Removal of bacteria from blood by charcoal hemoperfusion

[Hemoperfusion and plasmapheresis in the intensive care unit]

In addition to kidney replacement procedures, several other extracorporeal procedures are employed in the intensive care unit. Hemoperfusion with activated charcoal was the predominant treatment used for removal of toxins from the 1970s until the millennium. Nowadays, this treatment does no longer play a clinically meaningful role as even strongly protein-bound toxins can be removed by effective dialysis procedures in case poisoning. The concept of a cytokine adsorber was introduced 10 years ago, which is directed towards withstanding the cytokine storm. Despite negative data from prospective randomized controlled studies, its use is steadily increasing in Germany. A totally different treatment concept is the biomimetic pathogen adsorber, which removes bacteria, viruses and fungi from the bloodstream by binding to immobilized heparin. Whether this rapid reduction of the pathogen load translates into an improvement of clinically relevant endpoints is unclear, as prospective randomized controlled studies are lacking. For the early hours of septic shock a very old procedure, plasmapheresis, has recently regained interest. The results of two large randomized controlled studies in this setting from Europe and Canada will become available in 2025/2026. The rationale to use plasma exchange in early sepsis is that this procedure not only removes cytokines but also replenishes reduced levels of protective factors, such as angiopoietin‑1, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS-13) and protein C, if fresh plasma is used as exchange fluid. All afore mentioned procedures do not only have a different mode of action but are also used at seperate time points of bloodstream infections and/or sepsis.

Hämoperfusion und Plasmapherese auf der Intensivstation

Neben Nierenersatzverfahren werden auf der Intensivstation mehrere andere extrakorporale Verfahren eingesetzt. In den 1970er- bis 2000er-Jahren stand die Hämoperfusion mit Aktivkohlekapseln zur Entfernung von Toxinen im Vordergrund. Dies ist mittlerweile aufgrund der effektiven Dialyseverfahren, die im Vergiftungsfall auch stark proteingebundene Toxine entfernen, fast bedeutungslos geworden. Vor 10 Jahren erlebte ein Zytokinadsorber die Markteinführung, der darauf gerichtet ist, den „Zytokinsturm“ zu überstehen. Dieser erfreut sich trotz ernüchternder Daten aus prospektiven, randomisierten, kontrollierten Studien wachsender Beliebtheit. Ein gänzlich anderes Therapiekonzept ist der biomimetische Pathogenadsorber, der Bakterien, Viren und Pilze durch Bindung an immobilisiertes Heparin aus dem Blutstrom entfernt. Ob sich diese schnelle Reduktion der Pathogenlast in eine Verbesserung klinisch relevanter Endpunkte übersetzt, ist unklar, da hier prospektive, randomisierte und kontrollierte Studien gänzlich fehlen. Für ein sehr altes Verfahren, nämlich die Plasmapherese, werden wir für die Frühphase der Sepsis bis zum Jahr 2025/2026 Ergebnisse aus 2 großen randomisierten, kontrollierten Studien aus Europa und Kanada erhalten. Neben der Entfernung von Zytokinen erhofft man sich durch die Verwendung von Frischplasma als Austauschflüssigkeit auch das Wiederauffüllen reduzierter protektiver Faktoren wie Angiopoietin 1, ADAMTS13 („a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13“) und Protein C. Alle genannten Verfahren funktionieren nicht nur unterschiedlich, sondern werden auch zu unterschiedlichen Zeitpunkten der Blutstrominfektion/Sepsis eingesetzt.

Safety and efficacy of the Seraph® 100 Microbind® Affinity Blood Filter to remove bacteria from the blood stream: results of the first in human study

Background

Bacterial burden as well as duration of bacteremia influence the outcome of patients with bloodstream infections. Promptly decreasing bacterial load in the blood by using extracorporeal devices in addition to anti-infective therapy has recently been explored. Preclinical studies with the Seraph® 100 Microbind® Affinity Blood Filter (Seraph® 100), which consists of heparin that is covalently bound to polymer beads, have demonstrated an effective binding of bacteria and viruses. Pathogens adhere to the heparin coated polymer beads in the adsorber as they would normally do to heparan sulfate on cell surfaces. Using this biomimetic principle, the Seraph® 100 could help to decrease bacterial burden in vivo.

Methods

This first in human, prospective, multicenter, non-randomized interventional study included patients with blood culture positive bloodstream infection and the need for kidney replacement therapy as an adjunctive treatment for bloodstream infections. We performed a single four-hour hemoperfusion treatment with the Seraph® 100 in conjunction with a dialysis procedure. Post procedure follow up was 14 days.

