Glucans are fungal cell wall PAMPs that promote survival in polymicrobial and candidal sepsis. Dectin-1 is the primary PRR for glucans. The goals of the present study were to characterize 1) the effects of fungal infection on Dectin-1; 2) the effects of polymicrobial sepsis in the presence and absence of glucan on Dectin-1; 3) the effects of systemic administration of glucans on Dectin-1; and 4) the intracellular trafficking of glucans. Mice were either systemically infected with Candida albicans, or made septic by CLP with and without glucan phosphate (GP) injection, or injected with GP. Flow cytometry was performed to assess cell surface Dectin-1 expression. C. albicans sepsis resulted in an increase in the percentage of Dectin-1 positive (Dectin+) blood and splenic leukocytes by increasing the percentage of neutrophils. C. albicans infection increased the percentage of Dectin+ splenic T cells. CLP decreased the percentage of highly Dectin-1 positive leukocytes in the blood by decreasing the percentage of Dectin+ neutrophils. GP treatment in sepsis further decreased the percentages of Dectinhigh blood leukocytes and Dectin+ neutrophils. CLP decreased the percentage of Dectin+ splenic leukocytes by decreasing the percentage of splenic macrophages. GP administration to CLP mice further decreased the percentage of Dectin+ splenocytes by decreasing the percentage of Dectin+ macrophages. Administration of GP resulted in a prolonged decrease in the percentage of Dectinhigh blood leukocytes. The changes in Dectin-1 expression with GP were because of decreases in the percentage of Dectin+ neutrophils and monocytes. In the trafficking studies, macrophages were incubated with fluorescent labeled glucans and then stained for intracellular organelles and signal transduction molecules. Cells were imaged using confocal microscopy. GP is internalized by clathrin and trafficked to the Golgi apparatus. GP internalization is regulated but not dependent on caveolin-1. GP co-localized with SRA, TLR2, and PI3K/p85. The trafficking of laminarin and particulate glucan is similar. We speculate that loss of cell surface Dectin-1 may be important in the protection conferred by glucans in sepsis. Additionally, intracellular trafficking and interaction with signaling components may be important steps in modulation of cellular function by glucan-pattern recognition receptor complexes.

The spleen is a key participant in the pathophysiology of sepsis and inflammatory disease. Many splenocytes exhibit a cholinergic phenotype, but our knowledge regarding their cholinergic biology and how they are affected by sepsis is incomplete. We evaluated effects of acute sepsis on the spleen using the cecal ligation and puncture (CLP) model in C57BL/6 and ChATBAC-eGFP mice. Quantification of cholinergic gene expression showed that choline acetyltransferase and vesicular acetylcholine transporter (VAChT) are present and that VAChT is upregulated in sepsis, suggesting increased capacity for release of acetylcholine (ACh). High affinity choline transporter is not expressed but organic acid transporters are, providing additional mechanisms for release. Flow cytometry studies identified subpopulations of cholinergic T and B cells as well as monocytes/macrophages. Neither abundance nor GFP intensity of cholinergic T cells changed in sepsis, suggesting that ACh synthetic capacity was not altered. Spleens have low acetylcholinesterase activity, and the enzyme is localized primarily in red pulp, characteristics expected to favor cholinergic signaling. For cellular studies, ACh was quantified by mass spectroscopy using d4-ACh internal standard. Isolated splenocytes from male mice contain more ACh than females, suggesting the potential for gender-dependent differences in cholinergic immune function. Isolated splenocytes exhibit basal ACh release, which can be increased by isoproterenol (4 and 24 h) or by T cell activation with antibodies to CD3 and CD28 (24 h). Collectively, these data support the concept that sepsis enhances cholinergic function in the spleen and that release of ACh can be triggered by stimuli via different mechanisms.

