j o u r n a l o f s u r g i c a l r e s e a r c h  d e c e m b e r 2 0 1 9 ( 2 4 4 ) 4 9 2 e5 0 1

Available online at www.sciencedirect.com

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journal homepage: www.JournalofSurgicalResearch.com

Characterization of Fecal PeritonitiseInduced

Sepsis in a Porcine Model

Inwon Park, MD, PhD,a Jae Hyuk Lee, MD, PhD,a,* Dong-Hyun Jang, MD,a
Doyun Kim, MD,a Hyunglan Chang, MD,a Hyuksool Kwon, MD,a
Seonghye Kim, BS,a Taek Soo Kim, MD,b and You Hwan Jo, MD, PhDa,c
a
Department of Emergency Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si,
Gyeonggi-do, Republic of Korea
b
Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Republic of Korea
c
Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea

article info abstract

Article history: Background: Although there are well-established small-animal sepsis models, the longitu-
Received 9 April 2019 dinal assessment of hemodynamic variables, laboratory values, and blood culture in a
Received in revised form single living sepsis model is limited. Therefore, we aimed to comprehensively characterize
3 June 2019 fecal peritonitiseinduced sepsis in a porcine model.
Accepted 21 June 2019 Materials and methods: Autologous feces (1 g/kg) was administered into the peritoneum of 11
Available online xxx male pigs (49
8 kg). The pigs were monitored up to 12 h with full fluid and vasopressor
support to maintain the mean arterial pressure at >65 mm Hg. Longitudinal blood culture
Keywords: and laboratory values were obtained at defined time intervals. The cytokine levels in
Sepsis plasma were analyzed. Furthermore, a clinical registry of sepsis patients at a single
Fecal peritonitis emergency department was used to compare the Sepsis-related Organ Failure Assessment
Pig scores with those of the porcine model.
Bacteremia Results: The hyperdynamic phase of increasing cardiac output with decreasing systemic
vascular resistance was maintained until 2 h, followed by the reverse (hypodynamic
phase). With the escalating requirement for fluid and vasopressor, the lactate level pro-
gressively increased while the platelet count, urine output, and serum albumin level
consistently decreased. Bacteremia developed 7 h (median) after the administration of
feces, and Escherichia coli was the most common pathogen. The pattern of Sepsis-related
Organ Failure Assessment scores with prominent cardiovascular failure was comparable
to clinical data.
Conclusions: We implemented a porcine fecal peritonitiseinduced sepsis model that dem-
onstrates culture-proven bacteremia and multiple organ failure, particularly cardiovascu-
lar system failure. This model could facilitate the development of technologies for the early
diagnosis of bacterial pathogens in blood.
ª 2019 Elsevier Inc. All rights reserved.

