The Effects of Interferon-gamma on Sepsis-induced Immunoparalysis

Study Overview
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Brief Summary
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The primary aim of this study is to assess the effects of adjunctive therapy with Interferon (IFN)-gamma on immune function in patients with septic shock in a placebo-controlled manner. Moreover, the investigators want to evaluate new markers that could be used to identify patients with immunoparalysis, and to monitor the patient's immunological response to IFN-γ. In addition, mechanistic studies will be performed to further elucidate mechanisms (such as epigenetic modifications) behind immunoparalysis and the effects of IFN-γ on these mechanisms. With use of the results the investigators will obtain in this pilot study, the investigators will conduct a large multicentre clinical trial with IFN-γ.

Detailed Description
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Sepsis is the leading cause of death in the ICU with an estimated 6 million victims per year worldwide. Although septic shock is traditionally viewed as an excessive systemic inflammatory reaction to invasive microbial pathogens, pharmacological suppression of the innate immune response in sepsis has proved to be unsuccessful. An important reason for this might be that the vast majority of septic patients survive the initial pro-inflammatory hit, but die in the subsequent immunosuppressed state due to secondary/opportunistic infections. This so-called 'immunoparalysis' is increasingly recognized as the overriding immune dysfunction in septic patients. Reversal of sepsis-induced immunoparalysis is therefore a promising adjunctive treatment for patients presenting with septic shock. It was demonstrated that interferon-gamma (IFN)-gamma can reverse immunoparalysis in vitro and in vivo in animals and in healthy volunteers. Moreover, in a case-series of septic patients interferon-gamma treatment leaded to reversal of immunoparalysis, reduction in mechanical ventilation time and length of stay with no relevant side-effects. The primary aim of this study is to assess the effects of adjunctive therapy with IFN-gamma on immune function in patients with septic shock in a placebo-controlled manner. Moreover, the investigators want to evaluate new markers that could be used to identify patients with immunoparalysis, and to monitor the patient's immunological response to IFN-γ. In addition, mechanistic studies will be performed to further elucidate mechanisms (such as epigenetic modifications) behind immunoparalysis and the effects of IFN-γ on these mechanisms.

Official Title
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The Effects of Interferon-gamma on Sepsis-induced Immunoparalysis, a Randomised Double-blind Placebo-controlled Pilot (Phase IIIb) Study

Conditions
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Sepsis, Septic Shock

Intervention / Treatment
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* Drug: Interferon-gamma, Recombinant
* Other: Saline 0.9%


Participation Criteria
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Eligibility Criteria
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Inclusion criteria: Written informed consent from patient of legal representative Age >18 years Presence of septic shock of bacterial origin with evidence of bacterial infection (last 96 hours, with at least one pathogenic microorganism in blood, sputum, urine, normally sterile body fluid, or on central venous catheter; Focus of infection identified (e.g. ruptured bowel, purulent drainage/sputum); or leukocytes in normally sterile body fluid), Two SIRS criteria (last 24 hours, fever (>38.3 ˚C), hypothermia (<35.6 ˚C), tachycardia (>90bpm), tachypnea (>20/min), or partial pressure of arterial carbon dioxide (PaCO2) <32 mmHg, or mechanical ventilation, leukocytosis (>12,000/μl), leucopenia (<4,0000/μl), or >10% immature forms), and presence of shock with need for vasopressor therapy to maintain systolic blood pressure (SBP) ≥ 90 mmHg. Exclusion Criteria: Pregnancy or lactating Subjects with a history of allergy or intolerance to IFN-gamma Systemic autoimmune disease, hematologic disease (neoplasma, acute leukemia), transplant patients, or patients on steroid medication receiving a prednisolone equivalent of > 5 mg per day Human immunodeficiency virus positivity Presence of an advanced directive to withhold or to withdraw life sustaining treatment Underlying disease with a prognosis for survival < 3 months, or moribund patient highly likely to die within 24 hours. Cardiopulmonary resuscitation (<72 hours) before enrollment Acute myocardial infarction or pulmonary embolization (<72 hours) Participation in a clinical trial until 30 days prior to inclusion Subjects with a history of documented epileptic seizures Subjects with severe renal impairment (creatinine clearance less than 30 mL/min) Subjects with severe liver failure (impaired synthesis of proteins such as coagulation factors manifested by increased prothrombin time) Subjects with an absolute neutrophil count of less than 500/mm3 at study entry

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Single Group Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Interferon-gamma<br> | Drug: Interferon-gamma, Recombinant<br>* Interferon-gamma (Immukine, Boehringer-Ingelheim, Alkmaar, the Netherlands), 100mcg subcutaneously, on days 0-2-4-7-9-11. Interferon-gamma treatment will be initiated when the noradrenalin dose is reduced to 50% of maximum dose, ensuring that the sepsis-induced pro-inflammatory phase has passed<br>|
| Placebo Comparator: Saline 0.9%<br> | Other: Saline 0.9%<br>* subcutaneous administration on days 0, 2, 4, 7, 9, and 11.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The primary endpoint is the tumor necrosis factor (TNF)-α secretion by ex vivo lipopolysaccharide (LPS)-stimulated leukocytes as a marker of immunosufficiency/antimicrobial response. |  | at admission and at days 0, 2, 7, 14 and 28 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Outcome of bacterial infection (occurrence of secondary and/or opportunistic infections, duration of antibacterial treatment, microbiological evaluation) |  | At days 0, 2, 7, 14 and 28 | 
| Hemodynamic stability (noradrenalin infusion rate, amount of infused fluids per day, amount of urine produced per day, daily fluid balance) |  | At days 0, 2, 7, 14 and 28 | 
| Mortality (including time to death) at week 2 and week 6 after end of treatment (all causes) |  | At days 14 and 28 | 
| Length of stay at ICU and duration of hospitalization |  | At days 28 and 56 | 
| Organ function | Cardiovascular function: lactate level, vasopressor usage, and cardiovascular Sequential Organ Failure Assessment (SOFA) score Respiratory function: oxygenation index, Pulmonary Arterial Oxygen Tension (PaO2) / fraction of inspired oxygen (FiO2) (P/F) ratio, and respiratory SOFA score Renal function: creatinine level, urine output, renal replacement therapy usage, and renal SOFA score Hematologic function: hematologic SOFA score Hepatic function: Hepatic SOFA score | at days 0, 14, and 28 | 
| Production of other cytokines by leukocytes ex vivo stimulated with various stimuli (including LPS, peptidoglycan, candida) |  | At admission, at days 0, 2, 7, 14, and 28 | 
| Markers of immune status (including human leukocyte antigen expression on monocytes (mHLA)-DR and programmed death (PD)-1 expression, interleukin (IL)-6 plasma concentration) |  | At admission and at days 0, 2, 7, 14, and 28 | 
| the correlation between the level of immunoparalysis (indicated by the commonly used marker mHLA-DR and new markers of immune status found), and effectiveness of IFN-γ (indicated by TNF-α secretion by ex vivo LPS-stimulated PBMC's). |  | At days 0, 14, and 28 | 
| Transcriptional activity of leukocytes, including microarrays with a focus on inflammatory pathways |  | At admission and at days 0, 2, 7, 14, and 28 | 
| Changes in phenotype or gene expression caused by mechanisms other than changes in the underlying DNA sequence (epigenetic modifications) |  | At admission and at days 0, 7, and 28 | 
| reversibility of monocytes tolerance | the reversibility of monocytes tolerance by the mean of innate immune training (cytokines production such as TNF and Interleukin (IL)-6 will be assessed). | Day 0 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Sepsis, SIRS, Septic shock, Immunoparalysis, Interferon-gamma