulated by priming with LPS which was offset by ETOH. Acetaldehyde, a possible metabolite of ETOH, was tested with no effect on CD14 expression. Taken together, our results show that ETOH downregulates the recognition of LPS, and suggest that the inhibitory action is likely to be mediated by the depression in CD14 expression which was also accompanied by a significantly altered membrane fluidity. Thus, the antagonism by ETOH of the binding of LPS results in a depression in the LPS-induced TF-activation.

Manipulation of local and systemic host defence in the prevention of perioperative sepsis

This review addresses some of the immunological issues surrounding the complex problem of perioperative sepsis. It identifies an immunological paradox between the relative immunosuppression of the immediate postoperative period and the relative immune activation of established sepsis, in addition to discussing current knowledge of the mechanisms surrounding these phenomena. Much remains unknown about perioperative immunoregulation; there are a number of potential mechanisms, however, whereby local and systemic immune defences can be modified or enhanced. Provided patients at risk can be identified, such manipulations may find application in preventing infection and sepsis after surgery.

A novel synthetic lipid A analog with low endotoxicity, DT-5461, prevents lethal endotoxemia

Bacterial endotoxin (lipopolysaccharide [LPS]) causes severe damage to the host organism as a result of excessive release of inflammatory cytokines, including interleukin-1 (IL-1) and tumor necrosis factor alpha (TNF-alpha), from mononuclear phagocytes during gram-negative bacterial infection. We evaluated the ability of a novel synthetic lipid A analog with low endotoxicity, DT-5461, to antagonize LPS-induced IL-1 and TNF-alpha production in cells of monocyte/macrophage lineage and examined the protective effect of DT-5461 against lethal endotoxic shock in mice. The IL-1- or TNF-alpha-inducing activity of DT-5461 is 100,000 to 10,000 times less active than that of Escherichia coli LPS (EcLPS) or synthetic lipid A. DT-5461 significantly inhibited EcLPS-induced IL-1 and TNF-alpha release when murine peritoneal macrophages were incubated with DT-5461 2 h prior to EcLPS stimulation at the same concentration (1 microgram/ml). The antagonistic effect of DT-5461 on the production of IL-1 and TNF-alpha induced by EcLPS occurred in a concentration-dependent manner. DT-5461 also inhibited IL-1 and TNF-alpha induction when murine peritoneal macrophages were stimulated by LPS from Salmonella typhimurium or synthetic lipid A, as well as by EcLPS, but not by muramyl dipeptides. This indicated that DT-5461 specifically antagonized the action of LPS. DT-5461 also antagonized EcLPS-mediated activation of human peripheral blood monocytes. DT-5461 blocked the binding of fluorescein isothiocyanate-labelled LPS to murine peritoneal macrophages as well as it did the binding of EcLPS and synthetic lipid A, i.e., in a concentration-dependent fashion. Injection of DT-5461 2 h before EcLPS challenge prevented the production of serum IL-1 and TNF-alpha in D-galactosamine-treated mice. Furthermore, this treatment modality protected mice against LPS-induced lethal toxicity. This study suggests that DT-5461 possesses a potent LPS antagonistic effect and may be useful in a protective strategy against lethal endotoxemia caused by gram-negative bacterial infection.

Prophylactic use of human endotoxin-core hyperimmune gammaglobulin to prevent endotoxaemia in colostrum-deprived, gnotobiotic lambs challenged orally with Escherichia coli

The efficacy of human IgG polyclonal antibody to endotoxin-core in preventing endotoxaemia and subsequent disease was studied in colostrum-deprived gnotobiotic lambs challenged orally at about 5 h old with 10(9) cfu Escherichia coli. Human endotoxin-core hyperimmune gammaglobulin was given intravenously to 5 lambs at 1.9 g IgG/kg bodyweight prior to challenge. Human albumin was given intravenously to 3 control lambs. Bacteraemia was observed in all lambs, but the incidence was lower (P < 0.01) and the onset later (P < 0.05) in gammaglobulin pre-treated lambs. These lambs showed no signs of disease, whereas clinical endotoxaemia, manifesting as watery mouth disease, was diagnosed in 2 of the 3 control lambs which were killed between 18 and 22 h after challenge. Thus, prophylactic treatment of colostrum-deprived lambs with human IgG enriched in endotoxin-core antibodies was effective in reducing the degree of bacteraemia and preventing endotoxaemia, leukopenia and clinical disease following oral challenge with E. coli.

