IL-6 and TNF-α serum levels are associated with early death in community-acquired pneumonia patients

Sex-related immunity: could Toll-like receptors be the answer in acute inflammatory response?

An increasing number of studies have highlighted the existence of a sex-specific immune response, wherein men experience a worse prognosis in cases of acute inflammatory diseases. Initially, this sex-dependent inflammatory response was attributed to the influence of sex hormones. However, a growing body of evidence has shifted the focus toward the influence of chromosomes rather than sex hormones in shaping these inflammatory sex disparities. Notably, certain pattern recognition receptors, such as Toll-like receptors (TLRs), and their associated immune pathways have been implicated in driving the sex-specific immune response. These receptors are encoded by genes located on the X chromosome. TLRs are pivotal components of the innate immune system, playing crucial roles in responding to infectious diseases, including bacterial and viral pathogens, as well as trauma-related conditions. Importantly, the TLR-mediated inflammatory responses, as indicated by the production of specific proteins and cytokines, exhibit discernible sex-dependent patterns. In this review, we delve into the subject of sex bias in TLR activation and explore its clinical implications relatively to both the X chromosome and the hormonal environment. The overarching objective is to enhance our understanding of the fundamental mechanisms underlying these sex differences.

In Vivo Immune-Modulatory Activity of Lefamulin in an Influenza Virus A (H1N1) Infection Model in Mice

Lefamulin is a first-in-class systemic pleuromutilin antimicrobial and potent inhibitor of bacterial translation, and the most recent novel antimicrobial approved for the treatment of community-acquired pneumonia (CAP). It exhibits potent antibacterial activity against the most prevalent bacterial pathogens that cause typical and atypical pneumonia and other infectious diseases. Early studies indicate additional anti-inflammatory activity. In this study, we further investigated the immune-modulatory activity of lefamulin in the influenza A/H1N1 acute respiratory distress syndrome (ARDS) model in BALB/c mice. Comparators included azithromycin, an anti-inflammatory antimicrobial, and the antiviral oseltamivir. Lefamulin significantly decreased the total immune cell infiltration, specifically the neutrophils, inflammatory monocytes, CD4+ and CD8+ T-cells, NK cells, and B-cells into the lung by Day 6 at both doses tested compared to the untreated vehicle control group (placebo), whereas azithromycin and oseltamivir did not significantly affect the total immune cell counts at the tested dosing regimens. Bronchioalveolar lavage fluid concentrations of pro-inflammatory cytokines and chemokines including TNF-α, IL-6, IL-12p70, IL-17A, IFN-γ, and GM-CSF were significantly reduced, and MCP-1 concentrations were lowered (not significantly) by lefamulin at the clinically relevant 'low' dose on Day 3 when the viral load peaked. Similar effects were also observed for oseltamivir and azithromycin. Lefamulin also decreased the viral load (TCID50) by half a log10 by Day 6 and showed positive effects on the gross lung pathology and survival. Oseltamivir and lefamulin were efficacious in the suppression of the development of influenza-induced bronchi-interstitial pneumonia, whereas azithromycin did not show reduced pathology at the tested treatment regimen. The observed anti-inflammatory and immune-modulatory activity of lefamulin at the tested treatment regimens highlights a promising secondary pharmacological property of lefamulin. While these results require confirmation in a clinical trial, they indicate that lefamulin may provide an immune-modulatory activity beyond its proven potent antibacterial activity. This additional activity may benefit CAP patients and potentially prevent acute lung injury (ALI) and ARDS.

Odds and associated factors for thrombosis development among Lebanese COVID-19 patients: a case-control retrospective study

Background

Thromboembolism is reported to be up to 27% in COVID-19 patients due to SARS-CoV-2 infection. Dysregulated systemic inflammation and various patient traits play a vital role in thrombosis progression.

Purpose

To assess odds and associated factors for thrombosis development among Lebanese COVID-19 patients.

Methods

This was a case-control retrospective study conducted in January-May 2021. Patients infected with COVID-19 and developed thrombosis were classified as cases and patients who were thrombosis-free identified as control. A questionnaire assessed socio-demographics, clinical parameters, and WHO COVID-19 disease severity.

Results

Among 267 patients, 26 (9.7%) developed thrombosis and the majority of thrombosis 34.6% was myocardial infarction, and the least (3.8%) was for catheter-related thrombosis. Results showed that the risk of thrombosis development is higher in patients with previous thromboembolic event (OR = 9.160) and previous intake of anti-hypertensive medications at home (OR = 3.116). However, females (OR = 0.330; CI: 0.118-0.925), intake of anticoagulants during hospital admission (OR = 0.126; CI: 0.053-0.300) and non-severe COVID-19 were at lower thrombosis risk (OR = 0.273). Patients who developed thromboembolic events had longer hospital stay (OR = 0.077).

Conclusion

Patients with COVID-19 and thromboembolism were at higher risk of mortality as compared to patients with COVID-19 but without thromboembolism. The use of anticoagulants significantly reduced the risk for thromboembolism.

Sphingolipid-Induced Bone Regulation and Its Emerging Role in Dysfunction Due to Disease and Infection

The human skeleton is a metabolically active system that is constantly regenerating via the tightly regulated and highly coordinated processes of bone resorption and formation. Emerging evidence reveals fascinating new insights into the role of sphingolipids, including sphingomyelin, sphingosine, ceramide, and sphingosine-1-phosphate, in bone homeostasis. Sphingolipids are a major class of highly bioactive lipids able to activate distinct protein targets including, lipases, phosphatases, and kinases, thereby conferring distinct cellular functions beyond energy metabolism. Lipids are known to contribute to the progression of chronic inflammation, and notably, an increase in bone marrow adiposity parallel to elevated bone loss is observed in most pathological bone conditions, including aging, rheumatoid arthritis, osteoarthritis, and osteomyelitis. Of the numerous classes of lipids that form, sphingolipids are considered among the most deleterious. This review highlights the important primary role of sphingolipids in bone homeostasis and how dysregulation of these bioactive metabolites appears central to many chronic bone-related diseases. Further, their contribution to the invasion, virulence, and colonization of both viral and bacterial host cell infections is also discussed. Many unmet clinical needs remain, and data to date suggest the future use of sphingolipid-targeted therapy to regulate bone dysfunction due to a variety of diseases or infection are highly promising. However, deciphering the biochemical and molecular mechanisms of this diverse and extremely complex sphingolipidome, both in terms of bone health and disease, is considered the next frontier in the field.

Dipeptidyl-peptidase 3 and IL-6: potential biomarkers for diagnostics in COVID-19 and association with pulmonary infiltrates

Coronavirus SARS-CoV-2 spread worldwide, causing a respiratory disease known as COVID-19. The aim of the present study was to examine whether Dipeptidyl-peptidase 3 (DPP3) and the inflammatory biomarkers IL-6, CRP, and leucocytes are associated with COVID-19 and able to predict the severity of pulmonary infiltrates in COVID-19 patients versus non-COVID-19 patients. 114 COVID-19 patients and 35 patients with respiratory infections other than SARS-CoV-2 were included in our prospective observational study. Blood samples were collected at presentation to the emergency department. 102 COVID-19 patients and 28 non-COVID-19 patients received CT imaging (19 outpatients did not receive CT imaging). If CT imaging was available, artificial intelligence software (CT Pneumonia Analysis) was used to quantify pulmonary infiltrates. According to the median of infiltrate (14.45%), patients who obtained quantitative CT analysis were divided into two groups (> median: 55 COVID-19 and nine non-COVID-19, ≤ median: 47 COVID-19 and 19 non-COVID-19). DPP3 was significantly elevated in COVID-19 patients (median 20.85 ng/ml, 95% CI 18.34-24.40 ng/ml), as opposed to those without SARS-CoV-2 (median 13.80 ng/ml, 95% CI 11.30-17.65 ng/ml; p < 0.001, AUC = 0.72), opposite to IL-6, CRP (each p = n.s.) and leucocytes (p < 0.05, but lower levels in COVID-19 patients). Regarding binary logistic regression analysis, higher DPP3 concentrations (OR = 1.12, p < 0.001) and lower leucocytes counts (OR = 0.76, p < 0.001) were identified as significant and independent predictors of SARS-CoV-2 infection, as opposed to IL-6 and CRP (each p = n.s.). IL-6 was significantly increased in patients with infiltrate above the median compared to infiltrate below the median both in COVID-19 (p < 0.001, AUC = 0.78) and in non-COVID-19 (p < 0.05, AUC = 0.81). CRP, DPP3, and leucocytes were increased in COVID-19 patients with infiltrate above median (each p < 0.05, AUC: CRP 0.82, DPP3 0.70, leucocytes 0.67) compared to infiltrate below median, opposite to non-COVID-19 (each p = n.s.). Regarding multiple linear regression analysis in COVID-19, CRP, IL-6, and leucocytes (each p < 0.05) were associated with the degree of pulmonary infiltrates, as opposed to DPP3 (p = n.s.). DPP3 showed the potential to be a COVID-19-specific biomarker. IL-6 might serve as a prognostic marker to assess the extent of pulmonary infiltrates in respiratory patients.

