Journal of Critical Care 40 (2017) 229–242

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Journal of Critical Care

journal homepage: www.jccjournal.org

Sepsis and septic shock: Pathogenesis and treatment perspectives

Hayk Minasyan
Mamikonyanz 38-38, Yerevan 0014, Armenia

a r t i c l e i n f o a b s t r a c t

Keywords: The majority of bacteremias do not develop to sepsis: bacteria are cleared from the bloodstream. Oxygen released
Bacteremia from erythrocytes and humoral immunity kill bacteria in the bloodstream. Sepsis develops if bacteria are resis-
Sepsis tant to oxidation and proliferate in erythrocytes. Bacteria provoke oxygen release from erythrocytes to arterial
Septic shock blood. Abundant release of oxygen to the plasma triggers a cascade of events that cause: 1. oxygen delivery failure
Pathogenesis to cells; 2. oxidation of plasma components that impairs humoral regulation and inactivates immune complexes;
Treatment
3. disseminated intravascular coagulation and multiple organs' failure. Bacterial reservoir inside erythrocytes
provides the long-term survival of bacteria and is the cause of ineffectiveness of antibiotics and host immune re-
actions. Treatment perspectives that include different aspects of sepsis development are discussed.
© 2017 Elsevier Inc. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
2. Pre-septic (local) and septic (bloodstream) stages of infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
3. The features of sepsis causing bacteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
4. Bacteria killing in the tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
5. Survival of sepsis causing bacteria in phagocytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
6. Bacteria killing in the bloodstream . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
7. Sepsis and septic shock pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
7.1. Oxidation of blood plasma components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
7.2. Anemia, cell hypoxia and lactate production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
8. Diagnostic problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
9. Treatment problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
10. Treatment perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
10.1. Suppression of bacterial antioxidant mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
10.1.1. Inhibition of bacterial catalase production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
10.1.2. Inhibition of bacterial superoxide dismutase production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
10.2. Suppression of bacterial capsule and biofilm production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
10.3. Bloodstream bacteria removal by technical devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
10.4. Development of new antimicrobials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
10.5. The use of ozone and hyperbaric oxygen therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
10.6. Replacement therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
10.7. Search for optimal blood transfusion triggers for sepsis patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
10.8. Inactivation of endotoxins and exotoxins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
10.9. “Biological weapon” against sepsis causing bacteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
10.9.1. Bacteriophage therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
10.9.2. Therapy by Bdellovibrio like organisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
10.9.3. Saccharomyces therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
10.10. Acceleration of blood flow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
11. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

E-mail address: haykminasyan@rambler.ru.

http://dx.doi.org/10.1016/j.jcrc.2017.04.015
0883-9441/© 2017 Elsevier Inc. All rights reserved.
230 H. Minasyan / Journal of Critical Care 40 (2017) 229–242

Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

1. Introduction stage is absent. Local antibacterial defense is provided by phagocytosis

Sepsis is both best known yet most poorly understood medical dis-
orders [1]. Sepsis leads to shock, multiple organ failure and death if
not recognized early and treated promptly [2]. It is a serious clinical con-
dition that represents a patient's response to infection and has a high
mortality rate [3]. Sepsis remains the dominant challenge in the care
of critically ill patients [4]. More than 30 million cases of sepsis world-
wide per annum are estimated. The incidence of sepsis increases 9-
13% annually, a mortality rate is 33–35% [5-12] (Table 1). The most com-
mon sites of infection are the lungs (40%), abdomen (30%) and urinary
tract (10%) [13]. Sepsis may be caused by gram-positive, gram-negative
and poly microbial infection [14,15]. Gram-negative infection most
often occurs in the lungs [16]. Staphylococcus aureus and Streptococcus
pneumoniae are gram-positive isolates, whereas Escherichia coli, Klebsi-
ella species, and Pseudomonas aeruginosa predominate among gram-
negative isolates [17,18]. Gram-positive organisms cause sepsis by pro-
ducing exotoxins and by their cell wall components [19]. Gram-negative
bacteria cause sepsis by their membrane lipopolysaccharides (endo-
toxins) [20]. Bacterial toxins play a pivotal role in the pathophysiology
of sepsis, however, the literature illustrates that no single mediator/sys-
tem/pathway/pathogen drives the pathophysiology of sepsis [21]. Cur-
rent knowledge of sepsis pathogenesis includes infection interaction
with the host before bacteria enter the bloodstream [1,22-26]. Actually,
the mechanisms of host defense in the tissues differ from the mecha-
nisms of intravasal (bloodstream) defense because extravasal defense
is provided mainly by leukocytes whereas intravasal defense is fulfilled
by erythrocytes. The humoral immunity events take place in pre-septic
stage and interfere with the study of sepsis “per se.” As a result, the
pathogenesis and pathophysiology of some pivotal aspects of sepsis re-
main unclear.
2. Pre-septic (local) and septic (bloodstream) stages of infection
Not all bacteremias lead to sepsis. People have everyday bacteremia,
particularly, from oral cavity, but sepsis rarely develops [27-31]. It oc-
curs when the infection is resistant to host antibacterial defense. The lat-
ter is different in the tissues and the bloodstream. If the infection
develops locally (tissue, cavity, etc.) and then enters the bloodstream,
there are two stages of sepsis: pre-septic (local) and septic (general-
ized). If infection enters the bloodstream directly from an external
source (contaminated intravenous injection, bite, etc.), the pre-septic
(leukocytes and their local versions: resident macrophages), comple-
ment, NETs, etc., whereas in the bloodstream bacteria are killed by bac-
tericidal humoral factors and oxygen that is released from erythrocytes
[32,33]. Bacteria proliferate in the tissues being resistant to comple-
ment. Blood natural resistance factors (complement, lysozym, etc.) are
not effective if infection enters the blood from the tissues. Sepsis de-
velops when bacteria in the bloodstream survive oxidation on the sur-
face of erythrocytes [32-36].
3. The features of sepsis causing bacteria
Relatively few pathogens can cause sepsis. For causing sepsis bacte-
ria should have certain features that provide their survival, proliferation
and dissemination in human body. The characteristics of the pathogens,
that most frequently cause sepsis, may or may not be common for all of
them (see Table 2).
Sepsis causing bacteria are both gram positive and gram negative.
Gram-positive organisms are better suited to invade host tissues than
gram-negative organisms [37]. The lack of endotoxin in the outer cell
wall is compensated for by the presence of exposed peptidoglycan and
a range of other toxic secreted products. Cell wall components of
gram-positive bacteria may signal via the same receptor as gram-nega-
tive endotoxin [37]. Gram-negative organisms are associated with
poorer outcomes in first-hit infections; an inverse relationship between
Gram status and mortality is observed in second-hit infections [38].
The majority of sepsis causing bacteria is facultative anaerobes [39].
This type of respiration is the most flexible and it facilitates pathogen
survival, proliferation and dissemination in the variety of environmen-
tal conditions. The pathogens that are not facultative anaerobes, may
express additional respiratory mechanisms that make their respiration
close to facultative anaerobes [40,41].
All sepsis causing bacteria produce superoxide dismutase (SOD),
catalase and glutathione peroxidases (Table 2), that protect them
against oxidative stress caused by reactive oxygen species. The primary
source of oxidative stress for sepsis causing bacteria is the attack by host
phagocytic cells. All successful pathogens have evolved effective
systems for defense against oxidative stress [42]. Phagocytes utilize
the cytotoxic effects of the reactive oxygen species, such as superoxide,
hydrogen peroxide, and the highly toxic hydroxyl radical. Sepsis causing
bacteria have evolved effective enzymatic pathways of oxidant inactiva-
tion, including those catalyzed by superoxide dismutase (SOD),

Table 1
The dynamics of sepsis and septic shock incidence and mortality.

The dynamics of sepsis and septic shock incidence and mortality.

SEPSIS Data Study Number of Country of Year of Authors
participants, trials study publication
Incidence 31.5 milliona 2015 27 studies Worldwide 2016 Fleischmann et al. [5]
436/100,000 2012 USCBb USA 2016 Stoller et al. [6]
Incidence 13.0% annually 2004–2009 36 trials USA 2013 Gaieski et al. [7]
increase 9.0% annually 2008–2012 82,300 Italy 2017 Yébenes et al. [8]
Mortality 33.2%c 2006–2009 14,418 Worldwide 2014 Stevenson et al. [9]
35·3%c 2012 2973 Worldwide 2014 Vincent et al. [10]
Mortality From 40.4% to From 1998 to 203,481 USA 2013 Walkeyet al. [11]
decline 31.4% 2009
From 35.0% to From 2000 to 101,064 Australia, 2014 Kaukonen et al. [12]
18.4% 2012 New Zealand
a
– Global estimates of sepsis (cases a year)
b
– US Census included 308,745,538 individuals
c
– 28 day mortality
 H. Minasyan / Journal of Critical Care 40 (2017) 229–242 231

Table 2 to hydrogen peroxide by the enzyme superoxide dismutase. In turn, a

The common features of sepsis causing bacteria. constituent of the azurophil granules, myeloperoxidase, generates
The common features of sepsis causing bacteria hypochlorous acid (HOCl) from hydrogen peroxide. HOCL is the most
effective bacterial killer [46].

Respiration

Hemolysins
Gram stain

Slime layer
Neutrophils can degranulate and release antimicrobial factors into

Catalase

Oxidase

Capsule

Motility
S–layer

Biofilm
the extracellular space [47]. They can also generate neutrophil extracel-

GPX
SOD
lular traps (NETs), which are composed of granule and nuclear constit-
Staphylococcus aureus + FAN + + + – + + + + + –
Coagulase–negative staph. + FAN – + + – + + + + + –
uents that kill bacteria extracellularly [48]. NETs disarm pathogens with
Streptococcus pneumonia + FAN + – + – + + + + + – elastase, cathepsin G and histones that have a high affinity for DNA [49].
Haemophilus influenza b – FAN + + + + + + + + + – NETs may serve as a physical barrier that prevents further spread of the
Neisseria meningitidis – A, MA + + + + + + + + + –
pathogens [50].
Klebsiella pneumonia – FAN + + + – + + + + + –
Enterococcus faecalis + FAN + + + + + + + + + – Platelets activate neutrophils to trap bacteria. Platelets rapidly local-
Acinetobacter baumanii – A + + ? – + + + + + + ize to sites of injury and infection [51]. Both platelets and neutrophils
Escherichia coli – FAN + + + – + + + + + +
have the potential to trap microbial pathogens independently of each
Salmonella enterica – FAN + + + – + + + + + +
Shigella dysenteriae – FAN + + + – + + + + + – other; however, together platelet-neutrophil interactions induce trans-
Citrobacter freundii – A, FAN + + + – + + + + + ± cellular synthesis and hyperactivation of neutrophils to produce in-
Serratia marcescens – FAN + + ? – + + + + + + creased pro-inflammatory molecules [50,52]. Platelets have the ability
Proteus mirabilis – FAN + + + – + + + + + +
Pseudomonas aeruginosa – A, FAN + + + + + + + + + + to bind and internalize bacteria through engulfing endosome-like vacu-
Bacteroides fragilis – OAN + + + – + + + + + ± oles that fuse with the α-granules of the platelet and allow the granular
SOD – superoxide dismutase. proteins to have access to the pathogens [53]. As a result, thrombocyto-
GPX – glutathione peroxidase. penia correlates with the severity of the sepsis and the rate of mortality
A – aerobic bacteria.
FAN – facultative anaerobic bacteria. [54].
MA – micro aerobic bacteria.
OANA – obligate anaerobic bacteria.
5. Survival of sepsis causing bacteria in phagocytes

catalase/peroxidase, and glutathione in combination with glutathione After phagocytosis by macrophages, bacteria are located in a mem-
peroxidase and glutathione reductase [43]. The same pathways may brane-bound vacuole (phagosome), but the ensuing trafficking of this
protect sepsis causing bacteria from oxidation and killing on the surface vacuole and subsequent bacterial survival strategies vary considerably
of erythrocytes [34]. [55]. If the ingested bacteria have no intracellular survival mechanisms,
Sepsis causing bacteria may be either oxidase positive or oxidase- the bacteria-containing phagosomes fuse with the lysosomal compart-
negative. The production of cytochrome c oxidase has no critical role ment, and bacteria are digested within 15–30 min. The metabolic
in causing sepsis. burst in activated phagocytes results in production of nitric oxide and
Certain structures of bacteria are indispensable for causing sepsis. All reactive oxygen species, such as chloramines, hydroxyl radicals, and hy-
sepsis causing bacteria have S-layer and produce capsules, slime layer drogen peroxide, which are usually converted into the potent oxidant
and biofilm (Table 2). These structures protect the bacteria in the tissues hypochlorous acid [56]. The cascade of these events is the following
against phagocytosis, ROS, lytic enzymes, immune complexes, etc., (see Fig. 1). After phagocytosis lysosomes fuse with the phagosome,
whereas in the bloodstream capsule and slime layer prevent triboelec- forming a phagolysosome and proteases are introduced into the
tric charging, attraction and fixation on the surface of erythrocytes, ox- phagosome. In addition, a membrane protein phagocyte oxidase
idation and killing by the oxygen released from erythrocytes [33]. (NADPH oxidase) winds up in the membrane of the phagolysosome.
Sepsis causing bacteria produce hemolysins. Erythrocytes are the Phagocyte oxidase takes an electron from NADPH and transfers it to
main bactericidal cells in the bloodstream and hemolysins are necessary O2, forming the superoxide radical, O-2. The superoxide radical is con-
for bacterial survival in the bloodstream. If the speed of bacterial growth verted to hydrogen peroxide by superoxide dismutase. Hydrogen per-
in the tissue is limited by host immune reactions, bacteria produce a oxide can damage microbes, but it is converted to more effective
capsule, slime layer and biofilm for surviving. After entering the blood- bactericidal (HOCl) by myeloperoxidase. Hypochlorite is the most effec-
stream, bacterial capsule and slime layer prevent triboelectric charging tive intracellular bactericidal.
and fixation on the surface of erythrocytes. If bacteria rapidly proliferate Sepsis causing bacteria protect themselves against the oxygen-de-
in the tissues, they are short of time to produce a capsule and slime layer pendent bactericidal mechanism of phagocytes by their capsule (chem-
and after entering the bloodstream, they are caught and fixed on the ical insulator) and by producing superoxide dismutase (SOD), catalase
surface of erythrocytes. If bacteria survive oxidation on the surface of and glutathione peroxidase (Fig. 1). Bacterial superoxide dismutase ac-
erythrocytes, they produce hemolysins that destroy erythrocytes or celerates the conversion of superoxide (02) to hydrogen peroxide
provide bacterial penetration into the inner space of erythrocytes. He- (H202), while bacterial catalase and glutathione peroxidase accelerate
molysins are important for the development of sepsis to advanced the conversion of hydrogen peroxide (H202) to water and oxygen
stages. (02) that is relatively non toxic for facultative anaerobes. This conver-
Motility is not a crucial factor for causing sepsis (Table 2.). Sepsis sion rapidly depletes all converted hydrogen peroxide to innocuous
causing bacteria may be either motile or not motile organisms. water and oxygen and prevents formation of extremely harmful for bac-
teria hydrochloride.
4. Bacteria killing in the tissues
6. Bacteria killing in the bloodstream
Neutrophils, monocytes and resident macrophages are the main
bactericidal cells in the tissues. Upon encountering bacteria, neutrophils Leukocytes cannot recognize and engulf pathogens in high velocity
engulf them into a phagosome, which fuses with intracellular granules liquids [32,33]. In the bloodstream bacteria are attracted and fixed on
to form a phagolysosome [44]. In the phagolysosome the bacteria are the surface of erythrocytes by electrical charge interaction force. Bacte-
killed after exposure to enzymes, antimicrobial peptides and reactive ria activate erythrocyte membrane receptors, stimulating the oxygen
oxygen species (ROS) [45]. Neutrophils undergo an ‘oxidative burst’ release (from oxyhemoglobin) that kills bacteria by “per contact” oxida-
during which the NADPH oxidase complex assembles at the tion. If this mechanism is effective, bacteria are killed on the surface of
phagosomal membrane and produces O2-, which is rapidly converted erythrocytes and then are disintegrated and digested in the
232 H. Minasyan / Journal of Critical Care 40 (2017) 229–242

