Sepsis is still a serious threat, especially to patients hospitalized in intensive care units (ICUs). Despite advances in modern technology that lead to an improved outcome in individuals suffering from sepsis, clinicians must be cautious when the septic condition is suspected. Changes in the epidemiology, etiology and foci of sepsis, together with a rise of antimicrobial resistance in the causative agents responsible for sepsis, create a qualitatively new situation. Because the septic patient must be treated without delay, the diagnosis of sepsis is usually based on the clinical findings, the knowledge of epidemiological history and predisposing conditions. Traditional methods used in the diagnosis of sepsis must be employed and used in combination with novel approaches of diagnosis, such as the detection of DNA from pathogenic microorganisms in the sterile body fluids and routine measurements of procalcitonin levels in the serum. Since many septic patients are hospitalized in ICUs, complications associated with the development of multiple organ dysfunction/failure are important. Respiratory, circulatory and renal failures are the most frequent types of organ dysfunction in the ICU. Furthermore, secondary nosocomial infections develop in about 20-50% of ICU patients. Thus, facing sepsis is a significant challenge, even for an experienced clinician.
Over the past two decades, it has become well accepted that sepsis exhibits two, oftentimes concomitant, inflammatory stages; a pro-inflammatory phase, referred to as the systemic inflammatory response syndrome (SIRS), and an anti-inflammatory phase, called the compensatory anti-inflammatory response syndrome (CARS). Considering that therapeutic interventions designed to attenuate the pro-inflammatory septic response have generally failed, much recent research has gone into understanding how and why septic patients display immunosuppressive characteristics, what the significance of septic immunosuppression may be and if there exists any therapeutic targets within the CARS. Herein, we describe the potential mechanisms of the immunosuppressive/CARS phase of sepsis by discussing what anti-inflammatory agents, receptors and cell populations are currently believed to contribute to CARS.
Sepsis is a very heterogeneous clinical syndrome broadly defined as the systemic host response to an infection. Until recently, the concept that mortality is the consequence of an uncontrolled hyperinflammatory response of the host was widely accepted. However, although some patients may die rapidly from septic shock accompanied by an overwhelming systemic inflammatory response syndrome triggered by a highly virulent pathogen, most patients survive the initial phase of sepsis, showing multiple organ failure days or weeks later. These patients often demonstrate signs of immune suppression rather than enhanced inflammation. As such, sepsis is now considered a misbalance between proinflammatory reactions (designed to kill invading pathogens but at the same time responsible for tissue damage) and anti-inflammatory responses (designed to limit excessive inflammation, but at the same time making the host more vulnerable for secondary infections). This chapter discusses key components of the pro- and anti-inflammatory response to sepsis and the regulation thereof.
Therapy for severe sepsis and septic shock remains a major unmet medical need and novel treatments to regulate the disordered inflammatory response in sepsis are needed if improved outcomes in sepsis are to be realized in the future. Current therapy is primarily supportive and includes timely administration of antibiotics, source control of infection, aggressive fluid resuscitation, organ support and use of activated protein C where clinically indicated. Bacterial mediators including endotoxin and superantigens as well endogenous proinflammatory cytokines are critical to the pathogenesis of sepsis-induced organ failure and are being targeted with numerous molecules and removal devices. Additional therapeutic strategies are focused at restoring the natural anticoagulant levels, blocking deleterious effects of the complement cascade, preserving mitochondrial function, and inhibiting excessive lymphocyte apoptosis. Molecules with pluripotent activity such as inter-alpha inhibitor proteins, sirtuin activators and estrogen-receptor ligands are also being investigated. Efforts are underway to re-establish microbial clearance mechanisms and permit immune reconstitution following sepsis-induced immune suppression. A review of the most current agents being investigated and their current status are presented in this chapter. The organization of this chapter includes sections addressing therapies targeting microbial mediators, including endotoxin, as well as therapies targeting inflammation and coagulation. There is also a section on agents targeting novel mediators and pathways.
