Sepsis syndrome and septic shock remain as significant causes of morbidity and mortality. To date, clinical trials of immunotherapeutic agents have failed to establish conclusively a role for these agents despite considerable animal data to suggest a positive benefit. This article discusses the hypotheses upon which these therapies are based, the critical issues associated with clinical trials and the molecules which have been clinically tested. Recommendations for future clinical trials in sepsis are made.
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References
1.
Wenzel RPThe mortality of hospital-acquired blood stream infections: need for a new vital statistic?Int J Epidemiol1988; 17: 225-227.
2.
Bone RC, Fisher Jr CJ, Clemmer TP et al. Sepsis syndrome: a valid clinical entity. Crit Care Med1989; 17: 389-393.
3.
Centers for Disease Control.Increase in national hospital discharge survey rates for septicemia - United States, 1979-1987. MMWR1990; 39: 31-34.
4.
Greenman RL, Schein Rmh, Martin MA et al. A controlled clinical trial of E5 murine monoclonal IgM antibody to endotoxin in the treatment of gram-negative sepsis. JAMA1991; 266: 1097-1101.
5.
Ziegler EJ, Fisher Jr CJ, Sprung CL et al. Treatment of gram-negative bacteremia in septic shock with HA-1A human monoclonal antibody against endotoxin - a randomized, double-blind, placebo-controlled trial. N Engl J Med1991 ; 324: 429-436.
6.
Fisher Jr CJ , Bellingan G.Immunotherapy of sepsis syndrome: a comparison of the available treatments. Klin Wochenschr1991; 69 (Suppl XXVI): 162-167.
7.
Parillo JE, Parker MM, Natanson C. et al. Septic shock in humans: advances in the understanding of pathogenesis, cardiovascular dysfunction, and therapy. Ann Int Med1990; 113: 227-242.
8.
Bone RCPathogenesis of sepsis. Ann Intern Med1991 ; 115: 457-469.
9.
Parillo JEPathogenic mechanisms of septic shock. N Engl J Med1993; 328: 1471-1477.
10.
Hesse DG, Tracey KJ, Fong Y. et al. Cytokine appearance of human endotoxemia and primate bacteremia . Surg Gynecol Obstet1988; 166: 147-153.
Waage A., Brandtzag P., Halstensen A. et al. The complex pattern of cytokines in serum from patients with meningococcal septic shock. Association between interleukin-6, interleukin-1 and the fatal outcome. J Exp Med1989; 169: 333-338.
13.
Marks JD, Marks CB, Luce JM et al. Plasma tumor necrosis factor in patients with septic shock. Am J Respir Dis1990; 141: 94-97.
14.
Cannon JG, Tompkins RG, Gelfand JA et al. Circulating interleukin-1 and tumor necrosis factor in septic shock and experimental endotoxin fever. J Infect Dis1990; 161: 79-84.
15.
Calandra T. , Baumgartner JD, Gram EG et al. Prognostic values of tumor necrosis factor/cachectin, interleukin-1, interferon-alpha and interferon-gamma in the serum of patients with septic shock. J Infect Dis1990; 161: 982-987.
16.
Michie HR, Monogue KR, Spriggs DR et al. Detection of circulating tumor necrosis factor after endotoxin administration. N Engl J Med1988; 318: 1481-1482.
17.
Fischer E., Marano MA, VanZee KJ et al. Interleukin-1 receptor blockade improves survival and hemodynamic performance in E. coli septic shock, but fails to alter host responses to sublethal endotoxemia. J Clin Invest1992; 89: 1551-1557.
18.
Wakabayashi G., Gelfand JA, Burke JF et al. A specific receptor antagonist for interleukin-1 prevents Escherichia coli-induced shock in rabbits. FASEB J1991; 5: 338-343.
19.
Aiura K., Gelfand JA, Burke JF et al. Interleukin-1 (IL-1) receptor antagonist prevents Staphylococcus epidermidis-induced hypotension and reduces circulating levels of tumor necrosis factor and IL-1beta in rabbits. Infect Immun1993; 61: 3342-3350.
20.
Granowitz EV , Santos AA, Poutsiaica DD et al. Production of interleukin-1 receptor antagonist during experimental endotoxemia. Lancet1991; 338: 1423-1424.
21.
Tracey KJ, Beutler B., Lowry SF et al. Shock and tissue injury induced by recombinant human cachectin . Science1986; 234: 470-474.
22.
