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Mahdizade Ari M, Amini ME, Sholeh M, Zahedi Bialvaei A. The effect of polyclonal and monoclonal based antibodies as promising potential therapy for treatment of sepsis: A systematic review. New Microbes New Infect 2024; 60-61:101435. [PMID: 38860003 PMCID: PMC11163170 DOI: 10.1016/j.nmni.2024.101435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/23/2024] [Accepted: 05/14/2024] [Indexed: 06/12/2024] Open
Abstract
While mortality caused by sepsis remains an unsolved problem, studies showed conflicting results about effectiveness of monoclonal and polyclonal antibodies in patients suffering sepsis. For this reason, this current study provides an update of review clinical randomized trial studies until March 2024. The main object of this study is to determine effects of monoclonal and polyclonal antibodies on mortality rate and hospitalization of patients suffering sepsis. Search of Scopus, Web of science, EMBASE, PubMed and Cochrane were performed and randomized controlled trials which conducted in patients with septic shock or bacterial sepsis were included. Two reviewers assessed all searched trials for eligibility according to already defined criteria and did data collection and analyses afterwards. Present study showed monoclonal and polyclonal antibodies are a safe strategy with mild-to-moderate adverse effects. However, most studies indicate no significant change among inter-and intra-group comparison (p > 0.05) and further studies are needed, results showed an increase in survival rate, ventilator-and ICU-free days, resolve organ dysfunction, mediating inflammation related cytokines.
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Affiliation(s)
- Marzie Mahdizade Ari
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Esmaeil Amini
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Sholeh
- Department of Bacteriology, Pasteur Institute of Iran, Tehran, Iran
| | - Abed Zahedi Bialvaei
- Microbial Biotechnology Research Center, Iran University of Medical Sciences, Tehran, Iran
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2
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Cross AS. Hit 'em Where It Hurts: Gram-Negative Bacterial Lipopolysaccharide as a Vaccine Target. Microbiol Mol Biol Rev 2023; 87:e0004522. [PMID: 37432116 PMCID: PMC10521362 DOI: 10.1128/mmbr.00045-22] [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: 07/12/2023] Open
Abstract
Infections with antimicrobial-resistant (AMR) bacteria pose an increasing threat to the ability to perform surgical procedures, organ transplantation, and treat cancer among many other medical conditions. There are few new antimicrobials in the development pipeline. Vaccines against AMR Gram-negative bacteria may reduce the use of antimicrobials and prevent bacterial transmission. This review traces the origins of lipopolysaccharide (LPS)-based vaccines against Gram-negative bacteria, the role of O polysaccharides and LPS core regions as potential vaccine targets, the development of new vaccine technologies, and their application to vaccines in current development.
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Affiliation(s)
- Alan S. Cross
- Center for Vaccine Development and Global Health, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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3
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Mabrook M, Abd El-Aziz AM, Youssif M A, Hassan R. Inhibition of CL-11 reduces pulmonary inflammation in a mouse model of Klebsiella pneumoniae lung infection. Microb Pathog 2022; 164:105408. [PMID: 35063609 DOI: 10.1016/j.micpath.2022.105408] [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: 12/08/2021] [Revised: 01/08/2022] [Accepted: 01/13/2022] [Indexed: 11/24/2022]
Abstract
Infection caused by K. pneumoniae is associated with severe inflammation due to stimulation of the innate immune components including the complement system, which is the main player of the innate immune response. Excessive complement-mediated inflammation may cause severe lung injury. Here we clearly show that K. pneumoniae binds to different lectin pathway carbohydrate recognition molecules and activates the complement cascade via the LP. Administration of anti-CL-11 antibodies 6 h before the infection impairs LP functional activity but it shows no effect on the survival time of mice infected with K. pneumoniae. Similarly, no significant difference in bacterial load in blood and lung tissues was observed between mice that received anti-CL-11 and control group treated with an isotype antibody. Interestingly, treatment of mice with anti-CL-11 prior to infection significantly improved histopathological changes and lung injury score induced by K. pneumoniae. Moreover, administration of anti-CL-11 reduced leukocytes infiltration into lung tissues and decreased the levels of the inflammatory mediators TNF-α, IL-6, and IL-1β in the infected mice. These findings indicate that inhibition of the LP could secure a significant level of protection against lung injury during the infection caused by K. pneumoniae.
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Affiliation(s)
- Maha Mabrook
- Department of Microbiology and Immunology, Faculty of Pharmacy, Mansoura University, Mansoura, 35516, Egypt
| | - Abeer M Abd El-Aziz
- Department of Microbiology and Immunology, Faculty of Pharmacy, Mansoura University, Mansoura, 35516, Egypt
| | - Ali Youssif M
- Department of Microbiology and Immunology, Faculty of Pharmacy, Mansoura University, Mansoura, 35516, Egypt; Department of Veterinary Medicine, School of Biological Sciences, University of Cambridge, Cambridge, United Kingdom.
| | - Ramadan Hassan
- Department of Microbiology and Immunology, Faculty of Pharmacy, Mansoura University, Mansoura, 35516, Egypt
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4
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Abstract
The outer membrane (OM) of Gram-negative bacteria poses a barrier to antibiotic entry due to its high impermeability. Thus, there is an urgent need to study the function and biogenesis of the OM. In Enterobacterales, an order of bacteria with many pathogenic members, one of the components of the OM is enterobacterial common antigen (ECA). We have known of the presence of ECA on the cell surface of Enterobacterales for many years, but its properties have only more recently begun to be unraveled. ECA is a carbohydrate antigen built of repeating units of three amino sugars, the structure of which is conserved throughout Enterobacterales. There are three forms of ECA, two of which (ECAPG and ECALPS) are located on the cell surface, while one (ECACYC) is located in the periplasm. Awareness of the importance of ECA has increased due to studies of its function that show it plays a vital role in bacterial physiology and interaction with the environment. Here, we review the discovery of ECA, the pathways for the biosynthesis of ECA, and the interactions of its various forms. In addition, we consider the role of ECA in the host immune response, as well as its potential roles in host-pathogen interaction. Furthermore, we explore recent work that offers insights into the cellular function of ECA. This review provides a glimpse of the biological significance of this enigmatic molecule.
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Affiliation(s)
- Ashutosh K Rai
- Department of Biology, Texas A&M University, College Station, Texas, USA
| | - Angela M Mitchell
- Department of Biology, Texas A&M University, College Station, Texas, USA
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5
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Which Multicenter Randomized Controlled Trials in Critical Care Medicine Have Shown Reduced Mortality? A Systematic Review. Crit Care Med 2019; 47:1680-1691. [DOI: 10.1097/ccm.0000000000004000] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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6
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Abstract
The increasing insight into pathomechanisms of dysregulated host response in several inflammatory diseases led to the implementation of the term “cytokine storm” in the literature more than 20 years ago. Direct toxic effects as well as indirect immunomodulatory mechanisms during cytokine storm have been described and were the basis for the rationale to use several substances and devices in life-threatening infections and hyperinflammatory states. Clinical trials have been performed, most of them in the form of minor, investigator-initiated protocols; major clinical trials focused mostly on sepsis and septic shock. The following review tries to summarize the background, pathophysiology, and results of clinical investigations that had implications for the development of therapeutic strategies and international guidelines for the management of hyperinflammation during syndromes of cytokine storm in adult patients, predominantly in septic shock.
