Antimicrobial-induced endotoxin and cytokine activity in an in vitro model of septicemia in foals

The benefits, limitations and opportunities of preclinical models for neonatal drug development

Increased research to improve preclinical models to inform the development of therapeutics for neonatal diseases is an area of great need. This article reviews five common neonatal diseases - bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, perinatal hypoxic-ischemic encephalopathy and neonatal sepsis - and the available in vivo, in vitro and in silico preclinical models for studying these diseases. Better understanding of the strengths and weaknesses of specialized neonatal disease models will help to improve their utility, may add to the understanding of the mode of action and efficacy of a therapeutic, and/or may improve the understanding of the disease pathology to aid in identification of new therapeutic targets. Although the diseases covered in this article are diverse and require specific approaches, several high-level, overarching key lessons can be learned by evaluating the strengths, weaknesses and gaps in the available models. This Review is intended to help guide current and future researchers toward successful development of therapeutics in these areas of high unmet medical need.

Treatment of endotoxaemia and septicaemia in the equine patient

Endotoxins, constituents of the cell wall of gram-positive and gram-negative bacteria, regularly result in severe illness and death in horses. In endotoxaemia, these constituents are present in the systemic circulation; in septicaemia, whole microbes invade normally sterile parts of the body. Interaction of these endotoxins with pathogen recognition receptors leads to an inflammatory response that cannot always be sufficiently contained and hence needs direct treatment. Over the last decennia, our understanding of the pathophysiology of endotoxaemia and septicaemia has significantly increased. Based on improved understanding of the interaction between receptors and endotoxins as well as the subsequent downstream signalling pathways, new therapeutic targets have been identified in laboratory animal species and humans. Important species differences in the recognition of endotoxins and pathogens by their receptors as well as the inflammatory response to receptor activation hamper extrapolation of this information to the horse (and other species). Historically, horses with endotoxaemia and septicaemia have been treated mainly symptomatically and supportively. Based on the identified therapeutic targets, this review describes the current knowledge of the treatment for endotoxaemia and septicaemia in the horse with reference to the findings in other animal species and humans.

Hypothalamic-pituitary gland axis function and dysfunction in horses

Hypothalamic-pituitary (HP) dysfunction has been documented in a limited capacity in horses and foals associated with critical illness, stress, and pain. This article reviews species-specific details of anatomy, function, hormones, receptors, and testing of the HP axis in the horse. A discussion of critical care medicine relevant to HP dysfunction in the horse with some reference to current understanding in human medicine is made, focusing primarily on current and relevant literature. A brief mention of other conditions described in human and veterinary medicine is also provided for reference only, such as syndrome of inappropriate antidiuretic hormone secretion and other conditions.

Polymyxin B protects horses against induced endotoxaemia in vivo

REASONS FOR PERFORMING STUDY

A safe, affordable and effective treatment for endotoxaemia in horses is needed in order to reduce the incidence of this potentially fatal condition.

OBJECTIVE

To evaluate the effect of polymyxin B (PMB) on signs of experimentally-induced endotoxaemia.

HYPOTHESIS

PMB ameliorates the adverse effects of endotoxaemia without causing nephrotoxicity.

METHODS

Four groups of 6 healthy mature horses each received 20 ng endotoxin/kg bwt i.v. over 30 mins. Additionally, each group received one of the following i.v.; 5000 u PMB/kg bwt 30 mins before endotoxin infusion; 5000 u PMB/kg bwt 30 mins after endotoxin infusion; 1000 u PMB/kg bwt 30 mins prior to endotoxin infusion; or saline. Clinical response data and samples were collected to determine neutrophil count, serum tumour necrosis factor (TNF) activity, plasma thromboxane B2 concentration and urine gamma glutamyltranspeptidase (GGT) to creatinine ratio.

RESULTS

Treatment with PMB before or after administration of endotoxin significantly reduced fever, tachycardia and serum TNF, compared to horses receiving saline. The differences in response to endotoxin were greatest between horses that received saline vs. those that received 5000 u PMB/kg bwt prior to endotoxin. Urine GGT:creatinine did not change significantly.

CONCLUSIONS AND POTENTIAL RELEVANCE

This study indicates that PMB may be a safe and effective treatment of endotoxaemia, even when administered after onset. Although nephrotoxicity was not demonstrated with this model, caution should be exercised when using PMB in azotaemic patients.

Update on treatments for endotoxemia

Endotoxemia is a major cause of morbidity and mortality in horses affected by colic. This article briefly reviews the pathogenesis of endotoxemia in horses with colic, reviews current established treatments, and describes new advances in the treatment of endotoxemia.

Equine neonatal sepsis

Neonatal infection remains a leading cause of morbidity and mortality in the equine industry, despite advances in prevention and treatment. Many factors can influence a foal's risk for the development of sepsis in the peripartum period. This article discusses those factors, causative organisms, and therapeutic options. Factors that influence prognosis and potential preventative strategies also are addressed.

Equine endotoxaemia--a state-of-the-art review of therapy

The pathophysiology of endotoxaemia, a leading cause of death in the horse, is beginning to be understood in greater detail. Endotoxin may be absorbed into the systemic circulation in a number of different ways: most commonly the body's normal defense mechanisms are disrupted or bypassed, or the normal clearance mechanisms overwhelmed. Following this wide-spread effects are observed, although the most significant are seen in the cardiovascular system. Fever, arterial hypoxaemia and signs of abdominal pain are also common. With increased understanding of the disease new therapeutic agents have become available, however, while the newer agents offer some advantages it is important to recognise that supportive care is the mainstay of treatment for endotoxaemia. Supportive care consists of aggressive fluid therapy (crystalloid, colloid and hypertonic), the administration of non-steroidal antiinflammatory drugs and, where appropriate, antimicrobials. The principles of supportive care are discussed in detail. Other therapies such as hyperimmune plasma, polymyxin B, pentoxifylline, dimethyl sulfoxide and heparin are commonly used in the treatment of equine endotoxaemia and their use is reviewed here. Furthermore, newer agents such as anti-tumour necrosis factor antibodies, detergent, activated protein C and insulin, which have yet to gain widespread acceptance but may have an important role in the treatment of endotoxaemia in the future, are examined.

Pharmacokinetics of imipenem-cilastatin following intravenous administration in healthy adult horses

In two studies, six healthy adult horses were given imipenem-cilastatin by slow intravenous (i.v.) infusion at an imipenem dosage of 10 mg/kg (study 1) and 20 mg/kg (study 2). The same horses were used in each dosage schedule, with a 2-week washout period between studies. In each dosage group, serial blood and synovial fluid samples were collected for 6 h after completion of the infusion. HPLC was used to determine the imipenem concentration in all samples. Imipenem was well tolerated by all horses at both dosages; no adverse effects were noted during the study period or during the 24-hour postinfusion observation period. The pharmacokinetic profiles of imipenem in the plasma and synovial fluid indicate that an imipenem dosage of 10-20 mg/kg by slow i.v. infusion q6h (every 6 h) is appropriate for most susceptible pathogens.

Treatment of endotoxemia

Although recognition of clinical signs of endotoxemia is not difficult, determining the underlying cause for the development of endotoxemia may be a challenging task. For this reason, importance must be placed on performance of a thorough physical examination, attention to detail, and determination of whether or not surgical intervention is required. In most instances, a definitive diagnosis may require repeated examinations and laboratory work. In the meantime, affected animals require treatment for endotoxemia, with the aim being to reduce the duration of endotoxemia, prevent the interaction of additional endotoxins with cell surface receptors, and reduce the synthesis and release of inflammatory mediators.