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. 1994 Jun;219(6):632–642. doi: 10.1097/00000658-199406000-00006

Pneumonia in the surgical intensive care unit. Immunologic keys to the silent epidemic.

W Naziri 1, W G Cheadle 1, J D Pietsch 1, S Appel 1, H C Polk Jr 1
PMCID: PMC1243210  PMID: 8203972

Abstract

OBJECTIVE: The authors undertook a prospective study of trauma victims in the intensive care unit (ICU) to investigate the clinical course of pneumonia and the local and systemic immune responses to the pneumonia. SUMMARY BACKGROUND DATA: The silent epidemic of pneumonia has been an "unappreciated killer" in terms of being overlooked in surgical ICUs for the past 5 years, and specifically, the most common major infection after severe trauma. Little is known about the immune response to an acute pulmonary infection. METHODS: The authors studied 50 consecutive, critically ill trauma patients, with a mean injury severity score of 28 +/- 2, who developed pneumonia while ventilated mechanically. Patients were observed clinically, and specific immunologic parameters, including major histocompatibility antigen HLA-DR, complement receptor (CR3), and Fc receptor (FcRIII), were measured in circulating and local alveolar leukocytes for up to 30 days. Eleven patients provided unique clinical data via bronchoscopy for unilateral pneumonia, with collection of bronchoalveolar lavage (BAL) fluid from both the infected and uninfected sides. RESULTS: Patients developed clinical pneumonia 5.3 +/- 0.4 days after admission to the ICU. At diagnosis, mean temperature was 101.4 F, white blood cell count was 16,000/mm3, arterial oxygen tension was 104 +/- 14, fraction of inspired oxygen was 0.47, and positive end-expiratory pressure was 5. Thirty patients (Group A) recovered relatively promptly; 20 patients had prolonged illnesses (Group B), 15 of whom ultimately survived, and five of whom died. Patients with poor outcomes had greater leukocytosis (p < 0.05) and temperature elevation (p < 0.05) after 5 days of pneumonia. Immunologically, peripheral leukocyte expression of HLA-DR, FcRIII, and CR3 was equivalent in both groups. However, the expression of all three antigens on local alveolar leukocytes was decreased to a greater extent in the poor outcome group compared to the good outcome group, evident before any clinical differentiation between the two outcome groups. CONCLUSIONS: Pneumonia prolonged duration of mechanical ventilation, ICU and hospital stay, and overall infectious morbidity. Although immune suppression has been recognized as a result of initial injury, the development of pneumonia coincided with the nadir of immune function. Poor outcome patients were clinically identifiable 5 days after pneumonia and immunologically identifiable within 2 days. Moreover, there was localized suppression of pulmonary leukocytes at the site of the infiltrate compared to the uninfected lobes. This same alteration was noted in experimental Klebsiella pneumoniae pneumonia. This evidence suggests that there is active immune participation within the respiratory system. It also suggests that there are predispositions to pulmonary infections, and it may allow immune modulation targeted to pulmonary leukocytes to hasten clinical recovery and minimize pulmonary dysfunction.