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Affiliation(s)
- Herwig Gerlach
- Department of Anesthesia, Critical Care Medicine, and Pain Management, Vivantes - Klinikum Neukoelln, Klinik fuer Anaesthesie, operative Intensivmedizin und Schmerztherapie, Berlin, Germany
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7
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Tauber SC, Eiffert H, Brück W, Nau R. Septic encephalopathy and septic encephalitis. Expert Rev Anti Infect Ther 2016; 15:121-132. [DOI: 10.1080/14787210.2017.1265448] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Simone C. Tauber
- Department of Neurology, RWTH University Hospital, Aachen, Germany
| | - Helmut Eiffert
- Department of Medical Microbiology, Georg-August-University, Göttingen, Germany
| | - Wolfgang Brück
- Department of Neuropathology, Georg-August-University, Göttingen, Germany
| | - Roland Nau
- Department of Neuropathology, Georg-August-University, Göttingen, Germany
- Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
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8
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Bridge DR, Whitmire JM, Makobongo MO, Merrell DS. Heterologous Pseudomonas aeruginosa O-antigen delivery using a Salmonella enterica serovar Typhimurium wecA mutant strain. Int J Med Microbiol 2016; 306:529-540. [PMID: 27476047 DOI: 10.1016/j.ijmm.2016.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/22/2016] [Accepted: 06/27/2016] [Indexed: 01/30/2023] Open
Abstract
There is a broad interest in adapting live vaccine strains (LVS) for use as recombinant vaccines that can deliver heterologous antigens. The Salmonella enterica serovar Typhimurium SL1344 ΔwecA LVS contains a mutation in wecA that abrogates production of Enterobacterial common antigen. This ΔwecA strain is attenuated in vivo, persistently colonizes the host, and protects against both wild type and cross-Salmonella serovar lethal challenge in a murine model of salmonellosis. Given these characteristics, we hypothesized that the SL1344 ΔwecA strain could be used as a carrier for heterologous antigen expression. To test this hypothesis, SL1344 ΔwecA was engineered to express the Pseudomonas aeruginosa O11 O-antigen gene cluster. Intraperitoneal (IP) but not oral immunization of BALB/c mice with the heterologous expression strain protected against lethal P. aeruginosa intranasal (IN) challenge. Furthermore, IP immunization resulted in P. aeruginosa O11-specific Ig and IgG antibody production. Functional analysis of sera collected from the IP immunized mice showed antibody-mediated agglutination and opsonophagocytic activity against P. aeruginosa. En masse, these results indicate that the S. Typhimurium SL1344 ΔwecA strain expressing the P. aeruginosa O11 O-antigen gene cluster is able to induce a humoral immune response and to protect against lethal P. aeruginosa challenge. As such, the S. Typhimurium SL1344 ΔwecA LVS can likely serve as a vehicle for expression of a wide variety of heterologous antigens as a means to create recombinant vaccines.
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Affiliation(s)
- Dacie R Bridge
- Department of Microbiology and Immunology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
| | - Jeannette M Whitmire
- Department of Microbiology and Immunology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
| | - Morris O Makobongo
- Department of Microbiology and Immunology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
| | - D Scott Merrell
- Department of Microbiology and Immunology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
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Bridge DR, Whitmire JM, Gilbreath JJ, Metcalf ES, Merrell DS. An enterobacterial common antigen mutant of Salmonella enterica serovar Typhimurium as a vaccine candidate. Int J Med Microbiol 2015; 305:511-22. [PMID: 26070977 DOI: 10.1016/j.ijmm.2015.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 05/15/2015] [Accepted: 05/26/2015] [Indexed: 11/19/2022] Open
Abstract
Due to increasing rates of invasive Salmonella enterica serovar Typhimurium infection, there is a need for an effective vaccine to prevent this disease. Previous studies showed that a mutation in the first gene of the Enterobacterial common antigen biosynthetic pathway, wecA, resulted in attenuation of S. Typhimurium in a murine model of salmonellosis. Furthermore, immunization with a wecA(-) strain protected against lethal challenge with the parental wild type S. Typhimurium strain. Herein, we examined whether the S. Typhimurium wecA(-) strain could also provide cross-protection against non-parental strains of S. Typhimurium and S. Enteritidis. We found that intraperitoneal immunization (IP) with S. Typhimurium SL1344 wecA(-) resulted in a significant increase in survival compared to control mice for all Salmonella challenge strains tested. Oral immunization with SL1344 wecA(-) also resulted in increased survival; however, protection was less significant than with intraperitoneal immunization. The increase in survival of SL1344 wecA(-) immunized mice was associated with a Salmonella-specific IgG antibody response. Furthermore, analysis of sera from IP and orally immunized animals revealed cross-reactive antibodies to numerous Salmonella isolates. Functional analysis of antibodies found within the sera from IP immunized animals revealed agglutination and opsonophagocytic activity against all tested O:4 Salmonella serovars. Together these results indicate that immunization with a S. Typhimurium wecA(-) strain confers protection against lethal challenge with wild type S. Typhimurium and S. Enteritidis and that immunization correlates with functional antibody production.
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Affiliation(s)
- Dacie R Bridge
- Department of Microbiology and Immunology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Jeannette M Whitmire
- Department of Microbiology and Immunology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Jeremy J Gilbreath
- Department of Microbiology and Immunology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Eleanor S Metcalf
- Department of Microbiology and Immunology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - D Scott Merrell
- Department of Microbiology and Immunology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
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10
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Boyd JH, Russell JA, Fjell CD. The meta-genome of sepsis: host genetics, pathogens and the acute immune response. J Innate Immun 2014; 6:272-83. [PMID: 24525633 DOI: 10.1159/000358835] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 01/20/2014] [Indexed: 12/22/2022] Open
Abstract
Severe infection and the patient response constitute sepsis. Here, we review the meta-genome (patient genetics, pathogen communities and host response) and its impact upon the outcome of severe sepsis. Patient genetics, both predisposition for infection and the subsequent response to infection are reviewed. The pathogen is discussed with particular emphasis upon the modern era of microbiome analysis and nucleic acid diagnostics. Finally, we discuss the host clinical and immune responses and present new data to suggest that the immune response is the key to understanding sepsis and improving a death rate of nearly 30%.
