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Sepsis:

Evolving Concepts

John C. Marshall, MD FRCSC


St. Michaels Hospital

University of Toronto

Sepsis
Pepsis
Hippocrates 460 370 BC

Fermentation caused by living organisms

Germ theory of disease


Louis Pasteur 1822 - 1895

Consequences
Public health
Immunization Sterilization

Antibiotics

Susceptibility to LPS is Transferred with Bone Marrow Cells

C3H HeJ (Resistant)

C3H HeN (Sensitive)

- Michalek, J.Infect.Dis. 141:55, 1980

Susceptibility to LPS is Transferred with Bone Marrow Cells

C3H HeJ (Resistant)


IRRADIATION CROSSOVER BONE MARROW TRANSPLANT

C3H HeN (Sensitive)

+ LPS
- Michalek, J.Infect.Dis. 141:55, 1980

Susceptibility to LPS is Transferred with Bone Marrow Cells

C3H HeJ (Resistant)


IRRADIATION CROSSOVER BONE MARROW TRANSPLANT

C3H HeN (Sensitive)

+ LPS
HeJ Marrow Live

HeN Marrow Die

- Michalek, J.Infect.Dis. 141:55, 1980

Passive immunization

against tumor necrosis


factor/cachectin protects mice from the lethal effects of endotoxin.

Bruce Beutler

Beutler, Milsark, & Cerami


Science 229:869, 1985

Consequences
New diseases
New therapeutic targets Response is the disease Not unique to infection

ACCP/SCCM Consensus Conference 1991

Infection

Sepsis

SIRS

Trauma Burns Pancreatitis

Systemic Inflammatory Response Syndrome

Rates of Sepsis, U.S. 1979 - 2001

- Martin, N Engl J Med 348:1546, 2003

Most Common Causes of Death (WHO 2008)


1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Heart disease Stroke Lower respiratory infections COPD Diarrheal diseases HIV/AIDS Tuberculosis Lung cancer Vehicular trauma Prematurity

- Crit Care Med 36:296, 2008

<8

CVP
>8

Fluids
<65

Mean Arterial Pressure

Pressors
Transfusion, Inotropes

> 65

ScvO2
> 70

Goals achieved

The Impact of Goal-Directed Therapy


NNT to prevent 1 death = 6-8

60

Mortality (%)

50

Standard Therapy Goal-directed

40
30 20 10 0
Hospital Mortality 28 Day Mortality 60 Day Mortality

Rivers E, et al. N Engl J Med 2001;345:1368

Impact of Delayed Antibiotic Therapy on Clinical Outcome


Odds Ratio for Death
100

(95% CI)

10

Time from Onset of Hypotension (Hours)


-Kumar, Crit Care Med 34:1589, 2006

Impact of Source Control in 1170 Patients with Sepsis 28 Day Mortality Adequate Inadequate
31.4% (303/964) 42.7% (88/206)

p.
0.003

Odds Ratio 0.61 (0.45-0.83)

Despite conventional treatment, 25 - 30% of septic patients die of a process characterized by persistent inflammation and non-resolving

organ dysfunction.

Lipopolysaccharide (LPS)

TLR4

Endotoxin
CD14
IRAK TRAF2

MyD88

MAP Kinases: Erk, p38, Jnk PI3 Kinase

NFkB

Pro-inflammatory genes: IL-1, TNF PAF, Nitric oxide, Coagulation

Tissue ischemia, Cell necrosis, Apoptosis

TLR4

Endotoxin
CD14
IRAK TRAF2

MyD88

MAP Kinases: Erk, p38, Jnk PI3 Kinase

NFkB

Pro-inflammatory genes: IL-1, TNF PAF, Nitric oxide, Coagulation

Tissue ischemia, Cell necrosis, Apoptosis

Toll-like Receptors
TLR2 TLR3 TLR4 TLR5 TLR6 TLR7 TLR8 TLR9 Lipoteichoic acid, bacterial lipoprotein, Injured tissue Double-stranded RNA Endotoxin, elastase, heparan, HSP60, oxidized phospholipids Flagellin Mycoplasma lipopeptide Imiquod, viral DNA Viral DNA, single-strand RNA Bacterial DNA