Sepsis is characterised by a hyper-inflammatory response due to microbial infection. We here review our current understanding of host mechanisms employed to mediate this hyper-inflammatory response, drawing together current knowledge pertaining to pathogen recognition and host pro-inflammatory response. Recognition of microbial derived ligands by pattern recognition receptors (PRRs) is a key step in initiating pro-inflammatory signalling pathways. Examples of PRRs linked to the aetiology of sepsis include Toll-like, C-type lectin, RIG-1-like and also Nod-like receptors, which are involved in the formation of the inflammasome, crucial for the maturation of some pro-inflammatory cytokines. Bacterial superantigens have evolved to exploit host MHC class II and T cell receptors (normally considered part of the adaptive immune response) as innate PRRs to propagate a so-called 'cytokine storm', while synergy between different microbial ligands and host-derived alarmins can augment the inflammatory response still further through as yet poorly understood interactions. The host pro-inflammatory response results in the characteristic features of inflammation: rubor, calor, dolor, and tumor. We will review herein the key mediators of inflammation in sepsis, identifying their overlapping and intersecting roles in vascular changes in tone, endothelial permeability, coagulation and contact activation, leukocyte mobilisation and activation.
In cancer, therapies are targeted at 6 important pathways. In sepsis, there is ongoing controversy regarding the number and relative roles of pathways that are activated or repressed and which are important in the progression from health to death. Adding to complexity, there is interaction of pathways, there are differences in temporal pattern of up and down-regulation of pathways and there are different responses of pathways to therapies of sepsis. In this review, we define four key pathways of sepsis: (1) inflammation and immunity, (2) coagulation and fibrinolysis, (3) apoptosis, and (4) endocrine. Each of these pathways can impair endothelial function, a unifying aspect of the pathophysiology of sepsis. There are few studies of interactions of pathways except for the interacttion of inflammation/immunity with coagulation/fibrinolysis. Successful treatment of cancer requires that cancer therapies interrupt several key pathways of cancer. Accordingly, we suggest that successful treatment of sepsis will require therapies that interrupt several key pathways of sepsis. Perhaps the paucity of approved therapies for sepsis is related in part to the underevaluation of novel pathways, to lack of understanding of interactions of pathways and to lack of interruption of key pathways of sepsis.
Gram-negative bacterial pathogens of humans have evolved a range of virulence factors to promote motility, attach to epithelial or endothelial cell surfaces, avoid host immune responses, activate or inactivate host cellular pathways and ultimately cause clinical disease. Gram-negative sepsis is a life-threatening complication of these events. This review discusses the virulence factors of common Gram-negative bacteria causing human sepsis with a focus on Neisseria meningitidis. Adherence, motility, colonization and cell entry involve bacterial pili, flagella and outer membrane proteins. Endotoxin (lipopoly-or lipo-oligosaccharide), other membrane components or exotoxins can be potent inducers of the host inflammatory cascade via innate receptor pathways. Capsular polysaccharides and outer membrane proteins can help the bacterium evade immune defenses. The role in pathogenesis of iron acquisition, bacterial secretion systems, quorum sensing, and biofilm formation is also reviewed. Through multiple genetic mechanisms leading to phase variation, Gram-negative bacteria can adapt to changing host and environmental conditions and selective pressures. Further, the antimicrobial resistance of Gram-negative bacteria driven by antibiotic use will continue to influence the clinical outcomes of Gram-negative sepsis in the coming years.
Severe sepsis and septic shock are frequent causes of ICU admission, commonly encountered complications during the course of hospitalization, and among the most common causes of death in the noncoronary ICU. Dr. Roger C. Bone was a pioneer in our struggles to improve the early recognition and management of severe sepsis and septic shock. Through his leadership and guidance, great strides were made to develop a uniform definition and to ensure the comparability of clinical research trials to evaluate new therapeutic strategies and antimediator agents. Dr. Bone also helped shape our understanding of the various stages or physiologic alterations that occur in the septic patient which also drove forward the development of new therapeutic strategies. This chapter briefly reviews the impact Roger Bone has had on our current understanding and approach to the septic patient.
The important human pathogen Staphylococcus aureus is able to satisfy its nutrient iron requirement by acquiring heme from host hemoglobin in the context of infection. However, heme acquisition exposes S. aureus to heme toxicity. In order to detect the presence of toxic levels of exogenous heme, S. aureus is able to sense heme through the heme sensing system (HssRS) two-component system. Upon sensing heme, HssRS directly regulates the expression of the heme-regulated ABC transporter HrtAB, which alleviates heme toxicity. Importantly, the inability to sense or respond to heme alters the virulence of S. aureus, highlighting the importance of heme sensing and detoxification to staphylococcal pathogenesis. Furthermore, potential orthologues of the Hss and Hrt systems are found in many species of Gram-positive bacteria, a possible indication that heme stress is a challenge faced by bacteria whose habitats include host tissues rich in heme.
