Infection and Nutrition

Infection and Nutrition

Part 3: The role of nutrition

Main References

a) Robbins Basic Pathology 7th edition. Kumar, Cotran, Robbins editors. Saunders 2003. Philadelphia.

b) Immunology 6th edition. Roitt, Brostoff, Male editors. Mosby 2001. Edinburgh.

c) Nutrition, immune functions and health; Euroconferences, Paris; June 9-10, 2005

d) Internet. Accessed November 30, 2007e) Total Nutrition Therapy version 2. Abbott International 2003. f) The ASPEN Nutrition Support Practice Manual 2nd edition;

ASPEN 2005. MDg) Roitt’s Essential Immunology 11th edition. Delves et al

editors. Blackwell Publishing 2006. Massachusetts.

From viral infection . . .• virus gets into repiratory mucosa epithelium• viral RNA replicates inside the cell• cell dies and virus spreads to nearby cells

Other cells develop IFN vs. virus and protected from damage

• Macrophage recognize infected cell → IFN, TNF → cytokines → fever, body weakness, no appetite

• NK cell recognize → apoptosis• Cytotoxic T cell recognize → apoptosis

Adequate nutrients → RECOVERY Malnutrition → inadequate production of macrophages, neutrophils, materials for cellular replication and interferon, other cytokines

State of immune depressionBone marrow suppressed → low production of white blood cells

Macro/micro nutrients for :1. production of mediators (IFN,

intracellular modulators) 2. Structural repair and cellular

proliferation






State of immune depressionBone marrow suppressed → low production of white blood cells

Macro/micro nutrients for: 1. production of mediators

(Cytokines, intracellular modulators)

2. Cellular proliferation (bone marrow, LN)






State of immune depression

Bone marrow suppressed → low production of white blood cells

1. Macro/micro nutrients for WBC prolieration

2. Immuno-modulators needed like glutamine and omega-3-fatty acids

To bacterial infection . . .Bacteria → nasopharyngeal and respiratory mucosa, alveoli

Cell destruction → local inflammationMacrophages

Neutralize bacteria

Antigen presenting cells

↑ lymph node, bone marrow production of WBC

Adequate nutrients → RECOVERY

Complement/antibodies

Neutrophils/macrophages

Inadequate nutrients → Incomplete neutralization and protection

Pneumonia, Bronchitis

1. Macro/micro nutrients for complement and antibody production

2. Production of cytokines by macrophages, intracellular modulators




Neutralize bacteria








1. Macro/micro nutrients for WBC production in bone marrow, cell proliferation in lymph nodes




Neutralize bacteria








Macro/micro nutrients for wound healing/ structural

repair

Macro/micro nutrients for wound healing/ structural

repair

To sepsis/SIRS . . .Pneumonia, Bronchitis

Antigen/antibody complexes Bone marrow, lymph nodes → Sustained WBC production

Eicosanoids/local inflammation

Kidneys, GIT, Other organs (F)

↑Cytokines → pyrogens, brain centers→ bone marrow/lymph nodes → ↑ WBC

Multi-organ inflammation → Sepsis/SIRS

Immuno-modulators needed like glutamine and omega-3-fatty acids







Immuno-modulators needed like glutamine and omega-3-fatty acids










4. Wound healing

Inflammation is part of the injury process

SIRSTNF , IL-1 ,

IL-6, IL-12,

IFN , IL-3

IL-10, IL-4, IL-1ra,

Monocyte HLA-DR

suppression

CARS

days

Insult(trauma, sepsis)

Infl

amm

ato

ry b

alan

ce

Tissue inflammation, Early organ failure and death

weeks

Immunosuppression

2nd Infections Delayed MOF and death

Griffiths, R. “Specialized nutrition support in the critically ill: For whom and when? Clinical Nutrition: Early Intervention; Nestle

Nutrition Workshop Series

Inflammation and organ failure in the ICU

SIRSTNF , IL-1 ,

IL-6, IL-12,

IFN , IL-3

IL-10, IL-4, IL-1ra,

Monocyte HLA-DR

suppression

CARS

days

Insult(trauma, sepsis)

Infl

amm

ato

ry b

alan

ce

Tissue inflammation, Early organ failure and death

weeks

Immunosuppression

2nd Infections Delayed MOF and death

Griffiths, R. “Specialized nutrition support in the critically ill: For whom and when? Clinical Nutrition: Early Intervention; Nestle

Nutrition Workshop Series

glutamine

Immunonutrients

Pharmaconutrition

Dose Content in preps

Glutamine 0.4 – 0.5 g/kg 12 – 15 g/L

Arginine ? 4 – 16 g/L

Omega-3-fatty

acids (EPA)