The levels of vitamins and cytokines in serum of elderly patients with community-acquired pneumonia: A case-control study

Background and Aims

The community acquired pneumonia (CAP) is a common disease with high incidence rate and mortality among the elderly. This study aims to explore the association between vitamins, cytokines, and CAP infected by different pathogens in Handan First Hospital.

Methods

The subjects of this study were elderly patients with community-acquired pneumonia in Handan First Hospital and healthy elderly people in the community from February 2018 to December 2019. The study include 234 CAP patients and 180 healthy elderly people. The differences between the healthy and CAP groups were analyzed by blood routine test, urine routine test, Liquid chromatography tandem mass spectrometry (LC-MS/MS) detection of vitamin level, and Enzyme linked immunosorbent assay (ELISA) detection of cytokine level. Sputum culture was used to detect pathogens.

Results

According to our results, there was no significant difference in the contents of vitamin A, vitamin D, vitamin E, and vitamin C in serum between the healthy and CAP elderly. However, compared with the control group, the levels of serum cytokines of IL-2, IL-17, and TGF-β in the CAP patients were significantly increased. In addition, IL-17 was positively correlated with white blood cells, neutrophils, platelet/lymphocyte ratio and neutrophil/lymphocyte ratio of CAP patients, and negatively correlated with lymphocytes. The four pathogens with the highest positive rates were Streptococcus pneumoniae, Klebsiella pneumoniae, Mycoplasma pneumoniae and H. influenza. In patients with S. pneumoniae infection, the IL-2, IL-17, and TGF-β levels were significantly higher than the levels in the control group; IL-17 was also significantly increased in the serum of patients infected with M. pneumoniae, K. pneumoniae, and H. influenza.

Conclusions

There is no direct association between vitamins in serum and community acquired pneumonia (CAP). However, the cytokines are closely related to the clinical indicators and pathogens of CAP patients, which can provide references for the diagnosis, prognosis and treatment of CAP patients.

Effects of secretome supplementation on interleukin-6, tumor necrosis factor-α, procalcitonin, and the length of stay in acute exacerbation COPD patients

Acute exacerbation chronic obstructive pulmonary disease (AECOPD) is associated with significant poor survival. Mesenchymal stem cells (MSC) therapy has been a promising treatment for COPD; therefore, it has the potential to be an additional therapy for AECOPD. Its potential is associated with its secretome since it has anti-inflammatory and immunomodulator activities. The aim of this study was to determine the effect of the secretome as an adjuvant therapy in reducing the levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), procalcitonin, and the length of stay in AECOPD patients. A clinical control trial study was conducted among 28 moderate and severe AECOPD patients who were hospitalized from January to February 2023. The control group (n=14) received standard therapy of AECOPD while the treatment group (n=14) received standard therapy plus secretome 1 ml twice daily for three days. The levels of IL-6, TNF-α, and procalcitonin were measured at admission and on the fourth day of treatment. The length of stay was calculated from the time the patient was admitted until the patient was discharged from hospital. The data were compared using a paired Student t-test, chi-squared test and Mann-Whitney test as appropriate. In the treatment group, the levels of IL-6, TNF-α and procalcitonin after the treatment reduced 13.09 pg/mL, 5.00 pg/mL and 751.26 pg/mL, respectively compared to pre-treatment. In contrast, the levels of IL-6, TNF-α and procalcitonin increased 48.56 pg/mL, 44.48 pg/mL and 346.96 pg/mL, respectively after four days of treatment. There was a significant reduction of IL-6, TNF-α and procalcitonin in treatment group compared to the control group with p=0.022, p=0.009 and p=0.001, respectively. However, there was no significant reduction of the length of stay (p=0.072). In conclusion, administration of secretome to AECOPD patients could reduce the levels of IL-6, TNF-α and procalcitonin.

Nausea Predicts Bacteremia in Immunocompetent Patients with Pneumococcal Community-Acquired Pneumonia: Secondary Data Analysis from a Prospective Cohort

BACKGROUND

In pneumococcal community-acquired pneumonia (CAP), bacteremia is associated with increased mortality, but initial clinical severity scores frequently fail to identify bacteremic patients at risk. We have previously shown that gastrointestinal symptoms are common among patients admitted to the hospital with pneumococcal bacteremia. The aim of this study was to examine gastrointestinal symptoms and inflammatory responses in bacteremic and non-bacteremic pneumococcal CAP in a prospective cohort of immunocompromised and immunocompetent patients hospitalized with CAP.

METHODS

Logistic regression analysis was used to estimate the predictive value of gastrointestinal symptoms for pneumococcal bacteremia in patients with CAP. The Mann-Whitney test was used to compare inflammatory responses in patients with bacteremic vs. non-bacteremic pneumococcal CAP.

RESULTS

Eighty-one patients with pneumococcal CAP were included, of whom 21 (26%) had bacteremia. Immunocompetent patients with pneumococcal CAP had an odds ratio of 16.5 (95% CI 3.0-90.9, p = 0.001) for bacteremia if nausea was present, whereas no such association was found in the immunocompromised patients (OR 0.22, 95% CI 0.02-2.05, p = 0.18). The serum levels of C-reactive protein, procalcitonin and interleukin 6 were significantly higher in the patients with bacteremic pneumococcal CAP compared to non-bacteremic pneumococcal CAP patients (p < 0.001, p = 0.005, and p = 0.019, respectively).

CONCLUSIONS

In immunocompetent patients hospitalized with pneumococcal CAP, nausea may be a predictor of bacteremia. Bacteremic pneumococcal CAP patients display an increased inflammatory response compared to non-bacteremic pneumococcal CAP patients.

Novel protein biomarkers for pneumonia and acute exacerbations in COPD: a pilot study

Introduction

Community-acquired pneumonia (CAP) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD) result in high morbidity, mortality, and socio-economic burden. The usage of easily accessible biomarkers informing on disease entity, severity, prognosis, and pathophysiological endotypes is limited in clinical practice. Here, we have analyzed selected plasma markers for their value in differential diagnosis and severity grading in a clinical cohort.

Methods

A pilot cohort of hospitalized patients suffering from CAP (n = 27), AECOPD (n = 10), and healthy subjects (n = 22) were characterized clinically. Clinical scores (PSI, CURB, CRB65, GOLD I-IV, and GOLD ABCD) were obtained, and interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-2-receptor (IL-2R), lipopolysaccharide-binding protein (LBP), resistin, thrombospondin-1 (TSP-1), lactotransferrin (LTF), neutrophil gelatinase-associated lipocalin (NGAL), neutrophil-elastase-2 (ELA2), hepatocyte growth factor (HGF), soluble Fas (sFas), as well as TNF-related apoptosis-inducing ligand (TRAIL) were measured in plasma.

Results

In CAP patients and healthy volunteers, we found significantly different levels of ELA2, HGF, IL-2R, IL-6, IL-8, LBP, resistin, LTF, and TRAIL. The panel of LBP, sFas, and TRAIL could discriminate between uncomplicated and severe CAP. AECOPD patients showed significantly different levels of LTF and TRAIL compared to healthy subjects. Ensemble feature selection revealed that CAP and AECOPD can be discriminated by IL-6, resistin, together with IL-2R. These factors even allow the differentiation between COPD patients suffering from an exacerbation or pneumonia.

Discussion

Taken together, we identified immune mediators in patient plasma that provide information on differential diagnosis and disease severity and can therefore serve as biomarkers. Further studies are required for validation in bigger cohorts.

Prospective Roles of Tumor Necrosis Factor-Alpha (TNF-α) in COVID-19: Prognosis, Therapeutic and Management

The coronavirus disease 2019 (COVID-19) became a worldwide concern at the beginning of 2020 and has affected millions. Several previous studies revealed the impact of the imbalanced innate immune response on the progression of COVID-19 and its disease outcomes. High levels of proinflammatory cytokines such as tumor necrosis factor-alpha (TNF-α) and interleukins are produced readily by innate immune cells to fight Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) infections. Nonetheless, cytokine-mediated inflammatory events are also linked to detrimental lung injury and respiratory failure, which can result in deaths among COVID-19 patients. TNF-α is amongst the early cytokines produced to mediate proinflammatory responses and enhance immune cell infiltration in response to SARS-CoV-2 infections. In COVID-19, TNF-α-mediated inflammation can cause detrimental tissue damage and gradually promotes lung fibrosis, which later results in pneumonia, pulmonary edema, and acute respiratory distress syndrome. This review, therefore, aims to deliberate the immunomodulatory roles of TNF-α in promoting inflammation and its relation with COVID-19 morbidity and mortality. In addition, this review also proposes the potential of TNF-α as a biomarker for the prognosis of severe COVID-19 and its related complications and as a molecular target for anti-TNF-α therapy.

