Novel Mechanisms and Approaches to Treat Neonatal Sepsis

Study Overview
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Brief Summary
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Mortality related to neonatal sepsis exceeds 1 million deaths worldwide; the highest risk of mortality is in preterm neonates, especially low birth weight (LBW), and very low birth weight (VLBW) neonates. The estimated cost of caring for these patients is approximately $700 million in the US alone. In an effort to help mature the neonatal immune system, several adjuvant therapies have been studied; however, none have been implemented in clinical practice. One of the most frequently considered targets for adjuvant therapy is toll-like receptors (TLRs). TLRs detect conserved molecular products of microorganisms (lipopolysaccharide (LPS), and initiate immunity and inflammation. Early adjuvant administration in VLBW infants may be a viable approach to reducing the incidence of early and late sepsis. This research study will characterize immune genomic expression and functional capacity at the time of birth in both term and preterm neonates and determine what effects, if any, that adjuvants have on this function. Additionally, this study will seek to determine if immune function correlates with certain microbiota.

Detailed Description
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Blood samples will be collected from three populations: preterm infants, term infants and healthy adult controls. In addition, a collection of meconium (<1mL) from the diaper of these term and preterm neonates; Term neonates (gestational age 37-42 weeks) between birth and 72 hours of life who have blood collected for the following clinical indications: a. Blood will be collected at 0-72 hours of life from neonates that are undergoing state metabolic screens or for clinical evaluation jaundice. The sample will be obtained during the standard of care state metabolic screen or for clinical evaluation of jaundice. The neonate will only have an extra drop of blood placed (500-700 micro-liters) in a tube during the heel sticks. Neonates will only have 1 sample drawn throughout the duration of the study. Preterm neonates (gestational age 24-37 weeks) consisting of two populations between birth and 72 hours of life who have blood collected for the following clinical indications: Blood will be collected at 0-72 hours of life from neonates that are otherwise healthy and do not require additional laboratory testing who are undergoing state metabolic screens or for evaluation of jaundice. The neonate will only have an extra drop of blood placed (500-700 microliters) in a tube during the heel stick. Neonates will only have 1 sample drawn throughout the duration of the study. A second group of premature neonates will have blood drawn for complications related to prematurity (sepsis work-up). The neonate will only have an extra drop of blood placed (500-700 micro-liters) in a tube during one of these clinical blood draws. Healthy adult controls will have (4milleters) blood collected by way of vein puncture. For all infants, term and preterm, the following data will be collected at the time of blood collection: gender, gestational age, weight, mechanism of birth (vaginal vs cesarean section), evidence of infectious complication (chorioamnionitis, prolonged rupture of membranes, maternal group B strep colonization, hypoglycemia), use of perinatal antibiotics or steroids, laboratory values available in the electronic medial record (CBC, CMP, Lactic acid, CRP) and Apgar scores will be collected from each patient. Additionally the clinical outcomes of these patients, term and preterm,will be collected until time of discharge but not to exceed 90 days.

Official Title
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Novel Mechanisms and Approaches to Treat Neonatal Sepsis: Adjuvant Therapies, Host Microbiome, and Genomic Expression and Functional Capacity of Innate Immune Cells

Conditions
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Complication of Prematurity, Immunologic Deficiency Syndromes

Intervention / Treatment
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* Other: Adjuvant
* Other: Blood Collection


Participation Criteria
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Eligibility Criteria
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Preterm and Term neonates 0-72 hours old Inclusion Criteria: Consent to participate in the study Exclusion Criteria: non- survivable condition Healthy Adult Controls Inclusion Criteria: Consent to participate in the study Age >18 years old, <55 years old Exclusion Criteria: Age <18 years old, >55 years old Severe pre-existing organ dysfunction Oncolytic therapy within 14 days HIV positive status Current use of chronic steroids

