Abstract
Sepsis is a common and main cause of morbidity and mortality in intensive care units and emergency departments. Recent evidence illustrated that patients who are suffering from sepsis undergo a prolonged immunosuppressive phase. As a consequence, many septic patients are at risk for secondary infection which is considered to be the major reason for the high mortality of this disease nowadays. In this paper, we discuss the clinical significance of secondary infection and its potential immune mechanisms. In addition, the conventional measures and novel immunomodulatory strategies are also summarized.
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References
Kaukonen KM, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000–2012. JAMA. 2014;311(13):1308–16.
Stevenson EK, Rubenstein AR, Radin GT, et al. Two decades of mortality trends among patients with severe sepsis: a comparative meta-analysis. Crit Care Med. 2014;42(3):625–31.
Walkey AJ, Wiener RS, Lindenauer PK. Utilization patterns and outcomes associated with central venous catheter in septic shock: a population-based study. Crit Care Med. 2013;41(6):1450–7.
Goto T, Yoshida K, Tsugawa Y, Filbin MR, Camargo CA Jr, Hasegawa K. Mortality trends in U.S. adults with septic shock, 2005–2011: a serial cross-sectional analysis of nationally-representative data. BMC Infect Dis. 2016;16:294.
Zhao GJ, Li D, Zhao Q, Song JX, et al. Incidence, risk factors and impact on outcomes of secondary infection in patients with septic shock: an 8-year retrospective study. Sci Rep. 2016;6:38361.
Otto GP, Sossdorf M, Claus RA, Rödel J, et al. The late phase of sepsis is characterized by an increased microbiological burden and death rate. Crit Care. 2011;15(4):R183.
Walton AH, Muenzer JT, Rasche D, et al. Reactivation of multiple viruses in patients with sepsis. PLoS One. 2014;9(2):e98819.
Daviaud F, Grimaldi D, Dechartres A, et al. Timing and causes of death in septic shock. Ann Intensive Care. 2015;5(1):16.
Delano MJ, Ward PA. Sepsis-induced immune dysfunction: can immune therapies reduce mortality? J Clin Invest. 2016;126(1):23–31.
Hotchkiss RS, Monneret G, Payen D. Immunosuppression in sepsis: a novel understanding of the disorder and a new therapeutic approach. Lancet Infect Dis. 2013;13(3):260–8.
León C, Ruiz-Santana S, Saavedra P, et al. A bedside scoring system (“Candida score”) for early antifungal treatment in nonneutropenic critically ill patients with Candida colonization. Crit Care Med. 2006;34(3):730–7.
Delano MJ, Thayer T, Gabrilovich S, et al. Sepsis induces early alterations in innate immunity that impact mortality to secondary infection. J Immunol. 2011;186(1):195–202.
López-Collazo E, del Fresno C. Pathophysiology of endotoxin tolerance: mechanisms and clinical consequences. Crit Care. 2013;17(6):242.
Lekkou A, Karakantza M, Mouzaki A, et al. Cytokine production and monocyte HLA-DR expression as predictors of outcome for patients with community-acquired severe infections. Clin Diagn Lab Immunol. 2004;11(1):161–7.
Lukaszewicz AC, Grienay M, Resche-Rigon M, et al. Monocytic HLA-DR expression in intensive care patients: interest for prognosis and secondary infection prediction. Crit Care Med. 2009;37(10):2746–52.
Deng JC, Cheng G, Newstead MW, et al. Sepsis-induced suppression of lung innate immunity is mediated by IRAK-M. J Clin Invest. 2006;116(9):2532–42.
Fan X, Liu Z, Jin H, Yan J, Liang HP. Alterations of dendritic cells in sepsis: featured role in immunoparalysis. Biomed Res Int. 2015;2015:903720.
Luan YY, Dong N, Xie M, et al. The significance and regulatory mechanisms of innate immune cells in the development of sepsis. J Interf Cytokine Res. 2014;34(1):2–15.
Pène F, Zuber B, Courtine E, Rousseau C, et al. Dendritic cells modulate lung response to Pseudomonas aeruginosa in a murine model of sepsis-induced immune dysfunction. J Immunol. 2008;181(12):8513–20.
Cabrera-Perez J, Condotta SA, Badovinac VP, et al. Impact of sepsis on CD4 T cell immunity. J Leukoc Biol. 2014;96(5):767–77.
Zhao GJ, Yao YM, Lu ZQ, et al. Up-regulation of mitofusin-2 protects CD4+ T cells from HMGB1-mediated immune dysfunction partly through Ca(2+)-NFAT signaling pathway. Cytokine. 2012;59(1):79–85.