A multiple comorbidities mouse lung infection model in ApoE‑deficient mice

Acute pneumonia is characterised by a period of intense inflammation. Inflammation is now considered to be a key step in atherosclerosis progression. In addition, pre-existing atherosclerotic inflammation is considered to play a role in pneumonia progression and risk. In the present study, a multiple comorbidities murine model was used to study respiratory and systemic inflammation that results from pneumonia in the setting of atherosclerosis. Firstly, a minimal infectious dose of Streptococcus pneumoniae (TIGR4 strain) to produce clinical pneumonia with a low mortality rate (20%) was established. C57Bl/6 ApoE ^-/- mice were fed a high-fat diet prior to administering intranasally 10⁵ colony forming units of TIGR4 or phosphate-buffered saline (PBS). At days 2, 7 and 28 post inoculation (PI), the lungs of mice were imaged by magnetic resonance imaging (MRI) and positron emission tomography (PET). Mice were euthanised and investigated for changes in lung morphology and changes in systemic inflammation using ELISA, Luminex assay and real-time PCR. TIGR4-inoculated mice presented with varying degrees of lung infiltrate, pleural effusion and consolidation on MRI at all time points up to 28 days PI. Moreover, PET scans identified significantly higher FDG uptake in the lungs of TIGR4-inoculated mice up to 28 days PI. The majority (90%) TIGR4-inoculated mice developed pneumococcal-specific IgG antibody response at 28 days PI. Consistent with these observations, TIGR4-inoculated mice displayed significantly increased inflammatory gene expression [interleukin (IL)-1β and IL-6] in the lungs and significantly increased levels of circulating inflammatory protein (CCL3) at 7 and 28 days PI respectively. The mouse model developed by the authors presents a discovery tool to understand the link between inflammation related to acute infection such as pneumonia and increased risk of cardiovascular disease observed in humans.

Kinetics of inflammatory biomarkers to predict one-year mortality in older patients hospitalized for pneumonia: a multivariable analysis

OBJECTIVES

Long-term mortality is increased in older patients with pneumonia. We aimed to test whether residual inflammation is predictive of one-year mortality after pneumonia.

METHODS

Inflammation biomarkers (C-reactive protein [CRP], interleukin [IL]-6 and IL-8, tumor necrosis factor-α, serum amyloid A, neopterin, myeloperoxidase, anti-apolipoprotein A-1, and anti-phosphorylcholine IgM) were measured at admission and discharge in older patients hospitalized for pneumonia in a prospective study. Univariate and multivariate analyses were conducted using absolute level at discharge and relative and absolute differences between admission and discharge for all biomarkers, along with usual prognostic factors.

RESULTS

In the 133 included patients (median age, 83 years [interquartile range: 78-89]), one-year mortality was 26%. In univariate analysis, the relative difference of CRP levels had the highest area under the receiver operating characteristic curve (0.70; 95% confidence interval [CI] 0.60-0.80). A decrease of CRP levels of more than 67% between admission and discharge had 68% sensitivity and 68% specificity to predict survival. In multivariate analysis, lower body mass index (hazard ratio=0.87 [CI 95% 0.79-0.96], P-value=0.01), higher IL-8 (hazard ratio=1.02 [CI 95% 1.00-1.04], P-value=0.02), and higher CRP (1.01 [95% CI 1.00-1.02], P=0.01) at discharge were independently associated with mortality.

CONCLUSION

Higher IL-8 and CRP levels at discharge were independently associated with one-year mortality. The relative CRP difference during hospitalization was the best individual biomarker for predicting one-year mortality.

Telmisartan ameliorates LPS-induced pneumonia in rats through regulation of the PPARγ/NF-κB pathway

Pneumonia is a common disorder of the respiratory system associated with inflammation. Telmisartan (TEL) has been reported to treat inflammatory-related diseases. The current study is aimed to make investigations for the possible role and action mechanism of TEL on lipopolysaccharide (LPS)-induced pneumonia rats. Forty male Sprague Dawley (SD) rats aged 8 weeks were assigned into four groups ad libitum: a control group received saline only, an experimental group received LPS, a group received TEL (5 mg/kg), followed by LPS treatment, and a group received TEL (10 mg/kg), followed by LPS treatment. LPS (2 mg/kg) and equal saline were administered intratracheally. TEL was orally administrated 5 days before LPS. After LPS treatment for 24 h, bronchoalveolar lavage fluid (BALF) and serum were collected for the analysis of cell counts and/or cytokines. Lung tissues were used to perform histological examination, assess oxidative stress levels, and determine the levels of PPARγ/NF-κB pathway-related proteins. Rats received LPS treatment exhibited high levels of lung wet/dry ratio, ALP, LDH, BALF polymorphonuclear leukocytes count, inflammatory cytokines, and oxidative stress. Meanwhile, LPS also resulted in severe interstitial edema and inflammatory cells infiltration. Interestingly, TEL by oral administration remarkably ameliorated the adverse effects on pneumonia rats caused by LPS. In addition, western blotting further revealed that TEL could activate PPARγ and repress NF-κB (p65). TEL is protective against pneumonia through inhibition of the inflammation and oxidative stress via the PPARγ/NF-κB pathway. This article is protected by copyright. All rights reserved.

Apparent Association of Insulin With Interleukin-6 (IL-6) in Severe COVID-19 Patients Having Chronic Disease Comorbidities

Background

The severe acute respiratory syndrome caused by the novel coronavirus (COVID-19), due to its fast spread, is a disease with global health, social and economic burden. This is complicated by its high morbidity and mortality among those with medical comorbidities and older adults. During the outbreak in Libya, intensive care facilities were overwhelmed by the number of patients requiring special care. Admission to such facilities was reserved for severe cases showing low blood oxygen levels. Due to the inflammatory process in COVID-19, we believed it was essential to evaluate the outcome of inflammation reflected in the changes in interleukin-6 (IL-6) and insulin.

Objective

To study the changes in IL-6 and insulin during the course of the disease, if an association between them exists, and whether this association changes following seven days of treatment.

Method

We analyzed the data of 60 patients diagnosed with COVID-19 and admitted to the hospitals' Intensive Care Units (ICU) in the eastern part of Libya. The study was initiated on January 18th and concluded on March 22, 2021. Samples for the analysis were collected on the first day of admission and after seven days of hospitalization for patients who survived till the selected day. The collected samples were used to analyze IL-6 as an indicator of change in inflammation and insulin as a potential anti-inflammatory modulator. In addition, the association of insulin with IL-6 was statistically tested.

Results

Diabetes and hypertension, the most commonly observed chronic diseases in Libya, were found to represent the highest comorbidities among the ICU patients included in this study. Nonetheless, other diseases affected a smaller proportion of them, ranging from two patients for malignancy to 10 patients for cardiovascular disease. In addition, both age and gender showed differences in the number of ICU hospitalized patients and the death tally among them.

The study showed that the IL-6 level was on the rise during the course of COVID-19, whereas that of insulin was on the decrease. The two variables showed an association for admission day samples as well as for samples after seven days of ICU hospitalization.

Conclusion

Although, IL-6 appears to play a predictive role in the development and outcome of severe COVID-19, along with other biochemical and clinical findings it could serve as an indicator of the disease outcome. On the other hand, the role of insulin as a complementary factor for alleviating inflammation remains to be fully understood and requires further research. There is a pressing necessity for establishing the mechanism through which insulin is associated with inflammation modulatory pathways, in particular through the pathways involving IL-6.

Role of Clinical Characteristics and Biomarkers at Admission to Predict One-Year Mortality in Elderly Patients with Pneumonia

BACKGROUND

A hospitalization for community-acquired pneumonia results in a decrease in long-term survival in elderly patients. We assessed biomarkers at admission to predict one-year mortality in a cohort of elderly patients with pneumonia.

METHODS

A prospective observational study included patients >65 years hospitalized with pneumonia. Assessment of PSI, CURB-65, and biomarkers (C-reactive protein (CRP), procalcitonin (PCT), NT-pro-B-type natriuretic peptide (NT-proBNP), interleukin (IL)-6 and -8, tumor necrosis factor alpha (TNF-α), serum amyloid A (SAA), neopterin (NP), myeloperoxidase (MPO), anti-apolipoprotein A-1 IgG (anti-apoA-1), and anti-phosphorylcholine IgM (anti-PC IgM)) was used to calculate prognostic values for one-year mortality using ROC curve analyses. Post hoc optimal cutoffs with corresponding sensitivity (SE) and specificity (SP) were determined using the Youden index.