Clearance of Candida is Impaired in TLR4 Mutant C3H/HeJ Mice


8

Log cfu/Gm kidney

C3H HeN C3H/HeJ

* *

PMN/Mouse (X 106)

10 8

6
4 2 0 Baseline
C3H/HeN C3H HeJ

0 Day 1 Day 7

4 Hours

- Netea, J Infect Dis 185:1483, 2002

Mediators of Lethality in Murine Endotoxemia


Cytokines
IL-1, IL-12, IL-18, IL-27, TNF, IFN, TGF, LIF,MIF, GCSF, HMGB-1, MIP-1, MFP-14, LBP, PTH-RP IL-1ra, IL-4, IL-10, IL-13, IFN, HGF, LIF, CRP, MCP-1, BPI, CAP18, TSG-14, VLDL, VIP, C3, C4, melatonin TNFr p55, IL-1r, PAFr, LECAM-1, TREM-1, LDLr, CD11a, CD14 VIPr, Adenosine A3r PAF, PLA2 Vitamin B12, Vitamin D3 hck, COX-2, p38, jnk, NFB, iNOS, caspase-3

Receptors

Non-proteins Signal transduction Coagulation Factors

Stat4, Stat6, IB, HSP70, hemoxygenase PAI 1, Tissue Factor


TFPI, APC
- Marshall Nature Rev Drug Disc 2:391, 2003

LPS challenge in

human volunteers
causes altered

expression of 3714
distinct genes.

- Calvano, Nature 437:1032, 2005

Therapies Targeting Endotoxin


TLR4 Antagonists CD14 Antagonists Anti-LPS Strategies
E5564 (Eisai) Others IC14 Antibodies:

J5, HA-1A, E5
rBPI21 Polymyxin B dextran HDL, taurolidine Alkaline phosphatase Lipid emulsion Extracorporeal removal

TLR4

Endotoxin
CD14
IRAK TRAF2

MyD88

MAP Kinases: Erk, p38, Jnk PI3 Kinase

NFkB

Pro-inflammatory genes: IL-1, TNF PAF, Nitric oxide, Coagulation

Tissue ischemia, Cell necrosis, Apoptosis

TLR4

Endotoxin
CD14
IRAK TRAF2

MyD88

MAP Kinases: Erk, p38, Jnk PI3 Kinase

NFkB

Pro-inflammatory genes: IL-1, TNF PAF, Nitric oxide, Coagulation

Tissue ischemia, Cell necrosis, Apoptosis

Neutralization of Pro-Inflammatory Cytokines in Sepsis Interleukin-1 Receptor Antagonist


3 Studies; 1688 patients

28 Day Mortality Odds Ratio: 0.80 (0.65-0.99) p=0.04

Neutralization of Pro-Inflammatory Cytokines in Sepsis

Anti-TNF Antibodies
8 Studies; 6500 patients

28 Day Mortality Odds Ratio: 0.93 (0.87-0.99) p=0.02

TLR4

Endotoxin
CD14
IRAK TRAF2

MyD88

MAP Kinases: Erk, p38, Jnk PI3 Kinase

NFkB

Pro-inflammatory genes: IL-1, TNF PAF, Nitric oxide, Coagulation

Tissue ischemia, Cell necrosis, Apoptosis

Recombinant PAF Acetylhydrolase


Phase II Trial (N = 240) 28 Day Mortality (%)
Placebo Treated p.