Management of septic shock

Septic shock due to bacterial and other infections remains an increasing cause of hospital mortality and morbidity. Early recognition and prompt management with diagnostic evaluation, antimicrobial therapy, surgery when indicated and advanced life support undoubtedly saves many lives. Once treatment has been instituted, careful and frequent monitoring is required to optimise therapy and detect complications at an early stage. However, once shock and organ failure have become established the mortality remains high and has changed little in the last few years despite improvements in intensive management. A variety of other approaches to treatment are under investigation but as yet there are insufficient data to recommend their use.

Extracorporeal techniques of endotoxin removal: a review of the art and science

The incidence of sepsis in the United States has risen in the past few years, and mortality from sepsis has risen over the past several decades. These increases have occurred despite the progress made in antibiotic therapy. The high mortality rate may not be related to the bacteria themselves but rather to the host's response. Of particular concern is the bacterial release of endotoxins, the development of endotoxic shock, and the resulting multiorgan failure, which has a high fatality rate and is the leading cause of death in patients admitted to intensive care units. Removing or neutralizing endotoxins are the two major therapeutic approaches to treating sepsis. To date, pharmacological methods have not been successful. Extracorporeal techniques are based on filtration, sorption, or both. Results with hemofiltration have not been definitive, in part because endotoxin levels have not been measured. Sorption devices, based on polymyxin B and anion exchange matrices, do remove endotoxins. Clinical studies in Japan on septic shock or multiorgan failure with polymyxin-B-bound fibers in direct hemoperfusion continue to suggest the utility of extracorporeal techniques for endotoxin removal. Continued effort is required and warranted to assess the clinical efficacy of these techniques.

Chemical structure of the core region of Escherichia coli J-5 lipopolysaccharide

The lipopolysaccharide of Escherichia coli J-5 was sequentially de-O-acylated, dephosphorylated, reduced, de-N-acylated, and N-acetylated. The products were separated by high-performance anion-exchange chromatography into a nonasaccharide (1), two octasaccharides (2, 3), and a heptasaccharide (4). Compositional analysis, methylation analysis, and NMR spectroscopy revealed the structures of the products as: alpha-D-GlcpNAc-(1-7)-L-alpha-D-Hepp-(1-7)-[alpha-D-Glcp-(1-3)-]-L -alpha-D- Hepp-(1-3)-R1, (1) L-alpha-D-Hepp-(1-7)-[alpha-D-Glcp-(1-3)-]-L-alpha-D-Hepp-(1 -3)-R1, (2) alpha-D-GlcpNAc-(1-7)-L-alpha-D-Hepp-(1-7)-[alpha-D-Glcp-(1-3)-]-L -alpha-D- Hepp-(1-3)-R2, (3) alpha-D-Glcp-(1-3)-L-alpha-D-Hepp-(1-3)-R1, (4) in which 1R is L-alpha-D-Hepp-(1-5)-[alpha-Kdop-(2-4)-]-alpha-Kdop-(2 -6)- beta-D-GlcpNAc-(1-6)-D-GlcN-Acol, and 2R is L-alpha-D-Hepp-(1-5)-alpha-Kdop-(2-6)-beta-D-GlcpNAc-(1-6 )-D- GlcNAcol (LD-Hep, L-glycero-D-manno-heptose; Kdo, 3-deoxy-D-manno-octulopyranosonic acid; GlcNAcol, 2-acetamido-2-deoxy-glucitol). Fast-atom-bombardment mass spectrometry of de-O-acylated and dephosphorylated lipopolysaccharide showed that the isolated oligosaccharides represented the complete carbohydrate moiety of the lipopolysaccharide, and indicated that the non-reducing terminal D-GlcN residue in lipopolysaccharide was present as the free base.