Sepsis and pregnancy: do we know how to treat this situation?

Sepsis in obstetric care for the emergency clinician: A review

Sepsis remains a leading cause of mortality among pregnant and recently pregnant patients, rendering it a subject of vital importance to emergency clinicians in the US. However, death by sepsis has been found to be largely preventable with prompt and appropriate intervention. This narrative review provides a summary of the physiologic, epidemiologic, and systemic factors specific to obstetric sepsis that contribute to delays in diagnosis and treatment. Additionally, it provides a framework for emergency department providers to approach infection identification, antimicrobial selection, and appropriate resuscitation prior to disposition.

Maternal septic shock due to Acinetobacter lwoffii infection:a case report

The incidence of Acinetobacter infections has increased in recent years. Acinetobacter infections are resistant to most antibiotics and can be found in hospitalized patients. Pregnancies complicated by severe sepsis or septic shock are associated with a higher rate of preterm labor and delivery, fetal infection, and operative delivery. This case report describes septic shock due to Acinetobacter lwoffii infection in the 31st week of gestation. A 47-year-old woman, with a gestation of 31 weeks and one day, presented with a fever, and signs of bacterial infection on laboratory tests. Although the patient was started on tazobactam/piperacillin, she went into septic shock, and was transferred to our hospital. Cesarean section was performed at a gestation of 31 weeks and 4 days because of severe maternal pneumonia and non-reassuring fetal status. A. lwoffii was detected in blood cultures collected at the previous hospital, and susceptibility to piperacillin and meropenem to A. lwoffii was confirmed. The pneumonia responded to antibiotic treatment and there were no findings of infection in the neonate. Maternal sepsis is an infrequent but important complication, causing significant maternal and fetal morbidity and fetal and neonatal mortality; therefore, early antibiotic therapy is required to improve the clinical outcome.

Association between antenatal corticosteroid treatment and severe adverse events in pregnant women

BACKGROUND

Antenatal corticosteroids are considered the standard of care for pregnant women at risk for preterm birth, but studies examining their potential risks are scarce. We aimed to estimate the associations of antenatal corticosteroids with three severe adverse events: sepsis, heart failure, and gastrointestinal bleeding, in pregnant women.

METHODS

Of 2,157,321 pregnant women, 52,119 at 24 weeks 0/7 days to 36 weeks 6/7 days of gestation were included in this self-controlled case series study during the study period of 2009-2018. We estimated incidence rates of three severe adverse events: sepsis, heart failure, and gastrointestinal bleeding. Conditional Poisson regression was used to calculate incidence rate ratios (IRRs) for comparing incidence rates of the adverse events in each post-treatment period compared to those during the baseline period among pregnant women exposed to a single course of antenatal corticosteroid treatment.

RESULTS

Among 52,119 eligible participants who received antenatal corticosteroid treatment, the estimated incidence rates per 1000 person-years were 0.76 (95% confidence interval (CI): 0.69-0.83) for sepsis, 0.31 (95% CI: 0.27-0.36) for heart failure, and 11.57 (95% CI: 11.27-11.87) for gastrointestinal bleeding. The IRRs at 5 ~ 60 days after administration of antenatal corticosteroids were 5.91 (95% CI: 3.10-11.30) for sepsis and 4.45 (95% CI: 2.63-7.55) for heart failure, and 1.26 (95% CI: 1.02-1.55) for gastrointestinal bleeding; and the IRRs for days 61 ~ 180 were 2.00 (95% CI: 1.01-3.96) for sepsis, 3.65 (95% CI: 2.14-6.22) for heart failure, and 1.81 (95% CI: 1.56-2.10) for gastrointestinal bleeding.

CONCLUSIONS

This nationwide population-based study suggests that a single course of antenatal corticosteroids is significantly associated with a 1.3- to 5.9-fold increased risk of sepsis, heart failure, and gastrointestinal bleeding in pregnant women. Maternal health considerations, including recommendations for adverse event monitoring, should be included in future guidelines for antenatal corticosteroid treatment.