* Corresponding author. Department of Emergency Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil,
Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea. Tel.: þ82 31-787-7574; fax: þ82 31-787-4081.
E-mail address: hyukmd@gmail.com (J.H. Lee).
0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jss.2019.06.094
 p a r k e t a l  f e c a l p e r i t o n i t i s ei n d u c e d s e p s i s i n p i g s
Introduction
Sepsis, characterized by a dysregulated host response to se-
vere infection, remains a leading cause of death.1,2 Early
detection of pathogen in this fatal disease can lead to rapid
and appropriate antibiotics treatment, potentially preventing
the 7% mortality that occurs with every hour delay in the
administration of antibiotics.3,4 Blood culture is the gold
standard method for detecting pathogens in sepsis yet pro-
vides 40%w60% of pathogen identification in sepsis and re-
quires a long incubation period (up to 5 d).5,6 Despite the
importance and unmet needs of blood culture method in a
pathogen identification, preclinical sepsis model has been
predominated with rodents owing to their availability, size,
low cost, and extensibility to genetic modulation.7,8 However,
the small size of these animals limits the repetitive acquisi-
tion of a large volume of blood samples that is critical for a
microbiologic study to identify the underlying pathogen in
sepsis.9
Pigs, which have genetic, anatomical, and physiological
features similar to those of humans, are an ideal preclinical
model for recapitulating human diseases.10 In particular,
sepsis that involves a vigorous hemodynamic response which
can be measured with longitudinal clinical monitoring tool
requires a large animal model.11 A preclinical porcine model is
capable of presenting the same invasive monitoring parame-
ters in the clinical field.12 Therefore, the porcine model is
suggested to be an ideal experimental model for the evalua-
tion of hemodynamic variables such as mean blood pressure,
cardiac output, and stroke volume, overcoming the limita-
tions of the current rodent sepsis model.
In the clinical field, sepsis is well described by the objective
organ dysfunction scale such as Sepsis-related Organ Failure
Assessment (SOFA) score.13 Previous preclinical model has
relied on the histological studies to demonstrate organ failure,
which limits the longitudinal assessment of multiple organs
simultaneously. The goal of this study was to create a pre-
clinical intra-abdominal sepsis model and correlate SOFA
scores to understand predominant organ failure characteris-
tics.14,15 This may lead to the development of earlier treat-
ment strategies on target organs in the future.
Therefore, to maximally mimic clinical intra-abdominal
sepsis due to polymicrobial infection, we designed a preclin-
ical porcine model of fecal peritonitiseinduced sepsis. Longi-
tudinal hemodynamic responses, laboratory parameters of
organ failure, inflammatory cytokines representing host re-
sponses, and invading pathogens were evaluated to charac-
terize the porcine model of fecal peritonitiseinduced sepsis.
For validation, we compared the SOFA scores between the
developed porcine model and human patients with intra-
abdominal sepsis who visited the emergency department.13
Material and methods
Study setting
The Institutional Animal Care and Use Committee approved
this study (protocol no. BA1804-246/040-01), and all animals
493
received humane care according to the guide for the care and
use of laboratory animals of the National Institutes of Health.
The institutional review board also approved this study.
Sepsis patients who visited the emergency department of a
tertiary hospital between January 2010 and January 2018 were
prospectively registered (protocol no. B-1409-266-401), and the
retrospective analysis of intra-abdominal origin was approved
(protocol no. B-1904-537-101). The institutional review board
granted a waiver of informed consent.
Animal preparation
Eleven male Yorkshire-X domestic pigs (Sus scrofa) were used for
the experiments. Only male pigs were used owing to the small
sample size. The pigs were housed in a controlled environment
with free access to food and water before the experiment. The
animals were anesthetized with an intramuscular injection of
zolazepam (Zoletil, 5 mg/kg; Virbac, Carros, France). Then, the
animals were scrubbed with clean water and povidone-iodine
soap followed by meticulous bilateral shaving of the neck and
inguinal area. A 3-lead electrocardiography monitor and a pulse
oximeter (IntelliVue, Patient Monitor MP20; Philips, Amsterdam,
Netherlands) were applied to monitor the heart rate and oxygen
saturation, respectively. A temperature probe was inserted
through the rectum. The pigs were intubated with a 7-Fr endo-
tracheal tube and connected to a mechanical ventilator (Drager
Fabius GS, Lubeck, Germany) with appropriate concentration
(2%-3%) of inhalation anesthesia (sevoflurane; Baxter Inc, Deer-
field, IL) to maintain general anesthesia. The pigs were subjected
to volume-controlled ventilation with the following initial set-
tings: tidal volume, 6 mL/kg; positive end-expiratory pressure, 3
cmH2O; respiratory rate, 12-15/min; and fraction of inspired
oxygen, 0.21. Minute ventilation was adjusted to maintain an
arterial PCO2 of 35-40 mm Hg, measured using blood gas anal-
ysis. After sterilization with povidone-iodine dressing, a sterile
surgical drape was applied to the abdomen, covering both the
axilla and the inguinal site. Under the guidance of ultrasonog-
raphy, a 6-Fr arterial catheter (Merit Medical, South Jordan, UT)
was introduced into the left and right femoral arteries for
invasive blood pressure monitoring and recurrent blood sam-
pling, respectively. A Swan-Ganz catheter (model 131HF, 7 Fr;
Edwards Lifesciences, Irvine, CA) was applied to the right jugular
vein for monitoring of pulmonary capillary wedge pressure and
cardiac output. The left jugular vein was also cannulated with a
central venous catheter (ARROW CVC; Teleflex, Morrisville, NC)
for intravenous administration of fluid and vasopressors.
Suprapubic cystostomy was performed and the foley catheter
was introduced to monitor the urine output.
Induction of the fecal peritonitis model
To induce fecal peritonitis in pigs, autologous feces was
collected 1 d before the experiment, diluted with dextrose
saline (10 g/mL), and placed in a 37 C water bath for 1 h before
the experiment, to prevent unintended hypothermia in the
animals after feces administration. After preparing the
monitoring devices and intravenous catheter as described
previously, baseline blood samples were obtained through the
arterial catheter. Then, 5-cm midline celiotomy was
494 j o u r n a l o f s u r g i c a l r e s e a r c h  d e c e m b e r 2 0 1 9 ( 2 4 4 ) 4 9 2 e5 0 1