Results

Fifteen hemodialysis patients (3F/12 M, age 74.0 [68.0–78.5] years, dialysis vintage 28.0 [11.0–45.0] months) were enrolled. Seraph® 100 treatment started 66.4 [45.7–80.6] hours after the initial positive blood culture was drawn. During the treatment with the Seraph® 100 with a median blood flow of 285 [225–300] ml/min no device or treatment related adverse events were reported. Blood pressure and heart rate remained stable while peripheral oxygen saturation improved during the treatment from 98.0 [92.5–98.0] to 99.0 [98.0–99.5] %; p = 0.0184. Four patients still had positive blood culture at the start of Seraph® 100 treatment. In one patient blood cultures turned negative during treatment. The time to positivity (TTP) was increased between inflow and outflow blood cultures by 36 [− 7.2 to 96.3] minutes. However, overall TTP increase was not statistical significant.

Conclusions

Seraph® 100 treatment was well tolerated. Adding Seraph® 100 to antibiotics early in the course of bacteremia might result in a faster resolution of bloodstream infections, which has to be evaluated in further studies.

Trail registration: ClinicalTrials.gov Identifier: NCT02914132, first posted September 26, 2016.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04044-7.

Elimination of Staphylococcus aureus from the bloodstream using a novel biomimetic sorbent haemoperfusion device

Removal of bacteria from the blood by means of extracorporeal techniques has been attempted for decades. In late 2019, the European Union licensed the first ever haemoperfusion device for removal of bacteria from the blood. The active ingredient of Seraph 100 Microbind Affinity Blood Filter is ultrahigh molecular weight polyethylene beads with endpoint-attached heparin. Bacteria have been shown to bind to heparin as they would usually do to the heparan sulfate on the cell surface, thereby being removed from the blood stream. We describe the first case of a female chronic haemodialysis patient in which this device was clinically used for a Staphylococcus aureus infection that persisted for 4 days despite antibiotic therapy. After a single treatment, the bacterial load decreased and the blood cultures at the end of a 4 hour haemoperfusion exhibited no bacterial growth.

Sepsis: mechanisms of bacterial injury to the patient

In bacteremia the majority of bacterial species are killed by oxidation on the surface of erythrocytes and digested by local phagocytes in the liver and the spleen. Sepsis-causing bacteria overcome this mechanism of human innate immunity by versatile respiration, production of antioxidant enzymes, hemolysins, exo- and endotoxins, exopolymers and other factors that suppress host defense and provide bacterial survival. Entering the bloodstream in different forms (planktonic, encapsulated, L-form, biofilm fragments), they cause different types of sepsis (fulminant, acute, subacute, chronic, etc.). Sepsis treatment includes antibacterial therapy, support of host vital functions and restore of homeostasis. A bacterium killing is only one of numerous aspects of antibacterial therapy. The latter should inhibit the production of bacterial antioxidant enzymes and hemolysins, neutralize bacterial toxins, modulate bacterial respiration, increase host tolerance to bacterial products, facilitate host bactericidal mechanism and disperse bacterial capsule and biofilm.

Sepsis and septic shock: Pathogenesis and treatment perspectives

The majority of bacteremias do not develop to sepsis: bacteria are cleared from the bloodstream. Oxygen released from erythrocytes and humoral immunity kill bacteria in the bloodstream. Sepsis develops if bacteria are resistant to oxidation and proliferate in erythrocytes. Bacteria provoke oxygen release from erythrocytes to arterial blood. Abundant release of oxygen to the plasma triggers a cascade of events that cause: 1. oxygen delivery failure to cells; 2. oxidation of plasma components that impairs humoral regulation and inactivates immune complexes; 3. disseminated intravascular coagulation and multiple organs' failure. Bacterial reservoir inside erythrocytes provides the long-term survival of bacteria and is the cause of ineffectiveness of antibiotics and host immune reactions. Treatment perspectives that include different aspects of sepsis development are discussed.