Overall Severe Sepsis Trauma

28.4 44.2 10.5

14.5 21.4 5.9

0.03 0.03 NS

- Shuster, Crit Care Med 31:1612, 2003

Effects of L-NMMA on Survival in Septic Shock


100 80

Percent Surviving

60

Placebo

40

20

p<0.001 Wilcoxon

L-NMMA

14

21

28

Day of Study
- Lopez, Crit Care Med 32:21, 2004

rhAPC Reduces Mortality in Sepsis

-Bernard et al; NEJM 344:649, 2001

TLR4

Endotoxin
CD14
IRAK TRAF2

MyD88

MAP Kinases: Erk, p38, Jnk PI3 Kinase

NFkB

Pro-inflammatory genes: IL-1, TNF PAF, Nitric oxide, Coagulation

Tissue ischemia, Cell necrosis, Apoptosis

Corticosteroids in Septic Shock: A Meta-analysis

Annane D BMJ 2004;329:480

Adjuvant Therapy in Sepsis


Anti-endotoxin Therapy 9 trials; 3057 Patients Anti-TNF Antibodies 10 Trials; 6821 Patients IL-1ra 3 Trials; 1688 Patients Intravenous immune globulin 20 Trials; 2621 Patients Activated Protein C; All Patients 2 Trials 4303 Patients Activated Protein C; Patients with MOF 2 Trials; 2133 Patients 0.6 0.7 0.8 0.9 1.0 1.1 1.2 1.3

Experimental Agent Better

Placebo Better - Marshall, J Leukoc Biol 83:471, 2008

Probability of Survival at 90 Days


1.0 0.9 0.8 Probability of Survival 0.7 0.6 0.5
DrotAA Placebo

0.4
0.3 0.2 0.1 0.0

0 Number at risk Placebo DrotAA 845 851

10

20

30

40

50

60

70

80

90

Days Since Randomization

703 701

656 645

622 616

593 596

579 584

569 576

563 567

557 561

553 555

Ranieri et al. N Engl J Med 2012;366(22):205564.

But
Impact is modest Indications for use poorly defined

Dose-dependent Effects of L-NMMA on Survival


All doses

<5 mg/kg/hr

> 5mg/kg/hr 0 1 2 3 4 5 6

Study Drug Better - Lopez, Crit Care Med 32:21, 2004

TNF Levels Following Infusion


8 7 6

TNF (ng/ml)

5 4 3 2 1 0 Pre 2 24

TNF MAb Placebo

72

Hours Post-Infusion

Sepsis Syndrome
(Bone et al; 1987)
Suspected or proven infection, in association with: Tachycardia Tachypnea Hyper- or hypothermia Dysfunction of one or more organs

Sepsis Syndrome
24 year old man with penetrating injury to colon 86 year old woman with CHF and Enterococcal UTI 51 year old man with COPD exacerbation; Candida in sputum

Cytokine Levels in Human Sepsis


Median (pg/ml) Range

TNF IL-6 IL-8

83 965 2130

7 57,151 8 1,553,435 16 651,338


- MONARCS, Unpublished

The PIRO Concept Predisposition


Insult Response

Organ dysfunction
- Crit Care Med 31:1250, 2003

Cancer staging stratifies by:

Prognosis
Potential to respond to treatment

Insult

Inflammatory Response

Organ Dysfunction
Inflammation Iatrogenic

Infection Adaptive Injurious Injury, Ischemia

Risk of Death: Cause of Death of Biologic Parent


RR
All causes Natural causes Infection Cardiovascular Cancer 1.71 1.98 5.81 4.52 1.19

95% CI
1.14 2.57 1.25 3.12 2.47 13.7 1.32 15.4 0.16 8.99

- Sorensen et al N Engl J Med 318:727, 1988

Tumor Necrosis Factor G A; -308 (Promoter)


Author
Nadel

Disease
Meningococcemia (deaths)
Septic shock (deaths) Septic shock (deaths)

Cases Controls p.
0.56 0.29 0.03

Mira

0.52

0.24

0.008

Tang

0.40

0.08

<0.05

The TNF -308A/G Polymorphism Modifies the Response to Anti-TNF Therapy


Mean Change in DAS28
1 0
GG GA AA

*p=0.001

-1
-2 -3

-4

Etanercept (N=455)