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Affiliation(s)
- John H Boyd
- Division of Critical Care Medicine, St. Paul's Hospital, Vancouver, B.C., Canada
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11
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Hurley JC. Towards clinical applications of anti-endotoxin antibodies; a re-appraisal of the disconnect. Toxins (Basel) 2013; 5:2589-620. [PMID: 24351718 PMCID: PMC3873702 DOI: 10.3390/toxins5122589] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/09/2013] [Accepted: 12/13/2013] [Indexed: 12/21/2022] Open
Abstract
Endotoxin is a potent mediator of a broad range of patho-physiological effects in humans. It is present in all Gram negative (GN) bacteria. It would be expected that anti-endotoxin therapies, whether antibody based or not, would have an important adjuvant therapeutic role along with antibiotics and other supportive therapies for GN infections. Indeed there is an extensive literature relating to both pre-clinical and clinical studies of anti-endotoxin antibodies. However, the extent of disconnect between the generally successful pre-clinical studies versus the failures of the numerous large clinical trials of antibody based and other anti-endotoxin therapies is under-appreciated and unexplained. Seeking a reconciliation of this disconnect is not an abstract academic question as clinical trials of interventions to reduce levels of endotoxemia levels are ongoing. The aim of this review is to examine new insights into the complex relationship between endotoxemia and sepsis in an attempt to bridge this disconnect. Several new factors to consider in this reappraisal include the frequency and types of GN bacteremia and the underlying mortality risk in the various study populations. For a range of reasons, endotoxemia can no longer be considered as a single entity. There are old clinical trials which warrant a re-appraisal in light of these recent advances in the understanding of the structure-function relationship of endotoxin. Fundamentally however, the disconnect not only remains, it has enlarged.
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Affiliation(s)
- James C Hurley
- Rural Health Academic Center, Melbourne Medical School, University of Melbourne, Parkville 3010, Australia.
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12
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Alejandria MM, Lansang MAD, Dans LF, Mantaring III JB. Intravenous immunoglobulin for treating sepsis, severe sepsis and septic shock. Cochrane Database Syst Rev 2013; 2013:CD001090. [PMID: 24043371 PMCID: PMC6516813 DOI: 10.1002/14651858.cd001090.pub2] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Mortality from sepsis and septic shock remains high. Results of trials on intravenous immunoglobulins (IVIG) as adjunctive therapy for sepsis have been conflicting. This is an update of a Cochrane review that was originally published in 1999 and updated in 2002 and 2010. OBJECTIVES To estimate the effects of IVIG as adjunctive therapy in patients with bacterial sepsis or septic shock on mortality, bacteriological failure rates, and duration of stay in hospital. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 6), MEDLINE (1966 to December 2012), and EMBASE (1988 to December 2012). We contacted investigators in the field for unpublished data. The original search was performed in 1999 and updated in 2002 and 2008. SELECTION CRITERIA We included randomized controlled trials comparing IVIG (monoclonal or polyclonal) with placebo or no intervention in patients of any age with bacterial sepsis or septic shock. DATA COLLECTION AND ANALYSIS Two authors independently assessed the studies for inclusion and undertook methodologic quality assessment and data abstraction. We conducted pre-specified subgroup analyses by type of immunoglobulin preparation. MAIN RESULTS We included 43 studies that met our inclusion criteria in this updated review out of 88 potentially eligible studies. The studies included a large polyclonal IVIG trial in neonates that was concluded in 2011 and classified as ongoing in the 2010 version of this review. Pooled analysis of polyclonal and monoclonal IVIG was not done due to clinical heterogeneity. Subgroup analysis of 10 polyclonal IVIG trials (n = 1430) and seven trials on IgM-enriched polyclonal IVIG (n = 528) showed significant reductions in mortality in adults with sepsis compared to placebo or no intervention (relative risk (RR) 0.81; 95% confidence interval (CI) 0.70 to 0.93 and RR 0.66; 95% CI 0.51 to 0.85, respectively). Subgroup analysis of polyclonal IVIG in neonates, which now includes the recently concluded large polyclonal IVIG trial, showed no significant reduction in mortality for standard IVIG (RR 1.00; 95% CI 0.92 to 1.08; five trials, n = 3667) and IgM-enriched polyclonal IVIG (RR 0.57; 95% CI 0.31 to 1.04; three trials, n = 164). Sensitivity analysis of trials with low risk of bias showed no reduction in mortality with polyclonal IVIG in adults (RR 0.97; 95% CI 0.81 to 1.15; five trials, n = 945) and neonates (RR 1.01; 95% CI 0.93 to 1.09; three trials, n = 3561). Mortality was not reduced among patients (eight trials, n = 4671) who received anti-endotoxin antibodies (RR 0.99; 95% CI 0.91 to1.06) while anti-cytokines (nine trials, n = 7893) demonstrated a marginal reduction in mortality (RR 0.92; 95% CI 0.86 to 0.97). AUTHORS' CONCLUSIONS Polyclonal IVIG reduced mortality among adults with sepsis but this benefit was not seen in trials with low risk of bias. Among neonates with sepsis, there is sufficient evidence that standard polyclonal IVIG, as adjunctive therapy, does not reduce mortality based on the inclusion of the large polyclonal IVIG trial on neonates. For Ig-M enriched IVIG, the trials on neonates and adults were small and the totality of the evidence is still insufficient to support a robust conclusion of benefit. Adjunctive therapy with monoclonal IVIGs remains experimental.
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Affiliation(s)
- Marissa M Alejandria
- University of the Philippines,College of MedicineDepartment of Clinical Epidemiology547 Pedro Gil StErmita 1000ManilaPhilippines
| | - Mary Ann D Lansang
- Department of Medicine, Philippine General Hospital, University of the PhilippinesDepartment of Clinical Epidemiology and Section of Infectious DiseasesManilaPhilippines1000
| | - Leonila F Dans
- University of the Philippines Manila College of Medicine‐Philippine General HospitalDepartment of PediatricsTaft AvenueManilaNational Capital RegionPhilippines1000
| | - Jacinto Blas Mantaring III
- University of the PhilippinesSection of Newborn Medicine, Department of PediatricsPhilippine General HospitalTaft AveManilaPhilippines1000
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Abstract
Sepsis remains a common, serious, and heterogeneous clinical entity that is difficult to define adequately. Despite its importance as a public health problem, efforts to develop and gain regulatory approval for a specific therapeutic agent for the adjuvant treatment of sepsis have been remarkably unsuccessful. One step in the critical pathway for the development of a new agent for adjuvant treatment of sepsis is evaluation in an appropriate animal model of the human condition. Unfortunately, the animal models that have been used for this purpose have often yielded misleading findings. It is likely that there are multiple reasons for the discrepancies between the results obtained in tests of pharmacological agents in animal models of sepsis and the outcomes of human clinical trials. One of important reason may be that the changes in gene expression, which are triggered by trauma or infection, are different in mice, a commonly used species for preclinical testing, and humans. Additionally, many species, including mice and baboons, are remarkably resistant to the toxic effects of bacterial lipopolysaccharide, whereas humans are exquisitely sensitive. New approaches toward the use of animals for sepsis research are being investigated. But, at present, results from preclinical studies of new therapeutic agents for sepsis must be viewed with a degree of skepticism.
