Abstract
Purpose
The effects of stress-dose corticosteroid therapy were studied in a canine staphylococcal pneumonia model of septic shock.
Methods
Immediately following intrabronchial bacterial challenge, purpose-bred beagles were treated with stress doses of desoxycorticosterone (DOC), a mineralocorticoid agonist, and dexamethasone (DEX), a glucocorticoid agonist, or with placebo for 96 h. Oxacillin (30 mg/kg every 8 h) was started 4 h after infection onset. Bacterial dose was titrated to achieve 80–90 % lethality (n = 20) using an adaptive design; additional animals (n = 18) were investigated using the highest bacterial dose.
Results
Initial analysis of all animals (n = 38) demonstrated that the effects of DOC + DEX were significantly altered by bacterial dose (p = 0.04). The treatment effects of DOC + DEX were different in animals administered high or relatively lower bacterial doses in terms of survival (p = 0.05), shock reversal (p = 0.02), interleukin-6 levels (p = 0.02), and temperature (p = 0.01). DOC + DEX significantly improved the above parameters (p ≤ 0.03 for all) and lung injury scores (p = 0.02) after high-dose bacterial challenges, but not after lower challenges (p = not significant for all). Oxacillin trough levels were below the minimum inhibitory concentration of the infecting organism, and DOC + DEX increased the frequency of persistent staphylococcal bacteremia (odds ratio 3.09; 95 % confidence interval 1.05–9.11; p = 0.04).
Conclusions
Stress-dose corticosteroids were only beneficial in cases of sepsis with high risk for death and even short courses may interfere with host mechanisms of bacterial clearance.
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References
Annane D, Bellissant E, Bollaert PE, Briegel J, Keh D, Kupfer Y (2004) Corticosteroids for severe sepsis and septic shock: a systematic review and meta-analysis. Br Med J 329:480
Sprung CL, Annane D, Keh D, Moreno R, Singer M, Freivogel K, Weiss YG, Benbenishty J, Kalenka A, Forst H, Laterre PF, Reinhart K, Cuthbertson BH, Payen D, Briegel J, CORTICUS Study Group (2008) Hydrocortisone therapy for patients with septic shock. N Engl J Med 358:111–124
Minneci PC, Deans KJ, Eichacker PQ, Natanson C (2009) The effects of steroids during sepsis depend on dose and severity of illness: an updated meta-analysis. Clin Microbiol Infect 15:308–318
Kalil AC, Sun J (2008) Why are clinicians not embracing the results from pivotal clinical trials in severe sepsis? A bayesian analysis. PLoS ONE 3:e2291
Eichacker PQ, Parent C, Kalil A, Esposito C, Cui X, Banks SM, Gerstenberger EP, Fitz Y, Danner RL, Natanson C (2002) Risk and the efficacy of antiinflammatory agents: retrospective and confirmatory studies of sepsis. Am J Respir Crit Care Med 166:1197–1205
Skornik WA, Dressler DP (1974) The effects of short-term steroid therapy on lung bacterial clearance and survival in rats. Ann Surg 179:415–421
Heller AR, Heller SC, Borkenstein A, Stehr SN, Koch T (2003) Modulation of host defense by hydrocortisone in stress doses during endotoxemia. Intensive Care Med 29:1456–1463
Cronin L, Cook DJ, Carlet J, Heyland DK, King D, Lansang MA, Fisher CJ Jr (1995) Corticosteroid treatment for sepsis: a critical appraisal and meta-analysis of the literature. Crit Care Med 23:1430–1439
Minneci PC, Deans KJ, Banks SM, Eichacker PQ, Natanson C (2004) Meta-analysis: the effect of steroids on survival and shock during sepsis depends on the dose. Ann Intern Med 141:47–56
Hicks CW, Sweeney DA, Danner RL, Eichacker PQ, Suffredini AF, Feng J, Sun J, Behrend EN, Solomon SB, Natanson C (2012) Efficacy of selective mineralocorticoid and glucocorticoid agonists in canine septic shock. Crit Care Med 40(1):199–207
