BACTERIAL SEPSIS AND SEPTIC SHOCK 0891-5520/99 $8.00 + .

OO

CYTOKINES .AND
ANTICYTOKINES IN THE
PATHOGENESIS OF SEPSIS
Tom van der Poll, MD, PhD,
and Sander J. H. van Deventer, MD, PhD

Sepsis is a clinical syndrome that results from a systemic response of the

host to an infection. Activation of inflammatory pathways, including the cyto-
kine network, is considered to play a major role in the pathogenesis of sepsis.
Clinical trials with anti-inflammatoryagents in patients with sepsis are based on
the assumption that excessive proinflammatory activity of the cytokine network
negatively influences the outcome of severe bacterial infections. The failure of
these trials to show clinical benefit, in conjunction with recent experimental
data, raises doubt about the validity of this assumption. In this article, we
reevaluate the role of cytokines in the pathogenesis of sepsis and severe bacterial
infections. The cytokine network is discussed as consisting of proinflammatory
cytokines, anti-inflammatory cytokines, and soluble inhibitors of proinflamma-
tory cytokines.

THE CYTOKlNE NETWORK

Proinflammatory Cytokines

As reflected by the designation p r o i ~ ~ u ~these ~ a cytokines

~ o ~ , facilitate a
wide range of i n f l a ~ a t o r yprocesses. The most extensively studied proin-

This work was supported by a grant from the Royal Netherlands Academy of A r t s
and Sciences to T. van der Poll.

From the Laboratory of Experimental Internal Medicine (TvdP, SJHvD), and the Division
of Infectious Diseases, Tropical Medicine, and AIDS (TvdP), Academic Medical Center,
University of Amsterdam, Amsterdam, the Netherlands

JNFECTIOUS DISEASE CLINICS OF NORTH AMERICA

VOLUME 13 NUMBER 2 JUNJ3 1999 413

414 VAN DER POLL & VAN DEVENTER

flammatory cytokines in sepsis are tumor necrosis factor-a (TNF-a)and interleu-

kin (IL)-1. Other cytokines that may be important for the pathogenesis of sepsis
include IL-6, which has both proinflammatory and anti-inflammatory properties,
IL-12, and interferon-y (IFN-y).

Tumor Necrosis Factor-cw and Interleukin-1

Mature secretory human TNF-ahas a molecular mass of 17 kd; the soluble
TNF-a molecule is composed of three 17-kd polypeptides forming a compact
trimer.& TNF-a is produced as a 26-kd prohormone of 233 amino acids, which
is processed to a mature secreted form consisting of 157 amino acids, by cleavage
of a residue signal peptide by one or more matrix metalloproteinases. The
prohormone represents a transmembrane form of TNF-a,whereby the normally
secreted mature sequence is exposed extracellularly, allowing bioactivity to be
exerted at local tissue level. Two distinct cell surface TNF-a receptors have been
identified with respective molecular weights of 55 kd (type I, CD120a) and 75
kd (type 11, CD12Ob)." Stimulation of the type I TNF-a receptor reproduces
many TNF-a activities, such as cytotoxicity, expression of adhesion molecules
on endothelial cells and keratinocytes, and activation of NF-KB.The type I1 TNF-
a receptor may be important for the signaling effects of cell-bound TNF-a. The
extracellular domains of both TNF-a receptors share 28% sequence identity,
similar to the homology shared with a group of cell surface proteins that has
been designated the TNF receptor superfamily. Members of this superfamily
include TNF receptor-related protein, CD27, CD30, CD40, 4-1BB, nerve growth
factor receptor, 0x40,and Fas antigen."
IL-1 is the designation for two polypeptides, IL-la and IL-lp, encoded by
separate genes.12Together with their naturally occurring inhibitor, IL-1 receptor
antagonist (IL-lra), IL-la and IL-1p form the IL-1 gene family, the members of
which recognize the same cellular receptors. Both IL-1s are translated as 31-kd
precursor proteins, which are processed to mature peptides with molecular
weights of 17 to 22 kd. Pro-IL-la is fully active and remains mainly intracellular.
Pro-IL-la can be cleaved in a mature form by membrane-associated cysteine
proteases called calpains. Alternatively, pro-IL-la can be translocated to the cell
membrane, where it can exert biologic activity. In contrast to IL-la, a consider-
able amount of IL-1p is transported out of the cell. IL-1p is the predominant
type of IL-1 that can be found in the circulation during critical illness. Unlike
the IL-la precursor, pro-IL-1p is only marginally active and has no membrane-
associated form. Release of active IL-lp requires cleavage by IL-lp converting
enzyme (ICE), a cysteine protease that is predominantly located at the inner
surface of cell membranes. Overall, IL-lp seems to be a hormone-like protein
involved in systemic IL-1 effects, whereas IL-la is a regulator of intracellular
events and local IL-1 effects.I2
Two IL-1 receptor species have been identified.I2 The type I IL-1 receptor
has a molecular weight of 80 kd and can be found on virtually all cell types.
This receptor type is responsible for transducing cellular effects of IL-la and IL-
lp. At present, no biologic response generated by IL-1 is known to be mediated
by the type 11 IL-1 receptor, which has led to the concept that this receptor type
is inactive and serves as a negative regulator of IL-1 effects. The type I IL-1
receptor engages the so-called IL-1 receptor accessory protein for optimal signal
transduction. After low-affinity binding of IL-la or IL-1p to the type I IL-1
receptor, the IL-1 receptor accessory protein binds to the IL-1 receptor type I -
IL-1 complex, which then initiates signal transduction. Both TNF-a receptors
and the type I1 IL-1 receptor also occur in soluble forms, representing the
 CYIOKJNES AND A"EsIN TbE PATHOGENESIS OF SEPSIS 415

