The Gastrointestinal Tract in MODS:
A History
John C. Marshall MD FRCSCCritical Care Canada Forum
Toronto, Ontario
November 12, 2019University of TorontoSt. Michael’s Hospital
“When faecal matter is allowed to remain in the intestine, certain products are absorbed by the organism, and produce poisoning….
While most microbes are confined within the walls of the alimentary canal, the soluble excretions produced by them pass through into the lymph and blood.”
Mo
rtality
(P
erc
en
t)
0
20
40
60
80
100Control
Germ-free
Klebsiella M. S. aureus Endotoxin
tuberculosis
- J Exp Med 111:407, 1960
“The Gastrointestinal Tract:
The Motor of Multiple Organ Failure”
- Ann Surg 206:427, 1987
John Border
Jonathan Meakins
North America 20thc.
Edwin Deitch
Bacterial Translocation
• Sepsis• Trauma• Endotoxemia• Burns• Liver injury• Parenteral nutrition• Altered flora• Cardiac arrest• Antibiotics
Carole Wells
Per cent of Patients Infected
0 10 20 30 40 50 60
MO
F Sc
ore
1 - 2
3 - 4
5 - 8
9 - 16
Pseudomonas
Candida
S. epidermidis
0
Association of Organ Failure with Nosocomial Infection
- Marshall J Hosp Infect 19:7, 1991
Organism # Patients Mean CFU/ml
Candida 19 4.3 1.6
S. fecalis 12 6.8 0.8
Pseudomonas 10 6.9 1.1
S. epidermidis 10 5.7 1.6
E. coli 7 6.2 1.6
- Ann Surg 218:111, 1993
Global 21st C. The Microbiome
• 560 Bn tons carbon
• Sub-sea floor 2.9 X 1029 organisms
• ?1 billion species
S. epidermidis E. coli
S. aureus Pseudomonas
Enterococcus Klebsiella
Enterobacter
Acinetobacter
B. fragilis Morganella
C. difficile Haemophilus
Proteus
Candida
Thrive in the hospital water supply
• Hospital as a reservoir for nosocomial infection
“… one of the most important changes
we can make is to supercede the 20th-century
metaphor of war for describing the
relationship between people and infectious
agents. A more ecologically informed
metaphor, which includes the germs’-eye view
of infection, might be more fruitful … they are
equally part of the superorganism genome
with which we engage the rest of the
biosphere.”
- Joshua Lederberg, Science 288:287, 2000