RESULTS

A total of 133 patients were included (median age 83 years [IQR: 78-89]). Age, dementia, BMI, NT-proBNP (AUROC 0.65 (95% CI: 0.55-0.77)), and IL-8 (AUROC 0.66 (95% CI: 0.56-0.75)) were significantly associated with mortality, with NT-proBNP (HR 1.01 (95% CI 1.00-1.02) and BMI (HR 0.92 (95% CI 0.85-1.000) being independent of age, gender, comorbidities, and PSI with Cox regression. At the cutoff value of 2200 ng/L, NT-proBNP had 67% sensitivity and 70% specificity. PSI and CURB-65 were not associated with mortality.

CONCLUSIONS

NT-proBNP levels upon admission and BMI displayed the highest prognostic accuracy for one-year mortality and may help clinicians to identify patients with poor long-term prognosis.

An analysis of perinatal factors of low T3 syndrome in preterm neonates with a gestational age of 28-35 weeks

OBJECTIVE

Low triiodothyronine syndrome (LT3S) is a common endocrine disease in preterm neonates. Various serious acute or chronic diseases result in LT3S. Few studies have investigated the causal relationship between perinatal factors and LT3S in preterm neonates with a gestational age (GA) of 28-35 weeks. The present study comprehensively analyzed the perinatal factors of LT3S in preterm neonates.

METHODS

This was a retrospective study of neonates with and without LT3S from January 2018 to November 2019. Compared to 206 preterm neonates without LT3S, 158 neonates were diagnosed with LT3S, excluding neonates with congenital malformations, other endocrine diseases, genetic diseases and inherited metabolic diseases.

RESULTS

Five perinatal risk factors for LT3S were confirmed using univariate and multivariate analyses: smaller gestational age, lower birth weight, respiratory distress syndrome (RDS), neonatal sepsis, and dopamine use.

CONCLUSIONS

LT3S in preterm neonates was associated with multiple perinatal factors, including smaller gestational age, lower birth weight, RDS, sepsis, and dopamine use. Preterm neonates with a GA of 28-35 weeks who are exposed to a series of high-risk perinatal factors must be closely observed, diagnosed early and treated for primary diseases promptly to reduce the occurrence of LT3S and improve the outcomes.Key Message:Few studies have investigated the relationship between perinatal factors and Low triiodothyronine syndrome (LT3S) in preterm neonates with a gestational age (GA) of 28-35 weeks.LT3S was associated with multiple perinatal factors, including smaller gestational age, lower birth weight, respiratory distress syndrome (RDS), sepsis, and dopamine use.

Salivary Interleukin-6 and C-Reactive Protein/Mean Platelet Volume Ratio in the Diagnosis of Late-Onset Neonatal Pneumonia

Neonatal pneumonia is a serious respiratory infectious disease with a high rate of case fatality in developing countries. Salivary cytokines could serve as interesting noninvasive markers in the diagnosis of neonatal pneumonia. The aim was to assess the diagnostic role of salivary and serum interleukin-6 (IL-6), C-reactive protein/mean platelet volume (CRP/MPV) ratio, and the combination of these markers in the diagnosis of late-onset neonatal pneumonia in full-term neonates. Seventy full-term neonates, 35 with late-onset neonatal pneumonia and 35 controls, were enrolled in this prospective case-control study. Complete blood count (CBC), salivary and serum IL-6, and CRP concentrations were measured for all the study subjects. The sensitivity, specificity, positive predictive value, and negative predictive value of salivary IL-6, serum IL-6, and CRP/MPV ratio for the diagnosis of late-onset neonatal pneumonia were determined. At the cutoff point of >34 pg/ml, salivary IL-6 showed 82.86% sensitivity and 91.43% specificity. CRP/MPV ratio showed a sensitivity of 97.14% and specificity of 85.71% at a cutoff value > 0.88. The combination of salivary IL-6 and CRP/MPV ratio improved the sensitivity and specificity to 100%. The current study shows for the first time that both salivary IL-6 and CRP/MPV ratio are suitable markers for the diagnosis of late-onset neonatal pneumonia in full-term neonates.

Serum levels of SIRT3 and other inflammatory factors are associated with clinical outcomes and prognosis in severe community-acquired pneumonia in adults: A prospective study

The aim of this study was to investigate clinical significance of SIRT3 in severe community-acquired pneumonia (CAP) patients.This prospective observational research enrolled a total of 114 severe CAP patients who went to our hospital during January 2018 to December 2019. Serum SIRT3 and IL-1β, IL-6, and tumor necrosis factor (TNF)-α levels were determined using the enzyme-linked immunosorbent assay (ELISA) method. Demographic data, including age, sex, and body mass index (BMI), as well as clinical symptoms, SOFA and SMART-COP scores were collected. The routine blood test was conducted for all patients and white blood cell (WBC) amount, as well as serum levels of C-reactive protein (CRP), D-Dimer, and procalcitonin (PCT).Among all patients, 55 cases died during the study period. The serum levels of CRP, PCT, IL-1β, and IL-6, as well as SOFA and SMART-COP scores were markedly higher in deceased patients than in the survival patients. The expression of SIRT3 was significantly decreased in severe CAP patients compared with the healthy, especially in the deceased patients. SIRT3 levels were negatively correlated with levels of CRP, PCT, IL-1β, and IL-6. Patients with SIRT3 low expression showed remarkably higher expression of CRP, PCT, IL-1β, and IL-6, as well as high SMART-COP scores, higher 1-month mortality rate, and shorter survival. Only SIRT3 and IL-1β were independent risk factors for 1-month mortality in severe CAP patients.Lower serum SIRT3 level predicts poor clinical outcomes and prognosis in severe CAP patients.

Assessing the potential correlation of polymorphisms in the IL6R with relative IL6 elevation in severely ill COVID-19 patients'

Background

Elevated Interleukin-6 (IL-6) may play an important role in the pathophysiology of COVID-19 yet attenuated response is not seen across all severe patients. We aimed to determine the effect of IL-6 baseline levels and other clinical variables on mortality and outcomes in hospitalized COVID-19 patients as well as to explore genetic variants associated with attenuated IL-6 response.

Methods

Baseline IL-6 cytokine levels were measured in hospitalized patients participating in ongoing ODYSSEY phase 3 randomized study of tradipitant and placebo in hospitalized patients with severe COVID-19 who are receiving supplemental oxygen support. Furthermore blood samples for whole genome sequencing analysis were collected from 150 participants.

Results

We report significantly elevated IL-6 in COVID-19 infected hospitalized patients, n = 100 (p-value < 0.0001) when compared to controls n = 324. We also report a significantly increased level of IL-6 (p-value < 0.01) between the severe and mild COVID-19 patients with severity defined on a WHO scale. Excessive IL-6 plasma levels correlate with higher mortality (p-value 0.001). Additionally, based on our classification analysis, combination of IL-6 elevation and high levels of serum glucose can identify highest risk-group of COVID19 patients.

Furthermore, we explore the role of genetic regulatory variants affecting baseline IL-6 levels specifically in COVID-19 patients. We have directly tested the association between variants in the IL6 and IL6R gene region and IL6 plasma levels. We provide results for a common IL-6 variant previously associated with pneumonia, rs1800795, and rs2228145 that was previously shown to affect IL-6 plasma levels, as well as report on novel variants associated with IL-6 plasma levels detected in our study patients.

Conclusions

While it is unlikely that “cytokine storm” is the norm in severe COVID19, baseline elevations above 150 pg/ml may be associated with worst outcomes and as such may warrant treatment considerations. So far no clinical studies used IL-6 baseline assessment to stratify the patient population participating in clinical studies. We believe that careful examination and interpretation of the IL-6 levels and genetic variants can help to determine a patient population with a potentially very robust clinical response to IL-6 inhibition.

Trial Registration: Clinicaltrials.gov: NCT04326426.

Coagulation and anticoagulation in COVID-19

COVID-19 has become a pandemic in the United States and worldwide. COVID-19-induced coagulopathy (CIC) is commonly encountered at presentation manifested by considerable elevation of D-dimer and fibrin split products but with modest or no change in activated partial thromboplastin time and prothrombin time. CIC is a complex process that is distinctly different from conventional sepsis-induced coagulopathy. The cytokine storm induced by COVID-19 infection appears to be more severe in COVID-19, resulting in development of extensive micro- and macrovascular thrombosis and organ failure. Unlike conventional sepsis, anticoagulation plays a key role in the treatment of COVID-19, however without practice guidelines tailored to these patients. We propose a scoring system for COVID-19-coagulopathy (CIC Scoring) and stratification of patients for the purpose of anticoagulation therapy based on risk categories. The proposed scoring system and therapeutic guidelines are likely to undergo revisions in the future as new data become available in this evolving field.

