Treatment of sepsis and septic shock

Abstract

To provide a mixture for use in the treatment of hypotension in a human subject having sepsis.SOLUTION: The mixture comprises: (a) a first empty liposome comprising cholesterol, wherein an amount of cholesterol is 45% to 55% (weight per weight) and the liposome does not incorporate a pharmaceutical drug; and (b) a second empty liposome comprising sphingomyelin, wherein the liposome does not incorporate a pharmaceutical drug. The mixture is administered to the human subject in at least two doses, including a first dose and a second dose, with an interval of 6 to 96 hours between the first dose and the second dose.SELECTED DRAWING: None

Description

[Technical Field]

[0001] The present invention relates to a composition for use in treating sepsis, severe sepsis, septic shock, or prolonged and severe hypotension, preferably persistent hypotension, for use in treating hypotension, preferably persistent hypotension, in septic shock, sepsis, severe sepsis, acute respiratory distress syndrome, or acute lung injury, or for use in treating toxic shock syndrome in an animal, preferably a human, comprising a mixture of empty liposomes, the mixture of empty liposomes comprising (a) first empty liposomes containing cholesterol, the first empty liposomes having an amount of cholesterol of at least 30% (weight per weight), and (b) second empty liposomes containing sphingomyelin. In particular, the present invention relates to a composition for use in treating sepsis or septic shock in an animal, preferably a human. [Background technology]

[0002] Sepsis is a potentially life-threatening organ dysfunction caused by a dysregulated host response to infection. It is characterized by physiological, pathological, and biochemical abnormalities that lead to organ dysfunction (Levy M et al. Intensive Care Med 2003;29:530-38, Singer M et al. JAMA. 2016;315(8):801-810). Sepsis can result in tissue damage, multiple organ failure, and subsequent death (Cohen, 2002, Nature 420,885-891). Approximately 30-50% of patients with sepsis still die despite maximal care. The mechanisms underlying this systemic, dysregulated inflammatory response are complex and likely involve multiple pathways. Therefore, sepsis cannot be effectively treated with antimicrobial agents alone. Indeed, despite the availability of antibiotics, current therapies for treating sepsis have proven ineffective. Neutralization of certain inflammatory cytokines also fails, highlighting the need for new treatments (Wenzel and Edmond, 2012, N Engl J Med 366, 2122-2124).

[0003] Septic shock occurs in a subset of patients with sepsis and is associated with increased mortality. The pathophysiology of septic shock is not precisely understood; it involves the underlying circulatory system, and cellular / metabolic abnormalities severe enough to substantially increase mortality. Patients with septic shock can be identified by the clinical presentation of sepsis, with persistent hypotension requiring vasopressors to maintain mean arterial pressure above 65 mmHg despite adequate volume resuscitation, inadequate organ perfusion, and serum lactate levels above 2 mmol / L (18 mg / dL) (Singer M et al. JAMA 2016;315(8):801-10).

[0004] Sepsis and septic shock have lasting effects on patients, including prolonged tissue hypoperfusion, which can lead to long-term neurological and cognitive sequelae.

[0005] In addition to bacterial infections, viral infections can also increase susceptibility to bacterial co-infections, predisposing patients to infections that can lead to sepsis or septic shock. For example, influenza patients frequently exhibit increased susceptibility to Streptococcus pneumoniae co-infection, and sepsis has been reported as a major cause of mortality during influenza pandemics. The detailed mechanisms by which viral infections predispose patients to bacterial infections and subsequent sepsis are not fully understood, and there is a need for therapies to treat and prevent sepsis and septic shock in patients with viral infections.

[0006] Tailored empty liposomes, such as empty liposomes composed of cholesterol and / or sphingomyelin, and their use for the treatment of bacterial infections have recently been described, acting as traps for virulence factors such as bacterial toxins, enzymes, and toxic appendages (WO2013 / 186286, Henry BD et al., Nat Biotechnol 2015;33(1):81-88, Azeredo da Silveira, S and Perez, A, Expert Rev. Anti Infect. Ther. 2015;13(5):531-533, Azeredo da Silveira, S. and Perez, A. Expert Rev Anti Infect Ther 2017;15:973-975). These tailored empty liposomes also exhibit antiviral activity and have therefore been described as a treatment against viral infections, in particular to neutralize enveloped viruses such as influenza viruses (WO2017 / 216282). Summary of the Invention