Septic shock in obstetrics: guidelines of the All-Russian public organization “Federation of Anesthesiologists and Reanimatologists”

The article reflects the main provisions of the clinical guidelines on septic shock in obstetrics, approved by the All-Russian public organization “Federation of Anesthesiologists-Resuscitators” in 2022. The relevance of the problem is associated with high mortality and morbidity rates from sepsis and septic shock in obstetrics. The main issues of etiology, pathogenesis, clinical picture, methods of laboratory and instrumental diagnostics, features of using the qSOFA, SOFA, MOEWS, SOS, MEWC, IMEWS scales for sepsis verification are consistently presented. The article presents the starting intensive therapy (the first 6–12 hours) of the treatment of septic shock in obstetrics, taking into account the characteristics of the pregnant woman's body. The strategy of prescribing vasopressors (norepinephrine, phenylephrine, epinephrine), inotropic drugs (dobutamine) is described, antibiotics and optimal antibiotic therapy regimens, features of infusion and adjuvant therapy are presented. The issues of surgical treatment of the focus of infection and indications for hysterectomy, as well as the organization of medical care and rehabilitation of patients with sepsis and septic shock were discussed. The basic principles of prevention of sepsis and septic shock in obstetrics are described. The criteria for the quality of medical care for patients with septic shock and the algorithms of doctor's actions in the diagnosis and intensive care of patients with septic shock in obstetrics are presented.

Analysis of Causes of Maternal Death in East Java Province, Indonesia

BACKGROUND: The maternal mortality rate is an indicator that reflects the mother’s health status, especially the risk of death for the mother during pregnancy and childbirth. Measles, Mumps, and Rubella (MMR) has a close relationship with efforts to increase human development. Therefore, efforts are needed to reduce MMR by identifying the factors that influence MMR. AIM: The aim of the study was to analyze the factors causing the incidence of Maternal Death in East Java Province. METHODS: The research design used in this research is a quantitative research using descriptive-analytical. The population of this research is districts/cities in East Java Province, with a sample of 38 districts/cities. The research period starts from August to September 2021. Data analysis using grouping and percentage of cases. RESULTS: The results of the study found that cases of maternal death in East Java due to postpartum hemorrhage in 2021 were 131 cases. Cases due to hypertension as many as 115 cases. Cases due to infection as many as 25 cases. The incidence of maternal death due to abortion is 1 case. There were 13 cases of maternal death due to blood disorders. There were 6 cases of maternal death due to metabolic disorders — cases of maternal death due to Heart as many as 54 cases. Maternal deaths due to COVID-19 were 793 cases. CONCLUSION: Factors causing maternal death in East Java Province, namely, hypertension bleeding, infection, abortion, blood disorders, heart metabolic disorders, and COVID-19. The most influential factor in maternal mortality in 2021 is COVID-19.

Immune-metabolic adaptations in pregnancy: A potential stepping-stone to sepsis

Physiological shifts during pregnancy predispose women to a higher risk of developing sepsis resulting from a maladapted host-response to infection. Insightful studies have delineated subtle point-changes to the immune system during pregnancy. Here, we present an overlay of these point-changes, asking what changes and when, at a physiological, cellular, and molecular systems-level in the context of sepsis. We identify distinct immune phases in pregnancy delineated by placental hormone-driven changes in homeostasis setpoints of the immune and metabolic systems that subtly mirrors changes observed in sepsis. We propose that pregnancy immune-metabolic setpoint changes impact feedback thresholds that increase risk for a maladapted host-response to infection and thus act as a stepping-stone to sepsis. Defining maternal immune-metabolic setpoint changes is not only vital for tailoring the right diagnostic tools for early management of maternal sepsis but will facilitate an unravelling of the pathophysiological pathways that predispose an individual to sepsis.

Physiological Changes and Interactions Between Microbiome and the Host During Pregnancy

In recent years, it has become clear that microbiome play a variety of essential roles in human metabolism, immunity, and overall health and that the composition of these microbiome is influenced by our environment, diet, weight, hormones, and other factors. Indeed, numerous physiological and pathological conditions, including obesity and metabolic syndrome, are associated with changes in our microbiome, referred to as dysbiosis. As a result, it is not surprising that such changes occur during pregnancy, which includes substantial weight gain and significant changes in metabolism and immune defenses. The present review relates physiological changes during pregnancy to alterations in the microbial composition at various sites, including the gut, oral cavity, and vagina. Pregnancy has been linked to such microbial changes, and we believe that, in contrast to certain disease states, these microbial changes are vital for a healthy pregnancy, probably through their influence on the mother’s immunological, endocrinological, and metabolic status.

Maternal Sepsis: A Review of National and International Guidelines

OBJECTIVE

 Sepsis is a life-threatening syndrome caused by the body's response to infection. The Global Maternal Sepsis Study (GLOSS) suggests sepsis plays a larger role in maternal morbidity and mortality than previously thought. We therefore sought to compare national and international guidelines for maternal sepsis to determine their consistency with each other and the Third International Consensus for Sepsis and Septic Shock (SEPSIS-3).