extracellular domains cleaved from the respective transmembrane receptors.

Soluble TNF-a and IL-1 receptors retain their affinity for TNF-a and IL-1,
respectively, and compete with the cell surface receptors for the binding of these
f~tokines.~,12,
TNF-a and IL-1 share a remarkable array of biologic effects. Administration
of high doses of either TNF-a or IL-1 to laboratory animals reproduces many
characteristics of the sepsis syndrome.32*41 The simultaneous a d ~ s ~ a t i ofon
TNF-a and IL-1 results in synergistic toxicity in Both TNF-a and IL-1
are pyrogenic in humans. The systemic inflammatory effects of TNF-a have been
studied in normal humans, in whom TNF-a induced activation of the cytokine
network, the coagulation system, fibrinolysis, and neutrophils.43,44 IL-1 induces
similar inflammatory effects in patients with cancer, with the exception of neu-
trophil activation.=

Interleukin-6
The biologic activities of IL-6 are highly diverse and include induction of
acute-phase protein synthesis, immunoglobulin production, proliferation and
differentiation of T cells, enhancement of natural killer cell activities, and matu-
ration of megakaryocytes.23IL-6 induces cellular effects via gp130, a common
cytokine signal transducer that can also be activated by IL-11, leukemia-inhibi-
tory factor, oncostatin M, ciliairy neurotrophic factor, and cardiotrophin-1. The
IL-6 receptor exists in cell-bound and soluble forms, both of which can bind IL-
6. The complex of membrane-associated or soluble IL-6 receptor and lL-6can
induce the formation of a gp130/gp130 homodimer, resulting in IL-6 signal
transduction. Unlike the soluble TNF-a and IL-1 receptors, the soluble IL-6
receptor serves an agonistic function, allowing cells that lack a cell-surface IL-6
receptor to be responsive to IL-6."
IL-6 is able to influence a number of inflammatory responses that have
relevance for the pathogenesis of bacterial infection. IL-6 is considered a major
regulator of the acute-phase protein response. It stimulates human hepatocytes
to produce several acute phase reactants, including C-reactive protein, serum
amyloid A, al-acid glycoprotein, al-antitrypsin, and fibrinogen. The capacity of
IL-6 to induce an acute-phase protein response has been confirmed in cancer
patients infused with recombinant IL-6. Recently, a 4hour intravenous infusion
of recombinant IL-6 into patients with metastatic renal cell carcinoma was
found to induce laboratory signs of systemic inflammation, including a selective
activation of the coagulation system without an effect on the fibrinolytic sys-
Human studies in which IL-6 was infused intravenously have demon-
strated that although IL-6 can induce mild clinical symptoms, such as chills and
fever, it is by far not as toxic as TNF-a or IL-1. IL-6 has been considered an anti-
inflammatory cytokine by virtue of its capability to inhibit endotoxin-induced
TNF-a and IL-1 production by mononuclear cells in vitro and to reduce TNF-a
release in endotoxemic mice in vivo.2In addition, IL-6 can induce an inmase in
the plasma levels of soluble TNF-a receptor type I and IL-1 receptor antagonist,
which are naturally occurring inhibitors of TNF-a and IL-l.@