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Affiliation(s)
- Mitchell P Fink
- Departments of Surgery and Anesthesiology; David Geffen School of Medicine at UCLA; Los Angeles, CA USA
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14
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Abstract
For more than 30 years, intravenously administered immunoglobulins (ivIG) have been used to treat primary and secondary syndromes of immune deficiency. Increasing insight into pathomechanisms of severe sepsis and septic shock have led to the implementation of ivIG therapy in the strategies for adjunctive therapy in sepsis in both adults and children. Direct antitoxic effects, as well as indirect immunomodulatory mechanisms of ivIG have been described in the literature and were the basis for the rationale to use these substances in life-threatening infections and hyperinflammatory states. Several clinical trials have been performed, most of them as minor, investigator-initiated protocols. This review summarizes the results of clinical investigations and systematic meta-analyses that have implications for the development of therapeutic strategies, and international guidelines for the management of severe sepsis and septic shock in adult patients.
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Affiliation(s)
- Susanne Toussaint
- Department of Anesthesia, Critical Care Medicine, and Pain Management, Vivantes - Klinikum Neukoelln, Berlin, Germany
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15
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Abstract
Serious infection and the patient's response (sepsis) is a serious health problem that, even today, is associated with a mortality rate of 30 %-50 %. The phases of severe sepsis include an early hyperinflammatory response to pathogens and a late immunosuppressed phase. Toll-like receptors (TLRs) are a family of transmembrane innate immune receptors that play a major role in both phases of sepsis. Here, their physiology and the therapeutic strategies employed to date are reviewed. Currently, there are no approved therapies targeting TLRs, but it is anticipated that in the future, the less-studied TLRs, such as TLR3, TLR7, and TLR9, will evolve therapeutic targets, perhaps predominantly with agonists, versus the usual antagonist strategies. Furthermore, accurately characterizing the stage of sepsis will be essential to directing appropriate therapeutic choices.
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Affiliation(s)
- John H Boyd
- Critical Care Research Laboratories, Heart + Lung Institute, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6,
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16
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Enterobacterial common antigen mutants of Salmonella enterica serovar Typhimurium establish a persistent infection and provide protection against subsequent lethal challenge. Infect Immun 2011; 80:441-50. [PMID: 22025511 DOI: 10.1128/iai.05559-11] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Infection with Salmonella spp. is a significant source of disease globally. A substantial proportion of these infections are caused by Salmonella enterica serovar Typhimurium. Here, we characterize the role of the enterobacterial common antigen (ECA), a surface glycolipid ubiquitous among enteric bacteria, in S. Typhimurium pathogenesis. Construction of a defined mutation in the UDP-N-acetylglucosamine-1-phosphate transferase gene, wecA, in two clinically relevant strains of S. Typhimurium, TML and SL1344, resulted in strains that were unable to produce ECA. Loss of ECA did not affect the gross cell surface ultrastructure, production of lipopolysaccharide (LPS), flagella, or motility. However, the wecA mutant strains were attenuated in both oral and intraperitoneal mouse models of infection (P<0.001 for both routes of infection; log rank test), and virulence could be restored by complementation of the wecA gene in trans. Despite the avirulence of the ECA-deficient strains, the wecA mutant strains were able to persistently colonize systemic sites (spleen and liver) at moderate levels for up to 70 days postinfection. Moreover, immunization with the wecA mutant strains provided protection against a subsequent lethal oral or intraperitoneal challenge with wild-type S. Typhimurium. Thus, wecA mutant (ECA-negative) strains of Salmonella may be useful as live attenuated vaccine strains or as vehicles for heterologous antigen expression.
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Brade L, Heine H, Raina S, Klein G, Di Padova F, Brade H, Müller-Loennies S. Immunization with an anti-idiotypic antibody against the broadly lipopolysaccharide-reactive antibody WN1 222-5 induces Escherichia coli R3-core-type specific antibodies in rabbits. Innate Immun 2011; 18:279-93. [PMID: 21844130 DOI: 10.1177/1753425911401055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The mouse monoclonal antibody (mAb) WN1 222-5 recognizes a carbohydrate epitope in the inner core region of LPS that is shared by all strains of Escherichia coli and Salmonella enterica and is able to neutralize their endotoxic activity in vitro and in vivo. Immunization of mice with mAb WN1 222-5 yielded several anti-idiotypic mAbs one of which (mAb S81-19) competitively inhibited binding of mAb WN1 222-5 to E. coli and Salmonella LPS. After immunization of rabbits with mAb S81-19, the serological responses towards LPS were characterized at intervals over two years. Whereas the serological response against the anti-idiotype developed as expected, the anti-anti-idiotypic response against LPS developed slowly and antibodies appeared after 200 d that bound to E. coli LPS of the R3 core-type and neutralized its TNF-α inducing capacity for human peripheral mononuclear cells. We describe the generation of a novel anti-idiotypic antibody that can induce LPS core-reactive antibodies upon immunization in rabbits and show that it is possible, in principle, to obtain LPS neutralizing antibodies by anti-idiotypic immunization against the mAb WN1 222-5. The mimicked epitope likely shares common determinants with the WN1 222-5 epitope, yet differences with respect to either affinity or specificity do exist, as binding to smaller oligosaccharides of the inner core was not observed.
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Affiliation(s)
- Lore Brade
- Research Center Borstel, Leibniz-Center for Medicine and Biosciences, Borstel, Germany
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18
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Getts DR, Getts MT, McCarthy DP, Chastain EML, Miller SD. Have we overestimated the benefit of human(ized) antibodies? MAbs 2010; 2:682-94. [PMID: 20935511 DOI: 10.4161/mabs.2.6.13601] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The infusion of animal-derived antibodies has been known for some time to trigger the generation of antibodies directed at the foreign protein as well as adverse events including cytokine release syndrome. These immunological phenomena drove the development of humanized and fully human monoclonal antibodies. The ability to generate human(ized) antibodies has been both a blessing and a curse. While incremental gains in the clinical efficacy and safety for some agents have been realized, a positive effect has not been observed for all human(ized) antibodies. Many human(ized) antibodies trigger the development of anti-drug antibody responses and infusion reactions. The current belief that antibodies need to be human(ized) to have enhanced therapeutic utility may slow the development of novel animal-derived monoclonal antibody therapeutics for use in clinical indications. In the case of murine antibodies, greater than 20% induce tolerable/negligible immunogenicity, suggesting that in these cases humanization may not offer significant gains in therapeutic utility. Furthermore, humanization of some murine antibodies may reduce their clinical effectiveness. The available data suggest that the utility of human(ized) antibodies needs to be evaluated on a case-by-case basis, taking a cost-benefit approach, taking both biochemical characteristics and the targeted therapeutic indication into account.