[0007] A preferred composition of the present invention showed surprisingly positive results in improving clinical signs and symptoms in a first-in-human study in patients with severe pneumonia. Furthermore, and importantly, the preferred composition of the present invention was surprisingly found to result in improved hemodynamic parameters, prevention of hemodynamic deterioration, and more rapid resolution of septic shock. As a result, the composition of the present invention was effective in treating sepsis and septic shock, as evidenced by faster normalization of hemodynamic instability, leading to patient recovery and faster discharge from the intensive care unit (ICU). Based on this promising efficacy data and its possible mechanism of action, further efficacy studies are warranted in patients with suspected or confirmed infection, regardless of pathogen, and showing signs of developing complications or severe illness, particularly those with community-acquired pneumonia, hospital-acquired pneumonia, ventilator-associated pneumonia, intra-abdominal infections, skin and soft tissue infections, urinary tract infections, or bacteremia. Furthermore, based on this encouraging efficacy data and its possible mechanism of action, the compositions of the present invention are believed to be particularly beneficial in the treatment and prevention of sepsis or septic shock caused by or associated with bacterial or viral pathogens that use specific lipid microdomains to attack the host, and therefore the animal, preferably the human patient.

[0008] Thus, in a first aspect, the present invention provides a composition for use in the treatment of sepsis, severe sepsis, septic shock or prolonged and severe hypotension, preferably persistent hypotension, in an animal, preferably a human, for use in the treatment of hypotension, preferably persistent hypotension, in septic shock, sepsis, severe sepsis, acute respiratory distress syndrome or acute lung injury, or for use in the treatment of toxic shock syndrome, comprising, preferably consisting of, a mixture of empty liposomes, said mixture of empty liposomes comprising, preferably consisting of, (a) first empty liposomes comprising cholesterol, the first empty liposomes having an amount of cholesterol of at least 30% (weight per weight), and (b) second empty liposomes comprising sphingomyelin.

[0009] In another aspect, the present invention provides a composition for use in treating sepsis, severe sepsis, septic shock, or prolonged and severe hypotension, preferably persistent hypotension, in an animal, preferably a human, comprising, preferably consisting of, a mixture of empty liposomes, said mixture of empty liposomes comprising, preferably consisting of, (a) first empty liposomes comprising cholesterol, wherein the first empty liposomes have an amount of cholesterol of at least 30% (weight per weight), and (b) second empty liposomes comprising sphingomyelin.

[0010] In a further aspect, the present invention provides a composition for use in treating septic shock in an animal, preferably a human, comprising, preferably consisting of, a mixture of empty liposomes comprising, preferably consisting of, (a) first empty liposomes comprising cholesterol, wherein the first empty liposomes have an amount of cholesterol of at least 30% (weight per weight), and (b) second empty liposomes comprising sphingomyelin.

[0011] As this description continues, further aspects and embodiments of the invention will become apparent. [Brief explanation of the drawings]

[0012] [Figure 1A] Evolution of cardiovascular SOFA scores from baseline (pre-dose) to day 8 in the placebo (diamonds), CAL02 low-dose (triangles), and CAL02 high-dose (squares) groups, expressed as absolute values, for the entire study population (Figure 1A) and for the entire study population excluding patients without hypotensive events (three patients in the CAL02 high-dose group), expressed as the difference in scores from baseline (Figure 1B). *p<0.05 [Figure 1B] Evolution of cardiovascular SOFA scores from baseline (pre-dose) to day 8 in the placebo (diamonds), CAL02 low-dose (triangles), and CAL02 high-dose (squares) groups, expressed as absolute values, for the entire study population (Figure 1A) and for the entire study population excluding patients without hypotensive events (three patients in the CAL02 high-dose group), expressed as the difference in scores from baseline (Figure 1B). *p<0.05 [Figure 2] Evolution of cardiovascular SOFA scores in patients already in septic shock at baseline, expressed as absolute values, from baseline (before administration) to day 8 in the placebo (diamonds), CAL02 low dose (triangles), and CAL02 high dose (squares) groups. DETAILED DESCRIPTION OF THE INVENTION

[0013] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs.

[0014] As used herein, the term "about" means ±5%. For example, about 50% means 47.5% to 52.5%. Preferably, as used herein, the term "about" means ±3%. For example, about 50% means 48.5% to 51.5%.