Circulating lactate levels are a critical biomarker for sepsis and are positively correlated with sepsis-associated mortality. We investigated whether lactate plays a biological role in causing endothelial barrier dysfunction in sepsis. We showed that lactate causes vascular permeability and worsens organ dysfunction in CLP sepsis. Mechanistically, lactate induces ERK-dependent activation of calpain1/2 for VE-cadherin proteolytic cleavage, leading to the enhanced endocytosis of VE-cadherin in endothelial cells. In addition, we found that ERK2 interacts with VE-cadherin and stabilizes VE-cadherin complex in resting endothelial cells. Lactate-induced ERK2 phosphorylation promotes ERK2 disassociation from VE-cadherin. In vivo suppression of lactate production or genetic depletion of lactate receptor GPR81 mitigates vascular permeability and multiple organ injury and improves survival outcome in polymicrobial sepsis. Our study reveals that metabolic cross-talk between glycolysis-derived lactate and the endothelium plays a critical role in the pathophysiology of sepsis.

Le sepsis sévère est l’une des causes de mortalité les plus fréquentes à travers le monde. L’étiologie la plus fréquente étant des infections causées par des bactéries, le traitement repose sur l’administration rapide d’un traitement antibiotique adapté. Toutefois, la diminution de la sensibilité des bactéries observée au cours des dernières années nous pousse à repenser notre utilisation des antibiotiques. Parmi les options envisageables, on retrouve l’utilisation de nouveaux antibiotiques et l’optimisation des posologies d’antibiotiques couramment utilisés. Dans les deux cas, la modélisation pharmacocinétique est un outil indispensable pour caractériser la pharmacocinétique des agents antimicrobiens et ainsi guider les posologies. Les études pharmacocinétiques comportent toutefois de nombreux défis en pédiatrie. Afin de les contourner, nous avons utilisé des méthodes à risques minimaux pour étudier deux molécules chez les enfants : le linézolide, un nouvel antibiotique de la classe des oxazolidinones, qui a été administré chez des nouveau-nés prématurés, et la pipéracilline-tazobactam, une bêta-lactamine fréquemment utilisée en pédiatrie, qui a été administrée en utilisant une nouvelle posologie sous forme d’infusions prolongées. Premièrement, nous avons effectué une étude pharmacocinétique rétrospective du linézolide aux soins intensifs néonataux du CHU Sainte-Justine. Le linézolide est un antibiotique qui peut être utilisé pour traiter les infections causées par le staphylocoque à coagulase négative chez les nouveau-nés prématurés. Il s’agit d’une pratique relativement nouvelle et un programme de surveillance des concentrations plasmatiques avait été instauré il y a quelques années pour encadrer l’utilisation du linézolide dans cette population. Nous avons utilisé les données de ce programme et construit un modèle pharmacocinétique de population en utilisant des méthodes de modélisation non-linéaire à effets mixtes. Nous avons ainsi pu démontrer que les posologies utilisées chez les 26 nouveau-nés inclus dans notre étude atteignaient la cible préalablement déterminée (aire sous la courbe/concentration minimale inhibitrice [ASC/CMI 0-24] > 80), et qu’elles étaient donc probablement efficaces. De plus, nous avons observé que le linézolide semblait sécuritaire dans cette population. Nous nous sommes ensuite intéressés aux infusions prolongées de pipéracilline-tazobactam en pédiatrie. Déjà bien décrite dans la population adulte, l’utilisation d’infusions prolongées permet d’optimiser l’efficacité des bêta-lactamines puisque cette dernière dépend du temps où les concentrations plasmatiques sont supérieures à la concentration minimale inhibitrice (ƒt > CMI). Comme aucune posologie n’était établie en pédiatrie, nous avons d’abord effectué une étude de simulation où nous avons déterminé les posologies dites « optimales » en utilisant les paramètres pharmacocinétiques décrits en pédiatrie. Nous avons par la suite effectué une étude pharmacocinétique prospective où les posologies préalablement établies ont été administrées à 89 enfants de deux mois à six ans, duquel 79 ont eu des prélèvements sanguins pour déterminer les concentrations plasmatiques. Deux modèles pharmacocinétiques de population distincts (pipéracilline et tazobactam) ont été développés en utilisant la modélisation non-linéaire à effets mixtes. Des simulations ont par la suite été effectuées en utilisant le modèle final de la pipéracilline pour déterminer les posologies optimales selon l’âge. Pour des bactéries avec une CMI à 16 mg/L, nous avons observé que des infusions prolongées étaient nécessaires pour atteindre notre cible préalablement déterminée (ƒt > CMI > 50%) chez les enfants de six mois à six ans (130 mg/kg/dose toutes les 8 heures administré sur 4 heures), alors que des durées d’infusion standard de trente minutes étaient suffisantes chez les nourrissons de deux à six mois (75 mg/kg/dose toutes les 4 heures administré sur 30 minutes). Notre étude supporte également la faisabilité et l’innocuité des infusions prolongées en pédiatrie. / Severe sepsis remains one of the most important causes of pediatric mortality around the world. Bacterial infections represent the most common cause, and effective treatment depends on the prompt administration of antibiotics. However, we observe a concerning decrease in susceptibility to antibiotics over the last decades, prompting us to reevaluate our antibiotics use. New antibiotics or novel ways of administering currently available antibiotics more efficiently are the two main alternatives when facing increased antibiotic resistance. In both cases, pharmacokinetic (PK) modeling represents an invaluable tool to guide dosing. However, PK studies in children are challenging. We used minimal risk methods to study two different antibiotics in children: Linezolid, a new oxazolidinone antibiotic that was administered to premature neonates, and piperacillin-tazobactam, a frequently used beta-lactam that we administered in a novel way using extended infusions. First, we conducted a single-center retrospective PK study of linezolid in premature neonates in the neonatal intensive care unit of the CHU Sainte-Justine. We built a population PK model using nonlinear mixed-effects modeling with plasmatic concentrations collected for therapeutic drug monitoring per standard of care. We were able to demonstrate that the dosing regimens used in the 26 neonates included in our study reached our established target (area under the curve over the minimal inhibitory concentration [AUC/MIC 0-24] > 80), and, therefore, were deemed efficient. Moreover, we collected adverse events and found that linezolid administration appeared safe in this population. We then focused on piperacillin-tazobactam extended infusions in children. Beta-lactams efficacy depends on the fraction of time that concentrations are above the MIC (ƒt > MIC). Extended infusions are a simple way to achieve higher ƒt > MIC and are well studied in adults. Based on published piperacillin-tazobactam PK parameters in children, we first conducted a simulation PK study to establish optimal extended infusions dosing in children. We then conducted a single-center prospective PK study where the established dosing regimens were administered to 89 children from two months to six years old. Of those, 79 children contributed plasma PK samples. Two PK models (piperacillin and tazobactam) were developed using nonlinear mixed-effects modeling. Simulations were conducted using our final piperacillin model, allowing us to determine optimal dosing regimens according to age. For bacteria with MICs up to 16 mg/L, extended infusions (130 mg/kg/dose every 8 hours infused over 4 hours) were needed in children six months to six years old to reach our established target (ƒt > MIC > 50%), whereas standard 30 minutes infusion (75 mg/kg/dose every 4 hours infused over 30 minutes) were adequate in infants two months to six months old. Our study also supported the feasibility and safety of extended infusions in young children.

Sepsis represents a serious medical problem accounting for numerous deaths of critically ill patients in intensive care units (ICUs). An early, sensitive, and specific diagnosis is considered a key element for improving the outcome of sepsis patients. In addition to classical laboratory markers, ICU scoring systems and serum miRNAs are discussed as potential sepsis biomarkers. In the present prospective observational study, the suitability of miRNAs in sepsis diagnosis was tested based on proper validated and normalized data (i.e., absolute quantification by means of Droplet Digital PCR (ddPCR)) in direct comparison to classical sepsis markers and ICU scores within the same patient cohort. Therefore, blood samples of septic intensive care patients (n = 12) taken at day of admission at ICU were compared to non-septic intensive care patients (n = 12) and a healthy control group (n = 12). Our analysis indicates that all tested biomarkers have only a moderate informative power and do not allow an unequivocal differentiation between septic and non-septic ICU patients. In conclusion, there is no standalone laboratory parameter that enables a reliable diagnosis of sepsis. miRNAs are not superior to classical parameters in this respect. It seems recommendable to measure multiple parameters and scores and to interpret them with regard to the clinical presentation.