Fig. 1. The oxygen-dependent mechanism of bacteria killing inside phagocytes.

reticuloendothelial system (Fig. 2, scenario 1). If bacteria have a thick bacteria are filtered in the liver and the spleen. Bacteria may overload
capsule that prevents triboelectric charging, they may avoid attraction, the liver and the spleen and damage them (Fig. 2, scenario 2). If bacteria
oxidation and killing on the surface of erythrocytes and, as a result, survive oxidation on the membrane of erythrocytes, they enter

Fig. 2. Clearance of bacteria from blood circulation in health and disease.

 H. Minasyan / Journal of Critical Care 40 (2017) 229–242
erythrocytes by making holes in the membrane. Inside erythrocytes
bacteria may be killed by higher concentration of oxygen. However, bac-
teria may survive inside erythrocytes if there is lack of oxygen or bacte-
ria are resistant to oxidation (Fig. 2, scenario 3). Surviving, bacteria
proliferate in erythrocyte and the latter bacterial incubator and reser-
voir [34,35]. Bacteria inside erythrocytes have nutrients for prolifera-
tion, besides, they are out of reach of antibiotics, immune complexes
and other antibacterial factors. Bacterial proliferation tears erythrocyte
membrane and bacteria, being released back into the plasma, infect
new erythrocytes.
7. Sepsis and septic shock pathogenesis
In bacteremia, two events are critical for the development of sepsis:
a. infection resistance to oxidation; b. provoked by bacteria premature
release of oxygen from erythrocytes. The consequences of these two
events determine the course of sepsis and its deterioration to septic
shock. Oxidation of blood plasma components and lack of oxygen in
erythrocytes cause distant injury of the tissues.
7.1. Oxidation of blood plasma components
The oxidation of blood plasma components, including regulatory
hormones, proteins, peptides and other active substance is one of ig-
nored factors of sepsis and septic shock. Oxidation of plasma compo-
nents destroys humoral regulation. Human body comprises two
separate but interacting compartments: (a) compartment of blood cir-
culation (pulmonary and systemic circulation); (b) compartment out
of blood circulation. In the majority of cases, bacterial infection prolifer-
ates in the compartment out of blood circulation and then enters into
the compartment of blood circulation. It has different consequences:
from innocuous bacteremia to fatal septic shock.
Bacteremia, sepsis, severe sepsis and septic shock may be
interpreted as a continuum different amount of oxygen released by
erythrocytes into plasma. Bacterial stimulation of the surface receptors
of erythrocytes causes the release of oxygen. The more oxygen is re-
leased from erythrocytes to the arterial blood, the more severe is sepsis.
The consequences of oxygen release are multiple. First, erythrocytes be-
come unable to supply oxygen and perform their respiratory (oxygen
transportation) function. As a result, general multi-organ hypoxia de-
velops. Second, released oxygen activates platelets and causes dissemi-
nated intravascular coagulation. Third, released oxygen is highly
reactive and destroys and transforms plasma proteins, peptides, im-
mune complexes, hormones, amino acids, fatty acids, vitamins and
many other substances necessary for cell nutrition, proliferation, protec-
tion, energy production, functioning, etc.
Proteins are substrates for biological oxidation [57]. Oxidative
changes to proteins lead to inhibition of enzymatic and binding activi-
ties, increased susceptibility to aggregation and proteolysis, increased
or decreased uptake by cells, and altered immunogenicity [58]. The
most important aspect of this oxidation is inactivation of regulatory sub-
stances, in particular, hormones (including pituitary gland hormones).
Metal-catalyzed oxidation (MCO) represents a prominent pathway of
hGH degradation [59]. The Growth Hormone and Insulin-like Growth
Factor-1 (IGF-1) axis play a pivotal role in critical illness. Protein
wasting with skeletal muscle loss, delayed wound healing, and impaired
recovery of organ systems are some of the most feared consequences
[60]. Growth hormone administration reduces nitrogen production
and improves nitrogen balance in patients with severe sepsis [61]. Oxi-
dative inactivation of other proteins, for example, insulin, impairs the
ability of cells to uptake glucose, amino acids and other essential sub-
stances. Dityrosine formation and other oxidative chemical changes of
insulin due to its oxidation decrease and abolish its biological activity
[62]. Deactivation of insulin causes hyperglycemia - one of the metabol-
ic derangements that influence sepsis outcome [63-66].
233
The oxidation of blood components may cause hypothalamic-pitui-
tary-adrenal insufficiency [67]. Primary and secondary adrenal insuffi-
ciency occurs in patients with sepsis and is associated with a poor
outcome [68-71]. Blood oxidation also affects the hypothalamo-pitui-
tary-thyroidal axis, inactivating thyrotropin, thyroid gland hormones
(triiodothyronine(TT3), thyroxine (TT4) and their binding proteins.
Thyroid hormone regulates metabolism and has an impact on sepsis
prognosis. The level of TT4 is lower in patients with septic shock than
in patients without septic shock [72-74]. De-iodinations of
iodothyronines play key roles in metabolic regulation [75,76].
Vasopressin (Antidiuretic hormone) is oxidized as well. Oxytocin
and vasopressin are oxidized with the formation of dityrosine [77]. Its
oxidation and depletion cause vasodilatory shock - a syndrome with
high mortality [78-81]. Low expression levels of Angiotensin II and
ACE (angiotensin converting enzyme) are valuable in predicting the
mortality of patients with severe sepsis. Systemic vasodilatation and ar-
terial hypotension are landmarks of septic shock [82].
Albumin oxidation causes hypoalbuminemia in sepsis [83,84]. Even
mild oxidation of human serum albumin (HAS) impairs HSA functional
properties including protease susceptibility, ligand-binding affinity and
antioxidant activity [85-87]. The major structural change in oxidized
HSA is a disulfide-bonded cysteine at the thiol of Cys34 of reduced
HAS [88].
Oxidative damage results in protein modification [89]. Hypoalbu-
minemia is an independent mortality predictor [90]. Albumin is recom-
mended as the resuscitation fluid in sepsis [91,92], although it is still
unclear whether the use of albumin decreases mortality or not [93,94].
Oxygen released from erythrocyte destroys also immune complexes
and immunoglobulins, particularly IgG and IgM. The oxidation of IgG
significantly changes the immunoreactivity and specificity of IgG frac-
tions [95]. Oxidized immunoglobulins have autoimmune and proin-
flammatory activity [96-98].
Low levels of immunoglobulins are frequent in severe sepsis and
septic shock [99-101]. However, intravenous immunoglobulins (IVIG)
as adjunctive therapy for sepsis have not shown the benefit for the
treatment of sepsis [102,103]. It may be explained by the destruction
(oxidation) of injected immunoglobulins, besides, bacteria inside eryth-
rocytes are out of reach of immunoglobulins.
Thus, oxygen release to blood plasma from erythrocytes destroys
humoral regulation. This may be one of the causes of the development
of multiple organ dysfunction syndrome (known as multiple organ fail-
ure or multisystem organ failure) [104-107].
7.2. Anemia, cell hypoxia and lactate production
The release of oxygen to arterial blood (before erythrocytes enter to
capillaries) causes failure of oxygen delivery to cells and hypoxia
[33-36]. Another co-factors of hypoxia is anemia caused by intensive de-
struction of erythrocytes, suppression of bone-marrow, low production
of erythropoietin, etc. [108-111]. The main factor of anemia in sepsis is
increased destruction of erythrocytes by infection. Making holes in the
membranes of erythrocytes, bacteria cause hemoglobin pouring out, be-
sides, they penetrate inside erythrocytes. The liver and, especially, the
spleen actively destroy injured and bacteria-containing erythrocytes
[33-36].
Diminished availability of oxygen at the cellular level determines
general dysfunction of cells. Tissue-related hypoxic injury results from
hypoxemia and hypoperfusion and cytokine-mediated mitochondrial
dysfunction termed cytopathic hypoxia [112-116]. The lack of oxygen
transforms cell metabolism from aerobic to anaerobic. As a result,
Krebs cycle is suppressed and anaerobe metabolism with lactic acid ac-
cumulation occurs. Elevated lactic acid is a marker for the suboptimal
supply of oxygen to the tissues and is associated with increased mortal-
ity in sepsis [117-127]. Lack of oxygen delivery to the tissues results in
decreased cellular metabolism and increase in cellular lactate produc-
tion [117-121]. High levels of lactic acid are associated with increased
234 H. Minasyan / Journal of Critical Care 40 (2017) 229–242
mortality [118-127]. This association is independent of organ dysfunc-
tion [118-122]. Lactate clearance is more useful parameter for guiding
therapy (the initial lactate - subsequent lactate/initial lactate × 100)
[117-120]. Lactate non clearance in sepsis is a significant independent
predictor of death [117,119].
8. Diagnostic problems
Sepsis diagnosis relies on nonspecific physiological criteria (includ-
ing changes in temperature and heart and respiration rates) and cul-
ture-based pathogen detection. This results in diagnostic uncertainty,
therapeutic delays, the mis- and overuse of antibiotics and many other
problems that increase mortality [128-131]. Blood cultures are used to
identify the pathogens and are the gold standard for the diagnosis of
bacteremic patients. Blood cultures provide unambiguous etiology of
the infection and (following subculture) purified colonies for antimicro-
bial susceptibility testing. However, getting the colonies takes two–
three days and this approach is slow and leads to delayed and inappro-
priate treatment [132-134]. Moreover, sepsis may be culture negative
[135-137] and culture false-positive [138-140]. The accurate and timely
detection of sepsis remains a challenge [141]. For early detection of sep-
sis different markers are used, for example, acute-phase protein bio-
markers [142-144], procalcitonin [145-147], pentraxins [148-149],
cytokine/chemokine biomarkers (IL-6, IL-8, IL-10, TNF-α, etc.)
[150-151], macrophage migration inhibitory factor [152-153], high-mo-
bility-group box 1 (HMGB1) [154,155], coagulation biomarkers [156,
157], triggering receptor expressed on myeloid cells 1 (TREM-1)
[158-160], midregional proadrenomedullin [161], polymorphonuclear
CD64 index [162,163], etc. Taking into account that positive blood cul-
tures can be found in only 30% of sepsis patients [164] and low sensitiv-
ity of the blood culture method for many slow-growing and fastidious
organisms [165], several molecular approaches (including PCR) have
been suggested to improve the conventional culture-based identifica-
tion [166], however, a broader clinical evaluation of this approach is
still missing [141]. Another strategy is the extraction and amplification
of microbial nucleic acids from a blood culture and subsequent hybrid-
ization on a microarray platform to detect the gyrB, parE, and mecA
genes of 50 bacterial species, which has recently been evaluated in an
observational multicenter design with blood culture as the comparator
[167]. Systems biology approaches such as transcriptomics, proteomics,
and metabolomics have been tested as sepsis biomarkers [168,169].
However, despite decades of research and attempts of sepsis early diag-
nostics, improvements in the treatment of sepsis have been modest
[170].
Vital phase-contrast microscopy of the blood and microscopy of
stained blood samples may be informative for detection of sepsis. Re-
vealing of living bacteria in erythrocytes shows that sepsis is developing
to more advanced stages. Bacteria may also be seen on the surface of
erythrocyte but as soon as blood is taken from a vessel erythrocytes
lose triboelectric charge, and bacteria are released to plasma [32-35].
Out of the bloodstream (in vitro) bacteria are not triboelectrically
charged and can proliferate [33,36]. The refractive index of some path-
ogens is close to the index of erythrocyte inner media and so these bac-
teria may be optically invisible in erythrocytes [32]. Phase-contrast
microscopy and differential interference-contrast microscopy are effec-
tive and simple methods for immediate revealing bacteremia and mak-
ing predictions regarding its course. Dark field microscopy is an
additional microscopic technique, however, it has disadvantages –arti-
facts and image distortions. The microscopy of the blood plasma precip-
itate after plasma centrifugation and supernatant removal increases the
chance of bacteria detection.
Bacterial motion differs from Brownian motion and motile bacteria
are easily detected. Non-motile bacteria, particularly, Staphylococcus
and Streptococcus species, are identified by their microscopic appear-