performed and feces (1 mg/kg) was carefully administered
into the peritoneum. After the injection of feces, the perito-
neum and skin were closed with surgical staples.
The pigs were monitored for 12 h after the induction, and the
primary goal was to maintain over 65 mm Hg of mean arterial
pressure (MAP), with maximal support of fluid and vasopressor.
Maintenance fluid (5% dextrose in 0.9% normal saline) was kept
at approximately 1 mL/kg/h, and balanced crystalloid solution
(Plasma Solution A, CJ Healthcare, Seoul, Republic of Korea) was
challenged when MAP was under 65 mm Hg. The first vaso-
pressor (norepinephrine) was added after the cumulative
amount of loading fluid exceeded 30 mL/kg or when the fluid
challenge was not enough to maintain MAP > 65 mm Hg. The
second vasopressor (vasopressin) was added when the level of
norepinephrine exceeded 40 mg/min, and the third vasopressor
(epinephrine) was added when the MAP > 65 mm Hg was not
maintained with norepinephrine and vasopressin.
Measurements and calculations
The following monitoring variables were continuously
recorded (IntelliVue, Patient Monitor MP20; Philips,
Amsterdam, Netherlands): arterial blood pressure, heart
rate, lead II electrocardiographic variables, capnography
variables, pulse oximetry variables, and central venous
pressure. Cardiac output was measured using the thermo-
dilution technique 3 times every hour, and the median value
was used as the representative value.16 Arterial blood gas
analysis including lactate measurement (Nova CCX; Nova,
Waltham, MA), complete blood cell count (Hemavet 950FS;
Drew Scientific Inc, Miami Lakes, FL), and chemistry panel
test (albumin, creatinine, and bilirubin; VetScan; Abaxis,
Union City, CA) was conducted using blood samples obtained
through the right femoral artery and mixed venous blood
samples obtained through the pulmonary artery catheter
every hour (the chemistry panel test was performed every
2 h). Blood samples for culture were exclusively obtained
from the left femoral artery at the baseline and 2, 4, 5, 6, 7, 8,
9, 10, 11, and 12 h with aseptic technique to avoid the pos-
sibility of contamination and were incubated in pairs of
aerobe and anaerobe blood culture bottles (BD BACTEC;
Becton Dickinson, Franklin Lakes, NJ). Then, the pairs of
blood culture bottles were immediately transferred to the
microbiologic laboratory for storage in a blood culture system

A MAP B Hour Fluid C Cumulative Fluid

100 2000 15000

90
1500
10000
80
mmHg

mL

mL

1000
70
5000
500
60

50 0 0
0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12

Hours Hours Hours

D E F
HR BT Cardiac output
250 42 10
Body Temperature ( C)

200 40 8

150 38 6
L/min
bpm

100 36 4

50 34 2

0 32 0
0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12

Hours Hours Hours

G Stroke volume
H Systemic vascular resistance
I PCWP
0.10 2000 30

0.08
1500
20
dyn s/cm5

0.06
mmHg

1000
L

0.04
10
500
0.02

0.00 0 0
0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12

Hours Hours Hours

Fig. 1 e (A-I) Trends of hemodynamic variables in the fecal peritonitiseinduced porcine sepsis model. Data are presented as
medians and interquartile ranges. HR [ heart rate; BT [ body temperature; PCWP [ pulmonary capillary wedge pressure.
 p a r k e t a l  f e c a l p e r i t o n i t i s ei n d u c e d s e p s i s i n p i g s 495

A Norepinephrine B Vasopressin C Epinephrine

500 0.06 10

400 8

μg / kg / min
0.04

units / min
μg / min

300 6

200 4
0.02
100 2

0 0.00 0
0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12
Hours Hours Hours

D Lactate E SmvO2
20 100

15 90
mmol / L

10 80
%

5 70

0 60
0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12

Hours Hours

Fig. 2 e (A-E) Trends of administered fluid, vasopressors, and lactate level in the fecal peritonitiseinduced porcine sepsis
model. Data are presented as medians and interquartile ranges. SmvO2 [ mixed venous O2 saturation.

(BD BACTEC FX; Becton Dickinson, Franklin Lakes, NJ). The
final blood culture report was obtained from the microbio-
logical laboratory of the department of laboratory medicine.
Additional blood samples were collected in standard 4-mL K2
EDTA vacutainer tubes (BD Vacutainer Systems; Becton
Dickinson, Franklin Lakes, NJ) every hour. The collected
blood was centrifuged for 15 min at 3000 rpm, and the plasma
was transferred to a 1.5-mL tube and stored at 70 C in deep
freezer until analysis. The levels of proinflammatory cyto-
kines (tumor necrosis factor a, interleukin [IL]-1b, and IL-6)
and angiopoietin-2 were measured using an enzyme-linked
immunosorbent assay kit (PTA00, PLB00B, P6000B, DANG20;