Antimicrobial peptides (AMPs) are a key component of the host's innate immune system, targeting invasive and colonizing bacteria. For successful survival and colonization of the host, bacteria have a series of mechanisms to interfere with AMP activity, and AMP resistance is intimately connected with the virulence potential of bacterial pathogens. In particular, because AMPs are considered as potential novel antimicrobial drugs, it is vital to understand bacterial AMP resistance mechanisms. This review gives a comparative overview of Gram-positive and Gram-negative bacterial strategies of resistance to various AMPs, such as repulsion or sequestration by bacterial surface structures, alteration of membrane charge or fluidity, degradation and removal by efflux pumps. This article is part of the themed issue ‘Evolutionary ecology of arthropod antimicrobial peptides’.
Cell-cell communication in bacteria, called quorum sensing, relies on production, release, and detection of signaling molecules, termed autoinducers. Communication enables populations of cells to synchronize gene expression and therefore behave as a group in a manner akin to cells in multicellular organisms. Most quorum-sensing systems allow communication within an individual species of bacteria. However, one autoinducer, called AI-2, is produced and recognized by many different bacterial species, indicating that some bacteria communicate across species boundaries. Current studies are aimed at discovering the role that AI-2 plays in gene regulation. Differential gene expression in response to AI-2 may cause bacterial behavioral changes, such as biofilm formation or transition to a pathogenic state. Interestingly, multiple mechanisms to detect AI-2 exist. These differences likely reflect variations in the role that AI-2 plays for different bacteria. Additionally, structural analyses of the AI-2 receptor in V. harveyi have provided insight into bacterial trans-membrane signal transduction. A further understanding of bacterial quorum-sensing processes may facilitate development of new technologies aimed at interfering with bacterial communication and virulence.
In the emerging field of synthetic biology, a central goal is to reliably engineer bacteria to respond to environmental signals according to a pre-determined genetic program. The sensor systems and genetic circuitry inside bacteria are the 'eyes' and 'brain' of a new class of biotechnological applications in which bacteria are used as living, self-replicating computers that can beneficially interact with the physical world. These engineered gene networks are constructed by extracting natural sensor systems and other genetic parts from multiple organisms and recombining them into novel configurations. This chapter is a how-to guide. It describes several strategies for engineering new bacterial sensor systems and synthetic gene networks that are capable of sensing a desired stimulus and generating interesting dynamical or pattern-forming responses. We also provide specification sheets describing many two-component and quorum-sensing systems, focusing on the information that one needs to know in order to use them for engineering applications.
Chemotaxis is the process by which cells sense chemical gradients in their environment and then move towards more favorable conditions. In the case of Escherichia coli, the paradigm organism for chemotaxis, the pathway is now arguably the best characterized in all of biology. If one broadens their perspective to include other species of bacteria, then our knowledge of chemotaxis is far less developed. In particular, the chemotaxis pathways in unrelated species are quite different despite the conservation of many core signaling proteins. Here, we summarize the current state of knowledge regarding the chemotaxis pathways in E. coli and Bacillus subtilis, with a specific focus on the mechanisms for excitation and adaptation. The mechanisms vary widely, and the B. subtilis process, similar to those found in Thermotoga maritima and many archaea, may represent a new paradigm for bacterial chemotaxis. For instance, B. subtilis has three interacting means for restoring prestimulus behavior after stimulation, including one involving CheYp feedback. The one shared with E. coli, the receptor methylation system, is vastly different, as is the mechanism for conveying signals across the membrane.
Bacteria have developed several mechanisms which allow the preferred utilization of the most efficiently metabolizable carbohydrates when these organisms are exposed to a mixture of carbon sources. Interestingly, the same or similar mechanisms are used by some pathogens to control various steps of their infection process. The efficient metabolism of a carbon source might serve as signal for proper fitness. Alternatively, the presence of a specific carbon source might indicate to bacterial cells that they thrive in infection-related organs, tissues or cells and that specific virulence genes should be turned on or switched off. Frequently, virulence gene regulators are affected by changes in carbon source availability. For example, expression of the gene encoding the Streptococcus pyogenes virulence regulator Mga is controlled by the classical carbon catabolite repression (CCR) mechanism operative in Firmicutes. The activity of PrfA, the major virulence regulator in Listeria monocytogenes, seems to be controlled by the phosphorylation state of phosphotransferase system(PTS) components. In Vibrio cholerae synthesis of HapR, which regulates the expression of genes required for motility, is controlled via the Crp/cAMP CCR mechanism, whereas synthesis of Salmonella enterica HilE, which represses genes in a pathogenicity island, is regulated by the carbohydrate-responsive, PTS-controlled Mlc.
