Efficacy of locally delivered polyclonal immunoglobulin against Pseudomonas aeruginosa infection in a murine burn wound model

Polyvalent human immunoglobulin for infectious diseases: Potential to circumvent antimicrobial resistance

Antimicrobial resistance (AMR) is a global health problem that causes more than 1.27 million deaths annually; therefore, it is urgent to focus efforts on solving or reducing this problem. The major causes of AMR are the misuse of antibiotics and antimicrobials in agriculture, veterinary medicine, and human medicine, which favors the selection of drug-resistant microbes. One of the strategies proposed to overcome the problem of AMR is to use polyvalent human immunoglobulin or IVIG. The main advantage of this classic form of passive immunization is its capacity to enhance natural immunity mechanisms to eliminate bacteria, viruses, or fungi safely and physiologically. Experimental data suggest that, for some infections, local administration of IVIG may produce better results with a lower dose than intravenous application. This review presents evidence supporting the use of polyvalent human immunoglobulin in AMR, and the potential and challenges associated with its proposed usage.

Immunoglobulin G in Platelet-Derived Wound Healing Factors

We intended to reformulate an existing platelet-derived wound healing formula to target each phase of the healing wound with the appropriate phase-specific molecules. A decreased perfusion of the skin, often associated with conditions such as thalassemia, sickle cell disease, diabetes mellitus, and chronic vascular disease, is the most common etiology of cutaneous ulcers and chronic wounds. We had previously shown that a PDWHF topically applied to a chronic nonhealing ulcer of a β-thalassemia homozygote stimulated and accelerated closure of the wound. The PDWHF was prepared from a pooled platelet concentrate of a matching blood group, consisting of a combination of platelet α-granule-derived factors. Processing of the apheresis-pooled platelets yielded various amounts of proteins (3.36 g/mL ± 0.25 (SD) (N = 10)) by the better lysis buffer method. Immunoglobulin G was found to be the most abundant α-granule-secreted protein. Equally broad quantities of the IgG (10.76 ± 12.66% (SD) (N = 10)) and IgG/albumin ratios (0.6 ± 0.4 (SD) (N = 10)) were quantified. We have developed a method using a reformulated lysis buffer followed by size exclusion chromatography and affinity chromatography to extract, identify, quantify, and purify IgG from activated platelets. IgG purification was confirmed by Western blot and flow cytometry. It was thought unlikely that the platelet IgG could be accounted for by adsorption of plasma protein, though the variable quantities could account for diversity in wound healing rates. The IgG could protect the wound even from subclinical infections and functionally advance healing. It may be useful in the management of skin ulcers in the early phase of wound healing.

Lysocins: Bioengineered Antimicrobials That Deliver Lysins across the Outer Membrane of Gram-Negative Bacteria

The prevalence of multidrug-resistant Pseudomonas aeruginosa has stimulated development of alternative therapeutics. Bacteriophage peptidoglycan hydrolases, termed lysins, represent an emerging antimicrobial option for targeting Gram-positive bacteria. However, lysins against Gram-negatives are generally deterred by the outer membrane and their inability to work in serum. One solution involves exploiting evolved delivery systems used by colicin-like bacteriocins (e.g., S-type pyocins of P. aeruginosa) to translocate through the outer membrane. Following surface receptor binding, colicin-like bacteriocins form Tol- or TonB-dependent translocons to actively import bactericidal domains through outer membrane protein channels. With this understanding, we developed lysocins, which are bioengineered lysin-bacteriocin fusion molecules capable of periplasmic import. In our proof-of-concept studies, components from the P. aeruginosa bacteriocin pyocin S2 (PyS2) responsible for surface receptor binding and outer membrane translocation were fused to the GN4 lysin to generate the PyS2-GN4 lysocin. PyS2-GN4 delivered the GN4 lysin to the periplasm to induce peptidoglycan cleavage and log-fold killing of P. aeruginosa with minimal endotoxin release. While displaying narrow-spectrum antipseudomonal activity in human serum, PyS2-GN4 also efficiently disrupted biofilms, outperformed standard-of-care antibiotics, exhibited no cytotoxicity toward eukaryotic cells, and protected mice from P. aeruginosa challenge in a bacteremia model. In addition to targeting P. aeruginosa, lysocins can be constructed to target other prominent Gram-negative bacterial pathogens.

Combined bacteriophages and antibiotics as an efficient therapy against VRE Enterococcus faecalis in a mouse model

Clinical applications of bacteriophage therapy have been recently gathering significant attention worldwide, used mostly as rescue therapy in cases of near-fatal antibiotic failure. Thus, clinically relevant in-vivo models presenting both short- and long-term implications of phage therapy given as rescue treatment for fulminant infections are of highest importance. In this study, a cocktail consisting of two lytic bacteriophages was used to evaluate the therapeutic efficacy of phage therapy as a rescue treatment for severe septic peritonitis in a mouse model. We established that a single injection of the bacteriophage cocktail was sufficient to completely reverse a 100% mortality trend caused by Vancomycin-Resistant Enterococcus faecalis, with significant improvement in both the clinical state and laboratory test results, and without harmful effects on the microbiome. The combination of bacteriophages with a suboptimal antibiotic regimen imparts an additional beneficial effect on the treatment success.