2 – 6 g/day 1 – 2 g/L

Antioxidants

Carotenoids

Vitamin C,E

>100% daily

requirement

Single or

combinations

Maximum effect when given at the proper dose

Glutamine vs standard nutritional support on mortality

Comparison: mortality

Outcome: glutamine vs. control

Study Glutamine n/N

Control n/N

RR95% C.I. fixed

Weight % RR95% C.I. fixed

Griffiths

Houdijk

Jones

Powell-Tuck

Schloerb 1993

Schloerb 1999

Wischmeyer

China1

18/42

2/41

12/26

14/83

3/16

8/35

1/15

0/24

28/42

2/39

10/24

20/85

1/13

6/31

4/16

1/24

38.3

2.8

14.2

27.1

1.5

8.7

5.3

2.1

0.64 (0.43, 0.97)

0.95 (0.14, 6.43)

1.11 (0.59, 2.08)

0.72 (0.39, 1.32)

2.44 (0.29, 20.75)

1.18 (0.46, 3.03)

0.27 (0.03, 2.12)

0.33 (0.01, 7.80)

Total (95% CI) 58/282 72/274 100 0.79 (0.59, 1.04)

1 2 5 10Favors treatment Favors control

Jiang Hua, The clinical efficacy of glutamine: evidence from systematic review and clinical

trials; 11/01/03

Glutamine vs standard nutritional support on infectious complicationsComparison: infectious complications

Outcome: glutamine vs. control

Study Glutamine n/N

Control n/N

RR95% C.I. fixed

Weight % RR95% C.I. fixed

Houdijk

Neri

O’Riordan

Powell-Tuck

Schettinga

Schloerb 1993

Wischmeyer

Ziegler 1998

6/41

1/161/11

37/83

0/10

6/16

7/15

0/9

16/39

4/172/11

38/85

5/10

5/13

9/16

5/11

12.9

3.11.6

29.6

4.3

4.3

6.9

3.9

0.36 (0.16, 0.82)

0.27 (0.03, 2.13)0.50 (0.05, 4.75)

1.00 (0.71, 1.40)

0.09 (0.01, 1.45)

0.97 (0.38, 2.48)

0.83 (0.42, 1.65)

0.11 (0.01, 1.74)

Total (95% CI) 75/413 124/404 100 0.60 (0.48, 0.76)

1 2 5 10Favors treatment Favors control

Schloerb 1999 5/35 4/31 3.3 1.11 (0.33, 3.76)

Young 1/13 4/10 3.6 0.19 (0.03, 1.46)Ziegler 1992 3/24 9/21 7.6 0.29 (0.09, 0.94)

China1

China4

1/15

0/14

2/15

2/14

1.6

2.0

0.50 (0.05, 4.94)

0.20 (0.01, 3.82)

China2 0/60 3/60 2.8 0.14 (0.01, 2.71)China3 1/12 3/12 2.4 0.33 (0.04, 2.77)

China5 5/24 10/24 7.9 0.50 (0.20, 1.25)China6 1/15 3/15 2.4 0.33 (0.04, 2.85)

Jiang Hua, The clinical efficacy of glutamine: evidence from systematic review and clinical

trials; 11/01/03

EPA, antioxidants (enteral)

Gadek et al. Effect of enteral feeding with EPA, GLA, and antioxidants in patients with ARDS. Crit Care Med 1999; 27:1409-1420

EPA, antioxidants, zinc, selenium

• EPA• high fat low carbo• MCT• high protein• Zn, Se• antioxidants• high fiber

Calaguas MJ, Moog FLJ, Gaerlan AD, Saniel MV, & Llido LO.Department of Radiation Oncology, St. Luke’s Medical Center, Metro-Manila, Philippines

Basement membrane:1. Cell support2. Exchange 3. Transport4. Development5. Repair6. Defense7. Integrity of structure and

environment

Wound healing: nutrition needs

Basement membrane:1. Cell support2. Exchange 3. Transport4. Development5. Repair6. Defense7. Integrity of structure and

environment

Intercellular environment1. Tissue support/shape2. Exchange3. Growth4. Repair5. Defense6. Movement

Wound healing: nutrition needs

Nutrition intake and infection(s)

Nutrition intake & risk reduction

How much calories?Usual: 20-25 kcal/kg/day

Very sick: 15-20 kcal/kg/day

Jeejeebhoy K. 4th Asia Pacific Parenteral Nutrition Workshop. June 7-9, 2009; Kuala Lumpur, Malaysia

Consistent intake → better outcome

Infection and Nutrition

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