Minneci PC, Deans KJ, Hansen B, Parent C, Romines C, Gonzales DA, Ying SX, Munson P, Suffredini AF, Feng J, Solomon MA, Banks SM, Kern SJ, Danner RL, Eichacker PQ, Natanson C, Solomon SB (2007) A canine model of septic shock: balancing animal welfare and scientific relevance. Am J Physiol Heart Circ Physiol 293:H2487–H2500
Becker KL (2001) Principles and practice of endocrinology and metabolism. Lippincott Williams & Wilkins, Philadelphia, pp 2108–2121
Plumb DC (2005) Plumb’s veterinary drug handbook, 5th edn. PhrmaVet, Stockholm, Iowa, pp 578–80
Knaus WA, Harrell FE Jr, LaBrecque JF, Wagner DP, Pribble JP, Draper EA, Fisher CJ Jr, Soll L (1996) Use of predicted risk of mortality to evaluate the efficacy of anticytokine therapy in sepsis. The rhIL-1ra Phase III Sepsis Syndrome Study Group. Crit Care Med 24:46–56
Keh D, Boehnke T, Weber-Cartens S, Schulz C, Ahlers O, Bercker S, Volk HD, Doecke WD, Falke KJ, Gerlach H (2003) Immunologic and hemodynamic effects of “low-dose” hydrocortisone in septic shock: a double-blind, randomized, placebo-controlled, crossover study. Am J Respir Crit Care Med 167:512–520
Oppert M, Schindler R, Husung C, Offermann K, Graf KJ, Boenisch O, Barckow D, Frei U, Eckardt KU (2005) Low-dose hydrocortisone improves shock reversal and reduces cytokine levels in early hyperdynamic septic shock. Crit Care Med 33:2457–2464
Briegel J, Jochum M, Gippner-Steppert C, Thiel M (2001) Immunomodulation in septic shock: hydrocortisone differentially regulates cytokine responses. J Am Soc Nephrol 12[Suppl 17]:S70–S74
Pinsky MR, Vincent JL, Deviere J, Alegre M, Kahn RJ, Dupont E (1993) Serum cytokine levels in human septic shock. Relation to multiple-system organ failure and mortality. Chest 103:565–575
Novotny AR, Reim D, Assfalg V, Altmayr F, Friess HM, Emmanuel K, Holzmann B (2011) Mixed antagonist response and sepsis severity-dependent dysbalance of pro- and anti-inflammatory responses at the onset of postoperative sepsis. Immunobiology 31(1):201–213
Osuchowski MF, Connett J, Welch K, Granger J, Remick DG (2009) Stratification is the key: inflammatory biomarkers accurately direct immunomodulatory therapy in experimental sepsis. Crit Care Med 37:1567–1573
van der Goes A, Hoekstra K, van den Berg TK, Dijkstra CD (2000) Dexamethasone promotes phagocytosis and bacterial killing by human monocytes/macrophages in vitro. J Leukoc Biol 67:801–807
Meduri GU, Kanangat S, Bronze M, Patterson DR, Meduri CU, Pak C, Tolley EA, Schaberg DR (2001) Effects of methylprednisolone on intracellular bacterial growth. Clin Diagn Lab Immunol 8:1156–1163
Kaufmann I, Briegel J, Schliephake F, Hoelzl A, Chouker A, Hummel T, Schelling G, Thiel M (2008) Stress doses of hydrocortisone in septic shock: beneficial effects on opsonization-dependent neutrophil functions. Intensive Care Med 34:344–349
Shurin MR, Kusnecov A, Hamill E, Kaplan S, Rabin BS (1994) Stress-induced alteration of polymorphonuclear leukocyte function in rats. Brain Behav Immun 8:163–169
Rojas IG, Padgett DA, Sheridan JF, Marucha PT (2002) Stress-induced susceptibility to bacterial infection during cutaneous wound healing. Brain Behav Immun 16:74–84
Cetinkaya RA, Gorenek L, Coskun O, Eyigun CP, Senses Z, Ide T, Kilic S (2009) The effect of methylprednisolone on treatment in rats with induced sepsis. Clin Exp Med 9:45–50
Sibila O, Luna CM, Agusti C, Baquero S, Gando S, Patron JR, Morato JG, Absi R, Bassi N, Torres A (2008) Effects of glucocorticoids in ventilated piglets with severe pneumonia. Eur Respir J 32:1037–1046
