Inhibition of Streptococcus pneumoniae adhesion by specific salivary IgA after oral immunisation with a ribosomal immunostimulant

Nonspecific immunomodulators for recurrent respiratory tract infections, wheezing and asthma in children: a systematic review of mechanistic and clinical evidence

PURPOSE OF REVIEW

To provide an overview of the mechanistic and clinical evidence for the use of nonspecific immunomodulators in paediatric respiratory tract infection (RTI) and wheezing/asthma prophylaxis.

RECENT FINDINGS

Nonspecific immunomodulators have a long history of empirical use for the prevention of RTIs in vulnerable populations, such as children. The past decade has seen an increase in both the number and quality of studies providing mechanistic and clinical evidence for the prophylactic potential of nonspecific immunomodulators against both respiratory infections and wheezing/asthma in the paediatric population. Orally administered immunomodulators result in the mounting of innate and adaptive immune responses to infection in the respiratory mucosa and anti-inflammatory effects in proinflammatory environments. Clinical data reflect these mechanistic effects in reductions in the recurrence of respiratory infections and wheezing events in high-risk paediatric populations. A new generation of clinical studies is currently underway with the power to position the nonspecific bacterial lysate immunomodulator OM-85 as a potential antiasthma prophylactic.

SUMMARY

An established mechanistic and clinical role for prophylaxis against paediatric respiratory infections by nonspecific immunomodulators exists. Clinical trials underway promise to provide high-quality data to establish whether a similar role exists in wheezing/asthma prevention.

Immunostimulants revisited: focus on the pharmacology of Ribomunyl

Ribomunyl is an immunostimulant that was developed and commercialized in the 1980s in France and has subsequently been made available in a large number of countries. The formulation is composed of proteoglycans from Klebsiella pneumoniae and of ribosomes from four of the most commonly encountered bacterial strains in recurrent respiratory tract infections. While it is obviously difficult to present a thorough summary of all historical data, here we revisit the mode of action of this immunostimulant and present a perspective in the context of the most recent data and hypotheses on the mechanisms of the antibacterial immune responses. We provide various examples of these mechanisms in innate immunity (phagocytosis, cell adhesion, dendritic cell maturation, Toll-like receptors, interferon production, proinflammatory cytokines, activation of natural killer cells), as well as in adaptative immunity (polyclonal activation of T and B cells, specific immunoglobulin A immune response in an integrated view of the mucosal immune system, and T helper type 1/type 2 [Th1/Th2] regulation and balance). The effect of this immunostimulant on anti-infectious responses can be explained, not only by a stimulation of the antibacterial defense directly assumed by innate immunity, but also by a stimulation of the specific (adaptative) immune response related to the activation of dendritic cells, of which the pivotal role in T-cell differentiation is already well known. This supports the potential of bacterial immunostimulants such as Ribomunyl in anti-infective therapy.

Ribosomal immunotherapy for recurrent respiratory tract infections in children

Recurrent respiratory tract infections are common in children. They reflect the immaturity of the immune system in its encounter with environmental antigens. Little or no specific protective immune response has yet been established. These infections represent an important public health problem in terms of both treatment (anti-inflammatory or antibacterial drugs for children) and economy. Immunotherapy has been proposed as a means of preventing these recurrent infections by providing children with small doses of inactive bacterial antigens liable to trigger specific and protective immune responses. Among such drugs, ribosomal preparations (to which this review is limited) appear to be not only well tolerated, but also ideally targeted to induce mucosal responses. One preparation of ribosomal mucosal vaccine is commercially available in several countries. Numerous clinical trials in the world have confirmed the positive role of this mucosal ribosomal bacterial vaccine in significantly reducing the number of infections, courses of antibacterials, and absenteeism. In vitro and ex vivo investigations have confirmed that such vaccines indeed trigger protective specific immune responses.

Translocation of ribosomal immunostimulant through an in vitro-reconstituted digestive barrier containing M-like cells

Ribosomal preparations of pathogenic micro-organisms of the upper respiratory tract can be delivered orally for the prevention of recurrent infectious episodes, because they induce mucosal and protective immune responses. The mechanism of mucosal barrier translocation is difficult to study in animal models, little is therefore known about this process. In order to circumvent these problems, we have examined the uptake of ribosomal preparations in three experimental systems that model human intestinal cells. We found that M-like cells displayed a 8.7-fold increase in the uptake of a ribosomal immunostimulant when compared to absorptive or crypt enterocyte-like cells. The product was taken up, translocated, and delivered in the basolateral compartment by cultured M-like cells. No translocation was observed across monolayers of T84 cells (model of crypt cells). Only minimal translocation occured through monolayers of Caco-2 cells (model of absorptive enterocytes). This suggests that, in vivo, colyophilisat is delivered mainly through the M cells overlying lymphoid follicles (Peyer's patches) or nodules of the gut-associated mucosal lymphoid tissue, which are the major inductor sites of mucosal responses. Use of the M-like cell cultured model could be a key step for the development of even more efficient immunostimulators in animals and human.

Mucosally induced immunoglobulin E-associated inflammation in the respiratory tract

The purpose of the present study was to determine the immunologic responses, particularly immunopathologic reactions, associated with nasal immunization with the mucosal adjuvant, cholera toxin (CT). BALB/c mice were nasally immunized with tetanus toxoid (TT) combined with CT, and the responses of these mice were determined. After nasal immunization, mice produce a serum antibody response, primarily of the immunoglobulin G (IgG) isotype of predominantly IgG1 subclass, against both TT and CT. Along with the antibody responses, we also found that inflammatory reactions, which could be potentially fatal, developed within the lung. Furthermore, IgE responses were also induced after nasal immunization, and these responses were associated with the detection of interleukin 5 in the serum. Thus, nasal immunization with TT plus CT likely results in the activation of Th2 cells, which may contribute to serious immunopathologic reactions in the lung.

Pharmacology of ribosomal immunotherapy

The use of immunostimulating drugs is one way to intervene in the immune system. Many of these agents are of bacterial origin and most are able to stimulate the nonspecific immune response by acting on polymorphonuclear cells (PMNs) and macrophages. Ribosomal immunotherapy ('Ribomunyl') contains both proteoglycans from Klebsiella pneumoniae and ribosomes from 4 different bacterial strains. It can stimulate not only macrophages but also specific antibody production. 'Ribomunyl' has been shown to stimulate many of the functions of PMNs, specifically the formation of oxygenated free radicals, chemotaxis and adhesion. The effect of 'Ribomunyl' immunostimulant on the properties of macrophages is of special interest, as these cells participate in both the nonspecific immune response (phagocytosis, proinflammatory cytokine production) and the specific immune response (antigen processing and presentation, lymphocyte proliferation). 'Ribomunyl' has been shown to increase the production of many cytokines [interleukin (IL)-1, IL-6, IL-8, tumour necrosis factor-alpha and colony-stimulating factor], leading to the activation of the cytokine network. 'Ribomunyl' was also able to stimulate natural killer cells involved in viral immunity. Because of the presence of ribosomes from 4 frequently encountered bacterial strains, 'Ribomunyl' has specific immunostimulant properties. This has been clearly demonstrated in animals and humans, where specific antibody-forming B cells were found in the tonsils after oral administration. However, specific T-cell response has not been reported, suggesting that 'Ribomunyl' could act directly on B cells such as T-cell-independent bacterial antigens.