STUDY DESIGN

 Using Cochrane Database of Systematic Reviews, PubMed, Google Scholar, and organization Web sites, we identified seven guidelines on maternal sepsis in the English language-The American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Society of Obstetric Medicine of Australia and New Zealand, Royal College of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland Institute of Obstetricians and Gynaecologists, and World Health Organization. Guidelines were reviewed to ascertain the commonality and variation, if any, in definitions of maternal sepsis, tools and criteria utilized for diagnosis, obstetric warning systems used, as well as evaluation and management of maternal sepsis. These variables were also compared with SEPSIS-3.

RESULTS

 All guidelines provided definitions consistent with a version of the SEPSIS, although the specific version utilized were varied. Clinical variables and tools employed for diagnosis of maternal sepsis were also varied. Evaluation and management of maternal sepsis and septic shock were similar.

CONCLUSION

 In conclusion, national and international maternal sepsis guidelines were incongruent with each other and SEPSIS-3 in diagnostic criteria and tools but similar in evaluation and management recommendations.

KEY POINTS

· Definitions for maternal sepsis and septic shock are varied.. · Maternal sepsis guidelines differ in proposed criteria and tools.. · Maternal sepsis guidelines have similar management recommendations..

Sepsis scoring systems and use of the Sepsis six care bundle in maternity hospitals

BACKGROUND

This study aimed to assess the predictive power of three different Sepsis Scoring Systems (SSSs), namely maternity Systematic Inflammatory Response Syndrome (mSIRS), quick Sepsis-related Organ Failure Assessment (qSOFA) and Modified Early Warning System (MEWS) in identifying sepsis by comparing them with positive culture. This study also sought to evaluate compliance with using the Sepsis Six Care Bundle (SSCB) operated in an individual health board.

METHODS

A retrospective cohort study was conducted in 3 maternity hospitals of a single Scottish health board that admitted 2690 pregnancies in a 12 weeks period in 2016. Data for study was obtained from medical notes, handheld and electronic health records for women who were prescribed antibiotics with a confirmed or suspected diagnosis of sepsis. Data on clinical parameters was used to classify women according to mSIRS, qSOFA and MEWS as having sepsis or not and this was compared to results of positive culture to obtain sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under Receiver Operating Characteristic curve (AUROC) along with their 95% confidence intervals. Data was also obtained on SSCB compliance.

RESULTS

A total of 89 women were diagnosed with sepsis, of which 14 had missing data, leaving 75 for final analysis. Sensitivity, specificity, PPV, NPV and AUROC of mSIRS and MEWS were almost similar with AUROC of both being around 50%. Only 33 (37.1%) had identifiable sepsis six sticker displayed on medical notes and only 2 (2.2%) had all elements of SSCB delivered within the recommended one-hour post-diagnosis period. Blood culture and full blood count with other lab tests had been performed for most women (97%) followed by intravenous antibiotics and fluids (93.9%).

CONCLUSIONS

mSIRS and MEWS were quite similar in detecting sepsis when compared to positive culture, with their ability to detect sepsis being close to chance. This underlines the need for creating a valid SSS with high sensitivity and specificity for clinical use in obstetric settings. Clinical use of SSCB was limited despite it being a health board policy, although there is considerable possibility of improvement following detailed audits and removal of barriers for implementing SSCB.

CHALLENGES IN THE MANAGEMENT OF PRESUMED FUNGAL ENDOPHTHALMITIS IN PREGNANCY

PURPOSE

To report a rare case of endogenous endophthalmitis in pregnancy and the challenges of managing culture-negative fungal infection.

METHODS

Retrospective case report. A 30-year-old woman presented with a subfoveal chorioretinal lesion with vitritis and anterior chamber inflammation in the context of intravenous drug use. Spectral domain optical coherence tomography and fluorescein angiography were used for documentation and monitoring.

RESULTS

After 2 months of systemic and intravitreal injections of amphotericin, the patient had clinical improvement in visual acuity, degree of inflammation, and in the size and activity of the chorioretinal lesion, which was presumed to be fungal in origin.

CONCLUSION

Among limited cases of endophthalmitis in pregnancy, we report a challenging case of presumed fungal endogenous endophthalmitis. The patient responded favorably to intravitreal and systemic antifungal medications.