Adhesion molecules as diagnostic and severity biomarkers in pediatric community-acquired pneumonia

BACKGROUND

Discrimination of the cases with severe and mild pneumonia is crucial due to the requirement of hospitalization, additional management, and treatment protocols. We aimed to analyze the role of IL6 (Interleukin), IL8, IL10, VCAM-1 (soluble Vascular Cell Adhesion Molecule), and sSELE (soluble E-selectin) in the diagnosis and prognostic evaluation of community-acquired pneumonia (CAP).

METHODS

Pediatric patients with severe pneumonia (SP) were hospitalized and patients with mild disease (MP) were treated in the community. IL6, IL8, IL10, VCAM-1, and sSELE levels of the patients were investigated and compared with the age- and gender-matched healthy subjects.

RESULTS

A total of 113 patients fulfilling the criteria for a diagnosis of CAP were enrolled in the study, 62 (54.8%) of which had SP and 51 (45%) had MP. MP and SP groups were significantly different in terms of IL8, IL10, and sSELE levels. Patients with SP and MP had significantly different WBC, ESR, and CRP values, as well.

CONCLUSIONS

Besides classical acute phase parameters, inflammatory response parameters such as IL6 and VCAM-1 levels may be helpful in diagnosis of pneumonia. In terms of determination of disease severity in pediatric CAP, systemic inflammatory markers like IL8 and IL10 and adhesion molecules like sSELE seem useful in clinical settings.

PLASMA INTERLEUKIN-6 LEVELS MAY BE ASSOCIATED WITH THE LENGTH OF STAY TIME OF ADULT HYPERGLYCEMIC PATIENTS IN AN INTENSIVE CARE UNIT

Context

Estimation of intensive care unit (ICU) length of stay time (LOS) may be challenging, and pro-inflammatory cytokines can be used as a marker for this purpose.

Objective

The current study aimed to investigate the association between pro-inflammatory cytokine levels and LOS in hyperglycemic patients admitted to adult ICU.

Design

This is a prospective observational study.

Subjects and Methods

All adult ICU patients with a blood glucose level higher than 250 mg/dL, during the study period were included. Hospitalization day demographics were recorded, and plasma IL-6, IL1-ß, and TNF-α concentrations were measured.

Results

A total of 74 patients were enrolled in the study. Diabetic ketoacidosis (DKA) was positive in 31 patients, and the remaining 43 were in the non-DKA (NDKA) group. There was no difference between the two groups in terms of age, gender, LOS, hemoglobin, hematocrit, lactate levels, and platelets count. IL-6, IL-1ß, and TNF-α levels did not show any difference between DKA and NDKA groups (p=0.784, 0.413, and 0.288, respectively). There was a positive correlation between IL-6 levels and LOS (n=74, Pearson correlation=0.330; p=0.004).

Conclusions

Among pro-inflammatory cytokines, IL-6 showed a better performance for the prediction of LOS than IL-1ß, TNF-α, and CRP.

Antimicrobial peptide-modified silver nanoparticles for enhancing the antibacterial efficacy

Antibiotic-resistant bacteria are becoming a serious threat to public health worldwide. To address this problem, we have developed multifunctional peptide (MFP)-coated silver nanoparticles (MFP@AgNPs) for antibacterial studies. MFPs, which can physically adsorb to AgNPs via electrostatic interactions are comprised of a matrix metalloproteinase (MMP) cleavable sequence (PVGLIG), an antimicrobial peptide (tachyplesin-1), and a target peptide (PGP-PEG). The resulting MFP@AgNPs were characterized by various technologies, including UV-vis spectrophotometry, zeta potential analyzer, circular dichroism (CD) spectroscopy, attenuated total reflection-Fourier-transform infrared spectroscopy (ATR-FTIR), and transmission electron microscopy (TEM). The MIC and MBC were investigated against both Gram-positive bacteria and Gram-negative bacteria. The antibacterial activity in vivo was evaluated on MDR-AB (multidrug-resistant Acinetobacter baumannii) infected mice. We found that MFP@AgNPs exhibited antibacterial activity against both Gram-positive bacteria and Gram-negative bacteria. Compared to bare AgNPs, MFP@AgNPs-1 killed MDR-AB faster and more efficiently. SEM images showed that MFP@AgNPs-1 induced cell disruption via cell membrane damage. In vivo studies further confirmed the enhanced antibacterial activity against MDR-AB infections. The developed MFP@AgNPs-1 reduced the cytotoxicity of AgNPs and enhanced the antibacterial activity against MDR-AB in vitro and in vivo, providing a possible solution against multidrug-resistant bacterial infections.

Treatment of severe pneumonia by hinokitiol in a murine antimicrobial-resistant pneumococcal pneumonia model

Streptococcus pneumoniae is often isolated from patients with community-acquired pneumonia. Antibiotics are the primary line of treatment for pneumococcal pneumonia; however, rising antimicrobial resistance is becoming more prevalent. Hinokitiol, which is isolated from trees in the cypress family, has been demonstrated to exert antibacterial activity against S. pneumoniae in vitro regardless of antimicrobial resistance. In this study, the efficacy of hinokitiol was investigated in a mouse pneumonia model. Male 8-week-old BALB/c mice were intratracheally infected with S. pneumoniae strains D39 (antimicrobial susceptible) and NU4471 (macrolide resistant). After 1 h, hinokitiol was injected via the tracheal route. Hinokitiol significantly decreased the number of S. pneumoniae in the bronchoalveolar lavage fluid (BALF) and the concentration of pneumococcal DNA in the serum, regardless of whether bacteria were resistant or susceptible to macrolides. In addition, hinokitiol decreased the infiltration of neutrophils in the lungs, as well as the concentration of inflammatory cytokines in the BALF and serum. Repeated hinokitiol injection at 18 h intervals showed downward trend in the number of S. pneumoniae in the BALF and the concentration of S. pneumoniae DNA in the serum with the number of hinokitiol administrations. These findings suggest that hinokitiol reduced bacterial load and suppressed excessive host immune response in the pneumonia mouse model. Accordingly, hinokitiol warrants further exploration as a potential candidate for the treatment of pneumococcal pneumonia.

Selenium and selenoproteins in viral infection with potential relevance to COVID-19

Selenium is a trace element essential to human health largely because of its incorporation into selenoproteins that have a wide range of protective functions. Selenium has an ongoing history of reducing the incidence and severity of various viral infections; for example, a German study found selenium status to be significantly higher in serum samples from surviving than non-surviving COVID-19 patients. Furthermore, a significant, positive, linear association was found between the cure rate of Chinese patients with COVID-19 and regional selenium status. Moreover, the cure rate continued to rise beyond the selenium intake required to optimise selenoproteins, suggesting that selenoproteins are probably not the whole story. Nonetheless, the significantly reduced expression of a number of selenoproteins, including those involved in controlling ER stress, along with increased expression of IL-6 in SARS-CoV-2 infected cells in culture suggests a potential link between reduced selenoprotein expression and COVID-19-associated inflammation. In this comprehensive review, we describe the history of selenium in viral infections and then go on to assess the potential benefits of adequate and even supra-nutritional selenium status. We discuss the indispensable function of the selenoproteins in coordinating a successful immune response and follow by reviewing cytokine excess, a key mediator of morbidity and mortality in COVID-19, and its relationship to selenium status. We comment on the fact that the synthetic redox-active selenium compound, ebselen, has been found experimentally to be a strong inhibitor of the main SARS-CoV-2 protease that enables viral maturation within the host. That finding suggests that redox-active selenium species formed at high selenium intake might hypothetically inhibit SARS-CoV-2 proteases. We consider the tactics that SARS-CoV-2 could employ to evade an adequate host response by interfering with the human selenoprotein system. Recognition of the myriad mechanisms by which selenium might potentially benefit COVID-19 patients provides a rationale for randomised, controlled trials of selenium supplementation in SARS-CoV-2 infection.