Drug delivery and tissue engineering to promote wound healing in the immunocompromised host: Current challenges and future directions

As regenerative medicine matures as a field, more promising technologies are being translated from the benchtop to the clinic. However, many of these strategies are designed with otherwise healthy hosts in mind and validated in animal models without other co-morbidities. In reality, many of the patient populations benefiting from drug delivery and tissue engineering-based devices to enhance wound healing also have significant underlying immunodeficiency. Specifically, patients suffering from diabetes, malignancy, human immunodeficiency virus, post-organ transplantation, and other compromised states have significant pleotropic immune defects that affect wound healing. In this work, we review the role of different immune cells in the regenerative process, highlight the effect of several common immunocompromised states on wound healing, and discuss different drug delivery strategies for overcoming immunodeficiencies.

Enhanced efficacy and anti-biofilm activity of novel nanoemulsions against skin burn wound multi-drug resistant MRSA infections

Multi-drug resistant MRSA (methicillin-resistant Staphylococcus aureus) is a global problem for human health, especially skin burn wound patients. Therefore, we estimated the antibacterial and anti-biofilm activity of a chlorhexidine acetate nanoemulsion (CNE) by previously ourselves designed against skin burn wound MRSA infections. Compared with its water solution (CHX), CNE showed a better and faster action against MRSA both in vitro and in vivo. Importantly, CNE was more effective at inhibiting biofilm formation and clearing the biofilm. We also found that the cell walls and membranes of MRSA were severely disrupted after treatment with CNE. Moreover, the relative electrical conductivity and the leakage of alkaline phosphates, K(+), Mg(2+), DNA and protein obviously increased because the cell wall and membrane were damaged. These data show that novel CNE is a promising potential antimicrobial candidate, especially for skin burn wound MRSA infections.

Targeted localized use of therapeutic antibodies: a review of non-systemic, topical and oral applications

Therapeutic antibodies provide important tools in the "medicine chest" of today's clinician for the treatment of a range of disorders. Typically monoclonal or polyclonal antibodies are administered in large doses, either directly or indirectly into the circulation, via a systemic route which is well suited for disseminated ailments. Diseases confined within a specific localized tissue, however, may be treated more effectively and at reduced cost by a delivery system which targets directly the affected area. To explore the advantages of the local administration of antibodies, we reviewed current alternative, non-systemic delivery approaches which are in clinical use, being trialed or developed. These less conventional approaches comprise: (a) local injections, (b) topical and (c) peroral administration routes. Local delivery includes intra-ocular injections into the vitreal humor (i.e. Ranibizumab for age-related macular degeneration), subconjunctival injections (e.g. Bevacizumab for corneal neovascularization), intra-articular joint injections (i.e. anti-TNF alpha antibody for persistent inflammatory monoarthritis) and intratumoral or peritumoral injections (e.g. Ipilimumab for cancer). A range of other strategies, such as the local use of antibacterial antibodies, are also presented. Local injections of antibodies utilize doses which range from 1/10th to 1/100th of the required systemic dose therefore reducing both side-effects and treatment costs. In addition, any therapeutic antibody escaping from the local site of disease into the systemic circulation is immediately diluted within the large blood volume, further lowering the potential for unwanted effects. Needle-free topical application routes become an option when the condition is restricted locally to an external surface. The topical route may potentially be utilized in the form of eye drops for infections or corneal neovascularization or be applied to diseased skin for psoriasis, dermatitis, pyoderma gangrenosum, antibiotic resistant bacterial infections or ulcerated wounds. Diseases confined to the gastrointestinal tract can be targeted directly by applying antibody via the injection-free peroral route. The gastrointestinal tract is unusual in that its natural immuno-tolerant nature ensures the long-term safety of repeatedly ingesting heterologous antiserum or antibody materials. Without the stringent regulatory, purity and clean room requirements of manufacturing parenteral (injectable) antibodies, production costs are minimal, with the potential for more direct low-cost targeting of gastrointestinal diseases, especially with those caused by problematic antibiotic resistant or toxigenic bacteria (e.g. Clostridium difficile, Helicobacter pylori), viruses (e.g. rotavirus, norovirus) or inflammatory bowel disease (e.g. ulcerative colitis, Crohn's disease). Use of the oral route has previously been hindered by excessive antibody digestion within the gastrointestinal tract; however, this limitation may be overcome by intelligently applying one or more strategies (i.e. decoy proteins, masking therapeutic antibody cleavage sites, pH modulation, enzyme inhibition or encapsulation). These aspects are additionally discussed in this review and novel insights also provided. With the development of new applications via local injections, topical and peroral routes, it is envisaged that an extended range of ailments will increasingly fall within the clinical scope of therapeutic antibodies further expanding this market.