[0015] When the terms "a" or "an" are used herein, unless otherwise indicated, they mean "at least one." In particular, the use of the terms "a" or "an" in relation to a single empty liposome, the first empty liposome, and the second empty liposome to describe empty liposomes and mixtures of empty liposomes according to the present invention typically and preferably refers to a plurality of single empty liposomes, as well as mixtures of empty liposomes, including a plurality of the first empty liposomes and a plurality of the second empty liposomes.

[0016] All ranges of values ​​disclosed herein are intended to refer to all values ​​subsumed within that range, inclusive of the values ​​defining the range. For clarity, for example, a value of 12 to 13 is intended to refer to the value 12 or 13, or to all values ​​in the range 12 to 13.

[0017] The term "empty liposome" as used herein refers to a liposome, preferably an artificial liposome, having an average diameter of 20 nm to 10 μm, preferably 20 to 500 nm, more preferably 20 nm to 400 nm, and even more preferably 40 nm to 400 nm or 20 nm to 200 nm, and consisting of one or more phospholipid bilayers, and typically and preferably unilamellar and multilamellar vesicles, more preferably small unilamellar vesicles (SUVs). In a preferred embodiment, the term "empty liposome" as used herein typically and preferably refers to a liposome that does not incorporate a drug, typically and preferably refers to a liposome that does not incorporate a pharmaceutical drug. As used herein and referring to the empty liposomes of the present invention, "incorporated" typically and preferably means encapsulated within the cavity of the liposome, within the latent bilayer of the liposome, or as part of the membrane layer of the liposome. In another preferred embodiment, the term "empty liposome" as used herein typically and preferably refers to a liposome consisting of sphingomyelin and cholesterol according to the present invention, or consisting of sphingomyelin, and further comprising only a water-soluble inorganic compound and / or a water-soluble organic molecule, typically and preferably the water-soluble inorganic compound and / or the water-soluble organic molecule originating from the synthesis of the empty liposome of the present invention, typically and preferably the water-soluble inorganic compound is an inorganic salt preferably selected from NaCl, KCl, and MgCl, and the water-soluble organic molecule is a buffer, preferably selected from glucose and HEPES. Typically and preferably, the water-soluble inorganic compound and / or the water-soluble organic molecule are incorporated into the empty liposome of the present invention due to their presence during the production of the empty liposome of the present invention. In another preferred embodiment, the term "empty liposome" as used herein typically and preferably refers to a liposome consisting of sphingomyelin and cholesterol according to the present invention, or consisting of sphingomyelin, in which the empty liposome does not contain an antioxidant.In a further preferred embodiment, the term "empty liposome" as used herein typically and preferably refers to a liposome consisting of sphingomyelin and cholesterol according to the present invention, or consisting of sphingomyelin, and further comprising only water-soluble inorganic compounds and / or water-soluble organic molecules, typically and preferably the water-soluble inorganic compounds and / or water-soluble organic molecules originating from the synthesis of the empty liposome according to the present invention, and typically and preferably the water-soluble inorganic compounds are inorganic salts preferably selected from NaCl, KCl, MgCl2, and the water-soluble organic molecules are buffers, preferably the water-soluble organic molecules are selected from glucose and HEPES, and the empty liposomes consisting of sphingomyelin and cholesterol according to the present invention or consisting of sphingomyelin do not contain antioxidants.