Infliximab (N=453)

- Maxwell, Hum Mol Genet 17:3532, 2008

Influence of Infectious Challenge on Response to Neutralization of TNF


LPS E. coli CLP
N=256 N=56 N=23

S. aureus Grp. B Strep. S. pneumoniae

N=14 N=10 N=21

-40

-20

20

40

60

Absolute Risk Reduction (%)


- Lorente & Marshall, Shock 24 (Suppl):107, 2005

Salmonella

N=11

Candida

N=14

Listeria

N=10

M. tuberculosis

N=11

-40

-30

-20

-10

10

20

30

Absolute Risk Reduction (%)


- Lorente & Marshall, Shock 24 (Suppl):107, 2005

Impact of Infection-Related Variables on ICU Outcome


OR for Mortality
1.38 1.82

Infectious Focus Intra-abdominal Pneumonia

N 31 30

95% CI
0.56-3.40 0.74-4.47

Bacteremia
Urinary Tract

57
23

1.83
0.49

0.79-4.26
0.15-1.60

Impact of Source Control in Patients with Low IL-6 Levels Source Control Mortality

Adequate
(N=545)

126 (23.1%)
48 (39.7%)*
* p<0.001

Inadequate
(N=121)

Impact of Source Control in Patients with High IL-6 Levels Source Control Mortality

Adequate
(N=419)

177 (42.3%)
40 (47.1%)*
* p=0.49

Inadequate
(N=85)

Impact of Organ Dysfunction on Response to Antibiotics


ICU Mortality Adequate Inadequate
LOD > 4 (N=72)
LOD < 4 (N=70) 21/36 (59%) 20/36 (56%)

p.
0.81

2/27 (7%)

16/43 (37%)

0.006

- Clech, Intensive Care Med 30:1327, 2004

Anti-TNF is Most Efficacious in Patients without Organ Dysfunction


28 Day Mortality (Per cent)
100

* p=0.003; OR 0.51 (0.32-0.80)


80
Placebo Afelimomab

60

40

20

0 0-4 5-8 9-12 13-16 17-20 21-24

Baseline MOD Score

Sepsis is an

iatrogenic disorder:
It develops in the survivors of acute life-threatening infection ICU care shapes its evolution

Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome

Mortality (%)

Controls

39.8

Volume-limited 31.0*
*P=0.007
ARDSNet; NEJM 342:1301, 2000

Fluid resuscitation

Impact of Fluid Strategy in ARDS


Conservative Liberal (N=503) (N=497)
60 day mortality Ventilator-free days ICU-free days CNS failure FD 25.5% 14.60.5 13.40.4 18.80.5 28.4% 12.10.5

p.

0.30 <0.001

11.20.4 <0.001 17.20.5 0.03

- ARDSNet, N Engl J Med 354:2564, 2006

Randomized Trials of Antibiotic Minimization


Control Singh 2000 (Resistance) Fagon 2000 (Mortality) Chastre 2003 (Resistance) 35% Restrictive 15% p. 0.02

25.8%

16.2%

0.02

62.0%

42.1%

0.04

Surviving Sepsis Campaign


Global process change initiative based on sepsis bundles 15,022 patients enrolled

7% absolute, 5.4% relative mortality reduction (p<0.001)

Impact of Bundle Elements on Hospital Mortality O.R.


Start antibiotics Glucose control APC for shock 0.86 0.67 0.81

95% CI
0.79 0.93 0.62 0.71 0.68 0.96

p.
<0.00001 <0.00001 0.02

Steroids
Low Vt

1.06
0.70

0.96 1.17
0.62 0.78

0.24
<0.00001

Conclusions
Improved understanding of biology of response to injury

Can be translated into effective new therapies


The obstacle is our intrinsic conceptual conservatism

Thank you!