A B C
WBC Hb Platelet
20 18 400

15 15 300
x103 / mm3
x103 / mm3

g / dL

10 12 200

5 9 100

0 6 0
0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12

Hours Hours Hours

D E F
Neutrophil Lymphocyte Monocyte
10 15 0.8

8
0.6
10
x103 / mm3

x103 / mm3
x103/mm3

6
0.4
4
5
0.2
2

0 0 0.0
0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12

Hours Hours Hours

Fig. 3 e (A-F) Trends of complete blood cell count in the fecal peritonitiseinduced porcine sepsis model. Data are presented
as medians and interquartile ranges. WBC [ white blood cell; Hb [ hemoglobin.
496 j o u r n a l o f s u r g i c a l r e s e a r c h  d e c e m b e r 2 0 1 9 ( 2 4 4 ) 4 9 2 e5 0 1

A P:F ratio
800

600

mmHg
400

200

0
0 1 2 3 4 5 6 7 8 9 10 11 12
Hours

B C
Urine output Creatinine
10 2.0

8
1.5
mL/kg/hr

mg / dL
1.0
4
0.5
2

0 0.0
0 1 2 3 4 5 6 7 8 9 10 11 12 0 2 4 6 8 10 12

Hours Hours

D E
Albumin Bilirubin
4 0.5

0.4
3
0.3
mg / dL

mg / dL

2
0.2
1
0.1

0 0.0
0 2 4 6 8 10 12 0 2 4 6 8 10 12

Hours Hours

Fig. 4 e (A-E) Trends of organ failure variables in the fecal peritonitiseinduced porcine sepsis model. Data are presented as
medians and interquartile ranges. P:F ratio [ ratio of arterial oxygen to the fraction of inspired oxygen.

Quantikine; R&D Systems Inc, Minneapolis, MN) according to
the manufacturer’s instruction.
Clinical sepsis data
To validate whether the modeling represents clinical sepsis
originated from intra-abdominal infection, a retrospective
analysis of prospectively collected data of patients with sepsis
at an urban tertiary emergency department was performed.
We included adult patients older than 18 y who visited the
emergency department and had a diagnosis of sepsis origi-
nated from intra-abdominal infection. Written informed con-
sent was acquired from all participants or their legal guardians
before enrollment into the study. The initial laboratory values,
including arterial blood gas variables, platelet count, serum
bilirubin level, and creatinine level, were measured. Hemody-
namic variables including mean arterial pressure and vaso-
pressor use were obtained until 6 h from presentation to the
emergency department. SOFA scores were calculated with the
aforementioned values except for the Glasgow Coma Scale
score, which cannot be measured in the porcine model. The
source of infection was determined by the attending physician,
and suspected intra-abdominal infections excluding those
with a hepatobiliary origin were analyzed.
Statistical analysis
Parametric and nonparametric variables are presented as
mean
standard deviation and median [interquartile range],
respectively. Statistical analyses and graph generation were
performed using GraphPad Prism 6.0 (GraphPad Software Inc,
San Diego, CA).
Results
The pigs were monitored up to 12 h from the administration of
feces into the peritoneum. The mean arterial pressure rapidly
 p a r k e t a l  f e c a l p e r i t o n i t i s ei n d u c e d s e p s i s i n p i g s 497

A B C
TNF-α IL-1β IL-6
400 600 15000

300
400 10000
pg/mL

pg/mL

pg/mL
200

200 5000
100

0 0 0
0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12
Hours Hours Hours

D E
Endotoxin Ang-2
0.3 30000

0.2 20000
pg/mL

pg/mL

0.1 10000

0.0 0
0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12
Hours Hours

Fig. 5 e (A-E) Trends of cytokine and endotoxin levels in the fecal peritonitiseinduced porcine sepsis model. Data are
presented as medians and interquartile ranges. TNF-a [ tumor necrosis factor-a; Ang-2 [ angiopoietin-2.