Arens C, Bajwa SA, Koch C, et al. Sepsis-induced long-term immune paralysis—results of a descriptive, explorative study. Crit Care. 2016;20:93.
Chang KC, Burnham CA, Compton SM, et al. Blockade of the negative co-stimulatory molecules PD-1 and CTLA-4 improves survival in primary and secondary fungal sepsis. Crit Care. 2013;17(3):R85.
Corthay A. How do regulatory T cells work? Scand J Immunol. 2009;70(4):326–36.
Monneret G, Debard AL, Venet F, et al. Marked elevation of human circulating CD4+CD25+ regulatory T cells in sepsis-induced immunoparalysis. Crit Care Med. 2003;31(7):2068–71.
Cavassani KA, Carson WF 4th, Moreira AP, Wen H, Schaller MA, Ishii M, Lindell DM, Dou Y, Lukacs NW, Keshamouni VG, Hogaboam CM, Kunkel SL. The post sepsis-induced expansion and enhanced function of regulatory T cells create an environment to potentiate tumor growth. Blood. 2010;115(22):4403–11.
Huang LF, Yao YM, Dong N, Yu Y, He LX, Sheng ZY. Association between regulatory T cell activity and sepsis and outcome of severely burned patients: a prospective, observational study. Crit Care. 2010;14(1):R3.
Tatura R, Zeschnigk M, Hansen W, et al. Relevance of Foxp3+ regulatory T cells for early and late phases of murine sepsis. Immunology. 2015;146(1):144–56.
LeBien TW, Tedder TF. B lymphocytes: how they develop and function. Blood. 2008;112(5):1570–80.
Lanzavecchia A. Antigen-specific interaction between T and B cells. Nature. 1985;314:537–9.
Browne EP. Regulation of B-cell responses by toll-like receptors. Immunology. 2012;136(4):370–9.
Rosser EC, Mauri C. Regulatory B cells: origin, phenotype, and function. Immunity. 2015;42(4):607–12.
Rauch PJ, Chudnovskiy A, Robbins CS, et al. Innate response activator B cells protect against microbial sepsis. Science. 2012;335(6068):597–601.
Kelly-Scumpia KM, Scumpia PO, Weinstein JS, et al. B cells enhance early innate immune responses during bacterial sepsis. J Exp Med. 2011;208(8):1673–82.
Monserrat J, de Pablo R, Diaz-Martín D, et al. Early alterations of B cells in patients with septic shock. Crit Care. 2013;17(3):R105.
Suzuki K, Inoue S, Kametani Y, et al. Reduced Immunocompetent B cells and increased secondary infection in elderly patients with severe Sepsis. Shock. 2016;46(3):270–8.
Mehta Y, Gupta A, Todi S, et al. Guidelines for prevention of hospital acquired infections. Indian J Crit Care Med. 2014;18(3):149–63.
Chaudhry H, Zhou J, Zhong Y, et al. Role of cytokines as a double-edged sword in sepsis. In Vivo. 2013;27(6):669–84.
Netea MG, van Tits LJ, Curfs JH, et al. Increased susceptibility of TNF-alpha lymphotoxin-alpha double knockout mice to systemic candidiasis through impaired recruitment of neutrophils and phagocytosis of Candida albicans. J Immunol. 1999;163(3):1498–505.
Song Z, Zhang J, Zhang X, et al. Interleukin 4 deficiency reverses development of secondary Pseudomonas aeruginosa pneumonia during sepsis-associated immunosuppression. J Infect Dis. 2015;211(10):1616–27.
Steinhauser ML, Hogaboam CM, Kunkel SL, et al. IL-10 is a major mediator of sepsis-induced impairment in lung antibacterial host defense. J Immunol. 1999;162(1):392–9.
Cao J, Xu F, Lin S, et al. IL-27 controls sepsis-induced impairment of lung antibacterial host defence. Thorax. 2014;69(10):926–37.
Namen AE, Lupton S, Hjerrild K, et al. Stimulation of B-cell progenitors by cloned murine interleukin-7. Nature. 1988;333(6173):571–3.
Hand TW, Morre M, Kaech SM. Expression of IL-7 receptor alpha is necessary but not sufficient for the formation of memory CD8 T cells during viral infection. Proc Natl Acad Sci U S A. 2007;104(28):11730–5.
Corfe SA, Paige CJ. The many roles of IL-7 in B cell development; mediator of survival, proliferation and differentiation. Semin Immunol. 2012;24(3):198–208.
Sheikh V, Porter BO, DerSimonian R, Kovacs SB, et al. Administration of interleukin-7 increases CD4 T cells in idiopathic CD4 lymphocytopenia. Blood. 2016;127(8):977–88.