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Targeted Treatment of Microvascular Dysfunction. Intensive Care Med 2010. [DOI: 10.1007/978-1-4419-5562-3_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Cohen J. Recent Developments in the Identification of Novel Therapeutic Targets for the Treatment of Patients with Sepsis and Septic Shock. ACTA ACUST UNITED AC 2009; 35:690-6. [PMID: 14620156 DOI: 10.1080/00365540310016358] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The overall mortality in patients with sepsis is approximately 30%; this figure increases to 50% or higher in patients with septic shock, and sepsis continues to be seen as a major clinical challenge. The recent success of several important trials has fuelled interest in further therapeutic developments. Here, I review the many different strategies that are being investigated, focusing in particular on those that are in late pre-clinical or early clinical development. These can be broadly divided into three groups: strategies aimed at bacterial targets, strategies aimed at disorders of immune regulation in the host, and finally, other novel strategies based on modifying host response; which, if any, of these will prove successful in large clinical trials is unknown. Nevertheless, the fact that sepsis has finally proved tractable as a target for new drug development lends support to those who believe that at least some of the compounds identified in this paper will prove to have clinical benefit.
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Affiliation(s)
- Jonathan Cohen
- Division of Medicine, Brighton & Sussex Medical School, Brighton, UK.
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Abstract
OBJECTIVE This article aimed at providing suggestions to improve the success rate of future sepsis trials. DESIGN Systematic review. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS CENTRAL (The Cochrane Library Issue 2, 2007) was searched using "sepsis" OR "severe sepsis" OR "septic shock" as search terms. The search was restricted to studies designed and conducted in adults with severe sepsis or septic shock after June 1992, published before September 2007, and powered for survival analysis. Twenty-seven trials were included and analyzed. The author suggested six key points for the design and conduct of future sepsis trials: 1) avoid mixing patients with severe sepsis and septic shock; 2) restrict time window to less than 24 hrs from onset of the first organ dysfunction or shock; 3) include only undisputable sepsis; 4) use the Sepsis-related Organ Failure Assessment score for eligibility; 5) include a first interim analysis after enrollment of 25% of the planned sample size to check the actual basal risk of death and to recalculate the number of patients needed; 6) strictly control for concomitant treatments on the basis of the Surviving Sepsis Campaign. CONCLUSIONS There is a need to limit the sources of heterogeneity in sepsis trials by a better definition of target populations, by a better estimation of basal risk of death, and by controlling cointerventions.
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Banks KE, Fortney KR, Baker B, Billings SD, Katz BP, Munson RS, Spinola SM. The enterobacterial common antigen-like gene cluster of Haemophilus ducreyi contributes to virulence in humans. J Infect Dis 2008; 197:1531-6. [PMID: 18422457 DOI: 10.1086/588001] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Haemophilus ducreyi 35000HP contains a cluster of homologues of genes required for the synthesis of enterobacterial common antigen (ECA), suggesting that H. ducreyi may express a putative ECA-like glycoconjugate. WecA initiates the synthesis of ECA by transferring N-acetylglucosamine to undecaprenyl-P, to form lipid I. A wecA mutant (35000HPwecA) was constructed, and 5 volunteers were inoculated at 3 sites with fixed doses of 35000HP on one arm and at 3 sites with varying doses of 35000HPwecA on the other arm. 35000HPwecA caused pustules to form at 3 sites inoculated with a dose 2.5-fold higher than that of 35000HP. However, at sites inoculated with similar doses of 35000HP and 35000HPwecA, pustules developed at 46.7% (95% confidence interval [CI], 23.3%-70.0%) of 15 parent-strain sites and at 8.3% (95% CI, 0.01%-23.6%) of 12 mutant-strain sites (P = .013). Thus, the expression of wecA contributes to the ability of H. ducreyi to cause pustules in humans.
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Affiliation(s)
- Keith E Banks
- Department of Medicine, Indiana University School of Medicine, Indianapolis, USA
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Multicenter, randomized, controlled trials evaluating mortality in intensive care: doomed to fail? Crit Care Med 2008; 36:1311-22. [PMID: 18379260 DOI: 10.1097/ccm.0b013e318168ea3e] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To determine how many multicenter, randomized controlled trials have been published that assess mortality as a primary outcome in the adult intensive care unit population, and to evaluate their methodologic quality. DATA SOURCE A sensitive search strategy for randomized controlled trials was conducted in the Cochrane Central Register of Controlled Trials and in MedLine using the PubMed interface. STUDY SELECTION All publications of adult, multicenter randomized controlled trials carried out in the intensive care unit, with mortality as a primary outcome, and including >50 patients were selected. DATA EXTRACTION Seventy-two randomized controlled trials were retrieved and were classified according to their effect on mortality: beneficial, detrimental, or neutral. DATA SYNTHESIS Ten of the studies reported a positive impact of the studied intervention on mortality, seven studies reported a detrimental effect of the intervention, and 55 studies showed no effect on mortality. CONCLUSIONS This literature search demonstrates that relatively few of the randomized controlled trials conducted in intensive care units and using mortality as a primary outcome show a beneficial impact of the intervention on the survival of critically ill patients. Methodological limitations of some of the randomized controlled trials may have prevented positive results. Other forms of evidence and end points other than mortality need to be considered when evaluating interventions in critically ill patients.
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Fry DE. Multiple Organ Dysfunction Syndrome. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
PURPOSE OF REVIEW Although enthusiasm of intensivists has been raised during the last 2-3 years due to several successful clinical trials, severe sepsis and septic shock still have an increasing incidence with more or less unchanged mortality. Within the last 12 months, the progress in sepsis research covering definitions, epidemiology, pathophysiology, diagnosis, standard and adjunctive therapy, as well as experimental approaches is encouraging. In this review, state-of-the-art publications of 2003 are presented to elucidate the possible impact on clinical routine. RECENT FINDINGS The rationale for using a new definition based on the PIRO system has been widely acknowledged, although it is not yet applicable in clinical practice. This includes genomic information for stratifying subgroups of patients, and a broader field of laboratory diagnostics due to clinical studies and basic research on the cellular mechanisms of inflammation and organ dysfunction. Early diagnosis is important for a fast implementation of specific therapies, and it has been confirmed that the time until the start of therapy has an impact on patient outcome. Thorough data analysis of successful trials with activated protein C has revealed encouraging details on long-term outcome and subgroup effects. Together with new findings on low-dose hydrocortisone, this stresses the relevance of adjunctive therapy in severe sepsis and septic shock. SUMMARY Scientific progress in areas of sepsis has been continuing throughout 2003, although the challenges are still enormous. The identification of more specific markers and new therapeutic approaches will hopefully improve the diagnosis, monitoring of therapy, and outcome in the septic patient.