decreased up to 2 h and was maintained near 65 mm Hg with
maximal fluid and vasopressor support (Fig. 1A-C), whereas
the heart rate and body temperature gradually increased
(Fig. 1D and E). In the first 2 h, as expected, the hyperdynamic
phase was seen. The cardiac output and stroke volume
increased with decreased systemic vascular resistance
(Fig. 1F-H). After the 2 h from the insult, the hypodynamic
phase was seen which can be identified by the decrease of
cardiac output and stroke volume with the increase of sys-
temic vascular resistance (Fig. 1F-H). The median value of
pulmonary capillary wedge pressure did not increase; how-
ever, some outliers seemed to increase at a later period of the
experiment (Fig. 1I).
Norepinephrine was initiated at 2 h, followed by vaso-
pressin and epinephrine at 5 and 7 h, respectively (Fig. 2A-C).
At 7 h, when the third vasopressor (epinephrine) was added,
the lactate level started to increase with a corresponding
decline in mixed venous oxygen saturation (Fig. 2D and E).
The white blood cell count decreased up to 3 h, whereas the
hemoglobin level increased until 9 h (Fig. 3A and B). Progres-
sive decline in platelet count occurred until the end of the
experiment (Fig. 3C). The neutrophil, lymphocyte, and
monocyte counts showed a similar pattern to that of the total
white blood cell count (Fig. 3D-F).
The P/F ratio (ratio of partial pressure of oxygen to the fraction
of inspired oxygen) was slightly decreased (Fig. 4A) but not
enough to fulfill the clinical definition of acute respiratory distress
syndrome (ARDS).17 The urine output gradually decreased with a
minor increase in serum creatinine level (Fig. 4B and C). The
serum albumin level substantially decreased, whereas the bili-
rubin level showed little increase (Fig. 4D and E).
Compared with the baseline value, tumor necrosis factor a
started to increase at 2 h and encountered peak at 3 h (Fig. 5A).
IL-1b and IL-6 started to increase at 5 and 3 h, respectively, and
kept increasing until the end of the experiment (Fig. 5B and C).
The endotoxin level showed a minimal increase during the

A B

Fig. 6 e Time from induction to bacteremia (A) and the different pathogens (B) in the fecal peritonitiseinduced porcine sepsis
model.
498 j o u r n a l o f s u r g i c a l r e s e a r c h  d e c e m b e r 2 0 1 9 ( 2 4 4 ) 4 9 2 e5 0 1

demonstrated the hemodynamic responses, laboratory pro-

Table 1 e Characteristics of the blood culture study in
fecal peritonitis porcine model. file, inflammatory cytokines, and microbiological character-
istics as well as their trends during the progression of septic
Variables Results
shock. From this polymicrobial sepsis study, we identified that
Median time from induction to positive blood 7 [6-10] the autologous fecal peritonitiseinduced porcine model rep-
culture study resents predominant E coli bacteremia with particular features
Positive blood culture ratio from total blood 54 (49.1%) of cardiovascular dysfunction.
culture study (excluding baseline) In this study, autologous feces were adopted as the source
Total count of identified pathogen 82 of infection to mimic the clinical situation as much as
Escherichia coli 47 (57.3%) possible. In the first 2 h, our model showed features of
Streptococcus sp. hyperdynamic shock, followed by a hypodynamic period that
Streptococcus gallolyticus 8 (9.8%) was maintained until the end of the experiment. As peritonitis
progressed to sepsis, the demand for fluid and vasopressor
Streptococcus dysgalactiae 5 (6.1%)
support to maintain the mean arterial pressure at >65 mm Hg
Streptococcus canis 5 (6.1%)
gradually increased with a corresponding increase in the
Streptococcus alactolyticus 3 (3.7%)
lactate level. Therefore, our model replicates the clinical fea-
Enterococcus sp. tures of patients with unresponsive and fulminant septic
Enterococcus cecorum 3 (3.7%) shock that progresses to multiple organ dysfunction, shock,
Enterococcus hirae 2 (2.4%) and death despite treatment with fluid and vasopressors.
Enterococcus durans 1 (1.2%) Although we presumed that multiple organ dysfunctions
Other sp. will be generated in our model, respiratory, hepatic, and renal
Campylobacter hyointestinalis 2 (2.4%)
injuries based on the SOFA scores were not prominent.13 The
oxygen demand was not increased enough to satisfy the
Acinetobacter sp. 1 (1.2%)
clinical definition of ARDS,17 and the level of bilirubin was not
Staphylococcus hominis 1 (1.2%)
apparently elevated in comparison with the distinct features
Lactococcus raffinolactis 1 (1.2%) of cardiovascular and coagulation failure. As our experiment
Bacillus cereus 1 (1.2%) focused on the acute phase of inflammation induction,
Clostridium perfringens 1 (1.2%) development of ARDS and hepatic dysfunction might occur at
Candida lusitaniae 1 (1.2%) a later time (24-48 h) beyond our observational period, as
Continuous variables are presented as median [interquartile demonstrated in previous studies.18,19 With respect to renal
range], and categorical variables are given as numbers (%). dysfunction, the increase of the creatinine level was insuffi-
cient to meet the criterion for renal failure based on the SOFA
score as well as Risk-InjuryeFailureeLosseEndstage (RIFLE)
experiment (Fig. 5D). The level of plasma angiopoietin-2, and Acute Kidney Injury Network (AKIN) criteria. Although
which represents endothelial dysfunction, increased decreased tendency in urine output was evident, at least 6 h of
compared with the baseline value (Fig. 5E). oliguric period (0.5 mL/kg/h) was needed to fulfill the renal
The median [interquartile range] time to the diagnosis of injury criteria in RIFLE and AKIN classification. As we can
bacteremia in blood was 7 h [6-10 h] from the induction of presume from the considerable decrease in the urine output,
fecal peritonitis (Fig. 6A). E coli (57.3%) was the most commonly the level of creatinine might not represent the early phase of
identified pathogen in blood culture, followed by Streptococcus renal failure in the porcine sepsis model.20 Therefore, it is
(25.6%) and Enterococcus (7.3%) (Fig. 6B). The detailed results of unclear whether the absolute values of the P/F ratio, bilirubin,
the time to diagnosis of bacteremia and the pathogens in and creatinine were insufficient to diagnose organ failure in
blood culture are shown in Tables 1 and 2. the early phase of sepsis in the porcine model, or whether the
The trend of SOFA scores excluding the Glasgow Coma Scale injury was not evident in the lung, liver, and kidney. Further
score was evaluated, and the model represented early cardio- studies including a histological evaluation of each organ
vascular dysfunction (Fig. 7A). In the clinical data, 282 patients might be needed to address this issue, and a swine-specific
with sepsis that originated from intra-abdominal (except hep- scoring system for organ failure may also be required.18
atobiliary) infection were included for comparison with the Nevertheless, from the clinical data, most of the SOFA
porcine model. Eighty-two pathogens were identified in 71 pa- scores were similar to human data, suggesting that our model
tients (25.2%) (Table 3). E coli (23.2%) was also the most commonly firmly recapitulates sepsis of intra-abdominal origin in human
identified pathogen in clinical blood culture, followed by Klebsiella patients.
(18.3%) and Staphylococcus (13.4%). The SOFA score of each system Previous studies with porcine models of sepsis used a
was comparable to that of the porcine model, with prominent single microorganism 18, 21, 22 or endotoxin 23, 24 for sepsis
features of cardiovascular dysfunction (Fig. 7B). induction. Although these studies may have the virtue of
reproducibility,25 they generally do not encompass clinical
features with respect to the polymicrobial characteristics of
Discussion septic patients that failed to confirm efficacy of several
therapeutic candidates in clinical trials.8 Furthermore,
In this study, in which a porcine model of fecal although some studies have used fecal peritonitis as a source
peritonitiseinduced sepsis was developed, we fully of sepsis, they did not report the longitudinal and
Table 2 e Identified microorganisms in blood culture at each hour of the experiment.
Time #1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11
Baseline
2h Escherichia coli
Bacillus cereus