Systemic inflammatory responses and multiple organ dysfunction syndrome following skin burn wound and Pseudomonas aeruginosa infection in mice

Burn wound-related sepsis is associated with the development of systemic inflammatory response syndrome and multiple organ dysfunction syndrome (MODS). This study is aimed at investigating the development and progression of SIS and MODS in a mouse model of skin burn sepsis. C57BL/6J mice were randomly divided into the sham, burn, Pseudomonas, and burn/Pseudomonas groups. The back skin of the sham, burn, and burn/Pseudomonas groups was burned about 10% of total area with using 37°C or 98°C water for 8 s, respectively, followed by inoculating with Pseudomonas aeruginosa. The Pseudomonas group was infected with P. aeruginosa without burn injury. Their body weights, mortality, organ histology, and function as well as systemic inflammation were measured longitudinally. The burn/Pseudomonas mice lost more body weights than did mice from the other groups and had a significantly higher mortality rate (P < 0.05). The burn/Pseudomonas mice exhibited significantly higher levels of bacterial loads in different organs and serum endotoxin, interleukin 1β, interleukin 6, tumor necrosis factor α, and C-reactive protein than those in mice from the other groups (P < 0.05). The burn/Pseudomonas mice also displayed more severe liver, lung, and kidney tissue damage and impaired organ functions, particularly at 72 h after inoculation than did the burn and Pseudomonas groups of mice. Our data indicate that burn and P. aeruginosa infection induced severe sepsis and rapidly progressed into systemic inflammatory response syndrome and MODS in mice.

High-dose immunoglobulin preparations improve survival in a CLP-induced rat model of sepsis

PURPOSE

The efficacy of intravenous immunoglobulin G in the treatment of patients with severe sepsis or septic shock is still being debated. We investigated the impact of high-dose immunoglobulin administration on the survival rate and serum high-mobility group box chromosomal protein 1 (HMGB1) level in a rat model of sepsis created by cecal ligation and puncture (CLP).

METHODS

Rats received either CLP-induced sepsis or had additional immunoglobulin treatment in 1,500 or 300 mg/kg. After induction of sepsis and respective treatment conditions, pulmonary and renal tissues were examined histologically for pathological changes at postoperative hour (POH) 4, and serum cytokine and HMGB1 levels were measured at POH 4, 8, 20, and 44. Using other rats, we also observed the survival rate after CLP for 7 days.

RESULTS

Treatment with immunoglobulin significantly improved survival rate at postoperative day 7 (73% in the high-dose group vs. 33% in the control group; p = 0.037). The serum lactate dehydrogenase, endotoxin, creatinine, and blood urea nitrogen levels were significantly lower in the high-dose group than in the other groups. The serum HMGB1 level had increased at 4 h postoperatively in the control group (10.2 ± 3.3 ng/mL) and low-dose group (10.3 ± 4.0 ng/mL), but it was significantly reduced in the high-dose group (4.2 ± 0.8 ng/mL) compared with the control group (p = 0.03).

CONCLUSIONS

Our results suggest that high-dose immunoglobulin therapy may improve the serum endotoxin and HMGB1 levels and overall survival rate in sepsis by inhibiting the inflammation.

Animal models of external traumatic wound infections

BACKGROUND

Despite advances in traumatic wound care and management, infections remain a leading cause of mortality,morbidity and economic disruption in millions of wound patients around the world. Animal models have become standard tools for studying a wide array of external traumatic wound infections and testing new antimicrobial strategies.

RESULTS

Animal models of external traumatic wound infections reported by different investigators vary in animal species used, microorganism strains, the number of microorganisms applied, the size of the wounds and for burn infections, the length of time the heated object or liquid is in contact with the skin.

METHODS

This review covers experimental infections in animal models of surgical wounds, skin abrasions, burns, lacerations,excisional wounds and open fractures.

CONCLUSIONS

As antibiotic resistance continues to increase,more new antimicrobial approaches are urgently needed.These should be tested using standard protocols for infections in external traumatic wounds in animal models.

Insights into acinetobacter war-wound infections, biofilms, and control

OBJECTIVE

Multidrug-resistant Acinetobacter baumannii is associated with a wide spectrum of infectious diseases ranging from nosocomial, community-acquired infections to those acquired following war or natural disaster. Especially to military personnel with war wounds, Acinetobacter infection is a formidable threat. The treatment has become exceedingly difficult, not only because the bacterium can develop extensive antimicrobial resistance but because it also forms biofilms that are resistant to host defense and antimicrobial treatment. Such causative factors as biofilm formation and resistance are highly likely to lead to nonhealing wounds. This review, although focused on A baumannii infections, aims to summarize what is known about immunization protection against wound biofilm infections and to apply such understanding in exploring the unknown area of war-wound infection protection.