[0018] Sepsis or septic shock: Sepsis is a disease with an infectious etiology and manifests as the pathology of the systemic inflammatory response syndrome (SIRS). It is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection (Levy M et al. Intensive Care Med 2003;29:530-38; Singer M et al. JAMA. 2016;315(8):801-810). Early symptoms include chills, sweating, fever, and hypotension. Increased levels of various inflammatory mediators and blood coagulation factors throughout the body lead to microcirculatory dysfunction, which worsens the condition and leads to septic shock, which includes organ perfusion abnormalities, uncontrollable hypotension, and multiple organ failure that can lead to death. The clinical manifestations of sepsis are persistent hypotension requiring vasopressors to maintain MAP ≥ 65 mmHg despite appropriate emergency fluid therapy, and serum lactate levels > 2 mmol / L (18 mg / dL). Therefore, the term "sepsis" as used herein refers to life-threatening organ dysfunction caused by a dysregulated host response to infection, as defined and recommended by Singer M et al. JAMA. 2016;315(8):801-810 (Recommendations; Box 3). Organ dysfunction can be identified as a sudden change in the total SOFA (Sequential [Sepsis-related] Organ Failure Assessment) score of ≥2 points resulting from infection. The baseline SOFA score can be assumed to be zero in patients without known pre-existing organ dysfunction. A SOFA score of ≥2 reflects an overall mortality risk of approximately 10% in the general hospital population with suspected infection. Even patients with moderate dysfunction can further deteriorate, highlighting the seriousness of this condition and the need for prompt and appropriate intervention if not already initiated.Patients with suspected infection who are likely to stay in the ICU for a long time or die in the hospital can be quickly identified as having a high likelihood of poor outcomes typical of sepsis if they have at least two of the following clinical criteria, which constitute a new bedside clinical score called the quick State of Emergency (qSOFA): respiratory rate ≥ 22 / min, impaired consciousness (i.e., altered mental status), or systolic blood pressure ≤ 100 mmHg. As used herein and as defined and recommended by Singer M et al. JAMA. 2016;315(8):801-810 (Recommendations; Box 3), the term "septic shock" is a subset of sepsis in which the underlying circulatory and cellular / metabolic abnormalities are severe enough to significantly increase mortality, resulting in a higher risk of mortality than sepsis alone. Patients with septic shock can be identified by the clinical presentation of sepsis, with persistent hypotension requiring vasopressors to maintain a mean arterial pressure (MAP) of ≥65 mmHg and a serum lactate level >2 mmol / L (18 mg / dL) despite adequate emergency fluid therapy (and therefore in the absence of hypovolemia). With these criteria, hospital mortality exceeds 40%.

[0019] Animal: As used herein, the term "animal" refers to living multi-cellular vertebrate organisms, a category that includes mammals and birds. The term mammal includes both human and non-human mammals. Similarly, the term "subject" includes both human and veterinary subjects.

[0020] As used herein, the terms "treat," "treatment," or "therapy" refer to a means of achieving a desired physiological effect. The effect may be therapeutic in terms of partially or completely curing a disease or condition and / or symptoms resulting from the disease or condition, including ameliorating the signs or symptoms of a disease or pathological condition, such as sepsis or septic shock, such as reducing fever or stabilizing blood pressure in a subject with septic shock, or improving symptoms such as chills, sweating, or increased organ function. The term "treat," as used herein in its broadest sense, includes and refers to the "prevention" of a disease. "Preventing" or "prevention" of a disease refers to arresting a disease or condition, such as sepsis or septic shock, i.e., arresting the partial or complete development of a disease, such as sepsis or septic shock, in, for example, a bacterial infection or a person at risk of bacterial infection. Thus, the term "treat," as used herein in its preferred sense, for purposes of its definition and for characterizing preferred aspects and embodiments of the present invention, does not exclude and should not refer to the "prevention" of a disease. In other embodiments and aspects of the present invention, the compositions and methods of use of the present invention are used to delay or prevent the onset of sepsis or septic shock, particularly in animals, preferably humans, at risk of sepsis or septic shock. Thus, the method involves selecting a human patient at risk for sepsis or septic shock, typically and preferably caused by an infection, and administering one or more of the compositions disclosed herein to the patient. The human patient may, for example, be someone who is intubated, i.e., under invasive mechanical ventilation, or who has been exposed to certain bacteria, such as Streptococcus pneumoniae or Staphylococcus aureus.

[0021] Patients at risk of sepsis were well described by Singer et al. (2016, JAMA): Two of three clinical variables—Glasgow Coma Scale score ≤13, systolic blood pressure ≤100 mmHg, and respiratory rate ≥22 breaths per minute—provide predictive validity similar to the full SOFA score outside the ICU. This model was found to be robust in multiple sensitivity analyses, including a simpler assessment of impaired consciousness (Glasgow Coma Scale score <15), and in out-of-hospital, emergency department, and hospital room settings within both US and non-US datasets. For patients suspected of infection in the ICU, the SOFA score has better predictive validity than this model and may reflect the modifying effects of interventions (e.g., vasopressors, sedatives, mechanical ventilation).

[0022] A "therapeutically effective amount" is the amount of a composition that achieves a desired effect in a treated subject. For example, this may be the amount necessary to inhibit septic shock, reduce fever, or prevent multiple organ failure in an animal, preferably a human patient, such as a patient with pneumonia and / or infected with Streptococcus pneumoniae. When administered to an animal, preferably a human patient, a dosage that achieves effective target tissue concentrations is generally used.

