title: Immunotherapy for refractory pulmonary infection after adult cardiac surgery: immune dysregulation syndrome.
abstract: OBJECTIVE
  Pulmonary dysfunction/multiorgan failure (PD/MF), usually due to refractory pulmonary infection, is an important cause of mortality and morbidity after cardiac operations. Moreover, the incidence of PD/MF may be increasing due to the emergence of antibiotic-resistant pathogens.
  
  
  METHODS
  Fifteen consecutive patients (median age 69 years) who were developing antibiotic-refractory PD/MF were administered 24 g per day intravenous immunoglobulin (IV-IgG; Carimune) for five days. Ten patients had undergone complex valve surgery, and five coronary bypass. Preoperatively, 93% of patients had significant comorbidity, 73% presented acutely, 53% were hypoalbuminemic and 47% had antecedent acute pulmonary derangement. Clinical variables were assessed by retrospective chart review for three days prior to (-3) the start of IV-IgG (day 0) and for five days afterwards (+5). A postoperative morbidity index (PMI) was generated as a weighted sum of: worsening lung infiltrates (I); leukocytosis (L); pulmonary dysfunction (P); ventilator requirement (V); septic shock (S); renal (R), gastrointestinal (G), or hepatic (H) dysfunction; thrombocytopenia (T); and delirium (D).
  
  
  RESULTS
  At day 0, all patients were refractory to major antibiotics, with morbidities of: 1-100%, L-93%, P-93%, V-60%, S-27%, R-67%, G-40%, H-13%, T-27%, and D-20%. Using regression analysis, IV-IgG administration was associated with a statistically significant fall in white blood count and improvement in PMI (p <0.006). Fourteen patients (93%) recovered uneventfully, and one patient (7%) died from progressive sepsis. No complications of IV-IgG therapy occurred.
  
  
  CONCLUSIONS
  Given the high predicted mortality of PD/MF patients, these data suggest that IV-IgG is a safe and efficacious adjunct to antibiotics in this setting. Further studies, including a randomized trial and investigation of immunomodulatory mechanisms, seem indicated.
authors.affiliation: Department of Cardiac Surgery, Vanderbilt University, 2400 Patterson Street, Suite 103, Nashville, TN 37203, USA. jsrankinmd@cs.com
authors.forename: J Scott
authors.initials: JS
authors.lastname: Rankin
authors.forename: Donald D
authors.initials: DD
authors.lastname: Glower
authors.forename: Tracey L
authors.initials: TL
authors.lastname: Teichmann
authors.forename: Lawrence H
authors.initials: LH
authors.lastname: Muhlbaier
authors.forename: Charles W
authors.initials: CW
authors.lastname: Stratton
mesh_terms: D000328:Adult; D000368:Aged; D001424:Bacterial Infections / Q000209:etiology / Q000628:therapy; D006348:Cardiac Surgical Procedures; D024901:Drug Resistance, Multiple, Bacterial; D005260:Female; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use*; D007155:Immunologic Factors / Q000627:therapeutic use*; D007167:Immunotherapy; D007958:Leukocyte Count; D008171:Lung Diseases / Q000209:etiology / Q000276:immunology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000628:therapy; D012141:Respiratory Tract Infections / Q000209:etiology / Q000276:immunology / Q000628:therapy*
chemical_list: D016756:Immunoglobulins, Intravenous; D007155:Immunologic Factors