Tetrahydropyrimidines, ZL-5015 Alleviated Lipopolysaccharide (LPS)-Induced Acute Pneumonia in Rats by Activating the NRF-2/HO-1 Pathway

BACKGROUND Acute pneumonia is a severe inflammatory disease of the respiratory system. Drugs used to treat acute pneumonia often have strong side effects. Recent studies have shown that tetrahydropyrimidines, ZL-5015 has anti-inflammatory and antitumor effects. However, whether ZL-5015 can relieve symptoms of acute pneumonia is unclear. MATERIAL AND METHODS In this study, we used lipo-polysaccharide (LPS) to stimulate SD rats to simulate conditions of acute pneumonia. Diverse doses of ZL-5015 were used for treatment of these rats. After the rates were sacrificed, serum, lung tissue, and bronchoalveolar lavage fluid were collected for the next study. Hematoxylin-eosin (H&E) staining then was used to detect pathologic changes in lung tissues. Enzyme-linked immunosorbent assay was performed to assess levels of inflammatory factors in serum. Commercial kits were used to assess levels of reactive oxygen species (ROS) in bronchoalveolar lavage fluid. RESULTS Treatment of ZL-5015 relieved stenosis of the alveolar space and pulmonary edema. Furthermore, levels of inflammatory factors (TNF-alpha, IL-1ß and IL-18) in the lung tissues and serum were downregulated after treatment with ZL-5015. Production of ROS also was suppressed after application of ZL-5015. Moreover, inhibition of expression of NRF-2 and HO-1 was relieved after treatment with ZL-5015. The therapeutic effect of ZL-5015 showed a dose-response relationship. CONCLUSIONS ZL-5015 alleviated LPS-induced inflammatory injury and oxidative damage by activating the NRF-2/HO-1 pathway.

Discovery and predictive modeling of urine microbiome, metabolite and cytokine biomarkers in hospitalized patients with community acquired pneumonia

Pneumonia is the leading cause of infectious related death costing 12 billion dollars annually in the United States alone. Despite improvements in clinical care, total mortality remains around 4%, with inpatient mortality reaching 5–10%. For unknown reasons, mortality risk remains high even after hospital discharge and there is a need to identify those patients most at risk. Also of importance, clinical symptoms alone do not distinguish viral from bacterial infection which may delay appropriate treatment and may contribute to short-term and long-term mortality. Biomarkers have the potential to provide point of care diagnosis, identify high-risk patients, and increase our understanding of the biology of disease. However, there have been mixed results on the diagnostic performance of many of the analytes tested to date. Urine represents a largely untapped source for biomarker discovery and is highly accessible. To test this hypothesis, we collected urine from hospitalized patients with community-acquired pneumonia (CAP) and performed a comprehensive screen for urinary tract microbiota signatures, metabolite, and cytokine profiles. CAP patients were diagnosed with influenza or bacterial (Streptococcus pneumoniae and Staphylococcus aureus) etiologies and compared with healthy volunteers. Microbiome signatures showed marked shifts in taxonomic levels in patients with bacterial etiology versus influenza and CAP versus normal. Predictive modeling of 291 microbial and metabolite values achieved a + 90% accuracy with LASSO in predicting specific pneumonia etiology. This study demonstrates that urine from patients hospitalized with pneumonia may serve as a reliable and accessible sample to evaluate biomarkers that may diagnose etiology and predict clinical outcomes.

MicroRNA-127-5p attenuates severe pneumonia via tumor necrosis factor receptor-associated factor 1

Pneumonia is a persistent and pervasive disease, the effects of which can be severe. MicroRNA (miR)-127-5p has been utilized as a novel biomarker for the diagnosis of severe pneumonia. The present study aimed to investigate the function of miR-127-5p during severe pneumonia. An in vitro model of severe pneumonia in Ana-1 murine macrophages was established using lipopolysaccharide (LPS). Subsequently, reverse transcription-quantitative PCR and ELISA were performed to detect the mRNA and protein expression levels of interleukin (IL)-1β, IL-6 and tumor necrosis factor (TNF)-α. Western blotting was also performed to measure the activity of AKT and NF-κB. The results indicated that compared with the control group, LPS treatment increased TNF receptor-associated factor 1 (TRAF1) expression levels and reduced miR-127-5p expression levels. Furthermore, the results revealed that the 3'-untranslated region of TRAF1 was targeted by miR-127-5p. miR-127-5p mimic reduced LPS-induced increases in IL-1β, IL-6 and TNF-α expression by targeting TRAF1, which was potentially mediated by inactivation of the AKT and NF-κB signaling pathways. Collectively, the results demonstrated that miR-127-5p may attenuate severe pneumonia by reducing LPS-induced inflammatory cytokine production, and inactivating the AKT and NF-κB signaling pathways by targeting TRAF1.

Cytokine levels predict 30-day mortality in octogenarians and nonagenarians with community-acquired pneumonia: a retrospective observational study

To analyze the value of cytokines (tumor necrosis factor [TNF]-α, interleukin [IL]-1β, IL-6, IL-8, IL-10) as predictors of mortality at 30 days in octogenarians and nonagenarians hospitalized in an internal medicine unit for community-acquired pneumonia (CAP). An observational, analytical, retrospective cohort study was conducted in the Department of Internal Medicine at Alicante General University Hospital between January 2014 and December 2015. Blood samples were frozen at - 80 °C, and cytokines were measured by ELISA. We included 115 patients, of whom 54% were men, with a mean age of 86.4 (standard deviation 4.5) years. There is a moderate correlation between IL-10 levels and CURB-65 score (p < 0.001) and a weak correlation with creatinine levels (p = 0.012) and urea levels (p = 0.032). Forty-five (39.1%) patients died within 30 days. In a multivariate analysis, the variables associated with mortality at 30 days were the following: age (adjusted odds ratio [ORa] 1.134, 95% confidence interval [CI] 1.02, 1.26), male sex (ORa 2.85, 95% CI 1.14, 7.14), IL-8 of 19 pg/mL or more (ORa 4.09, 95% CI 1.67, 10.01), and IL-10 of 11.29 pg/mL or more (ORa 4.00, 95% CI 1.58, 10.12). High IL-8 and IL-10 levels were shown to predict 30-day mortality in elderly patients with CAP. The inflammatory response in these patients seems to condition their prognosis. Further research in this line would provide more understanding about the physiopathological mechanisms and potential therapeutic targets for improving survival.

Personalizing the Management of Pneumonia

Pneumonia is a highly prevalent disease with considerable morbidity and mortality. However, diagnosis and therapy still rely on antiquated methods, leading to the vast overuse of antimicrobials, which carries risks for both society and the individual. Furthermore, outcomes in severe pneumonia remain poor. Genomic techniques have the potential to transform the management of pneumonia through deep characterization of pathogens as well as the host response to infection. This characterization will enable the delivery of selective antimicrobials and immunomodulatory therapy that will help to offset the disorder associated with overexuberant immune responses.

Association between neurodegenerative diseases and pneumonia: a retrospective population-based study

PURPOSE

The association between pneumonia and neurodegenerative diseases (NDs) has never been reported in detail. We address this relationship with reference to the general population.

METHODS

Using Taiwan's National Health Insurance Research Database to identify a pneumonia cohort (including the typical and atypical), we established an ND cohort of 19,062 patients and a non-ND cohort of 76,227 people. In both cohorts, the risk of pneumonia was measured using multivariable Cox proportional hazards models.

RESULTS

The adjusted hazard ratio (aHR) (95% confidence interval [CI]) for the pneumonia cohort was 2.10 (1.96-2.24), regardless of age, sex, comorbidities or drug use in the ND cohort. The aHR (95% CI) for adults aged 20-49 years was 2.08 (1.58-2.75), men 2.20 (2.01-2.40). However, older subjects were at greatest risk of pneumonia, (3.41 [2.99-3.88]) if the 20-49 years age group is used as the reference. For the ND and non-ND cohorts, those with comorbidities (with the exception of hyperlipidemia) had higher risk; aHR (95% CI) 2.35 (2.30-2.52). The aHR (95% CI) for those without comorbidities is 3.28 (2.52-4.26). No significant difference was observed in incidence of pneumonia between those who were and were not using statin medications; the aHR (95% CI) was 1.03 (0.93-1.14).

CONCLUSION

The ND cohort had a higher risk of pneumonia, regardless of age, sex, comorbidities or statin use. The risk of pneumonia was higher in elderly and male patients in the ND cohort.

Systemic interleukins levels in community-acquired pneumonia and their association with adverse outcomes

Introduction: Community-acquired pneumonia (CAP) is still one of the major causes of morbidity and mortality worldwide. Pro-inflammatory and anti-inflammatory interleukins have been studied to elucidate the role that inflammation plays in its pathogenesis. The aim of this study is to investigate inflammation in CAP, by analyzing in dynamic, serum levels of six interleukins (IL) and their predictive value regarding adverse outcomes.

Materials and methods: Forty adult patients with CAP, admitted in the Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania from December 2015 to February 2017, were enrolled in this study. Serum levels of pro-inflammatory: IL1β, TNF-α, IL-6, anti-inflammatory: IL-10 and IL-4, along with IL-17A were analyzed in dynamic, on day 1 and day 4.The receiver – operator curves (ROC) were used to analyze the outcome prediction of IL.