p a r k e t a l  f e c a l p e r i t o n i t i s ei n d u c e d s e p s i s i n p i g s
4h E. coli E. coli
5h E. coli E. coli
6h Enterococcus durans E. coli E. coli E. coli
Enterococcus hirae
7h Acinetobacter sp. E. coli E. coli E. coli Streptococcus E. coli
Staphylococcus hominis Enterococcus Streptococcus alactolyticus
cecorum dysgalactiae
Streptococcus canis
8h E. coli E. coli E. coli E. coli E. coli S. alactolyticus E. coli
S. alactolyticus Streptococcus
gallolyticus
9h E. coli E. coli E. coli E. coli E. coli
E. hirae
S. canis
S. gallolyticus
10 h E. coli S. gallolyticus Campylobacter E. cecorum E. coli E. coli E. coli E. coli E. coli
E. cecorum E. coli hyointestinalis E. coli S. gallolyticus
S. gallolyticus
11 h C. hyointestinalis E. coli E. coli E. coli E. coli E. coli E. coli E. coli
S. dysgalactiae S. gallolyticus
L. raffinolactis S. canis
12 h E. coli Clostridium E. coli E. coli E. coli E. coli E. coli E. coli E. coli E. coli
S. gallolyticus perfringens Candida S. dysagalactiae S. canis S. gallolyticus
lusitaniae S. canis
S. dysgalactiae S. dysgalactiae

499
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A B
SOFA Comparison with Clinical Data
10
Respiratory Repiratory Pig
8 Coagulation Clinical
Coagulation
Liver
6 Cardiovascular Cardiovascular
Score

Renal
4 Liver
Total
Renal
2
Total without CNS
0
0 2 4 6 8 10 12 0 1 2 3 4 5 6 8 10
Hours Score

Fig. 7 e Trends of SOFA scores in the fecal peritonitiseinduced porcine sepsis model (A) and comparison with clinical data
(B). CNS [ central nervous system.