Manejo de la sepsis en el embarazo. Revisión de la literatura

La sepsis se reconoce como una enfermedad común y mortal, cuya epidemiología obliga al médico tratante a realizar un diagnóstico oportuno por el alto riesgo de complicaciones o muerte. En las gestantes hay una gran vulnerabilidad debido a los cambios físicos y hormonales que están afrontado. Es indispensable iniciar el tratamiento tan pronto se tenga el diagnóstico, para evitar que sea mortal tanto para la madre como para el feto. Es por esto que el objetivo es una revisión sobre la intervención en las pacientes con diagnóstico de sepsis en estado de embarazo al ingreso a la UCI, bajo los siguientes ejes temáticos: definición clara de sepsis en el embarazo, factores de riesgo, intervención terapéutica en UCI y consecuencias para el feto durante su intervención. Se concluye que el manejo de la sepsis en las embarazadas es muy similar a las que no lo están. Hacen falta investigaciones con evidencia científica, velando siempre por la vida ya que no solo se trata un ser humano sino de dos.

Vibrational spectroscopic analysis of blood for diagnosis of infections and sepsis: a review of requirements for a rapid diagnostic test

Infections and sepsis represent a growing global burden. There is a widespread clinical need for a rapid, high-throughput and sensitive technique for the diagnosis of infections and detection of invading pathogens and the presence of sepsis. Current diagnostic methods primarily consist of laboratory-based haematology, biochemistry and microbiology that are time consuming, labour- and resource-intensive, and prone to both false positive and false negative results. Current methods are insufficient for the increasing demands on healthcare systems, causing delays in diagnosis and initiation of treatment, due to the intrinsic time delay in sample preparation, measurement, and analysis. Vibrational spectroscopic techniques can overcome these limitations by providing a rapid, label-free and low-cost method for blood analysis, with limited sample preparation required, potentially revolutionising clinical diagnostics by producing actionable results that enable early diagnosis, leading to improved patient outcomes. This review will discuss the challenges associated with the diagnosis of infections and sepsis, primarily within the UK healthcare system. We will consider the clinical potential of spectroscopic point-of-care technologies to enable blood analysis in the primary-care setting.

Refractory gram-negative septic shock complicated by extended purpura fulminans and multiple organ failure in a 23-year-old puerpera -a case report

Background

Pregnancy-related infections are the third most common cause of maternal death worldwide. The aim of this report is to present a case of pregnancy-related infection, which progressed into refractory septic shock accompanied by purpura fulminans and multiple organ failure.

Case

A 23-year-old woman in the postpartum period developed fulminant, refractory septic shock complicated by purpura fulminans and multiple organ failure syndrome (acute respiratory distress syndrome, acute kidney injury, and encephalopathy). Management included antibacterial therapy, fluid and transfusion therapy, nutritional support, protective mechanical ventilation, hydrocortisone, a large dose of ascorbic acid, and thiamine. There were no neurological consequences and all organ functions returned to normal, although the predicted hospital mortality based on the Sequential Organ Failure Assessment (SOFA) score was more than 90%.

Conclusions

Septic shock is a significant, yet not completely understood life-threatening condition, which can be associated with purpura fulminans, multiple organ dysfunction, disseminated intravascular coagulation, and massive tissue necrosis.

Rapid onset of severe septic shock in the pregnant mouse†

AIMS

Globally, sepsis is a major cause of mortality through the combination of cardiovascular collapse and multiorgan dysfunction. Pregnancy appears to increase the risk of death in sepsis, but the exact reason for the greater severity is unclear. In this study, we used polymicrobial sepsis induced by cecal ligation and puncture (CLP) and high-dose intraperitoneal lipopolysaccharide (LPS; 10 or 40 mg, serotype 0111: B4) to test the hypotheses that pregnant mice are more susceptible to sepsis and that this susceptibility was mediated through an excessive innate response causing a more severe cardiovascular collapse rather than a reduction in microbe killing.

METHODS AND RESULTS

Initial studies found that mortality rates were greater, and that death occurred sooner in pregnant mice exposed to CLP and LPS. In pregnant and nonpregnant CD1 mice monitored with radiotelemetry probes, cardiovascular collapse occurred sooner in pregnant mice, but once initiated, occurred over a similar timescale. In a separate study, tissue, serum, and peritoneal fluid (for protein, flow cytometry, nitric oxide, and bacterial load studies) were collected. At baseline, there was no apparent Th1/Th2 bias in pregnant mice. Post CLP, the circulating cytokine response was the same, but leukocyte infiltration in the lung was greater in pregnant mice, but only TNFα levels were greater in lung tissue. The bacterial load in blood and peritoneal fluid was similar in both groups.