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Affiliation(s)
- Herwig Gerlach
- Department of Anaesthesiology and Intensive Care, Vivantes--Neukoelln Clinic, Berlin, Germany.
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Abstract
Multiple clinical trials of adjunctive therapy for sepsis and septic shock have been conducted to neutralize bacterial components or to modulate host inflammatory responses to infection but with limited success. Many therapies are only beneficial only in patients with a high severity of illness and have minimal or harmful effects in patients that are less severely ill. Improved measures of severity of illness and discovery of biomarkers to help identify these high-risk patients are needed.
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Affiliation(s)
- Nitin Seam
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
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Aboab J, Nardi O, Lipiner D, Sharshar T, Annane D. Emerging drugs for the treatment of sepsis. Expert Opin Emerg Drugs 2006; 11:7-22. [PMID: 16503823 DOI: 10.1517/14728214.11.1.7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Septic shock still places a major burden on the healthcare system, although recent years have been marked by the demonstration that corticosteroids and activated protein C may substantially improve survival in selected populations. This review discusses the current management of septic shock and the potential development of new therapeutics following impressive advances in the pathomechanisms of septic shock.
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Affiliation(s)
- Jérome Aboab
- Intensive Care Unit, University of Versailles Saint Quentin, Hospital Raymond Poincaré, 104 bd Raymond Poincaré, 92380 Garches, France
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Asakura H, Takahashi Y, Kubo A, Ontachi Y, Hayashi T, Omote M, Arahata M, Kadohira Y, Maekawa M, Yamazaki M, Morishita E, Takami A, Yoshida T, Miyamoto KI, Nakao S. Immunoglobulin preparations attenuate organ dysfunction and hemostatic abnormality by suppressing the production of cytokines in lipopolysaccharide-induced disseminated intravascular coagulation in rats. Crit Care Med 2006; 34:2421-5. [PMID: 16810104 DOI: 10.1097/01.ccm.0000230382.38989.4f] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We attempted to clarify the effect of immunoglobulin concentrates on the rat lipopolysaccharide (LPS)-induced disseminated intravascular coagulation (DIC) model. DESIGN Prospective, comparative, experimental study. SETTING Laboratory at a university hospital. SUBJECTS Male Wistar rats, aged 6 to 7 wks and weighing 160 to 170 g. INTERVENTIONS Two kinds of experiments were performed. In the first, experimental DIC was induced by sustained infusion of 30 mg/kg LPS for 4 hrs via the tail vein, and two doses of immunoglobulin (25 or 100 mg/kg/4.5 hrs) were administered to rats 30 mins before infusion of LPS, after which immunoglobulin infusion was continued for a further 4 hrs. In the second, experimental DIC was induced by sustained infusion (5 mg/kg/1 hr) of LPS for 1 hr, and one dose of immunoglobulin (100 mg/kg/4 hrs) was administered to rats after LPS induction. The parameters were estimated at 4 hrs and 8 hrs in the first experiment and at 1, 5, and 10 hrs in the second one. MEASUREMENT AND MAIN RESULTS Similar results were observed in the two experiments. Consumption coagulopathy and hemostatic activation were attenuated, especially when immunoglobulin was administered before LPS infusion. Plasma levels of creatinine and alanine aminotransferase were significantly depressed by coadministration of immunoglobulin. Marked glomerular fibrin deposition was observed in the LPS-induced DIC model, but this deposition was reduced by immunoglobulin. In the first stage of the experiment, plasma levels of tumor necrosis factor (TNF) and interleukin (IL)-6 were suppressed by coadministration of immunoglobulin. In the second, plasma levels of IL-6 were significantly suppressed by immunoglobulin. CONCLUSION It was concluded that plasma levels of TNF and IL-6 could be significantly suppressed by immunoglobulin in the LPS-induced DIC model. Moreover, hemostatic abnormality, organ dysfunction, and glomerular fibrin deposition in this model were all ameliorated by immunoglobulin.
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Affiliation(s)
- Hidesaku Asakura
- Department of Internal Medicine III, Kanazawa University School of Medicine, Ishikawa, Japan.
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Triantafilou K, Triantafilou M. Innate recognition of bacteria: potential therapeutic targets for bacterial sepsis. Expert Rev Clin Immunol 2006; 2:787-99. [PMID: 20477633 DOI: 10.1586/1744666x.2.5.787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Sepsis is a paradoxical and complex disorder that results from an over-reaction of our innate immune system to bacterial infections. Although this disorder has been known since ancient times, the history of clinical research into novel therapies for sepsis has been disappointing. The inability to translate our findings to the clinic could be attributed to our lack of knowledge of the molecular mechanisms involved in sensing microbial pathogens. However, in the last decade, the innate immune sensors responsible for triggering this disease have been discovered. This review will examine mediators that have been targeted in the past, as well as in the present, and propose novel therapeutic interventions for the future.
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Affiliation(s)
- Kathy Triantafilou
- Infection and Immunity Group, University of Sussex, School of Life Sciences, Falmer, Brighton, BN1 9QG, UK.
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Kuhn R, Schubert D, Tautenhahn J, Nestler G, Schulz HU, Bartelmann M, Lippert H, Pross M. Effect of intraperitoneal application of an endotoxin inhibitor on survival time in a laparoscopic model of peritonitis in rats. World J Surg 2005; 29:766-70. [PMID: 16078128 DOI: 10.1007/s00268-005-7409-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Gram-negative sepsis due to fecal peritonitis is a hazardous disease with a high percentage having a lethal course. The inflammatory effects are induced by endotoxin release. We performed this study to evaluate the potential of direct intraperitoneal application of an endotoxin inhibitor in a laparoscopic peritonitis model in rats. The human feces specimen was prepared, and a standard fecal specimen (0.5 ml/kg b.w.) was applied via minilaparotomy. The rats were randomized to two studies. First, rats were randomized to three groups to define the survival time: (1) rats without further manipulation; (2) rats with laparoscopic lavage using NaCl; (3) rats with laparoscopic lavage using endotoxin inhibitor. Second, rats underwent the same procedure used in the first part of the study and an additional group with only NaCl lavage without peritonitis was randomized. To evaluate the immunologic or biochemical effects, animals were killed at a standard time of 20 hours until the postmortem examination was established. Interleukins 6 and 10 (IL-6, IL-10), malondialdehyde, and protein carbonyl group levels in plasma and particularly in peritoneal fluid were assayed. The first part of the experiment showed significantly increased survival after endotoxin inhibitor lavage. In the second part, administration of endotoxin inhibitor intraperitoneally caused a significant reduction of IL-6 in the peritoneal fluid, in contrast to that in the other groups. Laparoscopic application of endotoxin inhibitor intraperitoneally thus produced a beneficial effect on survival and reduction of IL-6 in peritoneal fluid. Hence, it is possible to influence the inflammation cascade by causing intraperitoneal endotoxin inhibition.