DATA SOURCES AND STUDY SELECTION

Publications were searched and selected through http://www.pubmed.gov by using the key words Acinetobacter baumannii, bacteria, war wounds, burn wounds, wound infections, biofilms, vaccines, and immunization. The literature selected was categorized according to the subheadings within this article.

CONCLUSIONS

It is imperative to develop such effective measures as active and passive immunization to control multidrug-resistant and tenacious A baumannii infections and to prevent nonhealing wounds. The authors' understanding in immunization against burn wound-related infections by the model bacteria will facilitate research progress in the poorly explored area of immunization against war-wound biofilm infections.

Therapy with anti-flagellin A monoclonal antibody limits Pseudomonas aeruginosa invasiveness in a mouse burn wound sepsis model

BACKGROUND

The aim of this study was to evaluate the effect of an anti-flagellin sub-type monoclonal antibody (anti-fla-a) on Pseudomonas aeruginosa infection in a mouse burn model and to assay bacterial dissemination and invasiveness.

METHODS

After immediate post-burn infection with P. aeruginosa, mortality and morbidity (daily weight changes) were monitored in mice treated with anti-fla-a as compared to untreated mice. Bacterial dissemination and invasiveness were monitored by bacterial counts at the burn site and spleen. Three different timing regimens for anti-fla-a treatment were studied: (a) prophylaxis (pre-infection), (b) therapeutic (post-infection), and (c) combined mode.

RESULTS

Combined regimen of anti-fla-a markedly improved survival of mice infected with P. aeruginosa from 6% to 96% (p<0.0001), similar to treatment with Imipenem. Furthermore, a significant improvement in survival was obtained when anti-fla-a was given prior to (75% survival) or post-infection (50% survival). It reduced bacterial load in the spleen (p=0.01), preventing bacterial sepsis.

CONCLUSION

Anti-fla-a is effective in reducing mortality and morbidity in murine P. aeruginosa-infected burn model.

Inhibition of proliferation of Pseudomonas aeruginosa by KGF in an experimental burn model using human cultured keratinocytes

Experimental models showed the ability of Pseudomonas aeruginosa to interact with epidermal keratinocytes [Green H, Kehinde O, Thomas J. Growth of cultured human epidermal cells into multiple epithelia suitable for grafting. Proc Natl Acad Sci USA 1979;76(11):5665-8], stimulating these cells to produce specific peptides that start an immunological chain reaction in the epidermis [O'Connor NE, Mulliken JB, Banks-Schlegel S, Kehinde O, Green H. Grafting of burns with cultured epithelium prepared from autologous epidermal cells. Lancet 1981;(1):75-8]. The immune reaction causes the release of cytokines and growth factors. The objective of this study was to test whether the presence of keratinocyte growth factor (KGF) alters P. aeruginosa proliferation in an experimental burn model.

METHODS

Human keratinocytes derived from neonatal foreskins were isolated and cultured following standard methods [Gallico III, GG, O'Connor NE, Compton CC, Kehinde O, Green H. Permanent coverage of large burn wounds with autologous cultured human epithelium. N Engl J Med 1984;311(7):448-51]. Some of these cells were genetically modified to produce KGF, and the other cells were supplemented with different KGF concentrations in the culture media. Both groups of keratinocytes were seeded in collagen matrices and cultured to form stratified epithelia. A hot plate was used to produce burn defects. Each matrix was inoculated with luminescent P. aeruginosa strain. Experiments were made using keratinocytes without KGF, keratinocytes supplemented with different concentrations of KGF, and keratinocytes genetically modified to produce KGF. Statistical analyses were made using Wilcoxon paired test.

RESULTS

When KGF was added to P. aeruginosa in the presence of keratinocytes, bacterial growth was inhibited, and the same was observed when genetically modified keratinocytes were used.

CONCLUSION

Many studies have been done on KGF, where its known properties were defined as a mitogen for keratinocytes [Munster AM. Cultured skin for massive burns: a prospective, controlled trial. Ann Surg 1996;224(3):372-7]. This method allows for a qualitative and quantitative evaluation in real time of the bacterial growth in wound sites after bacterial inoculation. KGF was involved in the reduction of bacterial viability. However, as KGF alone did not produce any effect on P. aeruginosa, it seems to modulate the skin innate immune response.