ance in stained samples of plasma precipitate. However, optical micros-
copy of stained blood samples is less informative for detection of
bacteria in erythrocytes. Standard staining of blood samples with meth-
ylene blue, eosin, azure cannot reveal bacteria in erythrocytes. Gram
stains of the plasma precipitate after centrifugation may reveal whether
bacteria are gram-positive or gram-negative [32]. Simultaneous use of
different methods of microscopy (phase-contrast, dark field, microsco-
py of stained samples, etc.) increase the effectiveness of bacteremia
and sepsis prognosis by revealing whether pathogens have penetrated
erythrocytes or not.
9. Treatment problems
Sepsis is a systemic infection. Empiric antimicrobial therapy is the
base of the treatment [171,172]. Current guidelines recommend starting
antibiotic therapy within one hour of identification of septic shock
[173]. Every hour delay is associated with a 6% rise in mortality
[174-176]. Survival rates dropped when antimicrobial treatment was
delayed to within the sixth hour [131]. There are no prospective data
that early broad-spectrum antibiotic therapy reduces mortality in se-
vere sepsis [177], but prompt initiation of antimicrobial therapy re-
mains important for suspected infections [178,179]. If the pathogen is
resistant to antibiotic, early or late initiation of antibiotic therapy cannot
improve the outcome. Inappropriateness of empirical antibiotic therapy
can contribute to high level of mortality [180]. The crisis emerges of an-
tibiotic resistance for microbial pathogens [181-183]. Without new and
effective antibiotics, the problem will escalate. However, new antibi-
otics cannot increase the effectiveness of sepsis therapy if pathogens
proliferate inside erythrocytes [34]. Antibiotics kill bacteria in blood
plasma, but insufficiently penetrate erythrocytes for killing bacteria
there. Constant bacterial reservoirs in erythrocytes decreases antibacte-
rial and immune therapy effectiveness and may be one of the factors
that make sepsis therapy so problematic.
10. Treatment perspectives
Although improvements in supportive care of patients with sepsis
(more effective and less damaging mechanical ventilation, improved
fluid resuscitation, and broad-spectrum antibiotic coverage) have im-
proved survival rates, sepsis remains a condition with high mortality.
Despite many clinical trials, no FDA-approved drug is available for use
in sepsis [184].
The biology of sepsis is complex and not specific to infection. More
than 100 randomized clinical trials have tested the hypothesis that
modulating the septic response to infection can improve survival.
None of these have resulted in new treatments [185].
The treatment of sepsis should be based on the understanding of its
pathogenesis. The pathogenesis of sepsis is not fully understood. Bacte-
ria from external or local sources enter bloodstream causing bacteremia.
Phagocytosis in the bloodstream is impossible and blood humoral bac-
tericidal factors and erythrocytes are the main antibacterial forces in
the bloodstream. Both erythrocytes and bacteria are triboelectrically
charged in the bloodstream. The charge of erythrocytes attracts the
charge of bacteria and keeps bacteria on the surface of erythrocytes.
The interaction of the charges at the surface of erythrocytes stimulates
the release of oxygen from oxyhemoglobin. The oxygen is released
from hemoglobin as a mixture of different allotropes of oxygen (mon-
atomic oxygen O(3P), dioxygen, singlet oxygen, triatomic oxygen O3,
etc.) that are very reactive and kill bacteria by oxidation. This auspicious
scenario is accompanied with no or mild clinical signs and ends without
complications. Bacteria can survive oxidation having thick capsule,
slime layer and producing catalase, SOD and GPX. If bacteria survive ox-
idation on the surface of erythrocyte, they may: 1. cause an intense re-
lease of oxygen from erythrocytes to the plasma without penetrating
erythrocytes; 2. cause the oxygen release and then penetrate erythro-
cytes. If bacteria do not penetrate erythrocytes, immune complexes
and antibiotics may eliminate the infection. If bacteria are killed inside
erythrocytes, bacteremia becomes self-limited and does not develop
 H. Minasyan / Journal of Critical Care 40 (2017) 229–242
to sepsis. Released oxygen oxidizes components of plasma and causes
hypoxia and functional problems in organs and tissues. Sepsis starts
when bacteria survive in erythrocytes, becoming a constant source of
bacterial proliferation and dissemination. Antibiotics and immune com-
plexes cannot kill bacteria inside erythrocytes and the infection be-
comes persistent and uncontrollable. Massive release of oxygen from
erythrocytes causes disseminated intravascular coagulation, oxidation
of plasma components (hormones, proteins, peptides, cytokines, etc.),
makes impossible oxygen delivery to cells, and leads to multiple organ
failure. The cornerstone of sepsis therapy should be: a. arterial blood
clearing from pathogens; b. prevention of premature release of oxygen
from erythrocytes; c. prevention of bacterial reservoir forming in eryth-
rocytes. The following is promising:
10.1. Suppression of bacterial antioxidant mechanisms
10.1.1. Inhibition of bacterial catalase production
The resistance of bacteria to oxidation on the surface and inside
erythrocytes depends upon several factors including catalase produc-
tion. Inhibition of bacterial catalase production increases the effective-
ness of bacteria killing by erythrocytes. However, available bacterial
catalase inhibitors are not safe [186-189] and new inhibitors are
needed.
10.1.2. Inhibition of bacterial superoxide dismutase production
The manganese and zinc binding protein calprotectin (CP) reduces
bacterial superoxide dismutase activity [190,191]. Bacterial MnSOD
phosphorylation on serine and threonine residues decreases the bacte-
ria capacity to counteract ROS [192].
10.2. Suppression of bacterial capsule and biofilm production
Capsule polysaccharides (CPS) are not only fundamental virulence
factors for a wide range of Gram-negative (e.g. Klebsiella pneumonia,
Escherichia coli and others) and Gram-positive (e.g. Streptococcus pneu-
monia, Staphylococcus aureus, etc.) pathogens [193-195], but they also
inhibit complement activity and phagocytosis [196], provide bacterial
resistance to antimicrobials [197], immune recognition by antigen-spe-
cific antibodies [198], killing by human antibody [199] and, being bacte-
rial cell “insulator”, bacterial capsule decreases attraction, fixation and
killing of bacteria by erythrocytes [33-36]. The biosynthesis of bacterial
capsules is regulated by tyrosine phosphatase (PTP) and a protein tyro-
sine kinase [200,201]. Inhibition of these proteins may stop capsule pro-
duction. As a result, bacterial virulence decreases and bacteria killing by
oxidation increases. Capsule inhibitory drugs may become an important
addition to anti-sepsis therapies.
In the biofilm form, bacteria are more resistant to various antimicro-
bial treatments, can survive harsh conditions and withstand the host's
immune system [202,203] Biofilm-associated infections are very diffi-
cult to treat with conventional antibiotics. A potential antibiofilm drug
that can either facilitate the dispersion of preformed biofilms or inhibit
the formation of new biofilms is needed [204]. To date, many
antibiofilm compounds have been identified from diverse natural
sources, for example, brominated furanones [205], ursine triterpenes
[206], corosolic acid and asiatic acid [207], ginseng [208] and 3-
indolylacetonitrile [209].
Indole, which is generated by the degradation of tryptophan by
tryptophanase [210] is an intercellular signal molecule that can affect
multiple aspects of some bacterial species [211] inhibiting biofilm for-
mation and motility [212]. N-acyl homoserine lactones, D-amino acids,
monomeric trimethylsilane (TMS), ionic liquids, particularly, 1-
alkylquinolinium bromide ionic liquids exhibit promising antimicrobial
and antibiofilm properties [213-217].
Nitric oxide (NO) is a signal for biofilm dispersal, inducing the tran-
sition from the biofilm mode of growth to the free swimming planktonic
state [218].
235
Unfortunately, till now no antibiofilm drug has been registered and
used in clinical practice [219,220].
10.3. Bloodstream bacteria removal by technical devices
The idea of bacteria removal from the bloodstream was offered more
than 25 years ago [221]. E. coli bacteria were successfully removed from
contaminated RBC/plasma by using a special matrix of micro-encapsu-
lated albumin activated charcoal (ACAC). The data indicated that the
bacteria adhered to the ACAC, but that the charcoal was not bactericidal.
Another device for removing bacterial toxins from blood useful for
treating sepsis was patented 10 years ago [222]. The device includes
hollow fiber material for selective binding of the toxins and removes
bacterial lipopolysaccharides (LPS) and lipoteichoic acids (LTA) from
blood or plasma in an extracorporeal perfusion system. Some years
ago, for bacteria and endotoxin removing from the blood magnetic
nanoparticles (MNPs) modified with bis-Zn-DPA, a synthetic ligand
that binds to both Gram-positive and Gram-negative bacteria, was
used [223].
An external device that mimics the structure of a spleen and cleanses
the blood in acute sepsis has been tested recently [224]. Blood flowing
from an infected individual is mixed with magnetic nanobeads coated
with an engineered human opsonin—mannose-binding lectin
(MBL)—that captures a broad range of pathogens and toxins without ac-
tivating complement factors or coagulation. Magnets pull the opsonin-
bound pathogens and toxins from the blood; the cleansed blood is
then returned back to the individual. The biospleen efficiently removes
multiple Gram-negative and Gram-positive bacteria, fungi and endo-
toxins from whole human blood flowing through a biospleen unit. A
mechanical devices has been developed to remove a variety of cyto-
kines, lipopolysaccharide, or C5a from plasma [225]. It is unclear wheth-
er such devices would be clinically efficacious for sepsis in humans.
A prototype in-line filtration/adsorption device has been developed
using novel synthetic pyrolysed carbon monoliths with controlled
mesoporous domains of 2–50 nm [226]. Porosity was characterized by
SEM and porosimetry. Removal of inflammatory cytokines TNF, IL-6,
IL-1β and IL-8 was assessed by filtering cytokine spiked human plasma
through the walls of the carbon modules under pressure. The effect of
carbon filtration on the plasma clotting response and total plasma pro-
tein concentration was also assessed. Significant removal of the cyto-
kines IL-6, IL-1β and IL-8 was observed.
A cytokine adsorption device (CAD) filled with porous polymer
beads which efficiently depletes middle-molecular weight cytokines
from a circulating solution has been also developed [227]. Continuous
venovenous hemofiltration (CVVHF) combined with plasmapheresis
(TPE) reduced mortality in single- and double-organ failure as high as
28% in septic patients with combined extracorporeal detoxification
[228].
Bacteria and erythrocytes are triboelctrically charged in the blood-
stream. Presumably, dialysis like device with “electric trap” for bacteria
may attract and remove bacteria from the bloodstream.
10.4. Development of new antimicrobials
Despite advances in medicine, sepsis continues to account for an in-
creasing number of deaths [229]. The cause is that until now erythrocyte
has been a neglected compartment in antibiotics pharmacokinetics and
pharmacodynamics. While it is generally agreed that antibiotic serum
concentrations should be above the minimal inhibitory concentration
for the infecting organism, it is also true that most infections are not in
serum but are found in one or more sequestered tissues, which may
have entirely different antibiotic penetration [230]. This is true also re-
garding the inner space of erythrocytes that may become a bacterial res-
ervoir in sepsis. It is also generally stated that only free antibiotic
molecules will inhibit bacteria. The importance of this concept is clear,
but the widely quoted free and bound antibiotic concentrations are
236 H. Minasyan / Journal of Critical Care 40 (2017) 229–242
actually derived from in vitro studies of binding to serum proteins, as
opposed to study of infection site binding factors. Thus, it is seldom ap-
parent what amount of antibiotic is actually available at an infection site
(and also inside erythrocytes) versus the amount bound to cellular de-
bris or otherwise inactivated by local condition [230]. Intraerythrocytic
concentrations of antibiotics is higher for lipid-soluble compounds, be-
sides, plasma proteins binds antibiotics [231]. Sepsis treatment is im-
possible without antibacterial drug penetration to erythrocyte. In
sepsis the erythrocyte is a long-term bacterial reservoir. High concen-