Large clinical trials testing hydrocortisone therapy in septic shock have produced conflicting results. Subgroups may benefit of hydrocortisone treatment depending on their individual immune response. We performed an exploratory analysis of the database from the international randomized controlled clinical trial Corticosteroid Therapy of Septic Shock (CORTICUS) employing machine learning to a panel of 137 variables collected from the Berlin subcohort comprising 83 patients including demographic and clinical measures, organ failure scores, leukocyte counts and levels of circulating cytokines. The identified theranostic marker was validated against data from a cohort of the Hellenic Sepsis Study Group (HSSG) (n = 246), patients enrolled in the clinical trial of Sodium Selenite and Procalcitonin Guided Antimicrobial Therapy in Severe Sepsis (SISPCT, n = 118), and another, smaller clinical trial (Crossover study, n = 20). In addition, in vitro blood culture experiments and in vivo experiments in mouse models were performed to assess biological plausibility. A low serum IFNg/IL10 ratio predicted increased survival in the hydrocortisone group whereas a high ratio predicted better survival in the placebo group. Using this marker for a decision rule, we applied it to three validation sets and observed the same trend. Experimental studies in vitro revealed that IFNg/IL10 was negatively associated with the load of (heat inactivated) pathogens in spiked human blood and in septic mouse models. Accordingly, an in silico analysis of published IFNg and IL10 values in bacteremic and non-bacteremic patients with the Systemic Inflammatory Response Syndrome supported this association between the ratio and pathogen burden. We propose IFNg/IL10 as a molecular marker supporting the decision to administer hydrocortisone to patients in septic shock. Prospective clinical studies are necessary and standard operating procedures need to be implemented, particularly to define a generic threshold. If confirmed, IFNg/IL10 may become a suitable theranostic marker for an urging clinical need.

The liver regulates inflammation during sepsis, and most liver functions are carried out by hepatocytes. Bacterial lipids, including lipopolysaccharide (LPS) and lipoteichoic acid (LTA), can be cleared by hepatocytes, but the underlying mechanisms are uncertain. Proprotein convertase subtilisin/kexin type 9 (PCSK9) regulates uptake of LPS by hepatocytes, but it is unknown whether LTA uptake is similarly regulated. Therefore, our objectives were to characterize the PCSK9-regulated pathway of bacterial lipid uptake by hepatocytes by identifying whether low-density lipoprotein (LDL) receptor (LDLR) and LDLR-related protein 1 (LRP1) are the target receptors, and by determining which lipoproteins are involved. To study this pathway, we assessed the uptake of fluorescently-labeled LPS or LTA by human HepG2 hepatocytes using flow cytometry. We pre-treated HepG2 cells with PCSK9, alone or in combination with anti-LDLR or anti-LRP1 antibodies, in order to identify the PCSK9-regulated receptors that are involved, and utilized media containing normal serum or lipoprotein-deficient serum to investigate the lipoprotein- dependence of this pathway. We also determined the roles of LDL and HDL in bacterial lipid uptake through a series of add-back experiments to lipoprotein-deficient serum, and blocked LDLR to confirm that LDLR mediates LDL-dependent uptake. The HepG2 cell response to variable degrees of bacterial lipid uptake was also assessed in a subset of experiments by measuring several cytokines and extracellular alanine aminotransferase (ALT) activity in the cell culture supernatant. We found that PCSK9 regulates LDLR-mediated uptake of both LPS and LTA through an LDL-dependent mechanism, while LRP1 is not involved. Increased bacterial lipid uptake did not result in any hepatocellular injury or cytokine production, as measured by ALT activity and interleukin (IL)-6, IL-8, IL-10, and IL-17 concentrations. In conclusion, we completed our objective of characterizing the PCSK9-regulated pathway of bacterial lipid uptake, and provide supporting evidence for targeting PCSK9 as a novel therapeutic avenue in sepsis. / Thesis / Master of Science (MSc) / Bacterial compounds stimulate inflammation that can be overwhelming during sepsis. Understanding the processes behind uptake and clearance of these compounds may lead to better sepsis treatments. Therefore, our goal was to understand how uptake of two bacterial compounds, lipopolysaccharide and lipoteichoic acid, occurs by liver cells called hepatocytes. Hepatocytes are naturally equipped to clear foreign compounds, so understanding their role in clearing bacterial compounds is important. Another goal was to identify the role of the protein PCSK9 in this uptake process, as treatments targeting PCSK9 could be applied to sepsis once we understand its role in this disease. Our research demonstrates the negative role of PCSK9 in regulating uptake of lipopolysaccharide and lipoteichoic acid through a lipoprotein receptor called LDLR, and identifies the role of lipoproteins in this process. These findings further our understanding of the hepatocyte response to bacterial compounds in relation to sepsis, and identify PCSK9 as a potential target for new sepsis therapies.