Development of an experimental model of infected skin ulcer

A model of infected skin ulceration could prove useful in assessing the clinical effectiveness of antimicrobial ointments and dressings. However, no such models have been previously established. Three types of wound were induced in rats: full-thickness wounds covered with gauze, burn wounds and wounds resulting from mechanical trauma. Wounds were inoculated with S. aureus or P. aeruginosa. Persistent infected wounds were observed only in full-thickness wounds covered with gauze. In a second experiment, colonies of P. aeruginosa or S. aureus were counted within 15 x 15 mm full-thickness wounds covered with gauze. Wounds were inoculated with 1.0 x 10(6) colony-forming units (CFU) of P. aeruginosa or S. aureus and then sealed to ensure an enclosed environment. Tissue bacterial counts exceeded 10(6) CFU/g from the next day until day 9 after infection. Bacterial counts exceeded 10(8) CFU/ml in wound exudate collected between days 1 and 7. We have developed a model of wound infection in which persistence of infection can be achieved for 9 days following ulceration due to the application of gauze to the base of a full-thickness wound.

Efficacy of Antibodies against the N-Terminal of Pseudomonas aeruginosa Flagellin for Treating Infections in a Murine Burn Wound Model

BACKGROUND

In an era of increasing drug resistance, immunotherapy is a desirable treatment against Pseudomonas aeruginosa infections. The flagellum, which is an important pseudomonal virulence factor, was targeted for immunotherapy. The aim of the study was to evaluate the efficacy of polyclonal immunotherapy targeted against the N-terminal of flagellin (anti-N'-fla-b) for treating severe P. aeruginosa infection in a murine burn wound model.

METHODS

Groups of 12 mice were infected (subeschar) with P. aeruginosa strain PA01, and were treated either with systemic anti-N'-fla-b immunoglobulin G (IgG), nonspecific IgG, or imipenem. The control groups included mice with burn alone, mice with untreated infected burn, and mice without burn infected with P. aeruginosa. Three separate regimens were examined: prophylaxis (preinfection), therapeutic (postinfection), and combined. The efficacy of anti-N'-fla-b was evaluated by monitoring the mortality and morbidity (relative weight loss) during a period of 2 weeks.

RESULTS

Anti-N'-fla-b IgG immunotherapy significantly decreased the mortality rate of infected burned mice followed by severe P. aeruginosa infection. The mortality rate in the anti-N'-fla-b-treated groups ranged from 0 to 17 percent compared with 58 to 83 percent in nontreated groups infected with 2 to 5 x 10(6) colony-forming units of P. aeruginosa (p < 0.05). The mortality rate in the anti-N'-fla-b-treated groups was similar to that of groups treated with imipenem. The three tested regimens yielded similar results. Morbidity paralleled survival results. Histopathologic examination revealed an earlier reepithelialization of the infected wound in the anti-N'-fla-b-treated mice compared with untreated mice.

CONCLUSION

Immunotherapy with anti-N'-fla-b IgG, given either as prophylaxis or therapeutically, effectively reduced mortality and morbidity and improved wound healing in a severely P. aeruginosa-infected murine burn model.

The complex mechanism of antibody-mediated clearance of Bordetella from the lungs requires TLR4

Although the antibacterial effects of Abs are well studied in in vitro systems, the in vivo effects of Abs cannot always be accurately predicted. Complicated cross-talk between different effector functions of Abs and various arms of the immune system can affect their activities in vivo. Using the mouse respiratory pathogen Bordetella bronchiseptica, we examined the mechanisms of Ab-mediated clearance of bacteria from the respiratory tract. Interestingly, although TLR4 was not necessary for protective immunity following infection, it was required for rapid bacterial clearance in mice that were vaccinated or adoptively transferred Abs. TLR4 was important for the rapid recruitment of neutrophils that are necessary for Ab-mediated bacterial clearance via a mechanism that requires both FcgammaR and CR3. These data are consistent with a model in which TLR4-mediated inflammatory responses aid in the recruitment of neutrophils, which phagocytose Ab- and complement-opsonized bacteria via FcgammaRs and CR3. Although pattern recognition receptors are known to be involved in innate immunity and the generation of adaptive immunity, their contributions to specific adaptive immune functions should be considered in ongoing efforts to improve vaccine-induced protective immunity.

Controlled-release and local delivery of therapeutic antibodies

Human and humanised antibodies are now poised to become a major new class of protein-based therapeutic agents. A significant fraction of new drugs in clinical testing (approximately 20% in 2002) are antibody classes. Monoclonal antibodies (mAbs) with high affinities against newly discovered disease targets, both cellularly and extracellularly, are now clinically proven to elicit high bioactivities against numerous diseases, including tumours, infections, asthma, inflammation, arthritis and osteoporosis. Clinical humanised antibody delivery is typically intravenous, with large multiple doses (grams) required for systemic volumes of distribution. Due to the relatively high costs of both this drug type, and its common mode of administration, alternatives are sought where doses might be reduced and the bioavailability and efficacy enhanced. Local, controlled-release methods that deliver antibodies locally to site of disease, offer new possibilities with these potential advantages. However, protein drugs frequently exhibit formulation challenges when packaged in delivery vehicles, and as globular proteins, antibodies are no exception. Several examples of mAb controlled-release and local delivery strategies against several disease targets are reviewed. Importantly, several antibody delivery methods work in tandem with existing clinically-accepted therapeutics, sometimes exhibiting potentiating or synergistic effects in animal models with small molecule, systemically administered drugs.