Interleukin-12 and Interferony

IL-12 is produced predominantly by monocytes and macrophages.36The
major cellular targets of IL-12 are T cells and natural killer cells, inducing the
production of EN-?, stimulating proliferation, and enhancing cytotoxic activity,
Structurally, IL-12 is a unique cytokine in that biologically active IL-12 is a
416 VAN DER POLL & VAN DEVENTER

heterodimer consisting of a p35 and a p40 subunit, encoded by separate genes.

The p40 subunit mediates binding to the IL-12 receptor (but does not induce
signal transduction), whereas the p35 subunit is critical for signal transduction.
Interestingly, the p35 chain has a structure and sequence homology to IL-6,
whereas the p40 chain displays homology to the IL-6receptor, suggesting that
IL-12 evolved from a c y t o k i n ~ ~ o k i n e - r ~ e pcomplex
tor that became covalently
Iinked. The p40 subunit is able to form homodimers, which bind to the IL-12
receptor with affinities similar to the IL-12 heterodimer without eliciting a
cellular effect. p40 homodimers act as inhibitors of IL-12 activity by blocking IL-
12 receptor binding sites. The production of p35 and p40 is differentially regu-
lated, and to a given stimulus, cells secrete a 10- to 100-fold excess of free p40
over the biologically active p35-p40 heterodimer. The IL-12 receptor is composed
of at least two receptors with low-affinity binding sites for IL-12 the IL-12
receptor 01 and IL-12 receptor p2. High-affinity binding of IL-12 and optimal
signal transduction require interaction between IL-12 and both IL-12 receptor
subunits.36
The main producers of IFN-y are activated natural killer cells, T-helper-1
cells, and cytotoxic T cells? IL-12 is important for IFN-y production by these
cell types; other cytokines that contribute to optimal IFN-y production are TNF-
a, IL-1, IL-15, and IL-18. Biologically active IFN-y exists as a noncovalent
homodimer. IFN-y actions related to i n f l a ~ a t i o are n inductioRof class I1 major
histocompatibilitycomplex (MHC) antigen expression on different cell types and
macrophage activation. LFN-y likely plays an important role in the production of
IgG against bacterial polysaccharides. The IFN-y receptor consists of two sub-
units, the a-chain, exhibiting high-affinity ligand-binding properties, and the @
chain, which is responsible for signaling7
IL-12 and EN? share many biologic ~ r o p e r t i e s .IFN-y ~ , ~ strongly potenti-
ates the synthesis of IL-12 and is considered to mediate many of the in vivo
effects of IL-12, although at least some IL-12 effects are IFN-y-independent." IL-
12 infusion in chimpanzees is associated with a delayed activation of many of
the i n f l a ~ t o r y
pathways that are also activated during sepsis, including the
cytokine network, neutropMs, and coagulation, suggesting that IL-12 may be
involved in sustaining the inflammatory response to a bacterial insult. IFN-y has
no such effects in humans (authors' unpublished observations).

A n t i - l n f i ~ m m ~ Cytokines
to~
Anti-inflammatory cytokines inhibit inflammatory processes, in part by
reducing the production of a number of proinflammatory cytokines. Cytokines
with a n t i - i n f l a ~ a t oproperties
~ include IL-4, IL-6, IL-10, IL-11, and IL-13. Of
these, the roles of IL-6 and IL-10 in severe bacterial infections have been investi-
gated most thoroughly The general characteristics of IL-6 have been described
above.