Global regulation of virulence gene expression via transcriptional regulators plays a central role in the ability of the bacterial pathogen Streptococcus pyogenes (the group A Streptococcus, GAS) to rapidly adapt during infection. The 'stand-alone' regulators Mga, RofA-like proteins (RALPs), and RopB/Rgg control important and diverse virulence regulons in response to growth-related signals and other environmental conditions in GAS. Stand-alone regulated genes encode factors important for colonization of tissues, immune evasion, persistence, dissemination, metabolism, and the response to stressors. Although conserved 'core' regulons have been established for each, recent studies have revealed significant inter-serotype and even intra-serotype variation in the regulatory patterns presented by the stand-alone regulators. This chapter will look at each stand-alone regulatory pathway in depth and discuss how these important global networks influence virulence as well as interact with each other to produce an integrated response during GAS infection.
The PEP-dependent carbohydrate:phosphotransferase systems (PTSs) of enteric bacteria constitute a complex sensory system which involves as its central element a PEP-dependent His-protein kinase (Enzyme I). As a unit, the PTS comprises up to 20 different transporters per cell which correspond to its chemoreceptors for PTS carbohydrates, and several targeting subunits, which include in the low [G+C] Gram-positive bacteria an ancillary Ser/Thr-protein kinase. The PTS senses the presence of carbohydrates, in particular glucose, in the medium and the energy state of the cell, in the form of either the intracellular PEP-to-pyruvate ratio or the D-fructose-bisphosphate levels. This information is subsequently communicated to cellular targets, in particular those involved in the chemotactic response of the cell towards PTS carbohydrates, and in sensing glucose in the medium, using cAMP and several targeting subunits as intermediates. Peptide targeting subunits ensure the fast, transient, and yet accurate communication of the PTS with its more than hundred different targets, avoiding at the same time unwanted cross-talk. Many elements of this sensory system are simultaneously elements of specific and global regulatory networks. Thus, the PTS controls, besides the immediate (in the ms to s range) chemotactic responses, the activity of the various carbohydrate transporters and enzymes involved in carbon and energy metabolism through inducer exclusion, and in a delayed response (in the min to h range) the synthesis of these transporters and catabolic enzymes through catabolite repression. Indirect consequences of this program are phenomena related to cell surface rearrangements, which include flagella synthesis, as well as memory, adaptation, and learning effects. The analogy between the PTS and other prokaryotic systems, and more complex sensory systems from eukaryotic organisms which share elements with regulatory systems is obvious.
Recently, the list of ubiquitous bacterial secondary messengers which include cAMP and ppGpp has been extended by 3',5'-cyclic diguanylic acid (c-di-GMP). C-di-GMP metabolism is tuned by the tightly controlled activity of diguanylate cyclases and c-di-GMP-specific phosphodiesterases. As c-di-GMP-metabolizing enzymes are not only found frequently in bacterial genomes, but also are often numerous in individual genomes, the c-di-GMP metabolic network is highly complex whereby signaling specificity is adjusted on the level of expression, enzymatic activity, protein localization and, most likely, receptor affinity. The targets of c-di-GMP, which include protein and RNA receptors, are subsequently being unraveled. Besides the transition between sessility and motility, probably the most ancient regulatory control of bacterial behavior by c-di-GMP, many more phenotypes such as virulence are affected by c-di-GMP. However, the exact molecular mechanisms of c-di-GMP action remain to be discovered.
Bacteria live almost exclusively in communities with other microorganisms, and often in association with multicellular hosts. These communities are capable of maintaining complex structural and functional stability over time, and exhibit fascinating properties of resiliency in response to environmental changes. This is a result of interactions between microbes and the environment and amongst members of the community. A multitude of chemical interactions occur in microbial communities where primary and secondary metabolites contribute to a wealth of interactions between organisms. The chemicals include a variety of nutrients, toxic or neutral metabolic byproducts, antibiotics, and cell-cell signaling molecules. These chemical and physical signals facilitate microbial relationship that can be competitive, cooperative or neutral, and thus are responsible for determining community structure. In turn, the surrounding community changes the microenvironment of individual cells who respond to chemical and environmental cues in a combinatorial manner. Current laboratory understanding of the genetics and mechanisms of interactions between microbes has the power to help us understand how complex microbial communities behave in the natural environment. In this chapter we review the current understanding of microbial communication, from the genetic and molecular aspects, to our current understanding of their ecological role.