Tagliabue C, Salvatore CM, Techasaensiri C, Mejias A, Torres JP, Katz K, Gomez AM, Esposito S, Principi N, Hardy RD (2008) The impact of steroids given with macrolide therapy on experimental Mycoplasma pneumoniae respiratory infection. J Infect Dis 198:1180–1188
Flynn PM, Shenep JL, Stokes DC, Hildner WK, Mackert PW, Snellgrove RL, Rehg JE (1986) Effect of methylprednisolone on bacterial clearance and endotoxin liberation during experimental sepsis induced by gram-negative bacteria. Infect Immun 52:26–30
Fadel MV, Repka JC, Cunha CL, Leao MT (2008) Inadequate timing between corticosteroid and antibiotics applications increases mortality due to sepsis. Braz J Infect Dis 12:416–422
Assfalg V, Huser N, Reim D, Kaiser-Moore S, Rossmann-Bloeck T, Weighardt H, Novotny AR, Stangl MJ, Holzmann B, Emmanuel KL (2010) Combined immunosuppressive and antibiotic therapy improves bacterial clearance and survival of polymicrobial septic peritonitis. Shock 33:155–161
Bollaert PE, Charpentier C, Levy B, Debouverie M, Audibert G, Larcan A (1998) Reversal of late septic shock with supraphysiologic doses of hydrocortisone. Crit Care Med 26:645–650
Briegel J, Forst H, Haller M, Schelling G, Kilger E, Kuprat G, Hemmer B, Hummel T, Lenhart A, Heyduck M, Stoll C, Peter K (1999) Stress doses of hydrocortisone reverse hyperdynamic septic shock: a prospective, randomized, double-blind, single-center study. Crit Care Med 27:723–732
Chawla K, Kupfer Y, Goldman I (1999) Hydrocortisone reverses refractory septic shock. Crit Care Med 27:A33
Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaud P, Bellissant E (2002) Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288:862–871
Mussack T, Briegel J, Schelling G, Biberthaler P, Jochum M (2005) Effect of stress doses of hydrocortisone on S-100B vs. interleukin-8 and polymorphonuclear elastase levels in human septic shock. Clin Chem Lab Med 43:259–268
Tandan SM, Guleria R, Gupta N (2005) Low dose steroids and adrenocortical insufficiency in septic shock: a double-blind randomized controlled trial from India. Am J Respir Crit Care Med 171:A43
Li Y, Cui X, Li X, Solomon SB, Danner RL, Banks SM, Fitz Y, Annane D, Natanson C, Eichacker PQ (2008) Risk of death does not alter the efficacy of hydrocortisone therapy in a mouse E. coli pneumonia model: risk and corticosteroids in sepsis. Intensive Care Med 34:568–577
COIITSS Study Investigators, Annane D, Cariou A, Maxime V, Azoulay E, D’honneur G, Timsit JF, Cohen Y, Wolf M, Fartoukh M, Adrie C, Santre C, Bollaert PE, Mathonet A, Amathieu R, Tabah A, Clec’h C, Mayaud J, Lejeune J, Chevret S (2010) Corticosteroid treatment and intensive insulin therapy for septic shock in adults: a randomized controlled trial. JAMA 303:341–348
Scott WA, Pongiglione G, Bromberg BI, Schaffer MS, Deal BJ, Fish FA, Dick M (1995) Randomized comparison of atenolol and fludrocortisone acetate in the treatment of pediatric neurally mediated syncope. Am J Cardiol 76:400–402
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The study was supported by NIH intramural funds, but the opinions expressed herein do not necessarily represent the opinions of the US Government.
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Hicks, C.W., Sweeney, D.A., Danner, R.L. et al. Beneficial effects of stress-dose corticosteroid therapy in canines depend on the severity of staphylococcal pneumonia. Intensive Care Med 38, 2063–2071 (2012). https://doi.org/10.1007/s00134-012-2735-5
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DOI: https://doi.org/10.1007/s00134-012-2735-5