Eliminating the carriage of Salmonella enterica serovar Enteritidis in domestic fowls by feeding activated charcoal from bark containing wood vinegar liquid (Nekka-Rich)

The protective efficacy of activated charcoal containing wood vinegar liquid (Nekka-Rich) against intestinal infection with Salmonella enterica serovar Enteritidis was sought. In the present study, the adsorption effects of activated charcoal of Nekka-Rich on S. Enteritidis and normal bacterial flora in the intestine, Enterococcus faecium, were examined. S. Enteritidis was effectively adsorbed by activated charcoal of Nekka-Rich. On the other hand, activated charcoal of Nekka-Rich showed lower binding capacity to E.faecium. The effects of wood vinegar liquid included in Nekka-Rich on the growth of S. Enteritidis and normal bacterial flora in the intestine, E. faecium and Bifidobacterium thermophilum, were also assessed. Wood vinegar liquid had an inhibitory effect on the S. Enteritidis growth, whereas growth of E. faecium and B. thermophilum was enhanced by wood vinegar liquid. Furthermore, the protective effects of Nekka-Rich were evaluated in a challenge chicken model with S. Enteritidis. Chickens were fed a basal diet containing Nekka-Rich or immunized with commercially obtained S. Enteritidis vaccine and challenged with S. Enteritidis. Significantly less fecal excretion of S. Enteritidis was observed in chickens fed Nekka-Rich for 10 d after challenge. On d 15 after challenge, S. Enteritidis was not isolated from fecal samples. On the other hand, immunization of chickens with S. Enteritidis vaccine did not fully inhibit bacterial growth. Fecal excretion of S. Enteritidis was consistently observed in the vaccinated chickens after challenge. These results suggest that Nekka-Rich would be a good product for eliminating the carriage of S. Enteritidis in domestic fowl.

Adsorption effect of activated charcoal on enterohemorrhagic Escherichia coli

The adsorption property of activated charcoal on verotoxin (VT)-producing Escherichia coli (VTEC) was examined using E. coli O157:H7. In the present study, E. coli O157:H7 strains were effectively adsorbed by activated charcoal. Adsorption was dose-dependent, and the maximum adsorption occurred within 5 min. At 10 mg of activated charcoal, bacteria tested were completely adsorbed. Activated charcoal also had the capacity to adsorb toxin (verotoxin 2) activity from the bacterial extract. Furthermore, the adsorption efficiency of activated charcoal for the normal bacterial flora in the intestine was assessed using Enterococcus faecium, Bifidobacterium thermophilum, and Lactobacillus acidophilus. Activated charcoal showed lower binding capacity to the normal bacterial flora tested than that to E. coli O157:H7 strains. These results suggest that activated charcoal could be a good adsorbent system for the removal of VTEC and verotoxin.

Coating charcoal with polyacrylate-polymethacrylate copolymer for haemoperfusion. II. Drug removal and polymer compatibility studies

The newly developed system of polyacrylate-polymethacrylate-coated charcoal, filled in a column has been tested for its efficiency in removing theophylline, as a model drug both from a buffer solution pH 7.4 and human plasma using a closed-circuit apparatus. Preliminary testing determined the capacity of the charcoal column and the effect of circulation rate of the buffer solution on the clearance of theophylline. It was found that the circulation rate does not significantly affect the clearance rate of theophylline, while the concentration of drug in the buffer solution has a considerable effect on the clearance of the drug, presumably due to the saturation of the column. The clearance of the drug from plasma in comparison to buffer solution was also investigated. It was found that more than 70 per cent of the drug was removed from the buffer solution within the first 15 min as compared with 65 per cent from plasma; with 95 per cent removed from buffer after 1 h in comparison to 93 per cent from plasma. The blood compatibility of the polymer was studied by incubating various concentrations (5-25 per cent w/v) of the polymer in blood for 30 min at 25 degrees C. A concentration of 5 per cent polymer was also incubated for a series of incubation times. The results indicated that with polymer concentrations up to 15 per cent there is no significant lysis of RBCs in comparison to a blank.(ABSTRACT TRUNCATED AT 250 WORDS)

Usual physicochemical criteria provide insufficient evidence that a functional hemoglobin solution can be used for transfusions after storage for 36 months at +4 degrees C

Hemoglobin solutions will be of clinical interest only if they are easy to use, efficient and can be stored for long periods. While most studies are concerned with hemoprotein improvement (P50 and plasmatic half-life) few deal with long term stability of liquid state solutions. Physicochemical and physiological analyses were carried out on a 70 g/l ready-to-use hemoglobin solution after 1.5, 2.5 and 3 years storage at +4 degrees C, away from light and without any protective additives. The evaluation of hemoglobin stability by tests used in clinical biology shows few structural and functional alterations. However, after 1.5 year total transfusional exchanges carried out on rats cause rapid death, which seems to point to hemoprotein modifications undetected by biological techniques. It therefore appears that physicochemical tests do not provide adequate grounds for claiming that a hemoglobin solution kept for over a year and a half at +4 degrees C can still be used effectively in transfusions.