Sepsis is life-threatening organ dysfunction produced by a dysregulated host response to infection in which neutrophils release neutrophil extracellular traps (NETs). NETs consist of DNA, histones, and antimicrobial peptides which kill pathogens. However, DNA and histones also exert damage by activating the intrinsic pathway of coagulation and inducing endothelial cell death, respectively. AADH, a 15kDa non-anticoagulant unfractionated heparin (UFH), prevents histone-mediated cytotoxicity in vitro and improves survival in septic mice. We explored the effectiveness of Vasoflux, a 5.5kDa low-molecular-weight-heparin as an anti-sepsis treatment as compared to enoxaparin and UFH. Vasoflux has reduced anticoagulant functions and hence reduces the risk of bleeding as compared to enoxaparin or UFH. We showed that UFH, enoxaparin, or Vasoflux at concentrations of up to 13.3uM, 40uM, or 40uM, neutralize histone-mediated cytotoxicity. These results suggest that these glycosaminoglycans (GAGs) are able to neutralize histone-mediated cytotoxicity independent of the AT-binding pentasaccharide. To quantitate the binding affinity between GAGs and histones, surface plasmon resonance was conducted. UFH is a more potent inhibitor of histone-mediated cytotoxicity compared to Vasoflux as UFH has a 10-fold greater binding affinity to histones compared to Vasoflux. To translate our in vitro findings to in vivo, Vasoflux, enoxaparin, and UFH were administered in a murine model of sepsis. Vasoflux at 8mg/kg - 50mg/kg reduced survival and exhibited damage in the lung, liver, and kidney in septic mice compared to 10 mg/kg of UFH or 8mg/kg of enoxaparin. This may be due to Vasoflux and UFH disrupting the DNA-histone complex, thereby releasing free procoagulant DNA. This is evident by our gel electrophoresis experiments, where addition of 1uM Vasoflux or 3.3uM UFH to DNA-histone complexes lead to histone dissociation from DNA. UFH bound to histones may be able to inhibit DNA-mediated thrombin generation, as it retains its anticoagulant properties, demonstrated by UFH-histone complexes attenuating DNA and TF-mediated thrombin generation. In contrast, Vasoflux may not neutralize the procoagulant DNA leading to a hypercoagulable state in the mice. Our study may have important clinical implications as there is an ongoing trial, HALO, which will administer intravenous UFH to patients suspected to have septic shock to reduce mortality. Based on our results, future clinical trials should consider the antithrombin-dependent anticoagulant activity of UFH being used as a sepsis treatment. / Thesis / Master of Science (MSc) / Sepsis is a life threatening condition caused by the body’s extreme response to microbial infection of the blood, whereby neutrophils release traps composed of cell-free DNA (cfDNA), histones, and antimicrobial proteins. In addition to fighting off infections, these traps also exert harmful effects like triggering clotting and killing host cells. Currently, no specific anti-septic drugs exist. Studies have shown that DNase1 (a recombinant protein that digests double stranded cfDNA) or a modified form of heparin (neutralizes histones) improves survival in septic mice. Our goal was to explore the protective effects of Vasoflux, (a non-anticoagulant heparin) and DNase1 in a mouse model of sepsis. We hypothesize that the combined therapy of DNase1 and Vasoflux will improve survival. We found that Vasoflux has minimal blood thinning activity and can prevent histones from killing cells. However, Vasoflux administered into septic mice worsened organ damage and decreased survival. We hypothesize that this damage may be due to Vasoflux’s ability to displace histones from histone-DNA complexes, thereby releasing free DNA, which promotes excessive blood clotting in sepsis.