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Affiliation(s)
- Roger Kuhn
- Department of Surgery, Otto-von-Guericke University, Leipziger Strasse 44, D-39120, Magdeburg, Germany.
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Macias WL, Nelson DR, Williams M, Garg R, Janes J, Sashegyi A. Lack of evidence for qualitative treatment by disease severity interactions in clinical studies of severe sepsis. Crit Care 2005; 9:R607-22. [PMID: 16280057 PMCID: PMC1414006 DOI: 10.1186/cc3795] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2005] [Revised: 07/14/2005] [Accepted: 07/18/2005] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION The design of clinical trials of interventions aimed at reducing mortality in patients with severe sepsis assumes that the relative treatment effect of the intervention is independent of the patients' risk for death. We reviewed published data from phase III clinical studies of severe sepsis to determine whether a relationship exists between risk for death and the relative benefit of the investigational agent. Such an interaction might warrant a change in the assumptions that underlie current trial designs. METHODS We conducted a systematic review of published phase III, randomized, placebo-controlled trials in adult patients with sepsis, severe sepsis, or septic shock up to November 2004. All studies enrolled patients with known or suspected infection, evidence of a systemic response to the infection, and one or more organ dysfunctions resulting from the systemic response. RESULTS Twenty-two publications, investigating 17 molecular entities, fulfilled criteria for phase III or equivalent studies aimed at reducing mortality in adult patients with severe sepsis or septic shock. Three studies achieved the prospectively defined primary end-point of a statistically significant reduction in 28-day all-cause mortality. The control group mortality rates for these studies were 31%, 43% and 61%, indicating that the beneficial effects of adjunct therapies could be demonstrated over a wide range of illness severity. Analysis of subgroup data from failed studies provided no evidence that the efficacy of the therapeutics being investigated varied by baseline placebo mortality rates. Among all studies, interventions with anticoagulant activity or anti-inflammatory activity did not appear to be harmful in patients with evidence of less coagulopathy or less inflammation. CONCLUSION Our review of published clinical data does not support the hypothesis that mortality risk of the population studied alters the relative treatment effect associated with anti-inflammatory or other agents used to treat severe sepsis. Clinical studies in severe sepsis should continue to enroll patients over a wide range of disease severity, as long as patients enrolled have evidence of sepsis-induced organ dysfunction(s), patients are at an appreciable risk for death (e.g. as evidenced by admission to an intensive care unit), and the potential for benefit outweighs the potential for harm.
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Affiliation(s)
- William L Macias
- Senior Medical Director, Lilly Research Laboratories, Indianapolis, Indiana, USA
| | - David R Nelson
- Associate Senior Statistician, Lilly Research Laboratories, Indianapolis, Indiana, USA
| | - Mark Williams
- Associate Medical Director, Lilly Research Laboratories, Indianapolis, Indiana, USA
| | - Rekha Garg
- Medical Fellow, Lilly Research Laboratories, Indianapolis, Indiana, USA
| | - Jonathan Janes
- Medical Fellow, Lilly Research Laboratories, Indianapolis, Indiana, USA
| | - Andreas Sashegyi
- Senior Statistician, Lilly Research Laboratories, Indianapolis, Indiana, USA
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Abstract
BACKGROUND Peritonitis involves cascading interactions between cytokines that initiate robust signalling processes via the interferon-g and nuclear factor kappa B pathways. The present study evaluates the interplay between various putative inducers of peritonitis and a battery of inflammation-related cytokines. METHODS Cultures of peritoneal mesothelial cells were isolated from omenta harvested from male Wistar rats. These cultures were exposed to tumour necrosis factor (TNF)-alpha, lipopolysaccharide, zymosan, myeloperoxidase, peritoneal fluid from rats with zymosan-induced peritonitis, and peritoneal fluid from control animals. The production of TNF-alpha, interleukin (IL)-1beta, IL-6, and IL-10 was assessed after 4, 12 and 24 h. RESULTS Lipopolysaccharide and zymosan stimulated TNF-alpha, IL-1beta, and IL-10 production; and peritoneal fluids from both control animals and animals with zymosan-induced peritonitis stimulated the production of TNF-alpha, IL-1RII, and IL-6. Expression and secretion of TNF-alpha occurred in a constitutive manner and was regulation at the protein level. The decoy molecule IL-1 receptor type II (IL-1RII) was produced at the same time as IL-1beta and production of the anti-inflammatory cytokine IL-10 was evident within 4 h. IL-6 was constitutively expressed and regulated at the transcriptional level as indicated by a marked discontinuity between the amount of IL-6 produced and the extent IL-6 messenger ribonucleic acid (mRNA) expression. CONCLUSIONS Tumour necrosis factor-alpha might not be the sole primary mediator of peritonitis. The anti-inflammatory molecules IL-1RII and IL-10 are induced at the same time as the pro-inflammatory cytokines TNF-alpha, IL-1beta, and IL-6. This suggests that complex control systems are set in place by the factors that stimulate peritoneal mesothelial cells and might have the potential to cause peritonitis.
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Affiliation(s)
- Veronica Yao
- School of Surgery and Pathology, The University of Western Australia, Perth, Western Australia, Australia
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Abstract
PURPOSE OF REVIEW Severe sepsis and septic shock are common and deadly conditions for which the epidemiology, pathogenesis, and management continue to evolve. Recent publications (2003 and early 2004) have been systematically reviewed for important new original research and scholarly reviews, with an emphasis on clinical advances in adults. RECENT FINDINGS Important new epidemiologic studies establish the increasing frequency (nearly 9% per year) and falling mortality rates associated with sepsis. Sepsis definitions were reviewed by a group of experts, and the principal features of the 1991 consensus conference definitions were supported, with a new framework for evaluation of sepsis proposed. New research and thoughtful reviews continue to elucidate the pathogenesis of sepsis, with emphasis on innate immunity and time-based changes in immune status, varying from hyperreactive immunity and inflammation to immune depression with enhanced risk for nosocomial infections. A comprehensive evidence-based approach to the management of severe sepsis is presented in an important document developed by representatives from many critical care and infectious disease societies. Management includes early targeted resuscitation, broad empiric antibiotic coverage and source control, effective shock evaluation and treatment, adjuvant therapy with recombinant human activated protein C and moderate-dose hydrocortisone in selected patients, and comprehensive supportive care. Recently published multicenter clinical trials for novel agents have been disappointing, particularly for a nitric oxide synthase inhibitor that effectively supported blood pressure but increased mortality. SUMMARY The works reviewed reflect the advances in the care of patients with sepsis.
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Affiliation(s)
- Curtis N Sessler
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University Health System, Richmond, Virginia, USA.