l n ~ e ~ e ~ k10
in-
IL-10 is an 18-kd polypeptide that can be synthesized by T cells, B cells,
monocytes, and macrophages.28Stimuli that can induce IL-10 production are
diverse and include bacteria, bacterial products (e.g., endotoxin), parasites, fungi,
and viruses. Several cytokines can enhance IL-10 synthesis, including TNF-
a, IL-1, IL-6, and IL-12. Important biologic effects of IL-10 are inhibition of
proinflammatory cytokine production by activated mononuclear cells, inhibition
 CYTOKINES AND ANTICYTOKINES IN TKE PATHOGENESIS OF SEPSIS 417

of class I1 MHC expression by monocytes and macrophages, inhibition of killing

of intracellular bacteria by macrophages, and suppression of monocyte procoag-
ulant activity It should be realized, however, that IL-10 also has immunostimula-
tory properties, such as enhancement of B cell function and stimulation of
development of cytotoxic T cells. The IL-10 receptor is in part homologous to
the class I1 cytokine receptor family, which further includes the receptors for
IFN-a/@and IFN-Y.~

Soluble Inhibitors of Proinflammatory Cytokines

Whereas anti-inflammatory cytokines inhibit the production of the proin-

flammatory cytokines, the action of these potentially toxic proteins can be inhib-
ited by naturally occurring soluble inhibitors, among which soluble TNF-a
receptors type I and 11, soluble K-1 receptor type 11, and IL-lra, inhibit TNF-a
and IL-1 activity, respectively.

Soluble TNF- Receptors

The transmembrane receptors for TNF-a can be processed to soluble forms
that represent the extracellular domains of the respective cellular receptors that
can be found in the circulation of normal humans at concentrations in the ng/
mL Soluble TNF-a receptor levels increase in a variety of infectious and
noninfectious diseases, including sepsis, malaria, acquired immunodeficiency
syndrome (AIDS), liver disease, rheumatoid disorders, and cancer. The eventual
effect of the formation of soluble TNF-a receptor-TNF-a complexes likely de-
pends on the ratio between soluble receptor and TNF-a concentrations. When
present in relatively low. concentrations, soluble TNF-a receptors may serve as
carriers for TNF-a. and augment its effects by stabilizing its trimeric structure
and prolonging its activity? Higher concentrations of soluble TNF-a receptors,
such as are found during severe bacterial infections, mainly act as inhibitors of
TNF-a activity.” Many different stimuli can induce TNF-a receptor shedding
from different cell types in vitro, including phorbol esters, C5a, A23187, IL-1,
IL-10, and TNF-a itself.

Soluble and Cell-Bound IL- f Receptor Type I1 and IL- 1

Receptor Antagonist
Two endogenousmechanisms are considered to be specific for the regulation
of IL-1 activity: the existence of an inactive IL-1 receptor (i.e., the type I1 IL-1
receptor), and the existence of an inactive form of IL-1 (i.e., IL-lra)>zBecause
the binding of IL-1 to the type I1 IL-1 receptor on the one hand does not generate
a biologic response, and on the other hand prevents IL-1 from interacting with
its active (type I) receptor, the type 11 IL-1 receptor functions to inhibit IL-1
effects. The “inactive” type II IL-1 receptor binds only IL-1@, the circulating
form of IL-1, with high affinity. Its affinity for IL-la and IL-lra is low, which
makes the type I1 IL-1 receptor an excellent tool to inhibit the systemic actions
of IL1. The type 11 IL-1 receptor also exists in a soluble form, generated by
shedding of the ligand-binding part of the receptor from the cell surface, which
also has the ability to bind IL-1 and serves as a competitive inhibitor of the
binding of IL-1 to cellular IL-1 receptors. In vitro, type I1 receptor shedding can
be induced by a number of stimuli, including endotoxin, TNF-a, IL-4, and
glucocorticoids.
418 VAN DER POLL & VAN DEVENTER

IL-lra can be considered a member of the IL-1 gene family.12It is produced

by the same cells, has the same molecular size as mature IL-1, and is structurally
related to it. IL-lra binds preferentially to the "active" type I IL-1 receptor but
does not induce any biologic response. IL-lra can be viewed as an inactive
cytokine that functions as a negative regulator of signal transduction of IL-1 via
its active type I receptor.