CONCLUSION

Sepsis-related mortality was markedly greater in pregnant mice. Cardiovascular collapse and organ dysfunction occurred sooner in pregnancy, but bacterial killing was similar. Circulating and tissue cytokine levels were similar, but immune cell extravasation into other organs was greater in pregnant mice. These data suggest that an excessive innate immune system response as shown by the exaggerated lung infiltration of leukocytes may be responsible for the greater mortality. Approaches that reduce off-site trafficking may improve the prognosis of sepsis in pregnancy.

Sepsis in Pregnancy: Recognition and Resuscitation

The normal physiologic changes of pregnancy complicate evaluation for sepsis and subsequent management. Previous sepsis studies have specifically excluded pregnant patients. This narrative review evaluates the presentation, scoring systems for risk stratification, diagnosis, and management of sepsis in pregnancy. Sepsis is potentially fatal, but literature for the evaluation and treatment of this condition in pregnancy is scarce. While the definition and considerations of sepsis have changed with large, randomized controlled trials, pregnancy has consistently been among the exclusion criteria. The two pregnancy-specific sepsis scoring systems, the modified obstetric early warning scoring system (MOEWS) and Sepsis in Obstetrics Score (SOS), present a number of limitations for application in the emergency department (ED) setting. Methods of generation and subsequently limited validation leave significant gaps in identification of septic pregnant patients. Management requires consideration of a variety of sources in the septic pregnant patient. The underlying physiologic nature of pregnancy also highlights the need to individualize resuscitation and critical care efforts in this unique patient population. Pregnant septic patients require specific considerations and treatment goals to provide optimal care for this particular population. Guidelines and scoring systems currently exist, but further studies are required.

High-flow nasal cannula in the treatment of acute hypoxemic respiratory failure in a pregnant patient: case report

Little evidence exists to support the use of noninvasive mechanical ventilation for acute hypoxemic respiratory failure. However, considering the complications associated with endotracheal intubation, we attempted to implement noninvasive mechanical ventilation in a 24-year-old patient who was 32 weeks pregnant and was admitted to the intensive care unit with acute hypoxemic respiratory failure and sepsis secondary to a urinary tract infection. Lack of tolerance to noninvasive mechanical ventilation led us to use an alternative method to avoid endotracheal intubation. The use of high-flow nasal cannula allowed to overcome this situation, wich supports this technique as a treatment option for critical obstetric patients that is safe for both the mother and fetus.

SOMANZ guidelines for the investigation and management sepsis in pregnancy

SOMANZ (Society of Obstetric Medicine Australia and New Zealand) has written a guideline to provide evidence-based guidance for the investigation and care of women with sepsis in pregnancy or the postpartum period. The guideline is evidence-based and incorporates recent changes in the definition of sepsis. The etiology, investigation and treatment of bacterial, viral and non-infective causes of sepsis are discussed. Obstetric considerations relevant to anaesthetic and intensive care treatment in sepsis are also addressed. A multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women have contributed to the development of the guidelines. This is an executive summary of the guidelines.

Towards a consensus definition of maternal sepsis: results of a systematic review and expert consultation

Background

There is a need for a clear and actionable definition of maternal sepsis, in order to better assess the burden of this condition, trigger timely and effective treatment and allow comparisons across facilities and countries. The objective of this study was to review maternal sepsis definitions and identification criteria and to report on the results of an expert consultation to develop a new international definition of maternal sepsis.

Methods

All original and review articles and WHO documents, as well as clinical guidelines providing definitions and/or identification criteria of maternal sepsis were included. A multidisciplinary international panel of experts was surveyed through an online consultation in March-April 2016 on their opinion on the existing sepsis definitions, including new definition of sepsis proposed for the adult population (2016 Third International Consensus Definitions for Sepsis and Septic Shock) and importance of different criteria for identification of maternal sepsis. The definition was agreed using an iterative process in an expert face-to-face consensus development meeting convened by WHO and Jhpiego.

Results

Standardizing the definition of maternal sepsis and aligning it with the current understanding of sepsis in the adult population was considered a mandatory step to improve the assessment of the burden of maternal sepsis by the expert panel. The literature review and expert consultation resulted in a new WHO consensus definition “Maternal sepsis is a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, child-birth, post-abortion, or post-partum period”. Plans are in progress to validate the new WHO definition of maternal sepsis in a large international population.