Bakgrund: Sepsis är en livshotande överreaktion i immunförsvaret som kan uppstå av en infektion. Tidig identifiering av sepsis är fundamentalt för att tillhandahålla snabb och effektiv vård. Detta skapar goda förutsättningar för patientens överlevnad. Syfte: Att kartlägga faktorer som påverkar sjuksköterskans identifiering av sepsis. Metod: För att sammanfatta och skapa en bild av det nuvarande kunskapsläget har en litteraturöversikt med kvantitativ design genomförts. Polit och Becks 9-stegs flödesschema utgjorde strukturen för skapandet av litteraturöversikten. Sökningar i databaserna CINAHL, MEDLINE och PsycINFO resulterade i 14 artiklar till resultatet, publicerade mellan 2012–2023. Resultat: I resultatet framkom att faktorer som påverkar sjuksköterskans identifiering av sepsis var sjuksköterskans kunskap, genomgången utbildning, hjälpmedel vid sepsisidentifiering samt bristande arbetsförhållanden. Bland annat framkom att sepsisidentifiering försenades på grund av bristande kunskap om sepsissymtom samt hög arbetsbelastning, och främjades av utbildning om sepsis och användning av screeningverktyg. Slutsats: Litteraturöversikten kartlägger faktorer som främjar och hindrar sjuksköterskans identifiering av sepsis. Detta möjliggör tidig adekvat behandling som skapar goda förutsättningar för överlevnad. Kärnkompetensen samverkan i team är grundläggande för samordning av vårdens resurser för en god och säker vård. / Background: Sepsis is a life-threatening overreaction in the immune system that can arise from an infection. Early identification of sepsis is fundamental to provide prompt and effective care. This creates good prerequisites for the patient's survival. Purpose: To map factors that influence the nurse's identification of sepsis. Method: To summarize and create a picture of the current state of knowledge a literature review with a quantitative design was conducted. Polit and Beck's 9-step flow chart formed the structure for the creation of the literature review. Searches in the databases CINAHL, MEDLINE and PsycINFO resulted in 14 articles used in the result, published between 2012-2023. Results: The result showed that factors influencing the nurse's identification of sepsis were the nurse's knowledge, completed training, aids for sepsis identification and lacking working conditions. Among other things, it appeared that sepsis identification was delayed due to a lack of knowledge about sepsis symptoms and high workload and was improved by education about sepsis and the use of screening tools. Conclusion: This literature review identifies factors that promote and impede the nurse’s identification of sepsis. This enables early adequate treatment which creates good conditions for survival. The core competency of collaboration in teams is fundamental for coordinating care resources for good and safe care.

Yes / Objectives: To develop a logistic regression model to predict the risk of sepsis following emergency medical admission using the patient’s first, routinely collected, electronically recorded vital signs and blood test results and to validate this novel computer-aided risk of sepsis model, using data from another hospital. Design: Cross-sectional model development and external validation study reporting the C-statistic based on a validated optimized algorithm to identify sepsis and severe sepsis (including septic shock) from administrative hospital databases using International Classification of Diseases, 10th Edition, codes. Setting: Two acute hospitals (York Hospital - development data; Northern Lincolnshire and Goole Hospital - external validation data). Patients: Adult emergency medical admissions discharged over a 24-month period with vital signs and blood test results recorded at admission. Interventions: None. Main Results: The prevalence of sepsis and severe sepsis was lower in York Hospital (18.5% = 4,861/2,6247; 5.3% = 1,387/2,6247) than Northern Lincolnshire and Goole Hospital (25.1% = 7,773/30,996; 9.2% = 2,864/30,996). The mortality for sepsis (York Hospital: 14.5% = 704/4,861; Northern Lincolnshire and Goole Hospital: 11.6% = 899/7,773) was lower than the mortality for severe sepsis (York Hospital: 29.0% = 402/1,387; Northern Lincolnshire and Goole Hospital: 21.4% = 612/2,864). The C-statistic for computer-aided risk of sepsis in York Hospital (all sepsis 0.78; sepsis: 0.73; severe sepsis: 0.80) was similar in an external hospital setting (Northern Lincolnshire and Goole Hospital: all sepsis 0.79; sepsis: 0.70; severe sepsis: 0.81). A cutoff value of 0.2 gives reasonable performance. Conclusions: We have developed a novel, externally validated computer-aided risk of sepsis, with reasonably good performance for estimating the risk of sepsis for emergency medical admissions using the patient’s first, electronically recorded, vital signs and blood tests results. Since computer-aided risk of sepsis places no additional data collection burden on clinicians and is automated, it may now be carefully introduced and evaluated in hospitals with sufficient informatics infrastructure. / Health Foundation