Pseudomonas aeruginosa-specific IgG1 and IgG2 subclasses in enhancement of pulmonary clearance following passive immunisation in the rat

Pseudomonas aeruginosa is an opportunistic Gram-negative pathogen, which causes serious debilitating infections in patients with compromised lung function. The mechanism by which P. aeruginosa is cleared from the lung is not fully defined, although our previous studies have established a role for cellular immunity in protection against P. aeruginosa infections. This study aimed to evaluate the role of P. aeruginosa-specific IgG in protection against P. aeruginosa in a rat model of acute pulmonary infection. Immunoaffinity chromatography was used to purify total rat IgG from rat immune serum (rats immunised with P. aeruginosa) and non-immune serum. Untreated recipient rats were injected intravenously with different concentrations of pure IgG prepared from serum of unimmunised rats (non-immune IgG) or from rats immunised intestinally with killed P. aeruginosa (immune IgG) and infected intratracheally with P. aeruginosa 18 h later. The protective capability of the purified IgG against P. aeruginosa was assessed by measurement of reduction in P. aeruginosa infection in the lung 4 h after instillation of bacteria. Enhanced bacterial clearance induced by IgG was determined to be dose-dependent with a 1 mg dose failing to enhance clearance, whereas 5 mg of immune IgG enhanced clearance from the airways and the lung tissue. Measurement of the IgG1, IgG2a and IgG2b isotypes in serum and the lung lavage following transfer of P. aeruginosa-specific IgG found that all three were present. These results demonstrate that anti-P. aeruginosa IgG can enhance bacterial clearance from the airways in an acute infection and identify an important role for IgG in acute respiratory infections caused by P. aeruginosa.

Locally delivered polyclonal antibodies potentiate intravenous antibiotic efficacy against gram-negative infections

PURPOSE

Comparison of the anti-microbial efficacy of locally delivered antibodies in tandem with conventional systemic administration of ceftazidime antibiotic therapy in two lethal gram-negative animal infection models.

METHODS

Previously published lethal E. coli-induced closed peritonitis and Klebsiella-induced burn wound infections were generated in outbred female CF-1 mice cohorts. Pooled human polyclonal antibodies were injected locally into sites of infection in these mice simultaneously with intravenous infusions of the broad-spectrum antibiotic, ceftazidime. Mouse survival was compared in sham control cohorts vs. both ceftazidime-alone or antibody-alone systemically infused cohorts as well as local antibody-systemic ceftazidime combination therapy cohorts. Microbial burdens in blood and tissue samples (by agar plating), as well as interleukin-6 cytokine levels (using ELISA) correlated with sepsis, were monitored in sacrificed animals as a function of antimicrobial treatment regimen.

RESULTS

Local delivery of human polyclonal antibodies to infection sites was shown to produce synergistic therapeutic efficacy in combination with systemic antibiotic administration in these lethal wound infection models in mice. Enhanced benefits of the unique combination therapy included host survival, bacterial burden both locally and systemically, and IL-6 levels in host serum.

CONCLUSIONS

Commercial pooled human antibodies contain a broad spectrum of antimicrobial activity against gram-negative pathogens. Prevention of systemization of infection correlates with host survival in these models. Local control of infection using doses of local, high-titer polyclonal antibodies can enhance traditional approaches to curb systemic spread of infection using intravenous antibiotics. Antibodies provide antimicrobial efficacy independent of known pathogen resistance mechanisms.

Polyclonal human antibodies reduce bacterial attachment to soft contact lens and corneal cell surfaces

Bacterial keratitis due to Pseudomonas aeruginosa is a potentially serious complication of extended-wear contact lens use. Adhesion of P. aeruginosa to soft contact lens materials or corneal endothelial cells in the presence of pooled human immunoglobulins and/or neutrophils in artificial tear fluid was studied in vitro as a potential method to treat contact lens-associated infection. Soft hydrophilic contact lens materials equilibrated in sterile saline were soaked in artificial tear fluid for 18 h prior to use. P. aeruginosa IFO 3455 was added to groups of lenses or confluent cultured bovine corneal endothelial cells with varying amounts of human polyclonal immunoglobulin (IgG) and human blood neutrophils or serum albumin as a control. After 2 or 4 h incubation, adherent viable bacteria on lenses were quantified. Fluorescence microscopy was used to assess bacterial adherence to bovine corneal endothelial cells in the presence and absence of IgG and neutrophils. Various concentrations of albumin had no effect on adhesion. Human immunoglobulin solutions (25 mg/ml) reduced P. aeruginosa adhesion by nearly 1 log and 2 logs after 2 and 4 h incubations, respectively. Neutrophils in combination with 25 mg/ml IgG reduced bacterial adhesion approximately 1 log over reduction in adhesion by neutrophils alone. Diluted human IgG (10 mg/ml) did not significantly decrease bacterial adhesion after 2 or 4 h, but did reduce adhesion in combination with human neutrophils at both time points. Similar reductions in amounts of fluorescently labeled bacteria adhered to cultured monolayers of corneal endothelial cells under these conditions were qualitatively observed.