ACTIVATION AND REGULATION OF THE CYTOKINE

NETWORK DURING SEVERE BACTERIAL INFECTION

Production of Cytokines in Clinical and

Experimental Infection

Numerous studies have been published on serum or plasma concentrations

of cytokines in patients with sepsis." In general, one could say that proinflame
matory cytokines can only be detected in a subset of patients, whereas anti-
inflammatory cytokines and soluble inhibitors can be found in the vast majority
of patients with sepsis and even in healthy individuals. It has been speculated
that the fact that many patients who fullfill the criteria of the so-called systemic
inflammatory response syndrome (SIRS) do not have detectable levels of proin-
flammatory cytokines in their circulation is a reflection of the relatively late
phase of the disease at which patients are admitted to the hospital (and blood
is obtained)? This may also explain why cytokines like TNF-a, IL-lp, IL-12, and
EN--+,which, according to animal models of septic shock, presumably play a
crucial role in the pathogenesis of severe sepsis (see below), either do not or do
not consistently correlate with severity of disease or mortality. In comparison
with other cytokines, IL-6 (a mixed pro- and anti-inflammatory cytokine) has
been reported most consistently in the circulation of septic patients, although
the actual levels of IL-6 show considerable variation.%In spite of the fact that
all published studies found a positive correlation between IL-6 concentrations
on admission and mortality, it will be difficult to determine a cut-off value to
use to identify a patient with a poor prognosis in clinical practice unless assays
become more standardized.
Induction of pathways that function to inhibit excessive activity of proin-
flammatory cytokines can be demonstrated in the majority of patients with
sepsis. This has led to the concept of the c o m p ~ s a~n ~t i o- i~n f l a ~ ~response
to~
syndrome (CARS), presumably following SIRS in time (Fig. I)? Indeed, the
circulating concentrations of soluble TNF-a receptors and of the IL-1 inhibitors,
soluble IL-1 receptor type 11 and IL-lra, increase s u b s ~ t i a l l yduring sepsis,
likely reflecting an attempt of the host to limit systemic TNF-a and IL-1
toxicity.8,47 Similarly, severe sepsis is associated with detectable serum IL-10
concentrations in 80% to 100% of patients." In addition, shortly after the onset
of a bacterial insult (or noninfectious trauma such as surgery) a r@actoy state
develops, which is characterized by a reduced capacity of mononuclear cells
to produce proinflammatory cytokines upon ti mu la ti on?^, 52 The designation
refract0y is not adequate, since mononuclear cells not only produce less proin-
flammatory cytokines, but release more IL-lra.52Although the term endotoxin
tolerance is frequently used to denominate this state, it should be noted that
endotoxin is not the only stimulus to which cells are refractory, and prior
exposure to endotoxin i s not a prerequisite for this phenomenon to OCCUT.
The kinetics of cytokine release and endotoxin tolerance has been studied
in experimental models of infection and ati ion. In these models, TNF-a
 CYTOKINES A N D ANTICYTOKINES IN THE PATHOGENESIS OF SEPSIS 419

A CARS A
A SIRS A

release of pro-inflammatory cytokines

release of anti-inflam~torycytokines

Figure 1. Pro- and anti-inflammatory events during sepsis. Sepsis is most likely associated
with an early transient activity of proinflammatory cytokines, corresponding to the clinical
designation systemic inflammatory response syndrome (SIRS). Shortly after this initial
phase, counterregulatory pathways become activated, generally referred to as compensa-
tory anti-in~ammatoryresponse syndrome (CARS), which include anti-inflammatory cyto-
kine release and the development of a refractory state characterized by a decreased
capacity of mononuclear cells to produce proin~ammatory cytokines on stimulation ex vivo.