Okusawa S., Gefand JA, Ikejima T. et al. Interleukin-1 induces a shock-like state in rabbits. Synergism with tumor necrosis factor and the effect of cyclooxygenase inhibition. J Clin Invest1988; 81: 1162-1172.
23.
Ziegler EJ, McCutchan JA, Fierer J. et al. Treatment of gram negative bacteremia and shock with human antiserum to a mutant Escherichin coli. N Engl J Med1982; 307: 1225-1230.
24.
Baumgartner J-D. , Glauser MP, McCutchan JA et al. Prevention of gram-negative shock and death in surgical patients by antibody to endotoxin core glycolipid. Lancet1985; 2: 59-63.
25.
Schedel I., Driekhausen U., Nentwig B. et al. Treatment of gram-negative septic shock with an immunoglobulin preparation: a prospective, randomized clinical trial. Crit Care Med1991; 19: 1104-1113.
26.
Exley AR, Cohen J., Buurman W. et al. Murine monoclonal antibody to recombinant human tumor necrosis factor in the treatment of severe septic shock. Lancet1990; 335: 1275-1276.
27.
Fisher Jr CJ , Opal SM, Dhainaut JF et al. Anti-TNF IgG monoclonal antibody (CB0006) in sepsis syndrome: pharmacokinetics, safety and role of pretreatment IL-6 as a predictor of time of survival. Circ Shock1991; 34: 167-168.
28.
Fisher Jr CJOpal SM, Dhainaut JF et al. Influence of an anti-tumor necrosis factor monoclonal antibody on cytokine levels in patients with sepsis. Crit Care Med1993; 21: 318-327.
29.
Fisher Jr CJSlotman GJ, Opal SM et al. Initial evaluation of human recombinant interleukin- 1 receptor antagonist in the treatment of sepsis syndrome - a randomized, open-label, placebo-controlled trial. Crit Care Med1994; 22: 12-21.
30.
Fisher Jr CJ , Dhainaut JF, Opal SM et al. Recombinant human interleukin-1 receptor antagonist in the treatment of patients with sepsis syndrome: results from a randomized, double-blind, placebo-controlled trial. JAMA1994; 271: 1836-1843.
31.
Abraham E., Wunderink R., Silverman H. et al. Efficacy and safety of monoclonal antibody to human tumor necrosis factor-alpha in patients with sepsis syndrome: a randomized. controlled, double-blind, multicenter clinical trial. JAMA1995; 273: 934-941.
32.
Giroir BPMediators of septic shock: new approaches for interrupting the endogenous inflammatory cascade. Crit Care Med1993; 21: 780-789.
33.
Morrison DC , Ryan JLBacterial endotoxins and host immune responses . Adv Immunol1979; 28: 293-450.
34.
Morrison DC , Ulevitch RJThe effects of bacterial endotoxins on host mediation systems. Am J Pathol1978: 93: 526-617.
35.
Mathison JC , Wolfson E., Ulevitch RJParticipation of tumor necrosis factor in the mediation of gram-negative bacterial lipopolysaccharide-induced injury in rabbits. J Clin Invest1988; 81: 1925-1937.
36.
Okusawa S., Gefand JA, Ikejima T. et al. Interleukin-1 induces a shock-like state in rabbits. Synergism with tumor necrosis factor and the effect of cyclooxygenase inhibition. J Clin Invest1988; 81: 1162-1172.
37.
Opal SM, Cross ASKelly NM et al. Efficacy of a monoclonal antibody directed against tumor necrosis factor in protecting neutropenic rats from lethal infection with Pseudomonas aeruginosa. J Infect Dis1990; 161: 1148-1152.
38.
Cannon JG, Tomplins RG, Gelfand JA et al. Circulating interleukin-1 and tumor necrosis factor in septic shock and experimental endotoxin fever. J Infect Dis1990; 161: 79-85.
39.
McCloskey RV , Straube RC, Sanders C. et al. Treatment of septic shock with human monoclonal antibody HA-1A. A randomized. double-blind, placebo-controlled trial. Ann Intern Med.1994; 121: 1-5.
40.
Weiss J., Elsbach P., Olsson I., Odeberg H.Purification and characterization of a potent bactericidal and membrane active protein from the granules of human polymorphonuclear leukocytes. J Biol Chem1978; 253: 2664-2672.
41.