comprehensive microbiologic descriptions highlighted in our provoking pathogen were inconsistent. Furthermore,
study.26-28 Interestingly, our microbiologic study demon- although the predominant microorganism in feces is vari-
strated that although the same amount of feces was able, the inflammatory response of the host to the invading
administered into the peritoneum and the hemodynamic pathogen might be consistent, which is identical to the
variables with fluid and vasopressor demands presented a clinical situation.
comparable pattern, the time from sepsis induction to the This study has several limitations. First, a control healthy
detection of bacteremia in the blood culture study and the group was not included for comparison with the sepsis group.
Nevertheless, we believe that the baseline (0 h) hemodynamic,
laboratory, and blood culture results may represent the mea-
surements of the control group that is also supported by
Table 3 e Characteristics of the blood culture results in baseline variables in previous study.28 Second, only healthy
sepsis patients. young male pigs were used in this experiment. The sepsis cases
Variables Results in the clinical registry included the heterogeneous elderly
Ratio of positive blood culture results from 71 (25.2%)
population with comorbidities and patients of both sexes.
intraabdominal sepsis patients Therefore, this study should be carefully interpreted when
Total count of identified pathogen 82
extrapolating to female patients or those with comorbid con-
ditions. Third, the microbiological composition and load of
Escherichia coli 19 (23.2%)
feces might differ among individual pigs. As a single set of
Klebsiella pneumonia 15 (18.3%)
experiment was time consuming and laborious, we were not
Staphylococcus sp.
able to apply identically prepared feces to all 11 pigs at once. To
Coagulase negative Staphylococcus 9 (11.0%) minimize bias, we purchased pigs from a single farm, bred
Staphylococcus aureus 2 (2.4%) them in identical conditions including food and water, and
Streptococcus sp. 6 (7.3%) collected autologous feces on the day before the experiment.
Pseudomonas aeruginosa 5 (6.1%) Fourth, compared to 100% bacteremia in fecal peritonitis
Acinetobacter baumannii 3 (3.7%) model, the SOFA score was compared with that of 282 patients
with sepsis (25.2% bacteremia) instead of 71 patients with
Bacillus cereus 3 (3.7%)
bacteremia. Indeed, SOFA score of culture positive sepsis was
Enterococcus faecium 3 (3.7%)
slightly higher than culture-negative sepsis. Nevertheless, the
Candida sp. 3 (3.7%)
trends of SOFA score including profound cardiovascular
Salmonella sp. (not typhi) 2 (2.4%) dysfunction were equivalent in both groups.
Actinomyces sp. 1 (1.2%)
Bifidobacterium sp. 1 (1.2%)
Burkholderia cepacian group 1 (1.2%) Conclusions
Clostridium perfringens 1 (1.2%)
We implemented a fecal peritonitiseinduced porcine sepsis
Eggerthella lenta 1 (1.2%)
model, characterized by pathogen-identifiable bacteremia and
Enterobacter aerogenes 1 (1.2%)
prominent cardiovascular dysfunction. Although our model
Finegoldia magna 1 (1.2%)
still has variabilities in terms of invading pathogens and their
Micrococcus sp. 1 (1.2%) identified time in blood culture, our model of organ dysfunction
Parvimonas micra 1 (1.2%) parallels clinical patients with sepsis originating from intra-
Proteus mirabilis 1 (1.2%) abdominal infection. In addition, this model allows for the
Serratia marcescens 1 (1.2%) assessment of larger volumes of blood samples, which may
Unidentified gram-negative rods 1 (1.2%) facilitate technology for the early diagnosis of bacterial path-
ogens in blood and lead to earlier interventions in intra-
Categorical variables are given as numbers (%).
abdominal sepsis.
 p a r k e t a l  f e c a l p e r i t o n i t i s ei n d u c e d s e p s i s i n p i g s
Acknowledgment
This research was supported by the Bio & Medical Technology
Development Program of the National Research Foundation
(NRF) funded by the Ministry of Science & ICT (NRF-
2017M3A9E2062210).
Authors’ contributions: J.H.L. and Y.H.J. designed the study
and prepared the protocol. I.P., J.H.L., D.-H.J., D.K., H.C., H.K.,
S.K., Y.H.J., and T.S.K. carried out experiments. All authors
participated in interpretation of data. I.P. and J.H.L. drafted
and revised the manuscript. All authors read and approved
the final manuscript.
Disclosure
The authors declare that they have no conflicts of interest.
references
1. Singer M, Deutschman CS, Seymour CW, et al. The third
international consensus definitions for sepsis and septic