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Selected References

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  1. Berger M., Wetzler E. M., Wallis R. S. Tumor necrosis factor is the major monocyte product that increases complement receptor expression on mature human neutrophils. Blood. 1988 Jan;71(1):151–158. [PubMed] [Google Scholar]
  2. Bone R. C. Abnormal cellular metabolism in sepsis. A new interpretation. JAMA. 1992 Mar 18;267(11):1518–1519. [PubMed] [Google Scholar]
  3. Ellis J. A., Lairmore M. D., O'Toole D. T., Campos M. Differential induction of tumor necrosis factor alpha in ovine pulmonary alveolar macrophages following infection with Corynebacterium pseudotuberculosis, Pasteurella haemolytica, or lentiviruses. Infect Immun. 1991 Sep;59(9):3254–3260. doi: 10.1128/iai.59.9.3254-3260.1991. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Ertel W., Faist E., Nestle C., Hueltner L., Storck M., Schildberg F. W. Kinetics of interleukin-2 and interleukin-6 synthesis following major mechanical trauma. J Surg Res. 1990 Jun;48(6):622–628. doi: 10.1016/0022-4804(90)90242-t. [DOI] [PubMed] [Google Scholar]
  5. Hershman M. J., Cheadle W. G., Wellhausen S. R., Davidson P. F., Polk H. C., Jr Monocyte HLA-DR antigen expression characterizes clinical outcome in the trauma patient. Br J Surg. 1990 Feb;77(2):204–207. doi: 10.1002/bjs.1800770225. [DOI] [PubMed] [Google Scholar]
  6. Kehrl J. H., Taylor A., Kim S. J., Fauci A. S. Transforming growth factor-beta is a potent negative regulator of human lymphocytes. Ann N Y Acad Sci. 1991;628:345–353. doi: 10.1111/j.1749-6632.1991.tb17267.x. [DOI] [PubMed] [Google Scholar]
  7. Martin L. F., Asher E. F., Casey J. M., Fry D. E. Postoperative pneumonia. Determinants of mortality. Arch Surg. 1984 Apr;119(4):379–383. doi: 10.1001/archsurg.1984.01390160015003. [DOI] [PubMed] [Google Scholar]
  8. Mosmann T. R., Moore K. W. The role of IL-10 in crossregulation of TH1 and TH2 responses. Immunol Today. 1991 Mar;12(3):A49–A53. doi: 10.1016/S0167-5699(05)80015-5. [DOI] [PubMed] [Google Scholar]
  9. Nichols R. L., Smith J. W., Klein D. B., Trunkey D. D., Cooper R. H., Adinolfi M. F., Mills J. Risk of infection after penetrating abdominal trauma. N Engl J Med. 1984 Oct 25;311(17):1065–1070. doi: 10.1056/NEJM198410253111701. [DOI] [PubMed] [Google Scholar]
  10. Nielsen S. L., Røder B., Magnussen P., Engquist A., Frimodt-Møller N. Nosocomial pneumonia in an intensive care unit in a Danish university hospital: incidence, mortality and etiology. Scand J Infect Dis. 1992;24(1):65–70. doi: 10.3109/00365549209048402. [DOI] [PubMed] [Google Scholar]
  11. Oswald I. P., Gazzinelli R. T., Sher A., James S. L. IL-10 synergizes with IL-4 and transforming growth factor-beta to inhibit macrophage cytotoxic activity. J Immunol. 1992 Jun 1;148(11):3578–3582. [PubMed] [Google Scholar]
  12. Perussia B., Tutt M. M., Qiu W. Q., Kuziel W. A., Tucker P. W., Trinchieri G., Bennett M., Ravetch J. V., Kumar V. Murine natural killer cells express functional Fc gamma receptor II encoded by the Fc gamma R alpha gene. J Exp Med. 1989 Jul 1;170(1):73–86. doi: 10.1084/jem.170.1.73. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Polk H. C., Jr, George C. D., Wellhausen S. R., Cost K., Davidson P. R., Regan M. P., Borzotta A. P. A systematic study of host defense processes in badly injured patients. Ann Surg. 1986 Sep;204(3):282–299. [PMC free article] [PubMed] [Google Scholar]
  14. Ravetch J. V., Kinet J. P. Fc receptors. Annu Rev Immunol. 1991;9:457–492. doi: 10.1146/annurev.iy.09.040191.002325. [DOI] [PubMed] [Google Scholar]
  15. Rello J., Quintana E., Ausina V., Castella J., Luquin M., Net A., Prats G. Incidence, etiology, and outcome of nosocomial pneumonia in mechanically ventilated patients. Chest. 1991 Aug;100(2):439–444. doi: 10.1378/chest.100.2.439. [DOI] [PubMed] [Google Scholar]
  16. Rodriguez J. L., Gibbons K. J., Bitzer L. G., Dechert R. E., Steinberg S. M., Flint L. M. Pneumonia: incidence, risk factors, and outcome in injured patients. J Trauma. 1991 Jul;31(7):907–914. [PubMed] [Google Scholar]
  17. Rodriguez J. L., Miller C. G., DeForge L. E., Kelty L., Shanley C. J., Bartlett R. H., Remick D. G. Local production of interleukin-8 is associated with nosocomial pneumonia. J Trauma. 1992 Jul;33(1):74–82. doi: 10.1097/00005373-199207000-00015. [DOI] [PubMed] [Google Scholar]
  18. Stephan R. N., Kupper T. S., Geha A. S., Baue A. E., Chaudry I. H. Hemorrhage without tissue trauma produces immunosuppression and enhances susceptibility to sepsis. Arch Surg. 1987 Jan;122(1):62–68. doi: 10.1001/archsurg.1987.01400130068010. [DOI] [PubMed] [Google Scholar]
  19. Swain S. L., Weinberg A. D., English M., Huston G. IL-4 directs the development of Th2-like helper effectors. J Immunol. 1990 Dec 1;145(11):3796–3806. [PubMed] [Google Scholar]
  20. Trinchieri G., Perussia B. Human natural killer cells: biologic and pathologic aspects. Lab Invest. 1984 May;50(5):489–513. [PubMed] [Google Scholar]
  21. Weinshank R. L., Luster A. D., Ravetch J. V. Function and regulation of a murine macrophage-specific IgG Fc receptor, Fc gamma R-alpha. J Exp Med. 1988 Jun 1;167(6):1909–1925. doi: 10.1084/jem.167.6.1909. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. White-Owen C., Alexander J. W., Babcock G. F. Reduced expression of neutrophil CD11b and CD16 after severe traumatic injury. J Surg Res. 1992 Jan;52(1):22–26. doi: 10.1016/0022-4804(92)90273-3. [DOI] [PubMed] [Google Scholar]

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