tration of antibacterial drugs in erythrocyte is indispensable for infec-
tion elimination.
10.5. The use of ozone and hyperbaric oxygen therapies
Alternative use of these treatments in sepsis patients may give con-
troversial results because their positive potential may be carried out in
case of adequate use only. Both hyperbaric oxygen therapy [232-235]
and ozone therapy [236,237] were studied in experimental and clinical
sepsis, but there are no recommendations regarding adequate use of
these therapies. The latter may improve or deteriorate the condition of
sepsis patients depending upon the stage of sepsis, infection resistance
to oxidation, severity of hypoxia, etc. Ozone and hyperbaric oxygen
therapies, increasing the oxidative potential of erythrocytes in arterial
blood, facilitate bacteria killing by oxidation, but in case of bacterial re-
sistance to oxidation and premature release of oxygen from erythro-
cytes, ozone and hyperbaric oxygen therapies may provoke
disseminated intravascular coagulation and intensify blood plasma
oxidation.
10.6. Replacement therapy
The replacement of hormones, peptides and other active substances in
sepsis is indispensable Corticosteroids were the first anti-inflammatory
drugs tested in randomized controlled trials [238-242], then catechol-
amines, anti-diuretic hormone, thyroxin, insulin, adrenocorticotropin,
growth hormone, estrogens, androgens, etc. were also tested [243-250].
The results of separate and combined use of hormones are controversial.
Hormonal replacement therapy (protocol) should include a combination
of hormones that takes into account their synergism and antagonism, an-
abolic and catabolic properties, half-life, resistance to oxidation, pharma-
cokinetics, pharmacodynamics, etc. The profile and proportions of most
important hormones and regulatory substances for support of vital func-
tions should be established. Injected components may be oxidized and
inactivated so constant control of their concentrations should be
performed.
10.7. Search for optimal blood transfusion triggers for sepsis patients
Approximately 40-50% of patients admitted to the ICU are trans-
fused at least 1 RBC unit. RBC transfusion in sepsis does not improve ox-
ygen delivery and consumption, mixed venous oxygen saturation or
lactate levels [251,252]. RBC transfusions in sepsis are not associated
with an improvement in tissue oxygenation in spite of a significant in-
crease in hemoglobin levels [253]. The existing evidence supports the
use of restrictive transfusion triggers in most patients [254]. Optimal
transfusion triggers in sepsis patients are not known. RBC transfusions
cause complications, such as infection, acute lung injury (TRALI), circu-
latory overload (TACO), immunomodulation (TRIM), multiorgan failure
and increased mortality [255]. Performing RBC transfusion in sepsis the
following should be taken into account: 1. the blood should be as fresh
as possible. Bacteria easily penetrate old erythrocytes. The lack of oxy-
gen in erythrocytes facilitates bacterial penetration as well; 2. in-bag he-
molysis increases free hemoglobin (protein and iron) in patient's
plasma stimulating bacterial growth and proliferation; 3. The more
massive is bacteremia, the less effective is blood transfusion; 4. Sepsis
patients are sensitive to even minimal number of bacteria in transfused
blood. Before blood transfusion a sterility test is necessary.
10.8. Inactivation of endotoxins and exotoxins
The systemic spread of microbial toxins is an important event in the
pathogenesis of sepsis [256,257]. Human-specific bacterial toxins make
pores in erythrocyte membrane [258]. The pores cause hemolysis [259].
One of the complications of sepsis is the rapid development of anemia
caused by hemolysis. Free hemoglobin is an important predictor of sur-
vival in sepsis. In non-survivors, free hemoglobin concentration was
twice the concentration compared to survivors [260]. Bigger size bacte-
ria enter erythrocytes through the pores [34-36]. The scenario is the fol-
lowing. After attraction and fixation of bacteria on the surface of
erythrocyte direct physical contact of bacterial body and erythrocyte
membrane occurs. Electric charge interaction causes the release of bac-
terial toxins. High local concentration of toxins on the surface of eryth-
rocyte irritates the membrane of erythrocyte causing oxygen release
from erythrocyte. If bacteria are resistant to oxidation they continue to
stimulate oxygen release from erythrocytes. Released oxygen oxidizes
plasma components and causes disseminated intravascular coagulation.
Bacterial toxins injure erythrocyte membrane and form pores that pro-
vide bacteria penetration. The inactivation of bacterial toxins may pre-
vent oxygen release and the penetration of bacteria to erythrocytes.
The following is promising: 1. toxin production inhibition by means of
bacterial protein inhibition; 2. toxin inactivation by binding with syn-
thetic polymers, natural or synthetic antibodies, different toxin-
inactivating compounds; 3. toxin inactivation by modulation of target
cell membrane characteristics.
10.9. “Biological weapon” against sepsis causing bacteria
Predation and antagonism is persistent at all levels of life, found in all
walks of life and possibly in all environments. Predation and antago-
nism between microorganisms has been known for a long time [261].
Antibiotics are the best illustration of antagonism between fungi and
bacteria. Antagonism and predation against sepsis causing pathogens
are very promising. The use of following therapies may be effective.
10.9.1. Bacteriophage therapy
Bacteriophages may be useful in the treatment of sepsis caused by
antibiotic resistant bacterial infections. They have some theoretical ad-
vantages over antibiotics being more effective in treating certain infec-
tions in humans [262-265]. Bacterial isolates from septicemia patients
spontaneously secrete phages active against other isolates of the same
bacterial strain, but not to the strain causing the disease [266]. Such
phages were also detected in the initial blood cultures, indicating that
phages are circulating in the blood at the onset of sepsis. The fact that
most of the septicemic bacterial isolates carry functional prophages sug-
gests an active role of phages in bacterial infections [266]. Prophages
present in sepsis-causing bacterial clones play a role in clonal selection
during bacterial invasion. The use of phages is an attractive option to
battle antibiotic resistant bacteria in certain bacterial infections, but
the role of phage ecology in bacterial infections is obscure [266].
10.9.2. Therapy by Bdellovibrio like organisms
Bdellovibrio and like organisms (BALOs) are small, predatory,
Deltaproteobacteria that prey on other bacteria. Many authors have un-
folded the possible use of BALOs as biological control agents in environ-
mental as well as medical microbiological settings [267,268]. BALOs,
particularly, Bdellovibrio bacteriovorus is a solitary hunter that attacks
a wide range of pathogens: Escherichia coli, Salmonella enteric, Pseudo-
monas aeruginosa, S. aureus and others [269-271].
One of the methods used by bacteria for predation is periplasmic in-
vasion. The predator cell invades and grows within a specific compart-
ment found in Gram-negative cells, the periplasm. This group of
 H. Minasyan / Journal of Critical Care 40 (2017) 229–242
predators is unique in the fact that the predator is a bacterium that is
clearly a living organism, as opposed to viruses and phages and is small-
er than the prey. They were named B.bacteriovorus, the name describing
the morphology and the supposed way of life of the bacteria; they were
curved and seemed to stick to their prey and to absorb the prey cell con-
tent, reminiscent of a leech (“bdella” in Greek). Robert E. Buzzzchanan
coined the term B.bacteriovorus [272]. Bdellovibrio are highly motile,
flagellated, tiny measuring about 0.25 × 1.0 μm, Gram-negative
Deltaproteobacteria [273].
Bdellovibrio bacteriovorus uses a single polar flagellum to stalk other
bacteria. Using appendages located at the nonflagellated pole, this tiny
predator binds its prey tightly. Secreted enzymes now permit the pred-
ator to burrow through the surface of its prey, where it wedges between
the outer membrane and the peptidoglycan wall. Here, it begins to re-
program both itself and its prey. This includes the partial degradation
of the prey peptidoglycan wall, which causes the prey to round up
into a structure called the bdelloplast. Nestled within the confines of
this bdelloplast, the predator consumes its host from the inside out
[274,275]. Bdellovibrio bacteriovorus has dual probiotic and antibiotic
nature [276] and it is reasonable to try it in the therapy of sepsis.
10.9.3. Saccharomyces therapy
Saccharomyces boulardii (SB) is a non-pathogenic, thermophilic
yeast, used as a probiotic strain in the prevention or the treatment of in-
testinal diseases, mainly diarrheas [277,278]. SB directly inhibits the
growth of several pathogens (Candida albicans, E. coli, Shigella, Pseudo-
monas aeruginosa, Staphylococcus aureus, Entamoeba hystolitica), and
cell invasion by Salmonella typhimurium and Yersinia enterocolitica
[279-281]. SB exerts several anti-microbial activities that could be divid-
ed in two groups: direct anti-toxin effects and inhibition of growth and
invasion of pathogens. The anti-toxin action elicited by SB is mainly due
to small peptides produced by the yeast. A 54 kDa serine protease is able
to inhibit enterotoxin and cyto-toxic activities of C. difficile by degrada-
tion of toxin A and B [281].
SB produces a phosphatase able to dephosphorylate endotoxins
(such as lipopolysaccharide of E. coli 055B5) and inactivates its cytotoxic
effects [282]. SB also has a positive effect on the maintenance of epithe-
lial barrier integrity during bacterial infection [283]. SB affects the im-
mune response of host cells and stimulates the secretion of secretory
immunoglobulin A [284,285]. SB inhibits the growth of Candida albicans
[286]. Probably, the antimicrobial and antifungal products, produced by
SB may be studied as a possible therapeutic option in sepsis.
10.10. Acceleration of blood flow
Bacteria cannot proliferate in big vessels (arteries, veins) because
blood high velocity causes triboelectric charging that inhibits bacterial
transmembrane metabolism. In arterial blood bacteria are attracted by
electric charge of erythrocytes and killed by released oxygen. In capil-
laries bacteria are killed by being squeezed between erythrocytes,
besides, during oxygen/CO2 exchange between erythrocytes and the tis-
sues, bacteria are killed by oxidation. In venules and small veins, slow
blood flow and deoxygenation are auspicious for the proliferation of
bacteria. Infection may grow in vessels with slow blood flow (systemic
veins, skin venous plexuses). Decreased blood velocity increases the risk
of thrombosis. Blood viscosity in venules increases 100% when blood
flow reduces 60% [287]. Coagulation abnormalities in sepsis range
from a small decrease in platelet count and subclinical prolongation of
global clotting times to fulminant disseminated intravascular coagula-
tion (DIC), characterized by simultaneous widespread microvascular
thrombosis and profuse bleeding from various sites [288]. Blood clots
become a source of iron and protein for bacterial proliferation. The
acceleration of blood flow velocity increases turboelectric charging of
bacteria and decreases the risk of thrombosis. Blood circulation may
be accelerated by different ways: muscular exercises and physical
237
rehabilitation [289,290], special physiotherapy [291], massage [292],
etc. Unfortunately, these procedures give short-term effect.
11. Conclusion
In bacteremia, two events are critical for the development of sepsis:
infection resistance to oxidation and intensive release of oxygen to arte-
rial blood. The consequences of these two events determine bacteremia
progression to sepsis and its deterioration to septic shock.
Infection resistance to oxidation provides bacterial survival on the
surface of erythrocytes, penetration of pathogens to erythrocytes,
forming infection reservoir inside erythrocytes, destruction of erythro-
cytes and anemia, infection dissemination to all organs and tissues.
Premature release of oxygen from erythrocytes causes inactivation
of plasma components, disseminated intravascular coagulation and
generalized hypoxia.
In sepsis, the following consecutive events occur: 1. Bacteria enter
the bloodstream; 2. Bacteria are attracted and fixed on the surface of
erythrocytes; 3. Bacteria irritate erythrocyte membrane, and erythro-
cyte releases oxygen; 4. Survived bacteria enter erythrocyte through
pores formed by bacterial capsule, wall components and toxins; 5. Bac-
teria survive inside erythrocyte and proliferate forming infectious reser-
voir; 6. Released from erythrocyte oxygen oxidizes plasma components
(proteins, hormones, peptides, amino acids, fatty acids, etc.), causing