[0023] As used herein, a "therapeutic dose" refers to a dose known to those skilled in the art to have a therapeutic effect.

[0024] The term "pneumonia" as used herein shall encompass "community-acquired pneumonia" (CAP), "hospital-acquired pneumonia" (HAP) or "ventilator-associated pneumonia" (VAP).

[0025] The term "community-acquired pneumonia" or "CAP" is known to those skilled in the art; see, e.g., the IDSA / ATS Guidelines for CAP in Adults (CID 2007:44(Suppl 2)S27). In particular, this term refers to pneumonia acquired outside of a hospital.

[0026] The term "hospital-acquired pneumonia (HAP)" refers to pneumonia acquired during or after hospitalization for another illness or procedure, with onset at least 48 to 72 hours after admission.

[0027] As defined herein, "ventilator-associated pneumonia (VAP)" is pneumonia that develops after 48 hours or more of mechanical ventilation and is characterized by invasion of the lower airways and lung parenchyma by microorganisms. VAP is a potentially serious condition.

[0028] Pneumonia is caused by infection with a wide range of microorganisms, including bacteria such as Streptococcus pneumoniae, Haemophilus influenzae, Legionella pneumophilia, Staphylococcus aureus, and Pseudomonas aeruginosa for CAP, and gram-negative bacteria such as Pseudomonas aeruginosa and Serratia marcescens for HAP, and Staphylococcus aureus, Klebsiella pneumoniae, Escherichia coli, Stenotrophomonas maltophilia, Acinetobacter species, and Haemophilus influenzae for HAP (Cilloniz et al., Thorax, 2011). Apr;66(4):340-6 and Jones RN. Clin Infect Dis 2010 Aug;51(Suppl 1):S81-7).

[0029] The term "severe community-acquired pneumonia" or "sCAP" is known to those skilled in the art. In particular, the term "severe community-acquired pneumonia" or "sCAP" refers to a subgroup of severe community-acquired pneumonia requiring intensive care. The Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) have published guidelines for the management of CAP, including a definition of sCAP (see Mandell et al., 2007, Infectious Diseases Society of America / American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults, Clin. Inf. Dis. 2007:44:S27-72 (Suppl 2), Table 4). According to the IDSA / ATS guidelines, sCAP is defined as CAP requiring intensive care. Admission to an intensive care unit is recommended if a CAP patient exhibits one or both of the two major criteria or if the three minor criteria listed in Example 1 and affected in this study are present.

[0030] As used herein, the term "for use" as used in "a composition for use in the treatment of a disease" is also intended to disclose the corresponding method of treatment and the use of the formulation for the manufacture of a medicament for the treatment of the corresponding disease.

[0031] In one aspect, the present invention provides a composition for use in treating septic shock in an animal, preferably a human, comprising, preferably consisting of, a mixture of empty liposomes comprising, preferably consisting of, (a) first empty liposomes comprising cholesterol, wherein the first empty liposomes have an amount of cholesterol of at least 30% (weight per weight), and (b) second empty liposomes comprising sphingomyelin.

[0032] In another aspect, the present invention provides a composition for use in treating hypotension, preferably persistent hypotension, in an animal, preferably a human, comprising, preferably consisting of, a mixture of empty liposomes comprising, preferably consisting of, (a) first empty liposomes comprising cholesterol, wherein the first empty liposomes have an amount of cholesterol of at least 30% (weight per weight), and (b) second empty liposomes comprising sphingomyelin, and wherein the hypotension, preferably the persistent hypotension, is associated with septic shock.

[0033] In a further aspect, the present invention provides a composition for use in the treatment of sepsis, severe sepsis, septic shock or prolonged and severe hypotension, preferably persistent hypotension, in an animal, preferably a human, for use in the treatment of hypotension, preferably persistent hypotension, in septic shock, sepsis, severe sepsis, acute respiratory distress syndrome or acute lung injury, or for use in the treatment of toxic shock syndrome, comprising, preferably consisting of, a mixture of empty liposomes, said mixture of empty liposomes comprising, preferably consisting of, (a) first empty liposomes comprising cholesterol, wherein the amount of cholesterol is at least 30% (weight per weight), and (b) second empty liposomes comprising sphingomyelin.