Prophylactic treatment of gram-positive and gram-negative abdominal implant infections using locally delivered polyclonal antibodies

The increasing clinical incidence and host risk of biomaterial-centered infections, as well as the reduced effectiveness of clinically relevant antibiotics to treat such infections, provide compelling reasons to develop new approaches for treating implanted biomaterials in a surgical context. We describe the direct local delivery of polyclonal human antibodies to abdominal surgical implant sites to reduce infection severity and mortality in a lethal murine model of surgical implant-centered peritoneal infection. Surgical implant-centered peritonitis was produced in 180 female CF-1 mice by the direct inoculation of surgical-grade polypropylene mesh disks placed in the peritoneal cavity with lethal doses of either methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa. Mice randomly received a resorbable antibody delivery vehicle at the implant site: either a blank carboxymethylcellulose (CMC) aqueous gel or the same CMC gel containing 10 mg of pooled polyclonal human immunoglobulin G locally on the implant after infection, either alone or in combination with systemic doses of cefazolin or vancomycin antibiotics. Human antibodies were rapidly released (first-order kinetics) from the gel carrier to both peritoneal fluids and serum in both infection scenarios. Inocula required for lethal infection were substantially reduced by surgery and the presence of the implant versus a closed lethal peritonitis model. Survival to 10 days with two different gram-negative P. aeruginosa strains was significantly enhanced (p < 0.01) by the direct application of CMC gel containing antibodies alone to the surgical implant site. Human-equivalent doses of systemic vancomycin provided a significantly improved benefit (p < 0.01) against lethal, implant-centered, gram-positive MRSA infection. However, locally delivered polyclonal human antibodies in combination with a range of systemic vancomycin doses against MRSA failed to improve host survival. Successful antibody therapy against gram-negative, implant-centered infections complements the clinically routine use of systemic antibiotics, providing a mechanism of protection independent of antibiotic resistance.

Intravenous immunoglobulin for prophylaxis and therapy of sepsis

Intravenous immunoglobulins (IVIg) are widely used as prophylaxis against and as supplemental treatment of sepsis and septic shock, although this concept does not belong to the currently approved medical indications for IVIg products. A reduction in mortality by pooled IVIgGMA more than by IVIgG alone was reported in the recent Cochrane database (eight trials, 492 patients). However, the failure to reduce mortality by IVIgG in the score-based immunoglobulin treatment in sepsis study (653 patients) seriously questions whether IVIgG may reduce mortality. Patients with streptococcal toxic shock syndrome might benefit from IVIg, although it remains questionable whether large controlled trials will ever be available. Intravenous immunoglobulin prophylaxis can undoubtedly reduce the occurrence of infections-especially pneumonias-in at-risk patients. More data are necessary to ascertain whether this beneficial effect is linked with a reduction of infection-related morbidity and mortality. Ongoing studies will document whether cardiac surgery patients with escalating systemic inflammatory response syndrome or mediastinitis will benefit from IVIg. IgM-specific complement inactivation may further stimulate the discussion of IVIgGMA superiority over IVIgG.

Locally delivered antibodies combined with systemic antibiotics confer synergistic protection against antibiotic-resistant burn wound infection

BACKGROUND

Nosocomially derived gram-negative infections, particularly from antibiotic-resistant pathogens, are a cause of morbidity in patients with severe burn wounds.

METHODS

Locally delivered polyclonal antibodies and systemically infused ceftazidime were combined in a lethal murine burn wound model against a virulent Pseudomonas aeruginosa strain that exhibits intermediate resistance to ceftazidime.

RESULTS

Survival was synergistically enhanced in cohorts of burned mice treated both locally (subeschar) with pooled polyclonal human immunoglobulin G (1-mg dose) and intravenously with infused ceftazidime (0.44 mg dose). Enhancement of survival correlated with reduced bacterial quantitation in local and systemic tissue observed in separate burned cohorts. Burned, infected mice treated prophylactically with either individual treatment at the same dose or a combination of both treatments administered systemically showed no survival enhancement as compared with the untreated control group.

CONCLUSION

Treatment of antibiotic-resistant burn wound infections with antibiotics together with locally delivered immunoglobulins may improve antibiotic protective effects against antibiotic-resistant pathogens.