Results: Serum levels of IL-1β, IL-6, TNF-α and IL-10 have decreased significantly in dynamic, while IL-4 increases. IL-17A has acted like a pro-inflammatory cytokine. We have found a correlation between IL-6 and IL-10 (r=0.429, p=0.000), IL-6 and IL-17A (r=0.295, p=0.008) and IL-10 and IL-17A (r=0.475, p=0.000). Out of 40 patients, 9 had adverse outcomes, consisting in 9 relapses from which 1 died. IL-6 discriminates alone between adverse and favorable outcomes. With multivariate analysis and multiple regression of all combined IL, we have found that there is a predictive model regarding adverse outcomes.

Conclusion: IL-10 and IL-17A behave like pro-inflammatory cytokines. IL-6 is a predictive marker for adverse outcomes alone. All IL studied together have an impact on adverse outcomes.

Biomarkers of Community-Acquired Pneumonia: A Key to Disease Diagnosis and Management

Community-acquired pneumonia (CAP) is a dangerous disease caused by a spectrum of bacterial and viral pathogens. The choice of specific therapy and the need for hospitalization or transfer to the intensive care unit are determined by the causative agent and disease severity. The microbiological analysis of sputum largely depends on the quality of the material obtained. The prediction of severity and the duration of therapy are determined individually, and existing prognostic scales are used generally. This review examines the possibilities of using specific serological biomarkers to detect the bacterial or viral aetiology of CAP and to assess disease severity. Particular emphasis is placed on the use of biomarker signatures and the discovery of biomarker candidates for a single multiplex analysis.

Interleukin-5, interleukin-6, interferon induced protein-10, procalcitonin and C-reactive protein among mechanically ventilated severe community-acquired viral and bacterial pneumonia patients

BACKGROUND

The serum cytokine levels among 45 mechanically ventilated, intensive care unit (ICU)-treated severe community-acquired pneumonia (SCAP) patients with known microbial etiology in three different etiology groups were assessed.

METHODS

Blood samples for C-reactive protein (CRP), procalcitonin (PCT), interleukin (IL)-5, IL-6, IL-10, human interferon gamma induced protein (IP)-10, and TNF-α (tumor necrosis factor alpha) were collected at time points 0, 12, 24, 48, 72 and 96 h after study inclusion.

RESULTS

There were 21 (43%) pure bacterial infections (bacterial group, BG), 5 (10%) pure viral infections (viral group, VG), and 19 (39%) mixed bacterial-viral infections (mixed group, MG) among 45 mechanically ventilated SCAP patients. CRP and PCT levels were significantly higher in the MG and values decreased with time in all groups. PCT differed also in time and group analysis (P = 0.001), the highest being in the MG. IL-5 levels were significantly higher in the VG compared to others (Ptime = 0.001, Pgroup = 0.051 and Ptimexgroup = 0.016). IL-6 and IP-10 levels decreased over time (Ptime = 0.003 and Ptime = 0.021), but there were no differences between groups.

CONCLUSION

SCAP patients with viral etiology have higher IL-5 levels. Patients with mixed viral and bacterial group have higher PCT compared to other etiologies.

Genetic variants of interferon regulatory factor 5 associated with the risk of community-acquired pneumonia

Interferon regulatory factor 5 (IRF5) is a key transcription factor involved in the control of the expression of pro-inflammatory cytokines and immune responses to infection, and multiple polymorphisms of the IFR5 gene have been shown to be associated with autoimmune and infectious diseases. Several studies have investigated single nucleotide polymorphisms (SNPs) in a number of genes associated with the susceptibility to or severity and outcome of community-acquired pneumonia (CAP), but no research has yet been conducted on the role of IRF5 gene polymorphisms in CAP. In this study, we investigated the effects of four IFR5 variants, rs77571059, rs2004640, rs10954213, and rs3807306 on the susceptibility to CAP by genotyping 228 CAP patients and 177 healthy donors. Our results indicated that IFR5 variants rs77571059 and rs2004640 and haplotype GTAA were associated with the susceptibility to CAP and rs77571059 was related to the severity of the disease, suggesting that IFR5 variants may contribute to the pathogenesis of CAP and may serve as prognostic markers of CAP susceptibility and outcome.

Expression Levels of Interferon Regulatory Factor 5 (IRF5) and Related Inflammatory Cytokines Associated with Severity, Prognosis, and Causative Pathogen in Patients with Community-Acquired Pneumonia

Background

Community-acquired pneumonia (CAP) is a common disease with significant morbidity and mortality. Interferon regulatory factor 5 (IRF5), which induces type I interferons (IFNs) and cytokines such as interleukin (IL)-6, tumor necrosis factor (TNF)-α, IL-10, and interferon gamma-induced protein (IP)10, is a key transcription factor involved in controlling the expression of proinflammatory cytokines and responses to infection. Here, we carefully investigated the role of IRF5 in regulating immune responses to CAP.

Material/Methods

QRT-PCR was used to detect the mRNA levels of IRF5, IL-6, IL-10, IP10, TNF-α, and IFN-α in the peripheral blood of 71 CAP patients and 31 healthy controls, as well as in the bronchoalveolar lavage cells of 20 patients with CAP and 23 patients with lung cancer (using samples from the unaffected lung). Flow cytometry was performed to detect the protein level of IRF5, and a CBA flex set was used to detect the levels of these cytokines in the volunteers.

Results

The expression levels of IRF5 and its related cytokines were significantly increased in CAP patients compared with the controls. Additionally, IRF5, IL-6, IL-10, and IP10 levels were found to be related with the severity of CAP. Furthermore, the levels of IRF5 and IFN-α increased significantly in the early phase of pneumonia caused by influenza virus infection.

Conclusions

IRF5 and its related inflammatory cytokines are associated with the severity, prognosis, and causative pathogen of CAP patients. This finding may provide new drug targets for the prevention and treatment of severe pneumonia caused by influenza virus.

Chemical constituents from Sanguisorba officinalis L. and their inhibitory effects on LPS-stimulated pro-inflammatory cytokine production in bone marrow-derived dendritic cells

Sanguisorba officinalis L. (Rosaceae) is a perennial herbaceous plant and its roots have been used as an important astringent medicine in Eastern Asian countries over many thousand years. In this phytochemical research, 23 compounds (1-23) were isolated from the roots of S. officinalis. Their chemical structures were identified by extensive spectroscopic methods, including 1D and 2D NMR experiments. The anti-inflammatory effects of extracts and isolated compounds were investigated by measuring the production of pro-inflammatory cytokine IL-12 p40, IL-6 and TNF-α in LPS-stimulated bone marrow-derived dendritic cell. Compounds 1, 3, 7-8, 11-14 revealed promising anti-inflammatory effects. These results suggested that some phenolic compounds and monoterpenoids from S. officinalis could be potential candidates for anti-inflammatory treatments.

Poverty as an independent risk factor for in-hospital mortality in community-acquired pneumonia: A study in a developing country population

BACKGROUND

Community-acquired pneumonia (CAP) is one of the most severe lower respiratory tract infections with a high in-hospital mortality. The aim of this study was to investigate the socioeconomic and medical risk factors affecting the prognosis of acute pneumonia. The results of this study can mention the value of socioeconomic backgrounds like poverty and illiteracy in clinical practice, even in a well-known biological phenomenon (eg acute pneumonia).

METHODS

In this cross-sectional study, all admitted patients to a tertiary teaching hospital with a diagnosis of community acquired pneumonia in a 12-month period were enrolled. Socioeconomic and demographic characteristics, underlying conditions, clinical manifestations and para-clinical test results at admission registered prospectively. A logistic regression model was conducted using in-hospital mortality as the dependent variable.

RESULTS

A total of 621 patients was included in this study. Among them, 47 patients (7.6%) died during the hospitalisation period. In multiple logistic regression analysis, pleural effusion, a higher CURB-65 score, hyponatremia, hyperglycaemia and poverty (being in the lower economic class) were identified as independent risk factors for in-hospital mortality in community-acquired pneumonia.

CONCLUSION

Numerous factors can influence the prognosis of CAP. In addition to the CURB-65 score and some other medical risk factors, socioeconomic backgrounds can also affect the early outcome in CAP. In this study, being in the lower economic class (as an indicator of poverty) is interpreted as an independent risk factor for a poor prognosis in CAP.