[0034] In another aspect, the present invention provides a composition for use in treating sepsis, severe sepsis, septic shock, or prolonged and severe hypotension, preferably persistent hypotension, in an animal, preferably a human, comprising, preferably consisting of, a mixture of empty liposomes, said mixture of empty liposomes comprising, preferably consisting of, (a) first empty liposomes comprising cholesterol, wherein the first empty liposomes have an amount of cholesterol of at least 30% (weight per weight), and (b) second empty liposomes comprising sphingomyelin.

[0035] In a further aspect, the present invention provides a composition for use in treating sepsis or severe septicemia in an animal, preferably a human, comprising, preferably consisting of, a mixture of empty liposomes, said mixture of empty liposomes comprising, preferably consisting of, (a) first empty liposomes comprising cholesterol, wherein the first empty liposomes have an amount of cholesterol of at least 30% (weight per weight), and (b) second empty liposomes comprising sphingomyelin.

[0036] In a further aspect, the present invention provides a composition for use in treating septic shock in an animal, preferably a human, comprising, preferably consisting of, a mixture of empty liposomes comprising, preferably consisting of, (a) first empty liposomes comprising cholesterol, wherein the first empty liposomes have an amount of cholesterol of at least 30% (weight per weight), and (b) second empty liposomes comprising sphingomyelin.

[0037] In a further aspect, the present invention provides a composition for use in treating prolonged and severe hypotension, preferably persistent hypotension, in an animal, preferably a human, comprising, preferably consisting of, a mixture of empty liposomes, said mixture of empty liposomes comprising, preferably consisting of, (a) first empty liposomes comprising cholesterol, wherein the first empty liposomes have an amount of cholesterol of at least 30% (weight per weight), and (b) second empty liposomes comprising sphingomyelin.

[0038] In a further aspect, the present invention provides a composition for use in treating hypotension, preferably persistent hypotension, in septic shock, sepsis, severe sepsis, acute respiratory distress syndrome or acute lung injury in an animal, preferably a human, comprising, preferably consisting of, a mixture of empty liposomes, said mixture of empty liposomes comprising, preferably consisting of, (a) first empty liposomes comprising cholesterol, wherein the first empty liposomes have an amount of cholesterol of at least 30% (weight per weight), and (b) second empty liposomes comprising sphingomyelin.

[0039] In a further aspect, the present invention provides a composition for use in treating persistent hypotension in septic shock in an animal, preferably a human, comprising, preferably consisting of, a mixture of empty liposomes, said mixture of empty liposomes comprising, preferably consisting of, (a) first empty liposomes comprising cholesterol, wherein the first empty liposomes have an amount of cholesterol of at least 30% (weight per weight), and (b) second empty liposomes comprising sphingomyelin.

[0040] In a further aspect, the present invention provides a composition for use in treating hypotension, preferably persistent hypotension, in septic shock in an animal, preferably a human, comprising, preferably consisting of, a mixture of empty liposomes, said mixture of empty liposomes comprising, preferably consisting of, (a) first empty liposomes comprising cholesterol, wherein the first empty liposomes have an amount of cholesterol of at least 30% (weight per weight), and (b) second empty liposomes comprising sphingomyelin.

[0041] In a further aspect, the present invention provides a composition for use in treating persistent hypotension in septic shock in a human, comprising, preferably consisting of, a mixture of empty liposomes, the mixture of empty liposomes comprising, preferably consisting of, (a) first empty liposomes comprising cholesterol, the first empty liposomes having an amount of cholesterol of at least 30% (weight per weight), and (b) second empty liposomes comprising sphingomyelin.

[0042] In a further aspect, the present invention provides a composition for use in treating hypotension, preferably persistent hypotension, in sepsis or severe septicemia in an animal, preferably a human, comprising, preferably consisting of, a mixture of empty liposomes, said mixture of empty liposomes comprising, preferably consisting of, (a) first empty liposomes comprising cholesterol, wherein the first empty liposomes have an amount of cholesterol of at least 30% (weight per weight), and (b) second empty liposomes comprising sphingomyelin.

[0043] In a further aspect, the present invention provides a composition for use in treating toxic shock syndrome in an animal, preferably a human, comprising, preferably consisting of, a mixture of empty liposomes, said mixture of empty liposomes comprising, preferably consisting of, (a) first empty liposomes comprising cholesterol, wherein the first empty liposomes have an amount of cholesterol of at least 30% (weight per weight), and (b) second empty liposomes comprising sphingomyelin.