Fisher Jr CJ , Opal SM, Marra MN et al. Bactericidal/permeability-increasing protein (BPI) reduces mortality in experimental sepsis. Circ Shock1991; 34: 20.
42.
Fisher Jr CJ, Opal SM, Marra MNBactericidal permeability increasing protein: a potent naturally occurring anti-endotoxin protein. In: Lamy M, Thijs LG eds. Mediators of Sepsis. Berlin: Springer-Verlag, 1992.
43.
Marra MN, Thornton MB, Snable JL, Wilde CG, Scott RWEndotoxin-binding and neutralizing properties of recombinant bactericidal/permeability-increasing protein and monoclonal antibodies HA-1A and E5. Crit Care Med1994; 22: 559-565.
44.
Fisher Jr CJ , Marra MN, Palardy BA et al. Human neutrophil bactericidal/permeability-increasing protein reduces mortality rate from endotoxin challenge: a placebo-controlled study. Crit Care Med1994; 22: 553-558.
45.
Opal SM, Palardy JE, Marra MN et al. Relative concentrations of endotoxin-binding proteins in body fluids during infection. Lancet1994; 344: 429-431.
46.
Beutler B., Cerami A.Cachectin: more than a tumor necrosis factor. N Engl J Med1987; 316: 379-385.
47.
Marks JD, Marks CB, Luce JM et al. Plasma tumor necrosis factor in patients with septic shock. Am J Respir Dis1990; 141: 94-97.
48.
Hesse DG, Tracey KJ, Fong Y. et al. Cytokine appearance of human endotoxemia and primate bacteremia . Surg Gynecol Obstet1988; 166: 147-153.
49.
Waage A., Halstensen A., Spevik T.Association between tumor necrosis factor in serum and total outcome in patients with meningococcal disease. Lancet1987; 1: 355-357.
50.
Tracey K., Fong Y., Hesse DG et al. Anti-cachectin/TNF monoclonal antibodies prevent septic shock during lethal bacteremia. Nature1987; 330: 662-664.
51.
Engelmann H. , Aderka D., Rubinstein M., Rotman D., Wallach D.A tumor necrosis factor binding protein purified to homogeneity from human urine protects cells from tumor necrosis factor toxicity. J Biol Chem1989; 264: 11974-11980.
52.
Olsson I., Lantz M., Nilsson E. et al. Isolation and characterization of a tumor necrosis factor binding protein from urine. Eur J Haematol1989; 42: 270-275.
53.
Robaye B., Hepbum A., Lecocq R., Fiers W., Bocynacms JM, Dumont JETumor necrosis factor-alpha induces the phosphorylation of 28 kDa stress proteins in endothelial cells: possible role in protection against cytotoxicity?Biochem Biophys Res Commun1989; 163: 301-308.
54.
Schutze S., Scheurich P., Pfizenmaier K., Kronke M.Tumor necrosis factor signal transduction: tissue-specific serine phosphorylation of a 26-kDa cytosolic protein. J Biol Chem1989; 264: 3562-3567.
55.
Vilcek J., Lee THTumor necrosis factor: new insights into the molecular mechanisms of its multiple actions. J Biol Chem1991; 266: 7313-7316.
56.
Dinarello CAInterleukin-1 and its biologically related cytokines . Adv Immunol1989; 44: 153-205.
57.
Damas P., Reuter A., Gysen P. et al. Tumor necrosis factor and interleukin-1 serum levels during severe sepsis in humans. Crit Care Med1989 ; 17: 975-978.
58.
Waage A., Brandtzag P., Halstensen A. et al. The complex pattern of cytokines in serum from patients with meningococcal septic shock. Association between interleukin-6, interleukin-1 and the fatal outcome. J Exp Med1989; 169: 333-338.
59.
Eisenberg SP , Evans RJ, Arend WP et al. Primary structure and functional expression from complimentary DNA of a human interleukin-1 receptor antagonist. Nature1990; 343: 341.
60.
Hannum CH, Wilcox CJ, Arend WP et al. Interleukin-1 receptor antagonist activity of a human interleukin-1 inhibitor. Nature1990; 343: 336.
Ohlsson K., Bjork P., Bergenfeldt M. et al. An interleukin-1 receptor antagonist reduces mortality from endotoxin shock. Nature1990; 348: 550-552.
63.
Fischer E., Marano MA, Barber A. et al. A comparison between the effects of interleukin-1 alpha administration and sublethal endotoxemia in primates. Am J Physiol1991; 261: R442-R452.