is the first cytokine appearing in the circulation." 33. 45* Infusion of either a
relatively low dose of endotoxin into healthy humans or a lethal dose of live
Escherichia coli into baboons results in transient release of TNF-a, peaking after
90 minutes. A close correlation exists between the magnitude of the bacterial
challenge and the extent of TNF-a release: the levels of TNF-a detected in the
lethal baboon studies are much higher than in the mild human volunteer studies.
Other proinflammatory cytokines are released shortly after TNF-a, including IL-
16, K-6, IL-12, and IFN-y. Anti-inflammatory mediators, in particular IL-10, IL-
Ira, and soluble TNF-a receptors, also rise after the initial "??-a peak.8,46,*7
The
early TNF-a production plays a role in the subsequent induction of both pro-
and a n t i - ~ ~ amediators,
t o ~ as indicated by the finding that anti-TNF-a
treatment attenuates the increase in plasma or serum concentrations of IL-lp,
IL-lra, IL-6, IL-10, and soluble TNF-a receptors after a ~ s ~ a t i ofo endotoxin
n
or live bacteria to humans or nonhuman primates.%
The mechanisms underlying the refractory state found in virtually every
patient admitted with sepsis remain to be elucidated. Endotoxin tolerance can
be reproduced by administration of low-dose endotoxin to healthy humans.@
Three hours after injection of endotoxin, whole blood obtained from these
subjects produce less TNF-a and IL-lp, and more IL-lra upon ex vivo resthula-
tion with endotoxin. Plasma obtained 2 hours, but not 1 hour, after in vivo
administration of endotoxin inhibits TNF-a and IL-lP production by endotoxin-
stimulated whole blood from six other healthy donors not previously exposed
to LPS. Together, these data indicate that endotoxin tolerance represents a pur-
poseful adaptation of the host rather than a generalized h ~ o r e s p o n s i v ~ e ~
and is at least partly mediated by soluble factors produced within 2 hours after
previous exposure to endotoxin.
Measuring cytokine levels in the circulation should be viewed as an inade-
quate exploration of the tip of the iceberg. It seems good to realize that sepsis
invariably originates from a localized infectious source within an organ or cavity.
420 VAN DER POLL & VAN DEVENTER

Evidence is accum~atingthat the cytokine response occurs p ~ o m i n a n t l yat

the site of the infection (i.e., in a compartmentalized way). Indeed, patients with
unilateral community-acquiredpneumonia have much higher concentrations of
TNF-a, IL-lp, and IL-6 in bronchoalveolar lavage fluid obtained from the in-
fected lung than in that taken from the uninfected lung or in serum.ll Accord-
ingly, in mouse models of pneumonia cytokine levels in lung tissue are up to
several logs higher than in concurrently drawn blood?', *9*so, 51 Similar observa-
tions have been made in patients and animals with peritonitis.1q*18

Role of Cytoklnes in Bacterial Infection

The role of individual cytokines in the pathogenesis of bacterial infection

has been studied in models in which either neutralizing antibodies or genetically
modified mice were employed. To better understand the mechanisms that are
functional in these models, it seems appropriate to discuss them in two parts:
models of systemic inflammation or infection, and models of initially localized
infections.
In 1985, Beutler and colleagueswere the first to report that passive immuni-
zation against TNF-a by pretreatment with a specific polyclonal antiserum
to TNF-a protect mice against the lethal effect of intravenously administered
endotoxin? Since then, the protective effect of neutralization of TNF-a has been
confirmed in a series of sepsis models in which bacteria or bacterial products
were administered systemically as a bolus or a brief infusion.& Anti-TNF-cx
treatment is highly protective against lethality when given before, simultane-
ously, or very shortly (30 minutes) after intravenous infusion of a lethal dose
(LDloo)of endotoxin or live bacteria. In healthy humans and chimpanzees,
anti-TNF-a attenuatesmany inflammatoryresponses induced by low-dose endo-
toxin, including cytokine release and activation of neutrophils and the fibrino-
lytic system, whereas coagulation activation remains unaffected. Mice deficient
for the type I TNF-a receptor are resistant to endotoxin after sensitization with
D-galactosamine.35,37 Taken together with the finding that administration of a
TNF-a mutant with exclusive affinity for the type I TNF-a receptor causes
significant systemic toxicity and inflammation in baboons,= the picture emerges
of TNF-a as a detrimental mediator in severe bacterial infection, mediating
toxicity via the type I TNF-a receptor. In fact, these data have prompted the
design and performance of a number of clinical trials in patients with sepsis
with different anti-TNF-a strategies (seebelow).
IL-1 activity has been blocked in animal models of sepsis by the administra-
tion of IL-lra. IL-lra protects various species against death owing to endotoxin
or live gram-positive or gram-negative bacteria.lZ,16, The role of endogenous
IL-1 in endotoxin-induced lethality has recently been called in question by
experiments with IL-1p and IL-1 receptor type I-deficient mi~e,'~,~O although one
study did demonstrate a survival advantage in endotoxin-challengedIL-1 recep-
tor type I-knockout mice.I Anti-IFN-y or anti-IL-12 therapy markedly reduces
lethality induced by endotoxin in mice.38*55 Similarly, mice that lack functional
IFN-y are relatively resistant to the toxic effects of endotoxin? IL-6 does not
seem to play an important role in the pathogenesis of endotoxin-induced in-
flammation, because IL-&deficient and wild-type mice show indistinguishable
responses after administration of endotoxin.'o*24 Endogenous IL-6 may play a
role in endotoxin-induced coagulation activation, however, because anti-IL-4
prevented the procoagulant response in endotoxemic chimpanzees.45
The anti-inflammatory cytokine IL-10 appears to have a protective function
 CYTOKJNFS AND ANTICYTOKJNFS IN THE PATHOGENESIS OF SEPSIS 421