Conclusion

The operationalization of the new maternal sepsis definition requires generation of a set of practical criteria to identify women with sepsis. These criteria should enable clinicians to focus on the timely initiation of actionable elements of care (administration of antimicrobials and fluids, support of vital organ functions, and referral) and improve maternal outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-017-0321-6) contains supplementary material, which is available to authorized users.

Sepsis in Special Populations

Sepsis is recognized by the presence of physiologic and laboratory changes that reflect the inflammatory response to infection on cellular and systemic levels. Comorbid conditions, such as cirrhosis, end-stage renal disease, and obesity, alter patients' susceptibility to infection and their response to it once present. Baseline changes in vital signs and chronic medications often mask clues to the severity of illness. The physiologic, hematologic, and biochemical adjustments that accompany pregnancy and the puerperium introduce similar challenges. Emergency providers must remain vigilant for subtle alterations in the expected baseline for these conditions to arrive at appropriate management decisions.

Design, Synthesis, and Structure-Activity Relationship Study of Novel Indole-2-carboxamide Derivatives as Anti-inflammatory Agents for the Treatment of Sepsis

Sepsis is characterized by a systemic inflammatory response syndrome. Derivatives of indole have been reported to exhibit diverse biological activities. This study reports on the design and synthesis of a new series of indole-2-carboxamide derivatives, which are screened for their anti-inflammatory activities in RAW 264.7 macrophages. A majority of these derivatives effectively inhibited lipopolysaccharides (LPS)-induced expression of tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL-6). Preliminary structure-activity relationship analysis was also conducted. The results indicate that the most promising compounds in the prepared series were 14f and 14g. They were found to effectively reduce LPS-induced pulmonary inflammation and overexpression of a series of inflammatory mediators. Furthermore, in vivo administration of 14f and 14g resulted in remarkable lung histopathological improvements in mice without toxicity in organs. Taken together, these data indicate that the newly discovered indole-2-carboxamide derivatives could be particularly useful for further treatment in inflammatory diseases.

Maternal Sepsis and Septic Shock

The year 2015 marked the 200th anniversary of the birth of Ignaz Semmelweis, the Hungarian physician who identified unhygienic practices of physicians as a major cause of childbed fever or puerperal sepsis. Although such practices have largely disappeared as a factor in the development of chorioamnionitis and postpartum or puerperal endometritis, it is appropriate that this article on sepsis in pregnancy acknowledges his contributions to maternal health. This review describes the incidence and mortality of sepsis in pregnancy, methods to identify and define sepsis in this population, including scoring systems, causes, and sites of infection during pregnancy and parturition and management guidelines.

Rhein inhibits lipopolysaccharide-induced intestinal injury during sepsis by blocking the toll-like receptor 4 nuclear factor-κB pathway

Sepsis is one of the leading causes of mortality in severe systemic inflammatory syndrome. The endotoxin-induced inflammatory response has been linked to the development of sepsis. Rhein is a lipophilic anthraquinone isolated from Rheum rhabarbarum (rhubarb), which has a protective effect on intestinal damage in vivo. However, the underlying mechanism responsible for the protective effects of rhein remains to be elucidated. In the present study, mice were exposed to 20 mg/kg lipopolysaccharide (LPS), prior to being treated with either 100 mg/kg rhein or 0.3 mg/kg toll‑like receptor 4 (TLR4) signaling inhibitor TAK‑242. In the rhein‑treated mice, the colon length (cm) was extended and colon injury was attenuated. In addition, treatment with rhein significantly decreased the expression levels of the LPS‑induced inflammatory cytokines interleukin (IL)‑1β, IL‑6, IL‑8, and tumor necrosis factor‑α, in both the plasma and colon tissue. However, mice treated with TAK‑242 exhibited increased expression levels of IL‑10, as determined by ELISA and western blot analysis. In addition, immunohistochemistry and western blot analyses demonstrated that treatment with rhein was able to reduce TLR4 expression and inhibit nuclear factor‑κB (NF‑κB) phosphorylation in colon tissue. Furthermore, LPS induction was blocked by TAK‑242. These results demonstrate that the observed rhein‑attenuated inflammatory response during sepsis may be achieved via the TLR4 NF‑κB signaling pathway. In conclusion, the results of the present study provide a novel insight into the protective effects of rhein on LPS‑induced intestinal inflammation, and demonstrate that rhein may act as a beneficial therapeutic agent in the treatment of sepsis-induced intestinal damage.