hormonal regulation disarrangement, humoral immunity inactivation
and nutrient delivery failure; Premature release of oxygen from eryth-
rocytes causes tissue hypoxia; All these factors cause multiple organ
failure.
Treatment of sepsis and septic shock after bacterial penetration to
erythrocytes and premature release of oxygen from oxyhemoglobin is
very problematic. The most perspective approach to sepsis and septic
shock is prevention of bacterial penetration to erythrocytes and prema-
ture release of oxygen to arterial blood. It may be achieved by suppres-
sion of bacterial antioxidant mechanisms and inactivation of bacterial
endotoxins and exotoxins. Development of new antimicrobials is a tem-
porary and less effective approach. Bloodstream bacteria removal by
technical devices, adequate replacement therapy and the use of “biolog-
ical weapon” against sepsis causing bacteria may be useful as addition to
sepsis and septic shock combined therapy.
Funding
No funding.
Conflict of interest
There is no conflict of interest.
References
[1] Cohen J, Vincent J-L, Adhikari NKJ, Machado FR, Angus DC, Calandra T, et al. The
Lancet infectious diseases commission: sepsis: a roadmap for future research. Lan-
cet Infect Dis 2015;15:581–614.
[2] Czura CJ. “Merinoff symposium 2010: sepsis”-speaking with one voice. Mol Med
2011;17:2–3.
[3] Stearns-Kurosawa DJ, Osuchowski MF, Valentine C, Kurosawa S, Remick DG. The
pathogenesis of sepsis. Annu Rev Pathol 2011;6:19–48.
[4] Tetta C, Fonsato V, Ronco C, CamussI G. Severe sepsis remains the dominant chal-
lenge in the care of critically ill patients. Crit Care Resusc 2005;7:32–9.
[5] Fleischmann C, Scherag A, Adhikari NK, Hartog CS, Tsaganos T, Schlattmann P, et al.
International forum of acute care trialists. Assessment of global incidence and mor-
tality of hospital-treated sepsis. Current estimates and limitations. Am J Respir Crit
Care Med 2016 Feb;193(3):259–72.
[6] Stoller J, Halpin L, Weis M, Aplin B, Qu W, Georgescu C, et al. Epidemiology of se-
vere sepsis: 2008–2012. J Crit Care 2016 Feb;31(1):58–62 [Epub 2015 Oct 24].
[7] Gaieski DF, Edwards JM, Kallan MJ, Carr BG. Benchmarking the incidence and mor-
tality of severe sepsis in the United States. Crit Care Med 2013 May;41(5):1167–74.
[8] Yébenes JC, Ruiz-Rodriguez JC, Ferrer R, et al. Epidemiology of sepsis in Catalonia:
analysis of incidence and outcomes in a European setting Ann. Intensive Care
2017;7:19. http://dx.doi.org/10.1186/s13613-017-0241-1.
238 H. Minasyan / Journal of Critical Care 40 (2017) 229–242
[9] Stevenson EK, Rubenstein AR, Radin GT, Wiener RS, Walkey AJ. Two decades of
mortality trends among patients with severe sepsis: a comparative meta-analysis.
Crit Care Med 2014 Mar;42(3):625–31.
[10] Vincent JL, Marshall JC, Namendys-Silva SA, et al. Assessment of the worldwide
burden of critical illness: the intensive care over nations (ICON) audit. Lancet
Respir Med 2014;2:380–6.
[11] Walkey AJ, Wiener RS, Lindenauer PK. Utilization patterns and outcomes associated
with central venous catheter in septic shock: a population-based study. Crit Care
Med 2013;41(6):1450.
[12] Kaukonen KM, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality related to severe
sepsis and septic shock among critically ill patients in Australia and New Zealand,
2000-2012. JAMA 2014;311(13):1308.
[13] Annane D, Aegerter P, Jars-Guincestre MC, Guidet B. Current epidemiology of sep-
sis. The CUB-Rea network. Am J Respir Crit Care Med 2003;168:165–72.
[14] Annane D, Bellissant E, Cavaillon JM. Septic shock: seminar. Lancet 2005;365:
63–78.
[15] Vincent JL, Rello J, Marshall J, et al. International study of the prevalence and out-
comes of infection in intensive care units. JAMA 2009;302:2323–9.
[16] Offord R. Causes and features of sepsis. Hosp Pharm 2002;9:93–6.
[17] Ranieri VM, Thompson BT, Barie PS, et al. Drotrecogin alfa (activated) in adults with
septic shock. N Engl J Med 2012;366:2055–64.
[18] Opal SM, Garber GE, LaRosa SP, et al. Systemic host responses in severe sepsis an-
alyzed by causative microorganism and treatment effects of drotrecogin alfa (acti-
vated). Clin Infect Dis 2003;37:50–8.
[19] Balk RA. Severe sepsis and septic shock: definitions, epidemiology, and clinical
manifestations. Crit Care Clin 2000;16:179–92.
[20] Horn KD. Evolving strategies in the treatment of sepsis and systemic inflammatory
response syndrome (SIRS). Q J Med 1998;91:265–77.
[21] Remick DG. Pathophysiology of sepsis. Am J Pathol 2007 May;170(5):1435–44.
[22] Wiersinga WJ, Leopold SJ, Cranendonk DR, van der Poll T. Host innate immune re-
sponses to sepsis. Virulence 2014 Jan 1;5(1):36–44.
[23] Wiersinga WJ. Current insights in sepsis: from pathogenesis to new treatment tar-
gets. Curr Opin Crit Care 2011 Oct;17(5):480–6.
[24] Kumar S, Ingle H, Prasad DV, Kumar H. Recognition of bacterial infection by innate
immune sensors. Crit Rev Microbiol 2013 Aug;39(3):229–46.
[25] Iskander KN, Osuchowski MF, Stearns-Kurosawa DJ, Kurosawa S, Stepien D,
Valentine C, et al. Sepsis: multiple abnormalities, heterogeneous responses, and
evolving understanding. Physiol Rev 2013 Jul;93(3):1247–88.
[26] Wu M, Gu J-T, Yi B, Tang Z-Z, Tao G-C. MicroRNA-23b regulates the expression of
inflammatory factors in vascular endothelial cells during sepsis. Exp Ther Med
2015 Apr;9(4):1125–32.
[27] Lockhart PB, Brennan MT, Sasser HC, Fox PC, Paster BJ, Bahrani-Mougeot FK. Bacter-
emia associated with toothbrushing and dental extraction. Circulation 2008;117
3118–3115.
[28] Forner L, Larsen T, Kilian M, Holmstrup P. Incidence of bacteremia after chewing,
tooth brushing and scaling in individuals with periodontal inflammation. J Clin
Periodontol 2006 Jun;33(6):401–7.
[29] MacFarlane TW, Samaranayake LP. Clinical oral microbiology. , 223PWright: Lon-
don; 1989.
[30] Hiffajee AD, Socransky SS, Dzink JL, et al. Clinical, microbiological and immunolog-
ical features of subjects with destructive periodontal diseases. J Clin Periodontol
1988;15:240–6.
[31] Goodson JM, Tanner AC, Haffajec AD, et al. Patterns of progression and regression of
advanced destructive periodontal disease. J Clin Periodontol 1982;9 (472-471).
[32] Minasyan H. Erythrocyte and blood antibacterial defense. Eur J Microbiol Immunol
2014;4(2):138–43.
[33] Minasyan H. Mechanisms and pathways for the clearance of bacteria from blood
circulation in health and disease. Pathophysiology 2016;23:61–6.
[34] Minasyan H. Erythrocyte: bacteria killer and bacteria pray. Int J Immunol. (Special
Issue: Antibacterial Cellular and Humoral Immunity). 2014;2(5-1):1-7.
[35] Minasyan H. Erythrocyte and leukocyte: two partners in bacteria killing. Int Rev
Immunol 2014;33(6):490–7.
[36] Minasyan H, Urumyan SA, Mkhitaryan DS. Erythrocytes bactericidal role in human
immunity. New Armenian Med J 2014;8(2):18–32.
[37] Sriskandan S, Cohen J. Gram-positive sepsis. Mechanisms and differences from
gram-negative sepsis. Dis Clin North Am 1999 Jun;13(2):397–412.
[38] Morgan MP, Szakmany T, Power SG, Olaniyi P, Hall JE, Rowan K, et al. Sepsis pa-
tients with first and second-hit infections show different outcomes depending on
the causative organism. Front Microbiol 2016;7:207 [Epub 2016 Feb 26].
[39] Hogg S. Essential microbiology. 1st ed. Wiley0-471-49754-1; 2005 99–100.
[40] Rock JD, Moir JW. Microaerobic denitrification in Neisseria meningitidis. Biochem
Soc Trans 2005 Feb;33(Pt 1):134–6.
[41] Rock JD, Mahnane MR, Anjum MF, Shaw JG, Read RC, Moir JW. The pathogen
Neisseria meningitidis requires oxygen, but supplements growth by denitrifica-
tion. Nitrite, nitric oxide and oxygen control respiratory flux at genetic and meta-
bolic levels. Mol Microbiol 2005 Nov;58(3):800–9.
[42] Miller RA, Britigan BE. Role of oxidants in microbial pathophysiology. Clin Microbiol
Rev 1997;10:1–18.
[43] Haas A, Goebel W. Microbial strategies to prevent oxygen-dependent killing by
phagocytes. Free Radic Res Commun 1992;16:137–57.
[44] Lee WL, Harrison RE, Grinstein S. Phagocytosis by neutrophils. Microbes Infect
2003;5(14):1299–306.
[45] Roos D, Winterbourn CC. Immunology. Lethal weapons. Science 2002;296(5568):
669–71.
[46] Roos D, van Bruggen R, Meischl C. Oxidative killing of microbes by neutrophils. Mi-
crobes Infect 2003;5(14):1307–15.
[47] Faurschou M, Borregaard N. Neutrophil granules and secretory vesicles in inflam-
mation. Microbes Infect 2003;5(14):1317–27.
[48] Brinkmann V, Reichard U, Goosmann C, Fauler B, Uhlemann Y, Weiss DS, et al. Neu-
trophil extracellular traps kill bacteria. Science 2004;303(5663):1532–5.
[49] Thomas MP, Whangbo J, McCrossan G, et al. Leukocyte protease binding to nucleic
acids promotes nuclear localization and cleavage of nucleic acid binding proteins. J
Immunol 2014;192(11):5390–7.
[50] Ma AC, Kubes P. Platelets, neutrophils, and neutrophil extracellular traps (NETs) in
sepsis. J Thromb Haemost 2008 March;6(3):415–20.
[51] Weyrich AS, Zimmerman GA. Platelets: signaling cells in the immune continuum.
Trends Immunol 2004;25:489–95.
[52] Yeaman MR. Platelets in defense against bacterial pathogens. Cell Mol Life Sci 2010
Feb;67(4):525–44.
[53] Youssefian T, Drouin A, Masse JM, Guichard J, Cramer EM. Host defense role of
platelets: engulfment of HIV and Staphylococcus aureus occurs in a specific subcel-
lular compartment and is enhanced by platelet activation. Blood 2002;99:4021–9.
[54] Akca S, Haji-Michael P, De Mendonca A, Suter P, Levi M, Vincent JL. Time course of
platelet counts in critically ill patients. Crit Care Med 2002;30:753–6.
[55] Garcia-del Portillo F, Finlay BB. The varied lifestyles of intracellular pathogens with-
in eukaryotic vacuolar compartments. Trends Microbiol 1995;3:373–80.
[56] Hasset DJ, Cohen MS. Bacterial adaptation to oxidative stress: implications for path-
ogenesis and interaction with phagocytic cells. FASEB J 1989;3:2574–82.
[57] Berlett BS, Stadtman ER. Protein oxidation in aging, disease and oxidative stress. J
Biol Chem 1997;272:20313–9316.
[58] Shacter E. Quantification and significance of protein oxidation inbiological samples.
Drug Metab Rev 2000;32(3&4):307–26.
[59] Hovorka SW, Hong J, Cleland JL, Schöneich Ch. Metal-catalyzed oxidation of human
growth hormone: modulation by solvent-induced changes of protein conforma-
tion. J Pharm Sci 2001(January);90(1):58–69.
[60] Elijah IE, Branski LK, Finnerty CC, Herndon DN. The GH/IGF-1 system in critical ill-
ness. Best Pract Res Clin Endocrinol Metab 2011 Oct;25(5):759–67.
[61] Voerman HJ, van Schijndel RJ, Groeneveld AB, de Boer H, Nauta JP, van der Veen EA,
et al. Effects of recombinant human growth hormone in patients with severe sep-
sis. Ann Surg 1992 Dec;216(6):648–55.
[62] Olivares-Corichi IM, Ceballos G, Medina-Santillan R, Medina-Navarro R, Guzman-
Grenfell AM, Hicks JJ. Oxidation by reactive oxygen species (ROS) alters the struc-
ture of human insulin and decreases the insulin-dependent D-glucose-C14 utiliza-
tion by human adipose tissue. Front Biosci 2005 Sep 1;10:3127–31.
[63] Taylor JH, Beilman GJ. Hyperglycemia in the intensive care unit: no longer just a
marker of illness severity. Surg Infect 2005;6:233–45.
[64] Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I,
et al. Intensive insulin therapy in the medical ICU. N Engl J Med 2006;354:449–61.
[65] Leonidou L, Michalaki M, Leonardou A, Polyzogopoulou E, Fouka K, Gerolymos M,
et al. Stress-induced hyperglycemia in patients with severe sepsis: a compromising
factor for survival. Am J Med Sci 2008 Dec;336(6):467–71.
[66] Inzucchi SE. Management of hyperglycemia in the hospital setting. N Engl J Med
2006;355(18):1903–11.
[67] Zaloga GP, Marik P. Hypothalamic-pituitary-adrenal insufficiency. Crit Care Clin
2001;17:25–41.
[68] Annane D, Sébille V, Troché G, Raphaël JC, Gajdos P, Bellissant E. A 3-level prognos-
tic classification in septic shock based on cortisol levels and cortisol response to
corticotropin. JAMA 2000;283:1038–45.
[69] Koo DJ, Jackman D, Chaudry IH, Wang P. Adrenal insufficiency during the late stage
of polymicrobial sepsis. Crit Care Med 2001;29:618–22.
[70] Schroeder S, Wichers M, Klingmüller D, et al. The hypothalamic-pituitary-adrenal
axis of patients with severe sepsis: altered response to corticotropin-releasing hor-
mone. Crit Care Med 2001;29:310–6.
[71] Yamashita S, Drynan J, Guest C, Silverberg J. Comparison of low-dose (1 μg) with
conventional-dose cosyntropin (250 μg) for adrenal insufficiency testing in critical
illness [abstr]. Crit Care Med 2001;29(suppl):A164.
[72] Lodha R, Vivekanandhan S, Sarthi M, Arun S, Kabra SK. Thyroid function in children
with sepsis and septic shock. Acta Paediatr 2007 Mar;96(3):406–9.
[73] Burman KD, Wartofsky L. Thyroid function in the intensive care unit setting. Crit
Care Clin 2001:1743–57.
[74] Ho HC, Chapital AD, Yu M. Hypothyroidism and adrenal insufficiency in sepsis and
hemorrhagic shock. Arch Surg 2004;139(11):1199–203.
[75] Leonard JL, Visser TJ. Biochemistry of deiodination. In: Hennemann G, editor. Thy-
roid hormone metabolism. New York, NY: Marcel Dekker; 1986. p. 189–229.
[76] McNabb FMA. Thyroid hormones. En-glewood Cliffs, NJ: Prentice Hall; 1992.