in endotoxin challenge models. Administration of recombinant IL-10 directly

before injection of a lethal dose of endotoxin to mice markedly reduces TNF-a
release and prevents lethality.19 In healthy humans, recombinant human IL-10
attenuates the rise in body temperature, plasma TNF-a, IL-6, and IL-8 concentra-
tiom, and activation of the fibrinolytic system and the coagulation 34

Neutralization of endogenously produced IL-10 in endotoxemic mice results in

an increased production of several proinflammatory cytokines, including TNF-
a,and an enhanced mortality.%Similarly, IL-10 gene-deficient mice demonstrate
enhanced mortality after endotoxin injection, in conjunction with elevated levels
of TNF-a, IL-1, IL-6, IL-12, IFN-y, and nitrate? In models of endotoxemia,
endogenous IL-10 represents an important autoregulatory mechanism control-
ling the production of proinflammatory cytokines and endotoxin toxicity in vivo.
It is important to note that intravenous injection of endotoxin or live bacteria
results in a relatively acute syndrome, unlike many cases of sepsis in which a
subacute or intermittent course is noted. Furthermore, clinical sepsis almost
invariably is the result of an infection that was at least initially localized in an
organ or body cavity. When discussing the role of cytokines in the pathogenesis
of sepsis, it is important to consider the function of these mediators during
localized infections. Cytokine production occurs in a compartmentalized fashion:
concentrations are likely several logs higher at, or close to, the site of the
infection than elsewhere in the body, including the blood compar~ent.Mouse
models indicate that proinflammatory cytokines play a crucial role in aspecific
host defense against bacterial infection. Indeed, elimination of TNF-a, It-12, or
IL-6 during murine pneumonia caused by either gram-positive or gram-negative
'
bacteria is associated with an enhanced outgrowth of bacteria in the lungs and
a decreased survival?** so, 51 Conversely, neutralization of endogenous IL-10 con-
fers a survival advantage during murine pneum0nia.4~Also, the lack of func-
tional 'I3W-a or IL-6 impairs host defense against E. coli peritonitis and systemic
infection with Listeria ~ o ~ o ~ t o g ~24*e 35s, 37
. l Together,
~* these data suggest that
the functions of the cytokine network in acute models (bolus administration of
endotoxin or bacteria) and more realistic infection models (pneumonia,peritoni-
tis) are completely opposite. Proinflammatory cytokines seem to be harmful
during overwhelming systemic inflammation,whereas they significantlycontrib-
ute to host defense during localized infection. Similarly, whereas the anti-in-
flammatory cytokine IL-10 protects against systemic toxicity provoked by bolus
a d ~ t r a t i o of
n endotoxin, it impairs host defense mechanisms during pneu-
monia (Fig. 2).