[0044] In a further aspect and highly preferred embodiment, the present invention provides a composition of the present invention for use in treating hypotension, preferably persistent hypotension, in said animal, preferably said human, with sepsis. In a further aspect and highly preferred embodiment, the present invention provides a composition of the present invention for use in treating hypotension, preferably persistent hypotension, in said human, with sepsis. In a further aspect and highly preferred embodiment, the present invention provides a composition of the present invention for use in treating persistent hypotension in said human, with sepsis.

[0045] In a further aspect and highly preferred embodiment, the present invention provides a composition of the invention for use in treating hypotension, preferably persistent hypotension, in said animal, preferably said human, with septic shock. In a further aspect and highly preferred embodiment, the present invention provides a composition of the invention for use in treating hypotension, preferably persistent hypotension, in said human, with septic shock. In a further aspect and highly preferred embodiment, the present invention provides a composition of the invention for use in treating persistent hypotension in said human, with septic shock.

[0046] In another aspect, the present invention provides a method of treating sepsis or septic shock, preferably septic shock, in an animal, preferably a human, in need thereof, said method comprising administering a therapeutically effective amount of a composition as defined in the accompanying claims. Preferably, said human patient has pneumococcal pneumonia or said sepsis or septic shock, preferably septic shock, caused by pneumococcal pneumonia.

[0047] For all aspects and embodiments disclosed herein, a therapeutically effective amount of a composition of the invention is typically and preferably used for the disclosed treatment.

[0048] Furthermore, all embodiments and preferred embodiments disclosed herein are to be understood as embodiments and preferred embodiments for any and all aspects of the present invention.

[0049] In an initial study, a preferred composition of the present invention and standard antibiotic therapy were compared with placebo and standard antibiotic therapy in adult patients admitted to the intensive care unit (ICU) for severe community-acquired pneumococcal pneumonia. Two different doses of the preferred composition of the present invention were compared: a low dose (4 mg / kg-low dose) and a high dose (16 mg / kg-high dose). Results demonstrated a synergistic effect between the preferred composition of the present invention (designated CAL02) and antibiotic therapy.

[0050] As a result, preferred compositions of the present invention synergistically capture and neutralize toxins released by a wide range of bacteria associated with severe infections in conjunction with antibiotic treatment of human patients. Preferred compositions of the present invention act regardless of the resistance profile of the target pathogen and do not induce the emergence of resistance.

[0051] In a preferred embodiment, the second empty liposome (b) comprises only the sphingomyelin as a lipid component. In a preferred embodiment, the second empty liposome (b) consists of sphingomyelin.

[0052] In a preferred embodiment, the amount of cholesterol in the first empty liposome (a) is 30% to 70% (weight per weight), preferably, the amount of cholesterol in the first empty liposome (a) is 35% to 60% (weight per weight).

[0053] In a preferred embodiment, the amount of cholesterol in the empty liposome (a) is 45% to 55% (weight per weight), preferably the amount of cholesterol in the empty liposome (a) is about 50% (weight per weight).

[0054] In a preferred embodiment, the first empty liposome (a) consists of cholesterol and sphingomyelin, and preferably the amount of cholesterol in the empty liposome (a) is 45% to 55% (weight per weight), and more preferably the amount of cholesterol in the empty liposome (a) is about 50% (weight per weight).

[0055] In a preferred embodiment, the first empty liposome (a) contains only the cholesterol and the sphingomyelin as lipid components.

[0056] In a preferred embodiment, the amount of cholesterol in the empty liposome (a) is 45% to 55% (weight per weight), preferably the amount of cholesterol in the empty liposome (a) is about 50% (weight per weight), and the second empty liposome (b) consists of sphingomyelin.

[0057] In a preferred embodiment, the first empty liposome (a) consists of cholesterol and sphingomyelin, the amount of cholesterol in the empty liposome (a) is 45% to 55% (weight per weight), preferably the amount of cholesterol in the empty liposome (a) is about 50% (weight / weight), and the second empty liposome (b) consists of sphingomyelin.

[0058] In a preferred embodiment, the first empty liposome (a) consists of cholesterol and sphingomyelin, the amount of cholesterol in the empty liposome (a) is 45% to 55% (weight per weight), preferably the amount of cholesterol in the empty liposome (a) is about 50% (weight per weight), the first empty liposome (a) contains only cholesterol and sphingomyelin as lipid components, and the second empty liposome (b) consists of sphingomyelin.