shock (Sepsis-3). JAMA. 2016;315:801e810.
2. Angus DC, van der Poll T. Severe sepsis and septic shock. N
Engl J Med. 2013;369:840e851.
3. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension
before initiation of effective antimicrobial therapy is the
critical determinant of survival in human septic shock. Crit
Care Med. 2006;34:1589e1596.
4. Kumar A, Haery C, Paladugu B, et al. The duration of
hypotension before the initiation of antibiotic treatment is a
critical determinant of survival in a murine model of
Escherichia coli septic shock: association with serum lactate
and inflammatory cytokine levels. J Infect Dis.
2006;193:251e258.
5. Phua J, Ngerng W, See K, et al. Characteristics and outcomes
of culture-negative versus culture-positive severe sepsis. Crit
Care. 2013;17:R202.
6. Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology
of sepsis in the United States from 1979 through 2000. N Engl J
Med. 2003;348:1546e1554.
7. Fink MP, Heard SO. Laboratory models of sepsis and septic
shock. J Surg Res. 1990;49:186e196.
8. Fink MP. Animal models of sepsis. Virulence. 2014;5:143e153.
9. Lewis AJ, Seymour CW, Rosengart MR. Current murine
models of sepsis. Surg Infect (Larchmt). 2016;17:385e393.
10. Swindle MM, Makin A, Herron AJ, Clubb Jr FJ, Frazier KS.
Swine as models in biomedical research and toxicology
testing. Vet Pathol. 2012;49:344e356.
11. Parker SJ, Watkins PE. Experimental models of gram-negative
sepsis. Br J Surg. 2001;88:22e30.
12. Kubiak BD, Albert SP, Gatto LA, et al. A clinically applicable
porcine model of septic and ischemia/reperfusion-induced
shock and multiple organ injury. J Surg Res. 2011;166:e59ee69.
501
13. Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related
organ failure assessment) score to describe organ
dysfunction/failure. On behalf of the working group on
sepsis-related problems of the European society of intensive
care medicine. Intensive Care Med. 1996;22:707e710.
14. Leligdowicz A, Dodek PM, Norena M, et al. Association
between source of infection and hospital mortality in patients
who have septic shock. Am J Respir Crit Care Med.
2014;189:1204e1213.
15. Blanco J, Muriel-Bombin A, Sagredo V, et al. Incidence, organ
dysfunction and mortality in severe sepsis: a Spanish
multicentre study. Crit Care. 2008;12:R158.
16. Hwang JE, Kim K, Lee JH, et al. Blood pressure-targeted
stepwise resuscitation of hemorrhagic shock in a swine
model. J Surg Res. 2016;204:192e199.
17. Force ADT, Ranieri VM, Rubenfeld GD, et al. Acute respiratory
distress syndrome: the Berlin Definition. JAMA.
2012;307:2526e2533.
18. Soerensen KE, Nielsen OL, Birck MM, et al. The use of
sequential organ failure assessment parameters in an awake
porcine model of severe Staphylococcus aureus sepsis.
APMIS. 2012;120:909e921.
19. Steinberg J, Halter J, Schiller H, Gatto L, Nieman G. The
development of acute respiratory distress syndrome after
gut ischemia/reperfusion injury followed by fecal
peritonitis in pigs: a clinically relevant model. Shock.
2005;23:129e137.
20. Haase M, Kellum JA, Ronco C. Subclinical AKI–an emerging
syndrome with important consequences. Nat Rev Nephrol.
2012;8:735e739.
21. Humes HD, Buffington DA, Lou L, et al. Cell therapy with a
tissue-engineered kidney reduces the multiple-organ
consequences of septic shock. Crit Care Med.
2003;31:2421e2428.
22. Leifsson PS, Iburg T, Jensen HE, et al. Intravenous inoculation
of Staphylococcus aureus in pigs induces severe sepsis as
indicated by increased hypercoagulability and hepatic
dysfunction. FEMS Microbiol Lett. 2010;309:208e216.
23. Lipcsey M, Larsson A, Eriksson MB, Sjolin J. Effect of the
administration rate on the biological responses to a fixed
dose of endotoxin in the anesthetized pig. Shock.
2008;29:173e180.
24. Castegren M, Skorup P, Lipcsey M, Larsson A, Sjolin J.
Endotoxin tolerance variation over 24 h during porcine
endotoxemia: association with changes in circulation and
organ dysfunction. PLoS One. 2013;8:e53221.
25. Nemzek JA, Hugunin KM, Opp MR. Modeling sepsis in the
laboratory: merging sound science with animal well-being.
Comp Med. 2008;58:120e128.
26. Jarkovska D, Markova M, Horak J, et al. Cellular mechanisms
of myocardial depression in porcine septic shock. Front
Physiol. 2018;9:726.
27. Correa TD, Vuda M, Blaser AR, et al. Effect of treatment delay
on disease severity and need for resuscitation in porcine fecal
peritonitis. Crit Care Med. 2012;40:2841e2849.
28. de Azevedo LC, Park M, Noritomi DT, et al. Characterization of
an animal model of severe sepsis associated with respiratory
dysfunction. Clinics (Sao Paulo). 2007;62:491e498.