CONCLUSION

Bacterial infection leads to the activation of the cytokine network, which

comprises proinflammatory cytokines, anti-inflammatory cytokines, and soluble
inhibitors of p~inflammatorycytokines. The balance between these counterrep-
latory pathways eventually determines the net p r o i n ~ ~ activity ~ t o of~ the
cytokine network (Fig. 3). The notion that proinflammatory cytokine activity is
necessarily linked to an adverse outcome in infectious diseases is outdated.
Clinical trials with anti-inflammatory strategies in patients with severe bacterial
infections are based primarily on animal studies in which bacteria or bacterial
products were administered systemicallyas a bolus, in the absence of a localized
infectious source. Under such circumstances, overwhelming activation of proin-
flammatorycytokine activity leads to excessive systemic atio ion and tissue
toxicity. It is unlikely, however, that many patients with clinically defined sepsis,
422 VAN DER POLL & VAN DEVENTER

20 - Endotoxemiamodel

I I I I

20 -
Pneumonia model

B Days
FIgure 2. The role of e n ~ n o u s1L-10 in the pathogenesis of endotoxin shock and
pneumococcal pneumonia. Neutralization of 11-10 during sublethal endotoxemia in mice
results in a 60% lethality (A), whereas the same intervention during murine pneumococcal
pneumonia protects against lethality (B). (Adapted from Marchant A, BruynsC, Vandena-
beale P et al: IL-10 controls IF-? and TNF p r ~ u c t i o nduring e x ~ r i m eendotoxemia.
~l
Eur J lmmunol24:1167, 1994; andVan der Poll T,Marchant A, Keogh CV et al: Interleukin-
10 impairs host defense in murine pneumococcal pneumonia. J Infect Dis 174994, 1996;
with permission.)

according to which patients are enrolled in sepsis trials, suffer from excessive
activity of proidammatory cytokine activity at the systemic level, especially at
the time they are admitted to the hospital (and enrolled in the trial). Indeed,
patients with severe sepsis almost invariably are in an immunologically refrac-
tory state, characterized by decreased proinflammatory cytokine production by
mononuclear cells upon restimulation ex vivo. This even has led to the perfor-
mance of one uncontrolled trial in which the immune status of patients with
sepsis was stimulated with daily treatment with recombinant IFN-y13
 CyTOKINEs AND ANTICYTOKINES I
N THE PATHOGENESIS OF SEPSIS 423

Bacterial Infection

anti-inflammatorycytokines:
TNF IL-10
IL-1 soluble inhibitors:
11-12 soluble TNF receptm
1FN-y soluble IL-1 receptor type II
IL-I RA

a ~ - ~ c t e naaW
l i tissue toxicity
organ failure

Figure 3. The cytokine network during severe bacterial infection. Bacterial infection leads
to the activation of pro-inflammatorycytokines and a number of anti-inflammatorypathways.
The balance between pro- and anti-inflammatory mechanisms determines the degree of
inflammation. Local pro-inflammatory activity is required for an adequate host defense
against bacterial infection. Excessive systemic activity of proinflammato~cytokines is
associated with toxicity.

It seems important to realize that of 18 published clinical trials with nonglu-

cocorticoid anti-inflammatory agents, including anti-TNF-a, soluble TNF-a re-
ceptors, and E-lra, none have demonstrated a beneficial effect with respect to
prospectively defined end points.56One trial in which a recombinant TNF-a
receptor type E-IgG fusion protein was given to patients with sepsis, even
demonstrated a significantly higher 28-day all-cause mortality in the groups
treated with the TNF-a-neutralizing compound (30% in the placebo group, and
48% and 53% in the groups treated with a low and high dose of the TNF-a
receptor fusion protein, re~pectively).'~ In the scientific community, the opinion
has emerged that the beneficial effect of a n t i - ~ ~ aagents t o ~tested so far,
if present, are small, and that high-dose anti-inflammatory therapy may even be
harmful in sepsis. For clinicians, it is extremely difficult to discern the patient
who will benefit from anti-inflammatory therapy from the patient who will not
be helped (or will be worsened) by such treatment. In this evaluation, one
should take into account that experimental studies of clinically relevant infec-
tious diseases suggest that the local activity of proinflammatory cytokines is
required for an adequate aspeeifit host defense against bacteria. Many patients
with sepsis syndrome who receive proinflammatory cytokine-neutralizingstrate-
gies as part of a clinical trial are not expected to benefit from such treatment.
424 VAN DER POLL & VAN DEVENTER

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f to
Tom van der Poll, MD, PhD
AcademirMedical Center, Room G2-132
Meibergdreef 9
1105 AZ Amsterdam
The Netherlands