[77] Rosei MA, Coccia R, Blarzino C, Foppoli C, Mosca L. The oxidation of oxytocin and
vasopressin by peroxidase/H2O2 system. Amino Acids 1995;8:385–91.
[78] Singh Ranger G. Antidiuretic hormone replacement therapy to prevent or amelio-
rate vasodilatory shock. Med Hypotheses 2002 Sep;59(3):337–40.
[79] Baldasso E, Ramos Garcia PC, Piva JP, Einloft PR. Hemodynamic and metabolic ef-
fects of vasopressin infusion in children with shock. J Pediatr 2007 Nov;83(5
Suppl):137–45.
[80] Holmes CL, Patel BM, Russell JA, Walley KR. Physiology of vasopressin relevant to
management of septic shock. Chest 2001 Sep;120(3):989–1002.
[81] Mousavi S. Vasopressin and septic shock. J Pharm Care 2013;1(2):65–73.
[82] Zhang W, Chen X, Huang L, Lu N, Zhou L, Wu G, et al. Severe sepsis: low expression
of the renin-angiotensin system is associated with poor prognosis. Exp Ther Med
2014;7(5):1342–8.
[83] Delaney AP, Dan A, McCaffrey J, Finfer S. The role of albumin as a resuscitation fluid
for patients with sepsis: a systematic review and meta-analysis. Crit Care Med
2011;39:386–91.
[84] Tamion F. Albumin in sepsis. Ann Fr Anesth Reanim 2010 Sep;29(9):629–34.
 H. Minasyan / Journal of Critical Care 40 (2017) 229–242
[85] Rothschild MA, Oratz M. Schreiber SS. Serum albumin Hepatology 1988;8:
385–401.
[86] Evans TW. Review article: albumin as a drug—biological effects of albumin unrelat-
ed to oncotic pressure. Aliment Pharmacol Ther 2002;16(Suppl. 5):6–11.
[87] Kawakami A, Kubota K, Yamada N, Tagami U, Takehana K, Sonaka I, et al. Identifi-
cation and characterization of oxidized human serum albumin. A slight structural
change impairs its ligand-binding and antioxidant functions. FEBS J 2006 Jul;
273(14):3346–57.
[88] Yamada N, Nakayama A, Kubota K, Kawakami A, Suzuki E, Byori Rinsho. Structure
and function changes of oxidized human serum albumin: physiological significance
of the biomarker and importance of sampling conditions for accurate measure-
ment, 56(5); 2008 May 409–15.
[89] Anraku M, Chuang VT, Maruyama T, Otagiri M. Redox properties of serum albumin.
Biochim Biophys Acta 2013 Dec;1830(12):5465–72 [Epub 2013 May 3].
[90] Lee SH, Jo YH, Kim K, Lee JH, Park HM, Rhee JE, et al. Prognostic importance of hy-
poalbuminemia in patients with severe sepsis and septic shock. J Korean Soc Emerg
Med 2013 Oct;24(5):599–606.
[91] Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving
sepsis campaign guidelines committee including the pediatric subgroup. Surviving
sepsis campaign: international guidelines for management of severe sepsis and
septic shock. Intensive Care Med 2012;2013(39):165–228.
[92] Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE
Working Group. GRADE: an emerging consensus on rating quality of evidence and
strength of recommendations. BMJ 2008;336:924–6.
[93] Finfer S, Bellomo R, McEvoy S, Lo SK, Myburgh J, Neal B, et al. SAFE study Investiga-
tors. Effect of baseline serum albumin concentration on outcome of resuscitation
with albumin or saline in patients in intensive care units: analysis of data from
the saline versus albumin fluid evaluation (SAFE) study. BMJ 2006;333:1044.
[94] Dubois MJ, Orellana-Jimenez C, Melot C, De Backer D, Berre J, Leeman M, et al. Al-
bumin administration improves organ function in critically ill hypoalbuminemic
patients: a prospective, randomized, controlled, pilot study. Crit Care Med 2006;
34:2536–40.
[95] Bozic B, Cucnik S, Kveder T, Rozman B. Autoimmun Rev 2006 Nov;6(1):28–32
[Epub 2006 Jan 27].
[96] Amano M, Kobayashi N, Yabuta M, Uchiyama S, Fukui K. Detection of histidine ox-
idation in a monoclonal immunoglobulin gamma (IgG) 1 antibody. Anal Chem
2014 Aug 5;86(15):7536–43. http://dx.doi.org/10.1021/ac501300m [Epub 2014
Jul 11].
[97] Dimitrov JD, Vassilev TL, Andre S, Kaveri SV, Lacroix-Desmazes S. Functional vari-
ability of antibodies upon oxidative processes. Autoimmun Rev 2008 Jul;7(7):
574–8 [Epub 2008 May 1].
[98] Omersel J, Jurgec I, Cucnik S, Kveder T, Rozman B, Sodin-Semrl S, et al. Autoimmune
and proinflammatory activity of oxidized immunoglobulins. Autoimmun Rev 2008
Jul;7(7):523–9.
[99] Päsler M, Dietz S, Werdan K. Hypogammaglobulinemia in Sepsis. In: Vincent PJ-L,
editor. Annual update in intensive care and emergency medicine 2012. Berlin Hei-
delberg: Springer; 2012. p. 98–108.
[100] Venet F, Gebeile R, Bancel J, Guignant C, Poitevin-Later F, Malcus C, et al. Assess-
ment of plasmatic immunoglobulin G, a and M levels in septic shock patients. Int
Immunopharmacol 2011;11:2086–90.
[101] Bermejo-Martín JF, Rodriguez-Fernandez A, Herrán-Monge R, Andaluz-Ojeda D,
Muriel-Bombín A, Merino P, et al. Immunoglobulins IgG1, IgM and IgA: a synergis-
tic team influencing survival in sepsis. J Intern Med 2014;276:404–12.
[102] Shankar-Hari M, Spencer J, Sewell WA, Rowan KM, Singer M. Bench-to-bedside re-
view: immunoglobulin therapy for sepsis - biological plausibility from a critical
care perspective. Crit Care 2012;16:206.
[103] Werdan K, Pilz G, Bujdoso O, Fraunberger P, Neeser G, Schmieder RE, et al. Score-
based immunoglobulin G therapy of patients with sepsis: the SBITS study. Crit
Care Med 2007;35:2693–701.
[104] Marshall J. Inflammation, coagulopathy, and the pathogenesis of multiple organ
dysfunction syndrome. Crit Care Med 2001;29(7):99–106.
[105] Balk RA. Pathogenesis and management of multiple organ dysfunction or failure in
severe sepsis and septic shock. Crit Care Clin 2000;16(2):337–52.
[106] Johnson D, Mayers I. Multiple organ dysfunction syndrome: a narrative review. Can
J Anesth 2001;48(50):502–9.
[107] Fry DE. Sepsis, systemic inflammatory response, and multiple organ dysfunction:
the mystery continues. Am Surg 2012;78(1):1–8.
[108] Piagnerelli M, Boudjeltia KZ, Gulbis B, Vanhaeverbeek M. Vincent JS anemia in sep-
sis: the importance of red blood cell membrane changes. Transf Altern Transf Med
2007;9(3):143–9.
[109] van Beest PA, Hofstra JJ, Schultz MJ, Boerma EC, Spronk PE, Kuiper MA. The inci-
dence of low venous oxygen saturation on admission to the intensive care unit: a
multi-center observational study in The Netherlands. Crit Care 2008;12(2):33.
[110] Hayden SJ, Albert TJ, Watkins TR, Swenson ER. Anemia in critical illness: insights
into etiology, consequences, and management. Am J Respir Crit Care Med 2012;
185(10):1049–57.
[111] Jelkmann W. Proinflammatory cytokines lowering erythropoietin production. J
Interf Cytokine Res 1998;18(8):555–9.
[112] Galley HF. Oxidative stress and mitochondrial dysfunction in sepsis. Br J Anaesth
2011;107(1):57–64.
[113] Brealey D, Singer M. Mitochondrial dysfunction in sepsis. Curr Infect Dis Rep 2003;
5(5):365–71.
[114] Bar-Or D, Bar-Or R, Rael LT, Brody EN. Oxidative stress in severe acute illness. Redox
Biol 2015;4C:340–5.
[115] Loiacono LA, Shapiro DS. Detection of hypoxia at the cellular level. Crit Care Clin
2010 Apr;26(2):409–21.
239
[116] Fink MP. Cytopathic hypoxia : mitochondrial dysfunction as mechanism contribut-
ing to organ dysfunction in sepsis. Crit Care Clin 2001;17(1):219–37.
[117] Arnold RC, Shapiro NI, Jones AE, et al. Emergency medicine shock research network
(EMShockNet) Investigators. Multicenter study of early lactate clearance as a de-
terminant of survival in patients with presumed sepsis. Shock 2009;32(1):35–9.
[118] Mikkelsen ME, Miltiades AN, Gaieski DF, et al. Serum lactate is associated with mor-
tality in severe sepsis independent of organ failure and shock. Crit Care Med 2009;
37(5):1670–7.
[119] Nguyen HB, Rivers EP, Knoblich BP, et al. Early lactate clearance is associated with
improved outcome in severe sepsis and septic shock. Crit Care Med 2004;32(8):
1637–42.
[120] Nguyen HB, Loomba M, Yang JJ, et al. Early lactate clearance is associated with bio-
markers of inflammation, coagulation, apoptosis, organ dysfunction and mortality
in severe sepsis and septic shock. J Inflamm (Lond) 2010;7(6).
[121] Marik PE, Bellomo R. Lactate clearance as a target of therapy in sepsis: a flawed par-
adigm. OA Critical Care 2013 Mar 01;1(1):3.
[122] Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM. Surviving sepsis
campaign: international guidelines for management of severe sepsis and septic
shock: 2012. Crit Care Med 2013 Feb;41(2):580–637.
[123] Levy B. Lactate and shock state: the metabolic view. Curr Opin Crit Care 2006 Aug;
12(4):315–21.
[124] Regnier MA, Raux M, Le MY, Asencio Y, Gaillard J, Devilliers C. Prognostic signifi-
cance of blood lactate and lactate clearance in trauma patients. Anesthesiology
2012 Dec;117(6):1276–88.
[125] Shapiro NI, Howell MD, Talmor D, Nathanson LA, Lisbon A, Wolfe RE. Serum lactate
as a predictor of mortality in emergency department patients with infection. Ann
Emerg Med 2005 May;45(5):524–8.
[126] Trzeciak S, Dellinger RP, Chansky ME, Arnold RC, Schorr C, Milcarek B. Serum lac-
tate as a predictor of mortality in patients with infection. Intensive Care Med
2007 Jun;33(6):970–7.
[127] Varpula M, Tallgren M, Saukkonen K, Voipio-Pulkki LM, Pettila V. Hemodynamic
variables related to outcome in septic shock. Intensive Care Med 2005 Aug;
31(8):1066–71.
[128] Claus RA, Otto GP, Deigner HP, Bauer M. Approaching clinical reality: markers for
monitoring systemic inflammation and sepsis. Curr Mol Med 2010 Mar;10(2):
227–35.
[129] Bauer M, Reinhart K. Molecular diagnostics of sepsis–where are we today? Int J
Med Microbiol 2010 Aug;300(6):411–3 [Epub 2010 May 26].
[130] Lodise TP, McKinnon PS, Swiderski L, Rybak MJ. Outcomes analysis of delayed anti-
biotic treatment for hospital-acquired Staphylococcus aureus bacteremia. Clin Infect
Dis 2003 Jun 1;36(11):1418–23.
[131] Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, et al. Duration of hy-
potension before initiation of effective antimicrobial therapy is the critical determi-
nant of survival in human septic shock. Crit Care Med 2006 Jun;34(6):1589–96.
[132] Ho KM, Robinson JO. Risk factors and outcomes of methicillin-resistant Staphylo-
coccus aureus bacteraemia in critically ill patients: a case control study. Anaesth In-
tensive Care 2009 May;37(3):457–63.
[133] Boardman AK, Campbell J, Wirz H, Sharon A, Sauer-Budge AF. Rapid microbial sam-
ple preparation from blood using a novel concentration device. PLoS One 2015 Feb
12;10(2):e0116837 (doi: 10.1371).
[134] Cheah AL, Spelman T, Liew D, Peel T, Howden BP, Spelman D, et al. Enterococcal
bacteraemia: factors influencing mortality, length of stay and costs of hospitaliza-
tion. Clin Microbiol Infect 2013 Apr;19(4):E181–9.
[135] 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;348:1546–54.
[136] Lever A, Mackenzie I. Sepsis: definition, epidemiology, and diagnosis. BMJ 2007;
335:879–83.
[137] Cantey JB, Sánchez PJ. Prolonged antibiotic therapy for “culture-negative” sepsis in
preterm infants: It's time to stop! J Pediatr 2011;159(5):707–8.
[138] Raja NS, Parratt D, Meyers M. Blood culture contamination in a district general hos-
pital in the UK: a 1-year study. Healthcare Infection 2009;14(3):95–100.
[139] Thomas S, Cheesbrough J, Plumb S, Bolton L, Wilkinson P, Walmsley J, et al. Impact
of a blood culture collection kit on the quality of blood culture sampling: fear and
the law of unintended consequences. Hospital Infection 2011;78(4):256–9.
[140] Loonen AJM, Wolffs PFG, Bruggeman CA, van den Brule AJC. Developments for im-
proved diagnosis of bacterial bloodstream infections. Eur J Clin Microbiol Infect Dis
2014;33(10):1687–702.
[141] Reinhart K, Bauer M, Riedemann NC, Hartog CS. New approaches to sepsis: molec-
ular diagnostics and biomarkers. Clin Microbiol Rev 2012 Oct;25(4):609–34.
[142] Tschaikowsky K, Hedwig-Geissing M, Braun GG, Radespiel-Troeger M. Predictive
value of procalcitonin, interleukin-6, and C-reactive protein for survival in postop-
erative patients with severe sepsis. J Crit Care 2011 Feb;26(1):54–64.
[143] Ho KM, Lee KY, Dobb GJ, Webb SA. C-reactive protein concentration as a predictor
of in-hospital mortality after ICU discharge: a prospective cohort study. Intensive
Care Med 2008 Mar;34(3):481–7.
[144] Gabay C, Kushner I. Acute-phase proteins and other systemic responses to inflam-
mation. N Engl J Med 1999 Feb 11;340(6):448–54.
[145] Sexton PM, Christopoulos G, Christopoulos A, Nylen ES, Snider Jr RH, Becker KL.
Procalcitonin has bioactivity at calcitonin receptor family complexes: potential me-
diator implications in sepsis. Crit Care Med 2008 May;36(5):1637–40.
[146] Limper M, de Kruif MD, Duits AJ, Brandjes DP, van Gorp EC. The diagnostic role of
procalcitonin and other biomarkers in discriminating infectious from non-infec-
tious fever. J Inf Secur 2010 Jun;60(6):409–16.
[147] Clec'h C, Fosse JP, Karoubi P, Vincent F, Chouahi I, Hamza L, et al. Differential diag-
nostic value of procalcitonin in surgical and medical patients with septic shock. Crit
Care Med 2006 Jan;34(1):102–7.
240 H. Minasyan / Journal of Critical Care 40 (2017) 229–242
[148] de Kruif MD, Limper M, Sierhuis K, Wagenaar JF, Spek CA, Garlanda C, et al. TX3
predicts severe disease in febrile patients at the emergency department. J Inf