Surgical irrigation with pooled human immunoglobulin G to reduce post-operative spinal implant infection

A multiple-site, nonlethal rabbit surgical model of spinal implant infection was used to assess the efficacy of a spinal wound lavage to reduce post-operative infection from methicillinresistant Staphylococcus aureus (MRSA). Multiple aqueous lavages of isotonic saline were compared to the same procedure using 1wt% pooled human immunoglobulin G (IgG) applied directly to the surgical implant sites. Visually observed clinically relevant signs of infection (e.g. , swelling, erythema, pus) were supported by bacterial enumeration from multiple biopsied tissue and bone sites post-mortem at 7 and 28 days post-challenge. Clinical signs of infection were significantly reduced in IgG-lavaged infected spinal sites. Bacterial enumeration also exhibited statistically significant reductions in soft tissues, bone and on K-wire spinal implants using IgG lavage compared with saline. Complete healing of all surgical wounds was seen after 28 days, although isolated fibrosed abscesses were observed in autopsied sites treated with both IgG and saline lavages. Local use of IgG wound lavage is proposed as supplementary infection prophylaxis against antibiotic resistant implant-centered or surgical wound infection.

Pooled human immunoglobulins reduce adhesion of Pseudomonas aeruginosa in a parallel plate flow chamber

The influence of pooled polyclonal immunoglobulin (IgG) interactions with both bacteria and model substrates in altering Pseudomonas aeruginosa surface adhesion is reported. Opsonization of this pathogen by polyclonal human IgG and preadsorption of IgG to glass surfaces both effectively reduce initial deposition rates and surface growth of P. aeruginosa IFO3455 from dilute nutrient broth in a parallel plate flow chamber. Polyclonal IgG depleted of P. aeruginosa-specific antibodies reduces the initial deposition rate or surface growth to levels intermediate between exposed and nonexposed IgG conditions. Bacterial surface properties are changed in the presence of opsonizing IgG. Plateau contact angle analysis via sessile drop technique shows a drop in P. aeruginosa surface hydrophobicity after IgG exposure consistent with a more hydrophilic IgG surface coat. Zeta potential values for opsonized versus nonopsonized bacteria exhibit little change. X-ray photoelectron spectroscopy measurements provide surface compositional evidence for IgG attachment to bacterial surfaces. Surface elemental ratios attributed to IgG protein signals versus those attributed primarily to bacterial polysaccharide surface or lipid membrane change with IgG opsonization. Direct evidence for antibody-modified P. aeruginosa surface properties correlates both with reduction of bacterial adhesion to glass surfaces under flow in nutrient medium reported and previous reports of IgG efficacy against P. aeruginosa motility in vitro and infection in vivo.

Establishment of Pseudomonas aeruginosa infection: lessons from a versatile opportunist

Pseudomonas aeruginosa is an ubiquitous pathogen capable of infecting virtually all tissues. A large variety of virulence factors contribute to its importance in burn wounds, lung infection and eye infection. Prominent factors include pili, flagella, lipopolysaccharide, proteases, quorum sensing, exotoxin A and exoenzymes secreted by the type III secretion system.

Efficacy of locally delivered polyclonal immunoglobulin against Pseudomonas aeruginosa peritonitis in a murine model

Infectious peritonitis results from bacterial contamination of the abdominal cavity. Conventional antibiotic treatment is complicated both by the emergence of antibiotic-resistant bacteria and by increased patient populations intrinsically at risk for nosocomial infections. To complement antibiotic therapies, the efficacy of direct, locally applied pooled human immunoglobulin G (IgG) was assessed in a murine model (strains CF-1, CD-1, and CFW) of peritonitis caused by intraperitoneal inoculations of 10(6) or 10(7) CFU of Pseudomonas aeruginosa (strains IFO-3455, M-2, and MSRI-7072). Various doses of IgG (0.005 to 10 mg/mouse) administered intraperitoneally simultaneously with local bacterial challenge significantly increased survival in a dose-dependent manner. Local intraperitoneal application of 10 mg of IgG increased animal survival independent of either the P. aeruginosa or the murine strains used. A local dose of 10 mg of IgG administered up to 6 h prophylactically or at the time of bacterial challenge resulted in 100% survival. Therapeutic 10-mg IgG treatment given up to 12 h postinfection also significantly increased survival. Human IgG administered to the mouse peritoneal cavity was rapidly detected systemically in serum. Additionally, administered IgG in peritoneal lavage fluid samples actively opsonized and decreased the bacterial burden via phagocytosis at 2 and 4 h post-bacterial challenge. Tissue microbial quantification studies showed that 1.0 mg of locally applied IgG significantly reduced the bacterial burden in the liver, peritoneal cavity, and blood and correlated with reduced levels of interleukin-6 in serum.