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Bayardelle P, Albertson TE, MacArthur RD. Antibody to Enterobacterial Common Antigen and Gram-Negative Sepsis. Crit Care Med 2004; 32:617-8. [PMID: 14758202 DOI: 10.1097/01.ccm.0000104953.49342.d5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Phillip Dellinger R, Parrillo JE. Mediator modulation therapy of severe sepsis and septic shock: Does it work? *. Crit Care Med 2004; 32:282-6. [PMID: 14707593 DOI: 10.1097/01.ccm.0000105423.06091.8e] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Luyer MDP, Buurman WA, Hadfoune M, Jacobs JA, Konstantinov SR, Dejong CHC, Greve JWM. Pretreatment With High-Fat Enteral Nutrition Reduces Endotoxin and Tumor Necrosis Factor-?? and Preserves Gut Barrier Function Early After Hemorrhagic Shock. Shock 2004; 21:65-71. [PMID: 14676686 DOI: 10.1097/01.shk.0000101671.49265.cf] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Gram-negative sepsis is a potentially fatal clinical syndrome characterized by a proinflammatory response (tumor necrosis factor-alpha) to bacterial (endo)toxins and gut barrier function loss. Recently, we found that high-fat enteral nutrition protects against late bacterial translocation in a model of hemorrhagic shock in rats. However, the basis for this protection is unknown. We hypothesized that the observed protection is the result of an early inhibition of endotoxin and the subsequent inflammatory response resulting in a preserved gut barrier function. Sprague-Dawley rats were divided into a group that was starved overnight (HS-S), fed with a low-fat enteral diet (HS-LF) or fed wih a high-fat enteral diet (HS-HF), and subsequently subjected to a nonlethal hemorrhagic shock. Ninety minutes after hemorrhage, arterial endotoxin significantly decreased in HS-HF rats (4.0 +/- 0.6 pg/mL) compared with HS-LF rats (10.7 +/- 0.9 pg/mL, P = 0.002) and HS-S rats (15.2 +/- 2.2 pg/mL P = 0.001). Interestingly, arterial tumor necrosis factor-alpha was also decreased in HS-HF rats (17.9 +/- 10.4 pg/mL) compared with HS-LF (83.5 +/- 16.7 pg/mL, P < 0.01) and HS-S rats (180.9 +/- 67.9 pg/mL, P < 0.02). Loss of tight junction structure (ZO-1) observed in ileum and colon of control hemorrhagic shock rats was prevented in HS-HF rats. In parallel, intestinal barrier function was preserved in HS-HF rats, evidenced by a reduced permeability to horseradish peroxidase (P < 0.05), less bacterial invasion, and a 10-fold reduction of bacterial translocation early after hemorrhagic shock. This report describes a new strategy to nutritionally prevent endotoxemia, the subsequent inflammatory response and gut barrier failure following hemorrhagic shock. High-fat enteral nutrition requires further evaluation as an intervention to prevent a potentially fatal systemic inflammatory response in patients at risk for sepsis.
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Affiliation(s)
- Misha D P Luyer
- Department of Surgery, Nutrition and Toxicology Research Institute Maastricht, University of Maastricht, Maastricht, The Netherlands
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Marshall JC. Such stuff as dreams are made on: mediator-directed therapy in sepsis. Nat Rev Drug Discov 2003; 2:391-405. [PMID: 12750742 DOI: 10.1038/nrd1084] [Citation(s) in RCA: 213] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Sepsis, a life-threatening disorder that arises through the body's response to infection, is the leading cause of death and disability for patients in an intensive care unit. Advances in the understanding of the complex biological processes responsible for the clinical syndrome have led to the identification of many promising new therapeutic targets, including bacterial toxins, host-derived mediators, and downstream processes such as coagulation and the endocrine response. Diverse therapies directed against these targets have shown dramatic effects in animal models; however, in humans, their impact has been frustratingly modest, and only one agent--recombinant activated protein C--has achieved regulatory approval. This review summarizes the approaches that have been evaluated in clinical trials, explores the reasons for the discordance between biological promise and clinical reality, and points to approaches that may lead to greater success in the future.
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Affiliation(s)
- John C Marshall
- Department of Surgery and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Eaton North 9-234, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, Ontario, Canada.
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Alejandria MM, Lansang MA, Dans LF, Mantaring JB. Intravenous immunoglobulin for treating sepsis and septic shock. Cochrane Database Syst Rev 2002:CD001090. [PMID: 11869591 DOI: 10.1002/14651858.cd001090] [Citation(s) in RCA: 106] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Death from severe sepsis and septic shock is common, and researchers have explored whether antibodies to the endotoxins in some bacteria reduces mortality. OBJECTIVES To estimate the effects of intravenous immunoglobulin (IVIG) in patients with bacterial sepsis or septic shock on mortality, bacteriological failure rates, and duration of stay in hospital. SEARCH STRATEGY We searched the Cochrane Infectious Diseases Group specialized register up to November 2001; the Cochrane Controlled Trials Register, The Cochrane Library issue 4, 2001; MEDLINE 1966 to November 2001; and EMBASE 1988 to September 2001. We contacted investigators active in the field for unpublished data. SELECTION CRITERIA Randomised trials comparing intravenous immunoglobulin (monoclonal or polyclonal) with placebo or no intervention, in patients with bacterial sepsis or septic shock. DATA COLLECTION AND ANALYSIS Inclusion criteria, trial quality assessment, and data abstraction were done in duplicate. We conducted pre-specified subgroup analyses by type of immunoglobulin preparation. MAIN RESULTS Twenty-seven out of 55 studies met our inclusion criteria. Pooled analysis of all types of IVIG preparations revealed a significant trend toward reduction of mortality (n= 8,856; RR=0.91; 95%CI 0.86-0.96). Overall mortality was reduced in patients who received polyclonal IVIG (n=492; RR=0.64; 95% CI 0.51 to 0.80). For the two high-quality trials on polyclonal IVIG, the RR for overall mortality was 0.30, but the confidence interval was wide (95% CI 0.09 to 0.99, n=91). Mortality was not reduced among patients who received monoclonal antibodies such as anti-endotoxins (n=2,826 in 5 good-quality studies; RR=0.97; 95% CI 0.88 to 1.07) or anti-cytokines (n=4,318; RR=0.93; 95% CI 0.86 to 1.01). A few studies measured secondary outcomes (deaths from sepsis or length of hospitalisation) but no differences in the intervention and control groups were identified except among those who received polyclonal IVIG, where sepsis-related mortality was significantly reduced (n=161; RR=0.35; 95% CI 0.18 to 0.69). REVIEWER'S CONCLUSIONS Polyclonal IVIG significantly reduced mortality and and is a promising adjuvant in the treatment of sepsis and septic shock. However, all the trials were small and the totality of the evidence is insufficient to support a robust conclusion of benefit. Adjunctive therapy with monoclonal IVIGs remains experimental.
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Affiliation(s)
- M M Alejandria
- Clinical Epidemiology Unit, University of the Philippines Manila, College of Medicine, 547 P. Gil St., Ermita, Manila, Philippines, 1000.
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