Secur 2010 Feb;60(2):122–7.
[149] Bottazzi B, Garlanda C, Cotena A, Moalli F, Jaillon S, Deban L, et al. The long pentra-
xin PTX3 as a prototypic humoral pattern recognition receptor: interplay with cel-
lular innate immunity. Immunol Rev 2009 Jan;227(1):9–18.
[150] Tsalik EL, Jaggers LB, Glickman SW, Langley RJ, van Velkinburgh JC, Park LP, et al.
Woods CW discriminative value of inflammatory biomarkers for suspected sepsis.
J Emerg Med 2012 Jul;43(1):97–106.
[151] Andaluz-Ojeda D, Bobillo F, Iglesias V, Almansa R, Rico L, Gandía F, et al. A combined
score of pro- and anti-inflammatory interleukins improves mortality prediction in
severe sepsis. Cytokine 2012 Mar;57(3):332–6.
[152] Calandra T, Roger T. Macrophage migration inhibitory factor: a regulator of innate
immunity. Nat Rev Immunol 2003 Oct;3(10):791–800.
[153] Bozza FA, Gomes RN, Japiassú AM, Soares M, Castro-Faria-Neto HC, Bozza PT, et al.
Macrophage migration inhibitory factor levels correlate with fatal outcome in sep-
sis. Shock 2004 Oct;22(4):309–13.
[154] Wang H, Yang H, Tracey KJ. Extracellular role of HMGB1 in inflammation and sep-
sis. J Intern Med 2004 Mar;255(3):320–31.
[155] Karlsson S, Pettilä V, Tenhunen J, Laru-Sompa R, Hynninen M, Ruokonen E. HMGB1
as a predictor of organ dysfunction and outcome in patients with severe sepsis. In-
tensive Care Med 2008 Jun;34(6):1046–53.
[156] Sakr Y, Reinhart K, Hagel S, Kientopf M, Brunkhorst F. Antithrombin levels, morbid-
ity, and mortality in a surgical intensive care unit. Anesth Analg 2007 Sep;105(3):
715–23.
[157] Dhainaut JF, Shorr AF, Macias WL, Kollef MJ, Levi M, Reinhart K, et al. Dynamic evo-
lution of coagulopathy in the first day of severe sepsis: relationship with mortality
and organ failure. Crit Care Med 2005 Feb;33(2):341–8.
[158] Cohen J. TREM-1 in sepsis. Lancet 2001 Sep 8;358(9284):776–8.
[159] Bouchon A, Facchetti F, Weigand MA, Colonna M. TREM-1 amplifies inflammation
and is a crucial mediator of septic shock. Nature 2001 Apr 26;410(6832):1103–7.
[160] Barati M, Bashar FR, Shahrami R, Zadeh MH, Taher MT, Nojomi M. Soluble trigger-
ing receptor expressed on myeloid cells 1 and the diagnosis of sepsis. J Crit Care
2010 Jun;25(2):362.e1-6.
[161] Struck J, Tao C, Morgenthaler NG, Bergmann A. Identification of an Adrenomedullin
precursor fragment in plasma of sepsis patients. Peptides 2004 Aug;25(8):
1369–72.
[162] Icardi M, Erickson Y, Kilborn S, Stewart B, Grief B, Scharnweber G. CD64 index pro-
vides simple and predictive testing for detection and monitoring of sepsis and bac-
terial infection in hospital patients. J Clin Microbiol 2009 Dec;47(12):3914–9.
[163] Gibot S, Béné MC, Noel R, Massin F, Guy J, Cravoisy A, et al. Combination biomarkers
to diagnose sepsis in the critically ill patient. Am J Respir Crit Care Med 2012 Jul 1;
186(1):65–71.
[164] Calandra T, Cohen J. International sepsis forum definition of infection in the ICU
consensus conference. The international sepsis forum consensus conference on
definitions of infection in the intensive care unit. Crit Care Med 2005 Jul;33(7):
1538–48.
[165] Socan M, Marinic-Fiser N, Kese D. Comparison of serologic tests with urinary anti-
gen detection for diagnosis of legionnaires' disease in patients with community-ac-
quired pneumonia. Clin Microbiol Infect 1999 Apr;5(4):201–4.
[166] Peters RP, van Agtmael MA, Danner SA, Savelkoul PH, Vandenbroucke-Grauls CM.
New developments in the diagnosis of bloodstream infections. Lancet Infect Dis
2004 Dec;4(12):751–60.
[167] Tissari P, Zumla A, Tarkka E, Mero S, Savolainen L, Vaara M, et al. Accurate and rapid
identification of bacterial species from positive blood cultures with a DNA-based
microarray platform: an observational study. Lancet 2010 Jan 16;375(9710):
224–30.
[168] Hartlova A, Krocova Z, Cerveny L, Stulik J. A proteomic view of the host-pathogen
interaction: the host perspective. Proteomics 2011 Aug;11(15):3212–20.
[169] Wong HR. Genetics and genomics in pediatric septic shock. Crit Care Med 2012
May;40(5):1618–26.
[170] Franks Z, Carlisle M, Rondina MT. Current challenges in understanding immune cell
functions during septic syndromes. BMC Immunol 2015;16:11.
[171] Burgess DS, Abate JB. Antimicrobial regimen selection. In: Dipiro JT, Talbert RL, Yee
GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy a pathophysiologic
approach. 6th ed. New York: McGraw-Hill; 2005. p. 1920–1.
[172] Opal SM. The evolution of the understanding of sepsis, infection, and the host re-
sponse: a brief history. Crit Care Clin 2009;25(4):637–63.
[173] Dellinger RP, Levy MM, Carlet JM, et al. Surviving sepsis campaign: international
guidelines for management of severe sepsis and septic shock: 2008. Crit Care
Med 2008;36(1):296–327.
[174] Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, et al. Surviving sepsis cam-
paign: international guidelines for management of severe sepsis and septic shock:
2012. Crit Care Med 2013;41:580–637.
[175] Soong J, Soni N. Sepsis: recognition and treatment. Clin Med 2012;12:276–80.
[176] Reade MC, Angus DC. Epidemiology of sepsis and non-infectious SIRS. In: Cavaillon
JM, editor. Sepsis and non-infection systemic inflamation, from biology to critical
care. Weinheim: Wiley-VCH Verlag GMbH and Co. KGaA; 2009. p. 13–27.
[177] Siddiqui S, Razzak J. Early versus late pre-intensive care unit admission broad spec-
trum antibiotics for severe sepsis in adults. Cochrane Database Syst Rev 2010;
10:CD007081.
[178] Brook I. The role of anaerobic bacteria in bacteremia. Anaerobe 2010;16:183–9.
[179] Textoris J, Wiramus S, Martin C, Leone M. Overview of antimicrobial therapy in in-
tensive care units. Expert Rev Anti-Infect Ther 2011;9:97–109.
[180] Garnacho-Montero J, Ortiz-Leyba C, Herrera-Melero I, Aldabó-Pallás T, Cayuela-
Dominguez A, Marquez-Vacaro JA, et al. Mortality and morbidity attributable to
inadequate empirical antimicrobial therapy in patients admitted to the ICU with
sepsis: a matched cohort study. J Antimicrob Chemother 2008 Feb;61(2):436–41.
[181] Alanis AJ. Resistance to antibiotics: are we in the post-antibiotic era? Arch Med Res
2005;36:697–705.
[182] Spellberg B, Bartlett JG, Gilbert DN. The future of antibiotics and resistance. N Engl J
Med 2013 Jan 24;368(4):299–302.
[183] Bhullar K, Waglechner N, Pawlowski A, et al. Antibiotic resistance is prevalent in an
isolated cave microbiome. PLoS One 2012;7(4):e34953.
[184] Ward PA, Bosmann M. A historical perspective on sepsis. Am J Pathol 2012;181(1):
2–7. http://dx.doi.org/10.1016/j.ajpath.2012.05.003.
[185] Marshall JC. Why have clinical trials in sepsis failed? Trends Mol Med 2014;20(4):
195–203.
[186] Phan TN, Kirsch AM, Marquis RE. Selective sensitization of bacteria to peroxide
damage associated with fluoride inhibition of catalase and pseudocatalase. Oral
Microbiol Immunol 2001 Feb;16(1):28–33.
[187] Tamanai-Shacoori Z, Jolivet-Gougeon Shacoori V, A., Vo Van JM, Repère M, Donnio
PY, et al. The antibacterial activity of tramadol against bacteria associated with in-
fectious complications after local or regional anesthesia. Anesth Analg 2007;105:
524–7.
[188] Al-kuraishy HM. Possible antibacterial possessions of tramadol hydrochloride for
urinary tract infection: in vitro study. Int Pharmaceut Sciencia 2012;2:97–102.
[189] Minai-Tehrani D, Ashrafi IS, Mohammadi MK, Damavandifar ZS, Zonouz ER,
Pirshahed TE. Comparing inhibitory effect of tramadol on catalase of Pseudomonas
aeruginosa and mouse liver. Curr Enzym Inhib 2014;10:54–8.
[190] Damo S, Chazin WJ, Skaar EP, Kehl-Fie TE. Inhibition of bacterial superoxide de-
fense. A new front in the struggle between host and pathogen. Virulence 2012
May 1;3(3):325–8. http://dx.doi.org/10.4161/viru.19635 (PMCID: PMC3442845).
[191] Kehl-Fie TE, Chitayat S, Hood MI, Damo S, Restrepo N, Garcia C, et al. Nutrient metal
sequestration by calprotectin inhibits bacterial superoxide defense, enhancing neu-
trophil killing of Staphylococcus aureus. Cell Host Microbe 2011;10(158):64. http://
dx.doi.org/10.1016/j.chom.2011.07.004.
[192] Archambaud C, Nahori MA, Pizarro-Cerda J, Cossart P, Dussurget O. Control of
Listeria superoxide dismutase by phosphorylation. J Biol Chem 2006 Oct 20;
281(42):31812–22.
[193] Boucher HW, Talbot GH, Bradley JS, Edwards JE, Gilbert D, et al. Bad bugs, no drugs:
no ESKAPE! An update from the Infectious Diseases Society of America. Clin Infect
Dis 2009;48:1–12.
[194] Hyams C, Camberlein E, Cohen JM, Bax K, Brown JS. The Streptococcus pneumoniae
capsule inhibits complement activity and neutrophil phagocytosis by multiple
mechanisms. Infect Immun 2010;78:704–15.
[195] Rasko DA, Sperandio V. Anti-virulence strategies to combat bacteria-mediated dis-
ease. Nat Rev Drug Discov 2010;9:117–28.
[196] Agarwal S, Vasudhev S, DeOliveira RB, Ram S. Inhibition of the classical pathway of
complement by meningococcal capsular polysaccharides. J Immunol 2014 Aug 15;
193(4):1855–63. http://dx.doi.org/10.4049/jimmunol.1303177 [Epub 2014 Jul 11].
[197] Campos Miguel A, Vargas MA, Regueiro V, Llompart CM, Albertí S, Bengoechea JA.
Capsule polysaccharide mediates bacterial resistance to antimicrobial peptides. In-
fect Immun 2004 December;72(12):7107–14.
[198] Dinkla K, Sastalla I, Godehardt AW, Janze N, Chhatwal GS, Rohde M, et al. Upregu-
lation of capsule enables Streptococcus pyogenes to evade immune recognition
by antigen-specific antibodies directed to the G-related alpha2-macroglobulin-
binding protein GRAB located on the bacterial surface. Microbes Infect 2007;9:
922–31.
[199] Clark SE, Eichelberger KR, Weiser JN. Evasion of killing by human antibody
andcomplement through multiple variations in the surface oligosaccharide of
Haemophilusinfluenzae. Mol Microbiol 2013;88:603–18.
[200] Soulat D, Jault JM, Duclos B, Geourjon C, Cozzone AJ, et al. Staphylococcus aureus
operates protein-tyrosine phosphorylation through a specific mechanism. J Biol
Chem 2006;281:14048–56.
[201] Bender MH, Cartee RT, Yother J. Positive correlation between tyrosine phosphory-
lation of CpsD and capsular polysaccharide production in Streptococcus
pneumoniae. J Bacteriol 2003;185:6057–66.
[202] Stewart PS, William Costerton J. Antibiotic resistance of bacteria in biofilms. Lancet
2001;3(58(9276)):135–8.
[203] Donlan RM, Costerton JW. Biofilms: survival mechanisms of clinically relevant mi-
croorganisms. Clin Microbiol Rev 2002;15(2):167–93.
[204] Rabin N, Zheng Y, Opoku-Temeng C, Du Y, Bonsu E, Sintim Herman O. Agents that
inhibit bacterial biofilm formation. Future Med Chem 2015;7(5):647–71.
[205] Hentzer M, Riedel K, Rasmussen TB. Inhibition of quorum sensing in Pseudomonas
aeruginosa biofilm bacteria by a halogenated furanone compound. Microbiology
2002;148(1):87–102.
[206] Hu J-F, Garo E, Goering MG. Bacterial biofilm inhibitors from Diospyros dendo. J Nat
Prod 2006;69(1):118–20.
[207] Garo E, Eldridge GR, Goering MG. Asiatic acid and corosolic acid enhance the sus-
ceptibility of Pseudomonas aeruginosa biofilms to tobramycin. Antimicrob Agents
Chemother 2007;51(5):1813–7.
[208] Wu H, Lee B, Yang L. Effects of ginseng on Pseudomonas aeruginosa motility and
biofilm formation. FEMS Immunol Med Microbiol 2011;62(1):49–56.
[209] Lee JH, Cho MH, Lee J. 3-indolylacetonitrile decreases Escherichia coli O157:H7 bio-
film formation and Pseudomonas Aeruginosa virulence. Environ Microbiol 2011;
13(1):62–73.
[210] Martino PD, Fursy R, Bret L, Sundararaju B, Phillips RS. Indole can act as an extracel-
lular signal to regulate biofilm formation of Escherichia coli and other indole-pro-
ducing bacteria. Can J Microbiol 2003;49(7):443–9.
[211] Lee JH, Lee J. Indole as an intercellular signal in microbial communities. FEMS
Microbiol Rev 2010;34(4):426–44.
 H. Minasyan / Journal of Critical Care 40 (2017) 229–242
[212] Bansal T, Englert D, Lee J, Hegde M, Wood TK, Jayaraman A. Differential effects of
epinephrine, norepinephrine, and indole on Escherichia coli O157:H7 chemotaxis,
colonization, and gene expression. Infect Immun 2007;75(9):4597–607.
[213] Geske GD, Wezeman RJ, Siegel AP, Blackwell HE. Small molecule inhibitors of bac-
terial quorum sensing and biofilm formation. J Am Chem Soc 2005;127(37):
12762–3.
[214] de la Fuente-Núňez C, Korolik V, Bains M. Inhibition of bacterial biofilm formation
and swarming motility by a small synthetic cationic peptide. Antimicrob Agents
Chemother 2012;56(5):2696–704.
[215] Kolodkin-Gal I, Romero D, Cao S, Clardy J, Kolter R, Losick R. D-amino acids trigger
biofilm disassembly. Science 2010;328(5978):627–9.
[216] Ma Y, Chen M, Jones JE, Ritts AC, Yu Q, Sun H. Inhibition of Staphylococcus
epidermidis biofilm by trimethylsilane plasma coating. Antimicrob Agents
Chemother 2012;56(11):5923–37.
[217] Busetti A, Crawford DE, Earle MJ. Antimicrobial and antibiofilm activities of 1-
alkylquinolinium bromide ionic liquids. Green Chem 2010;12(3):420–5.
[218] Barraud N, Hassett DJ, Hwang SH, Rice SA, Kjelleberg S, Webb JS. Involvement of ni-
tric oxide in biofilm dispersal of Pseudomonas aeruginosa. J Bacteriol 2006;
188(21):7344–53.
[219] Garrison AT, Bai F, Abouelhassan Y, Paciaroni NG, Jin S, Huigens III RW.