Audigé A, Hofer U, Dittmer U, et al. Evaluation of the immunomodulatory and antiviral effects of the cytokine combination IFN-α and IL-7 in the lymphocytic choriomeningitis virus and friend retrovirus mouse infection models. Viral Immunol. 2011;24(5):375–85.
Unsinger J, McGlynn M, Kasten KR, et al. IL-7 promotes T cell viability, trafficking, and functionality and improves survival in sepsis. J Immunol. 2010;184(7):3768–79.
Shindo Y, Fuchs AG, Davis CG, et al. Interleukin 7 immunotherapy improves host immunity and survival in a two-hit model of Pseudomonas aeruginosa pneumonia. J Leukoc Biol. 2017;101(2):543–54.
Inoue S, Unsinger J, Davis CG, et al. IL-15 prevents apoptosis, reverses innate and adaptive immune dysfunction, and improves survival in sepsis. J Immunol. 2010;184(3):1401–9.
Waldmann TA, Lugli E, Roederer M, et al. Safety (toxicity), pharmacokinetics, immunogenicity, and impact on elements of the normal immune system of recombinant human IL-15 in rhesus macaques. Blood. 2011;117(18):4787–95.
Wege AK, Weber F, Kroemer A, et al. IL-15 enhances the anti-tumor activity of trastuzumab against breast cancer cells but causes fatal side effects in humanized tumor mice (HTM). Oncotarget. 2017;8(2):2731–44.
Guo Y, Luan L, Rabacal W, et al. IL-15 superagonist-mediated immunotoxicity: role of NK cells and IFN-γ. J Immunol. 2015;195(5):2353–64.
Buchbinder EI, Desai A. CTLA-4 and PD-1 pathways: similarities, differences, and implications of their inhibition. Am J Clin Oncol. 2016;39(1):98–106.
Callahan MK, Postow MA, Wolchok JD. CTLA-4 and PD-1 pathway blockade: combinations in the clinic. Front Oncol. 2015;4:385.
Parry RV, Chemnitz JM, Frauwirth KA, et al. CTLA-4 and PD-1 receptors inhibit T-cell activation by distinct mechanisms. Mol Cell Biol. 2005;25(21):9543–53.
Shao R, Fang Y, Yu H, et al. Monocyte programmed death ligand-1 expression after 3-4 days of sepsis is associated with risk stratification and mortality in septic patients: a prospective cohort study. Crit Care. 2016;20(1):124.
Zhang Y, Li J, Lou J, et al. Upregulation of programmed death-1 on T cells and programmed death ligand-1 on monocytes in septic shock patients. Crit Care. 2011;15(1):R70.
Chang K, Svabek C, Vazquez-Guillamet C, et al. Targeting the programmed cell death 1: programmed cell death ligand 1 pathway reverses T cell exhaustion in patients with sepsis. Crit Care. 2014;18(1):R3.
Zhang Y, Zhou Y, Lou J, et al. PD-L1 blockade improves survival in experimental sepsis by inhibiting lymphocyte apoptosis and reversing monocyte dysfunction. Crit Care. 2010;14(6):R220.
Grigg C, Rizvi NA. PD-L1 biomarker testing for non-small cell lung cancer: truth or fiction? J Immunother Cancer. 2016;4:48.
Murphy KM, Nelson CA, Sedý JR. Balancing co-stimulation and inhibition with BTLA and HVEM. Nat Rev Immunol. 2006;6(9):671–81.
Shubin NJ, Monaghan SF, Heffernan DS, et al. B and T lymphocyte attenuator expression on CD4+ T-cells associates with sepsis and subsequent infections in ICU patients. Crit Care. 2013;17(6):R276.
Shao R, Li CS, Fang Y, et al. Low B and T lymphocyte attenuator expression on CD4+ T cells in the early stage of sepsis is associated with the severity and mortality of septic patients: a prospective cohort study. Crit Care. 2015;19:308.
Ren F, Li J, Jiang X, et al. Plasma soluble Tim-3 emerges as an inhibitor in sepsis: sepsis contrary to membrane Tim-3 on monocytes. Tissue Antigens. 2015;86(5):325–32.
Nowak EC, Lines JL, Varn FS, et al. Immunoregulatory functions of VISTA. Immunol Rev. 2017;276(1):66–79.
Anderson AC, Joller N, Kuchroo VK. Lag-3, Tim-3, and TIGIT: co-inhibitory receptors with specialized functions in immune regulation. Immunity. 2016;44(5):989–1004.
Hotchkiss RS, McConnell KW, Bullok K, et al. TAT-BH4 and TAT-Bcl-xL peptides protect against sepsis-induced lymphocyte apoptosis in vivo. J Immunol. 2006;176(9):5471–7.