Neutrophil Elastase Subverts the Immune Response by Cleaving Toll-Like Receptors and Cytokines in Pneumococcal Pneumonia

Excessive activation of neutrophils results in the release of neutrophil elastase (NE), which leads to lung injury in severe pneumonia. Previously, we demonstrated a novel immune subversion mechanism involving microbial exploitation of this NE ability, which eventually promotes disruption of the pulmonary epithelial barrier. In the present study, we investigated the effect of NE on host innate immune response. THP-1-derived macrophages were stimulated with heat-killed Streptococcus pneumoniae or lipopolysaccharide in the presence or absence of NE followed by analysis of toll-like receptor (TLR) and cytokine expression. Additionally, the biological significance of NE was confirmed in an in vivo mouse intratracheal infection model. NE downregulated the gene transcription of multiple cytokines in THP-1-derived macrophages through the cleavage of TLRs and myeloid differentiation factor 2. Additionally, NE cleaved inflammatory cytokines and chemokines. In a mouse model of intratracheal pneumococcal challenge, administration of an NE inhibitor significantly increased proinflammatory cytokine levels in bronchoalveolar lavage fluid, enhanced bacterial clearance, and improved survival rates. Our work indicates that NE subverts the innate immune response and that inhibition of this enzyme may constitute a novel therapeutic option for the treatment of pneumococcal pneumonia.

Efficacy and safety of trimodulin, a novel polyclonal antibody preparation, in patients with severe community-acquired pneumonia: a randomized, placebo-controlled, double-blind, multicenter, phase II trial (CIGMA study)

Purpose

The CIGMA study investigated a novel human polyclonal antibody preparation (trimodulin) containing ~ 23% immunoglobulin (Ig) M, ~ 21% IgA, and ~ 56% IgG as add-on therapy for patients with severe community-acquired pneumonia (sCAP).

Methods

In this double-blind, phase II study (NCT01420744), 160 patients with sCAP requiring invasive mechanical ventilation were randomized (1:1) to trimodulin (42 mg IgM/kg/day) or placebo for five consecutive days. Primary endpoint was ventilator-free days (VFDs). Secondary endpoints included 28-day all-cause and pneumonia-related mortality. Safety and tolerability were monitored. Exploratory post hoc analyses were performed in subsets stratified by baseline C-reactive protein (CRP; ≥ 70 mg/L) and/or IgM (≤ 0.8 g/L).

Results

Overall, there was no statistically significant difference in VFDs between trimodulin (mean 11.0, median 11 [n = 81]) and placebo (mean 9.6; median 8 [n = 79]; p = 0.173). Twenty-eight-day all-cause mortality was 22.2% vs. 27.8%, respectively (p = 0.465). Time to discharge from intensive care unit and mean duration of hospitalization were comparable between groups. Adverse-event incidences were comparable. Post hoc subset analyses, which included the majority of patients (58–78%), showed significant reductions in all-cause mortality (trimodulin vs. placebo) in patients with high CRP, low IgM, and high CRP/low IgM at baseline.

Conclusions

No significant differences were found in VFDs and mortality between trimodulin and placebo groups. Post hoc analyses supported improved outcome regarding mortality with trimodulin in subsets of patients with elevated CRP, reduced IgM, or both. These findings warrant further investigation.

Trial registration: NCT01420744.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5143-7) contains supplementary material, which is available to authorized users.

Cytokine responses, microbial aetiology and short-term outcome in community-acquired pneumonia

BACKGROUND

The inflammatory response to community-acquired pneumonia (CAP) is orchestrated through activation of cytokine networks and the complement system. We examined the association of multiple cytokines and the terminal complement complex (TCC) with microbial aetiology, disease severity and short-term outcome.

MATERIALS AND METHODS

Plasma levels of 27 cytokines and TCC were analysed in blood samples obtained at hospital admission, clinical stabilization and 6-week follow-up from 247 hospitalized adults with CAP. Fourteen mediators were included in final analyses. Adverse short-term outcome was defined as intensive care unit (ICU) admission and 30-day mortality.

RESULTS

Cytokine and TCC levels were dynamic in the clinical course of CAP, with highest levels seen at admission for most mediators. Admission levels of cytokines and TCC did not differ between groups of microbial aetiology. High admission levels of IL-6 (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.18-1.84, P = .001), IL-8 (OR 1.79, 95% CI 1.26-2.55, P = .001) and MIP-1β (OR 2.28, 95% CI 1.36-3.81, P = .002) were associated with a CURB-65 severity score of ≥3, while IL-6 (OR 1.37, 95% CI 1.07-1.74, P = .011) and MIP-1β (OR 1.86, 95% CI 1.03-3.36, P = .040) were associated with a high risk of an adverse short-term outcome.

CONCLUSIONS

In this CAP cohort, admission levels of IL-6, IL-8 and MIP-1β were associated with disease severity and/or adverse short-term outcome. Still, for most mediators, only nonsignificant variations in inflammatory responses were observed for groups of microbial aetiology, disease severity and short-term outcome.

The study of vitamin D administration effect on CRP and Interleukin-6 as prognostic biomarkers of ventilator associated pneumonia

PURPOSE

In regard with the effect of immune-stimulants in the treatment of infectious diseases, the effect of vitamin D administration on the outcome of patients with Ventilator-Associated Pneumonia (VAP) with a high rate of mortality, was studied.

MATERIAL AND METHOD

In this trial, 46 adult patients suffering from VAP and vitamin D deficiency were enrolled. The first group of patients received single intramuscular injection of vitamin D (300000Unit), while the other group were given the placebo.

RESULTS

Administration of vitamin D significantly enhanced its levels (P<0.0001) in the treated patients (12.28±8.26) in comparison with placebo group (1.15±1.50). Serum Interleukin-6 levels were significantly reduced in the treated group compared to placebo (P=0.01). Although C-Reactive protein (CRP) levels showed an improving trend in the vitamin D group, no significant difference between groups (P=0.12) was found. Interestingly, the mortality rate of patients that treated with vitamin D (5/24) was significantly lower (p=0.04) than that of the placebo group (11/22).

CONCLUSION

Our results indicate that vitamin D administration can significantly reduce the IL-6 as prognostic marker in VAP patients, and must be considered as adjunct option in the treatment of VAP patients.

Adh enhances Actinobacillus pleuropneumoniae pathogenicity by binding to OR5M11 and activating p38 which induces apoptosis of PAMs and IL-8 release

Members of the Trimeric Autotransporter Adhesin (TAA) family play a crucial role in the adhesion of Gram-negative pathogens to host cells, but the immunopathogenesis of TAAs remains unknown. Our previous studies demonstrated that Adh from Actinobacillus pleuropneumoniae (A. pleuropneumoniae) is required for full bacterial pathogenicity. Alveolar macrophages are the first line of defense against respiratory infections. This study compared the interactions between porcine alveolar macrophages (PAMs) and wild-type A. pleuropneumoniae (5b WT) or an Adh-deletion strain (5b ΔAdh) via gene microarray, immunoprecipitation and other technologies. We found that Adh was shown to interact with the PAMs membrane protein OR5M11, an olfactory receptor, resulting in the high-level secretion of IL-8 by activation of p38 MAPK signaling pathway. Subsequently, PAMs apoptosis via the activation of the Fax and Bax signaling pathways was observed, followed by activation of caspases 8, 9, and 3. The immunological pathogenic roles of Adh were also confirmed in both murine and piglets infectious models in vivo. These results identify a novel immunological strategy for TAAs to boost the pathogenicity of A. pleuropneumoniae. Together, these datas reveal the high versatility of the Adh protein as a virulence factor and provide novel insight into the immunological pathogenic role of TAAs.

Effects of different anaesthetics on cytokine levels in children with community-acquired pneumonia undergoing flexible fibreoptic bronchoscopy

Objective

To determine the effects of propofol and sevoflurane on cytokine levels in children with community-acquired pneumonia undergoing flexible fibreoptic bronchoscopy (FFB).

Method

Children with community-acquired pneumonia were randomly assigned to receive 3–5 mg/kg propofol i.v. or 8% inhaled sevoflurane. Haemodynamic variables, stress hormone responses and serum cytokines were compared between the two groups.

Results

Out of 50 children aged 2–12 years (propofol, n = 25; sevoflurane, n = 25), there were no significant between-group differences in haemodynamic variables and stress hormones. Interleukin (IL)-6 and IL-10 decreased significantly following FFB in both groups. IL-6 levels were significantly lower in the sevoflurane group than propofol group at 4 h and 1 d following FFB (61.3 ± 11.9 versus 82.6 ± 19.7 pg/ml; 52.8 ± 9.7 versus 75.4 ± 13.6 pg/ml, respectively). IL-10 levels in the sevoflurane group were significantly lower than in the propofol group at 1 d following FFB.

Conclusions

In children with community-acquired pneumonia, use of sevoflurane was associated with lower circulating IL-6 and IL-10 levels compared with propofol, following FFB. Pneumonia severity is reflected by higher blood cytokine levels, thus, sevoflurane may be more beneficial to recovery from community-acquired pneumonia than propofol, however further studies are required to test this hypothesis.