Bromophenazine derivatives with potent inhibition, dispersion and eradication ac-
tivities against Staphylococcus aureus biofilms. RSC Adv 2015;5:1120–4.
[220] Jennings MC, Ator LE, Paniak TJ, Minbiole KP, Wuest WM. Biofilm-eradicating prop-
erties of quaternary ammonium amphiphiles: simple mimics of antimicrobial pep-
tides. Chembiochem 2014;5(15):2211–5.
[221] Marks DH, Medina F, Lee S, Blackmon A, Schuschereba ST. Removal of bacteria from
blood by charcoal hemoperfusion. Biomater Artif Cells Artif Organs 1988;16(1-3):
135–40.
[222] Siedel D, Boos K. Device for removing bacterial toxins from blood or plasma, useful
for treating sepsis, also for analysis and diagnosis, includes hollow fiber material for
selective binding of the toxins. Patent DE10258944 (Germany); July 1, 2004.
[223] Lee JJ, Jeong KJ, Hashimoto M, Kwon AH, Rwei A, Shankarappa SA, et al. Synthetic
ligand-coated magnetic nanoparticles for microfluidic bacterial separation from
blood. Nano Lett 2014 Jan 8;14(1):1–5. http://dx.doi.org/10.1021/nl3047305
[Epub 2013 Jan 31].
[224] Kang JH, Super MI, Yung CW, Cooper RM, Domansky K, Graveline AR. An extracor-
poreal blood-cleansing device for sepsis therapy. Nat Med 2014;20:1211–6. http://
dx.doi.org/10.1038/nm.3640.
[225] Marshall JC. Sepsis: rethinking the approach to clinical research. J Leukoc Biol 2008;
83:471–82.
[226] Sandeman SR, Howell CA, Mikhalovsky SV, Phillips GJ, Lloyd AW, Davies JG, et al.
Inflammatory cytokine removal by an activated carbon device in a flowing system.
Biomaterials 2008;29:1638–44.
[227] DiLeo MV, Fisher JD, Burton BM, Federspiel WJ. Selective improvement of
tumor necrosis factor capture in a cytokine hemoadsorption device using
immobilized anti-tumor necrosis factor. J Biomed Mater Res B Appl Biomater
2011;96:127–33.
[228] Schmidt J, Mann S, Mohr VD, Lampert R, Firla U, Zirngibl H. Plasmapheresis com-
bined with continuous venovenous hemofiltration in surgical patients with sepsis.
Intensive Care Med 2000;26:532. http://dx.doi.org/10.1007/s001340051200.
[229] Opal SM. The evolution of the understanding of sepsis, infection, and the host re-
sponse: a brief history. Crit Care Nurs Clin North Am 2011 Mar;23(1):1–27.
http://dx.doi.org/10.1016/j.ccell.2010.12.001.
[230] Schentag JJ, Gengo FM. Principles of antibiotic tissue penetration and guidelines for
pharmacokinetic analysis. Med Clin North Am 1982;66(1):39–49.
[231] Kornguth ML, Kunin CM. Uptake of antibiotics by human erythrocytes. J Infect Dis
1976;133(2):175–84. http://dx.doi.org/10.1093/infdis/133.2.175.
[232] Ferré F, Silva S, Ruiz J, Mari A, Mathe O, Sanchez-Verlaan P, et al. Microcirculatory
effect of hyperbaric oxygen therapy in septic patients. Crit Care 2011;15(Suppl.
1):284.
[233] Buras JA, Holt D, Orlow D, Belikoff B, Pavlides S, Reenstra WR. Hyperbaric oxygen
protects from sepsis mortality via an interleukin-10-dependent mechanism. Crit
Care Med 2006 Oct;34(10):2624–9.
[234] Oter S, Edremitlioglu M, Korkmaz A, et al. Effects of hyperbaric oxygen treatment
on liver functions, oxidative status and histology in septic rats. Intensive Care
Med 2005;31:1262–8.
[235] Imperatore F, Cuzzocrea S, Luongo C, et al. Hyperbaric oxygen therapy prevents
vascular derangement during zymosan-induced multiple-organ-failure syndrome.
Intensive Care Med 2004;30:1175–81.
[236] Bocci V. Ozone as Janus: this controversial gas can be either toxic or medically use-
ful. Mediat Inflamm 2004;13:3–11.
[237] Madej P, Plewka A, Madej JA, et al. Ozonotherapy in an induced septic shock. I. Ef-
fect of ozonotherapy on rat organs in evaluation of free radical reactions and select-
ed enzymatic systems. Inflammation 2007;30:52–8.
[238] Annane D. Replacement therapy with hydrocortisone in catecholamine-dependent
septic shock. J Endotoxin Res 2001;7(4):305–9.
[239] Annane D. Glucocorticoids in the treatment of severe sepsis and septic shock.
Annane D Curr Opin Crit Care 2005 Oct;11(5):449–53.
[240] de Kruif MD, Lemaire LC, Giebelen IA, et al. Prednisolone dose-dependently influ-
ences inflammation and coagulation during human endotoxemia. J Immunol
2007;178(3):1845–51.
[241] Huh JW, Lim CM, Koh Y, Hong SB. Effect of low doses of hydrocortisone in patients
with septic shock and relative adrenal insufficiency: 3 days versus 7 days treatment
[abstract]. Crit Care Med 2006;34:A101.
[242] Kellum JA, Kong L, Fink MP, et al. GenIMS Investigators. Understanding the inflam-
matory cytokine response in pneumonia and sepsis: results of the genetic and
241
inflammatory markers of sepsis (GenIMS) study. Arch Intern Med 2007;167(15):
1655–63.
[243] Russell JA. Vasopressin in vasodilatory and septic shock. Curr Opin Crit Care 2007;
13:383–91.
[244] Vanhorebeek I, Langouche L, Van den Berghe G. Tight blood glucose control with
insulin in the ICU: facts and controversies. Chest 2007;132:268–78.
[245] Russell JA, Walley KR, Singer J, et al. Vasopressin versus norepinephrine infusion in
patients with septic shock. New Engl J Med 2008;358:877–87.
[246] Angelousi A, Karageoropoulos D, Kapaskelis A, Falagas M. Association between thy-
roid function tests at baseline and the outcome of patients with sepsis or septic
shock: a systematic review. Eur J Endocrinol 2011;164:147–55.
[247] Takala J, Ruokenen E, Webster N, Nielsen M, Zandstra D, Vundelinckx G, et al. In-
creased mortality associated with growth hormone treatment in critically ill adults.
N Engl J Med 1999;341:785–92.
[248] Yi C, Cao Y, Mao SH, Liu H, Ji LL, Xu SY, et al. Recombinant human growth hormone
improves survival and protects against acute lung injury in murine Staphylococcus
aureus sepsis. Inflamm Res 2009;58(12):855–62.
[249] Rettew JA, Huet YM, Marriott I. Estrogens augment cell surface TLR4 expression on
murine macrophages and regulate sepsis susceptibility in vivo. Endocrinology
2009;150(8):3877–84.
[250] Kanda N, Tsuchida T, Tamaki K. Testosterone inhibits immunoglobulin production
by human peripheral blood mononuclear cells. Clin Exp Immunol 1996;106(2):
410–5.
[251] Zimmerman JL. Use of blood products in sepsis: an evidence-based review. Crit
Care Med 2004;32:S542–7.
[252] Fernandes Jr CJ, Akamine N, De Marco FV, De Souza JA, Lagudis S, et al. RBC trans-
fusion does not increase oxygen consumption in critically ill septic patients. Crit
Care 2001;5:362–7.
[253] Mazza BF, Machado FR, Mazza DD, Hassmann V. Evaluation of blood transfusion ef-
fects on mixed venous oxygen saturation and lactate levels in patients with SIRS/
sepsis. Clinics (Sao Paulo) 2005;60:311–6.
[254] Sadaka F. Red blood cell transfusion in sepsis: a review. J Blood Disord Transfus
2012;S4:001.
[255] Carson JL, Carless PA, Hebert PC. Transfusion thresholds and other strategies for
guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev 2012;
4:CD002042.
[256] Holzheimer RG. Induced endotoxin release and clinical sepsis: a review. J
Chemother 2001 Nov;13;1(1):159–72.
[257] Grandel U, Grimminger F. Endothelial responses to bacterial toxins in sepsis. Crit
Rev Immunol 2003;23(4):267–99.
[258] LaRocca TJ, Stivison EA, Hod EA, Spitalnik SL, Cowan PJ, Randis TM, et al. Human-
specific bacterial pore-forming toxins induce programmed necrosis in erythro-
cytes. MBio 2014 Aug 26;5(5) (e01251-1214).
[259] Skals M, Bjaelde RG, Reinholdt J, Poulsen K, Vad BS, Otzen DE, et al. Bacterial RTX
toxins allow acute ATP release from human erythrocytes directly through the
toxin pore. J Biol Chem 2014;289:19098–109.
[260] Adamzik M, Hamburger T, Petrat F, Peters J, de Groot H, Hartmann M. Free hemo-
globin concentration in severe sepsis: methods of measurement and prediction of
outcome. Crit Care 2012;16:R125.
[261] Beebe JM. Studies on the myxobacteria. 2. The role of myxobacteria as bacterial
parasites. Iowa State Coll J Sci 1941;15:319–37.
[262] Wei H. Bacteriophages, revitalized after 100 years in the shadow of antibiotics.
Virol Sin 2015 Feb;30(1):1–2.
[263] Klein GO. Bacteriophage therapy can be the rescue when antibiotics no longer
work. Lakartidningen 2009 Sep 30–Oct 6;106(40):2530–3.
[264] Hanlon GW. Bacteriophages: an appraisal of their role in the treatment of bacterial
infections. Int J Antimicrob Agents 2007;30:118–28.
[265] Adhya S, Merril C. The road to phage therapy. Nature 2006;443:754–5.
[266] Gaidelytė A, Vaara M, Bamford DH. Bacteria, phages and septicemia. PLoS One
2007;2(11):e1145.
[267] Kadouri DE, K. To, Shanks RM, Doi Y. Predatory bacteria: a potential ally against
multidrug-resistant gram-negative pathogens. PLoS One 2013;8:e63397.
[268] Harini K, Ajila V, Hegde S. Bdellovibrio bacteriovorus: A future antimicrobial agent? J
Ind Soc Periodontol 2013;17(6):823–5. http://dx.doi.org/10.4103/0972-124X.124534.
[269] Dwidar M, Monnappa AK, Mitchell RJ. The dual probiotic and antibiotic nature of
Bdellovibrio bacteriovorus. BMB Rep 2012 Feb;45(2):71–8.
[270] Monnappa AK, Dwidar M, Seo JK, Hur JH, Mitchell RJ. Bdellovibrio bacteriovorus in-
hibits Staphylococcus aureus biofilm formation and invasion into human epithelial
cells. Sci Rep 2014 Jan 22;4:3811. http://dx.doi.org/10.1038/srep03811.
[271] Iebba V, Totino V, Santangelo F, Gagliardi A, Ciotoli L, Virga A, et al. Bdellovibrio
bacteriovorus directly attacks Pseudomonas aeruginosa and Staphylococcus aureus
cystic fibrosis isolates. Front Microbiol 2014;5:280 [Epub 2014 Jun 5].
[272] Stolp H, Starr MP. Bdellovibrio bacteriovorus gen.etsp.n., a predatory, ectoparasitic,
and bacteriolytic microorganism. Antonie Van Leeuwenhoek 1963;29:217–48
[PubMed].
[273] Kadouri D, O'Toole GA. Susceptibility of biofilms to Bdellovibrio bacteriovorus attack.
Appl Environ Microbiol 2005;71:4044–51.
[274] Sockett RE. Predatory lifestyle of Bdellovibrio bacteriovorus. Annu Rev Microbiol
2009;63:523–39.
[275] Wolfe AJ. Sighting the alien within: a new look at Bdellovibrio. J Bacteriol December
2010;192(24):6327–8.
[276] Dwidar M, Monnappa AK, Mitchell RJ. The dual probiotic and antibiotic nature of
Bdellovibrio bacteriovorus. BMB Rep 2012;45:71–8.
[277] McFarland LV, Surawicz CM, Greenberg RN, et al. A randomized placebo-controlled
trial of Saccharomyces boulardi in combination with standard antibiotic for Clos-
tridium difficile disease. JAMA-J Am Med Assoc 1994;271:1913–8.
242 H. Minasyan / Journal of Critical Care 40 (2017) 229–242
[278] Bleichner G, Blehaut H, Mentec H, Moyse D. Saccharomyces boulardii prevents di-
arrhea in critically ill tube-fed patients. A multicenter, randomized, double-blind
placebo-controlled trial. Intensive Care Med 1997;23:517–23.
[279] Mumy KL, Chen X, Kelly CP, McCormick BA. Saccharomyces boulardii interferes
with Shigella pathogenesis by post-invasion signaling events. Am J Physiol
Gastrointest Liver Physiol 2008;294:G599–609.
[280] Zbinden R, Bonczi E, Altwegg M. Inhibition of Saccharomyces boulardii on cell inva-
sion of Salmonella typhimurium and Yersinia enterocolitica. Microb Ecol Health Dis
1999;11:158–62.
[281] Altwegg M, Schnack J, Zbinden R. Influence of Saccharomyces boulardii on
Aeromonas hemolysin. Med Microbiol Lett 1995;4:417–25.
[282] Buts JP, Dekeyser N, StilmanT C, Delem E, Smets F, Sokal E. Saccharomyces boulardii
produces in rat small intestine a novel protein phosphatase that inhibits Escherichia
coli endotoxin by dephosphorylation. Pediatr Res 2006;60:24–9.
[283] Czerucka D, Dahan S, Mograbi B, Rossi B, Rampal P. Saccharomyces
boulardiipreserve the barrier function andmodulates the signal transduction path-
way induced inenteropathogenic Escherichia coli-infected T84 cells. InfectImmun
2000;68:5998–6004.
[284] Buts J, de Keyser N. Effect of Saccharomyces boulardii on intestinal mucosa. Dig Dis
Sci 2006;51:1485–92.
[285] Swidsinski A, Loening-Baucke V, Verstraelen H, Osowska S, Doerffel Y. Biostructure
of fecal microbiota in healthy subjects and patients with chronic idiopathic diar-
rhea. Gastroenterology 2008;135:568–79.
[286] Jawhara S, Poulain D. Saccharomyces boulardiidecreasesinflammation and intesti-
nal colonization by Candida albicansin a mouse model of chemically-induced colitis.
Med Mycol 2007;45:691–700.
[287] Levi M, Shultz M, van der Poll T. Sepsis and thrombosis. Semin Thromb Hemost
2013 Jul;39(5):559–66.
[288] House SD, Johnson PC. Diameter and blood flow of skeletal muscle venules during
local flow regulation. Am J Phys 1986 May;250(5 Pt 2):H828–37.
[289] Skinner EH. Early physical rehabilitation may improve physical quality of life do-
mains in patients admitted to ICU with sepsis syndromes [synopsis]. J Physyother
2015 Jul;61(3):158.
[290] Paratz JD, Kajambu G. Early exercise and attenuation of myopathy in the patient
with sepsis in ICU. Phys Ther Rev 2011 Feb;16(1):58–65.
[291] Sossdorf M, Otto GP, Menge K, Claus RA, Lösche W, Kabisch B, et al. Potential effect
of physiotherapeutic treatment on mortality rate in patients with severe sepsis and
septic shock: a retrospective cohort analysis. J Crit Care 2013 Dec;28(6):954–8.
[292] Mendes EW, Procinov RS. Massage therapy reduces hospital stay and occurrence of
late-onset sepsis in very preterm neonates. J Perinatol 2008 Dec;28(12):815–20.