Ages Eligible for Study
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Maximum Age: 55 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Preterm Neonate<br>Neonates of gestational age 24-37 weeks. Blood collection will be performed at the time of a clinically required heelstick or blood draw. Microfluidic techniques, utilizing whole blood, will be employed to characterize the baseline genomic profile and functional capacity of immune cells. Adjuvant drugs will be employed ex-vivo to determine if adjuvant therapies change genomic expression and bolster immune function. Meconium will be collected for microbiome analysis. Clinical outcomes will be recorded from the electronic medical record. | Other: Adjuvant<br>* Blood will be incubated, ex-vivo, with one of the adjuvant therapies or no adjuvant and then, using microfluidic techniques the immune genomic profile and the functional capacity of immune cells will be assessed.<br>* Other names: Non-specific toll-like receptor 4 agonist;Other: Blood Collection<br>* Blood collection will be performed on all groups.<br>|
| Term Neonates<br>Neonates of gestational age 37-42 weeks. Blood collection will be performed at the time of a clinically required heelstick or blood draw. Microfluidic techniques, utilizing whole blood, will be employed to characterize the baseline genomic profile and functional capacity of immune cells. Adjuvant drugs will be employed ex-vivo to determine if adjuvant therapies change genomic expression and bolster immune function. Meconium will be collected for microbiome analysis. Clinical outcomes will be recorded from the electronic medical record. | Other: Adjuvant<br>* Blood will be incubated, ex-vivo, with one of the adjuvant therapies or no adjuvant and then, using microfluidic techniques the immune genomic profile and the functional capacity of immune cells will be assessed.<br>* Other names: Non-specific toll-like receptor 4 agonist;Other: Blood Collection<br>* Blood collection will be performed on all groups.<br>|
| Healthy Adult Control<br>Healthy Adult aged 18-55 years will undergo a single blood collection by the way of vein puncture. Microfluidic techniques, utilizing whole blood, will be employed to evaluate the genomic profile and functional capacity of immune cells. Adjuvant drugs will be employed ex-vivo to determine if adjuvant therapies change genomic expression and bolster immune function. | Other: Adjuvant<br>* Blood will be incubated, ex-vivo, with one of the adjuvant therapies or no adjuvant and then, using microfluidic techniques the immune genomic profile and the functional capacity of immune cells will be assessed.<br>* Other names: Non-specific toll-like receptor 4 agonist;Other: Blood Collection<br>* Blood collection will be performed on all groups.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Genomic analysis | The genomic profile will be interpreted using Ingenuity Pathway Analysis (IPA) software to make functional predictions. Additionally, a cytokine analysis, and an evaluation for the prevalence of myeloid derived suppressor cells (MDSCs) that have been shown to correlate with poorer outcomes in adult sepsis studies will be performed. | Day 1 | 
| Functional immunologic analysis | Functional capacity will be confirmed directly by observing chemotaxis and quantifying generation of reactive oxygen species (ROS), rate of phagocytosis, and bacterial killing ability. Additionally, a cytokine analysis, and an evaluation for the prevalence of myeloid derived suppressor cells (MDSCs) that have been shown to correlate with poorer outcomes in adult sepsis studies will be performed. | Day 1 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Immune Function Correlation with Clinical Outcomes | The clinical course of these neonates will be followed for incidence of infectious complications including sepsis as evident by culture results. Therefore, allowing the investigators to determine if immunologic deficits present at birth correlate with clinical outcomes. | 90 days | 
| Ex-vivo Adjuvant Therapies On Immune Function | The implementation of adjuvants in both murine and human models has shown improved function of immune effector cells as well as in clinical outcomes. Adjuvant treatment of mice with TLR agonists stimulates polymorphonuclear leukocytes (PMN) recruitment and function, decreases rates of bacteremia, and increases survival to polymicrobial and gram negative sepsis. Vaccination with Bacillus Calmette-Guerin (BCG) at birth reduces mortality by 40% in LBW infants to sepsis (not tuberculosis) in sub-Saharan Africa. Utilizing an ex-vivo design we will evaluate the changes in immune cell functional capacity. | Day 1 | 
| Ex-vivo Adjuvant Therapies Effect On Immune Cell Genomic Expression | The implementation of adjuvants in both murine and human models has shown improved function of immune effector cells as well as in clinical outcomes. Adjuvant treatment of mice with TLR agonists stimulates polymorphonuclear leukocytes (PMN) recruitment and function, decreases rates of bacteremia, and increases survival to polymicrobial and gram negative sepsis. Vaccination with Bacillus Calmette-Guerin (BCG) at birth reduces mortality by 40% in LBW infants to sepsis (not tuberculosis) in sub-Saharan Africa. Utilizing an ex-vivo design we will evaluate the changes in immune cell genomic expression. | Day 1 | 
| Microbiome Influences Immune Cell Function | Correlated immune deficiencies with differences in the microbiome at the time of birth will be documented by using microbiomic differences present at the time of birth in term vs preterm neonates using Illumina 16s rRNA technology. This system uses highly conserved sequences among bacteria to identify and classify bacterium. The software then provides taxonomic classification to find a microbiomic signature that is specific to immune dysfunction. | Day 1 |