Liu YC, Yao FH, Chai YF, et al. Xuebijing injection promotes M2 polarization of macrophages and improves survival rate in septic mice. Evid Based Complement Alternat Med. 2015;2015:352642.
Liu QY, Yao YM, Yu Y, et al. Astragalus polysaccharides attenuate postburn sepsis via inhibiting negative immunoregulation of CD4+CD25(high) T cells. PLoS One. 2011;6(6):e19811.
Chen W, Lian J, Ye JJ, et al. Ethyl pyruvate reverses development of Pseudomonas aeruginosa pneumonia during sepsis-induced immunosuppression. Int Immunopharmacol. 2017;52:61–9.
Car BD, Eng VM, Schnyder B, et al. Interferon gamma receptor deficient mice are resistant to endotoxic shock. J Exp Med. 1994;179(5):1437–44.
Romero CR, Herzig DS, Etogo A, et al. The role of interferon-γ in the pathogenesis of acute intra-abdominal sepsis. J Leukoc Biol. 2010;88(4):725–35.
Jouanguy E, Altare F, Lamhamedi S, et al. Interferon-gamma-receptor deficiency in an infant with fatal bacille Calmette-Guérin infection. N Engl J Med. 1996;335(26):1956–61.
Döcke WD, Randow F, Syrbe U, et al. Monocyte deactivation in septic patients: restoration by IFN-gamma treatment. Nat Med. 1997;3(6):678–81.
Nakos G, Malamou-Mitsi VD, Lachana A, et al. Immunoparalysis in patients with severe trauma and the effect of inhaled interferon-gamma. Crit Care Med. 2002;30(7):1488–94.
Barreda DR, Hanington PC, Belosevic M. Regulation of myeloid development and function by colony stimulating factors. Dev Comp Immunol. 2004;28(5):509–54.
Meisel C, Schefold JC, Pschowski R, et al. Granulocyte-macrophage colony-stimulating factor to reverse sepsis-associated immunosuppression: a double-blind, randomized, placebo-controlled multicenter trial. Am J Respir Crit Care Med. 2009;180(7):640–8.
Orozco H, Arch J, Medina-Franco H, et al. Molgramostim (GM-CSF) associated with antibiotic treatment in nontraumatic abdominal sepsis: a randomized, double-blind, placebo-controlled clinical trial. Arch Surg. 2006;141(2):150–3.
Hall MW, Knatz NL, Vetterly C, et al. Immunoparalysis and nosocomial infection in children with multiple organ dysfunction syndrome. Intensive Care Med. 2011;37(3):525–32.
Bo L, Wang F, Zhu J, et al. Granulocyte-colony stimulating factor (G-CSF) and granulocyte-macrophage colony stimulating factor (GM-CSF) for sepsis: a meta-analysis. Crit Care. 2011;15(1):R58.
Romani L, Bistoni F, Montagnoli C, et al. Thymosin alpha1: an endogenous regulator of inflammation, immunity, and tolerance. Ann N Y Acad Sci. 2007;1112:326–38.
Romani L, Bistoni F, Perruccio K, et al. Thymosin alpha1 activates dendritic cell tryptophan catabolism and establishes a regulatory environment for balance of inflammation and tolerance. Blood. 2006;108(7):2265–74.
You J, Zhuang L, Cheng HY, et al. Efficacy of thymosin alpha-1 and interferon alpha in treatment of chronic viral hepatitis B: a randomized controlled study. World J Gastroenterol. 2006;12(41):6715–21.
Wang X, Li W, Niu C, et al. Thymosin alpha 1 is associated with improved cellular immunity and reduced infection rate in severe acute pancreatitis patients in a double-blind randomized control study. Inflammation. 2011;34(3):198–202.
Garaci E, Pica F, Rasi G, et al. Thymosin alpha 1 in the treatment of cancer: from basic research to clinical application. Int J Immunopharmacol. 2000;22(12):1067–76.
Wan J, Shan Y, Shan H, et al. Thymosin-alpha1 promotes the apoptosis of regulatory T cells and survival rate in septic mice. Front Biosci (Landmark Ed). 2011;16:3004–13.
Wu J, Zhou L, Liu J, et al. The efficacy of thymosin alpha 1 for severe sepsis (ETASS): a multicenter, single-blind, randomized and controlled trial. Crit Care. 2013;17(1):R8.
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Lu, Zq. (2019). Secondary Infection in Sepsis: Clinical Significance, Immune Mechanism, and Therapy Strategies. In: Fu, X., Liu, L. (eds) Severe Trauma and Sepsis. Springer, Singapore. https://doi.org/10.1007/978-981-13-3353-8_12
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DOI: https://doi.org/10.1007/978-981-13-3353-8_12
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