[0059] In a preferred embodiment, the mixture of empty liposomes comprises at least 20% (weight per weight) of the first(a) and second(b) empty liposomes, preferably the mixture of empty liposomes comprises at least 30% (weight per weight) of the first(a) and second(b) empty liposomes.

[0060] In a preferred embodiment, said mixture of empty liposomes comprises at least 40% (weight per weight) of said first(a) and said second(b) empty liposomes.

[0061] In a preferred embodiment, the first empty liposome (a) consists of cholesterol and sphingomyelin, more preferably the amount of cholesterol in the empty liposome (a) is about 50% (weight per weight), and the mixture of empty liposomes comprises at least 40%, preferably at least 45% (weight per weight) of the first (a) and the second (b) empty liposomes.

[0062] In a preferred embodiment, the first empty liposome (a) consists of a 1:1 (weight per weight - w / w) mixture of the first empty liposome and the second liposome, the first empty liposome being composed of cholesterol and sphingomyelin in a 1:1 weight ratio (1:1 w / w, 35:65 molar ratio), and the second empty liposome being composed of sphingomyelin alone.

[0063] In a preferred embodiment, the first empty liposome (a) consists of a 1:1 (weight per weight - w / w) mixture of the first empty liposome and the second liposome, the first empty liposome being composed of cholesterol and sphingomyelin in a 1:1 weight ratio (1:1 w / w, 35:65 molar ratio), and the second empty liposome being composed solely of sphingomyelin, the first empty liposome (a) comprising only the cholesterol and the sphingomyelin as lipid components, and the second empty liposome (b) comprising only the sphingomyelin as lipid component.

[0064] In a preferred embodiment, the first empty liposomes have an average diameter of about 130 nm and the second empty liposomes have an average diameter of about 90 nm.

[0065] In a preferred embodiment the composition is for use in the treatment of hypotension, preferably persistent hypotension, in septic shock, sepsis, severe sepsis, acute respiratory distress syndrome or acute lung injury, preferably for use in the treatment of hypotension, preferably persistent hypotension, in septic shock, wherein said hypotension, preferably said persistent hypotension, is associated with a systolic blood pressure <90 mmHg or a mean arterial pressure <70 mmHg.

[0066] In a preferred embodiment the composition is for use in the treatment of hypotension, preferably persistent hypotension, in septic shock, sepsis, severe sepsis, acute respiratory distress syndrome or acute lung injury, preferably for use in the treatment of hypotension, preferably persistent hypotension, in septic shock, wherein said hypotension, preferably said persistent hypotension, is associated with a systolic blood pressure <90 mmHg.

[0067] In a preferred embodiment the composition is for use in the treatment of hypotension, preferably persistent hypotension, in septic shock, sepsis, severe sepsis, acute respiratory distress syndrome or acute lung injury, preferably for use in the treatment of hypotension, preferably persistent hypotension, in septic shock, wherein the hypotension, preferably persistent hypotension, is associated with a mean arterial pressure <70 mmHg.

[0068] In a preferred embodiment the composition is for use in the treatment of hypotension, preferably persistent hypotension, in septic shock, sepsis, severe sepsis, acute respiratory distress syndrome or acute lung injury, preferably for use in the treatment of hypotension, preferably persistent hypotension, in septic shock, wherein the hypotension, preferably persistent hypotension, is associated with a systolic blood pressure <90 mmHg or a mean arterial pressure <70 mmHg, and wherein the hypotension, preferably persistent hypotension, is pretreated with a vasopressor for at least 2 hours.

[0069] In a preferred embodiment the composition is for use in the treatment of hypotension, preferably persistent hypotension, in septic shock, sepsis, severe sepsis, acute respiratory distress syndrome or acute lung injury, preferably for use in the treatment of hypotension, preferably persistent hypotension in septic shock, wherein the hypotension, preferably the persistent hypotension, is associated with a systolic blood pressure <90 mmHg or a mean arterial pressure <70 mmHg, and wherein the hypotension, preferably persistent hypotension, has been pretreated with a vasopressor for at least 2 hours after fluid resuscitation.

[0070] In a preferred embodiment the composition is for use in the treatment of hypotension, preferably persistent hypotension, in septic shock, sepsis, severe sepsis, acute respiratory distress syndrome or acute lung injury, preferably for use in the treatment of hypotension, preferably persistent hypotension in septic shock, wherein said hypotension, preferably said persistent hypotension, is associated with a systolic blood pressure <90 mmHg or a mean arterial pressure <70 mmHg, and wherein said hypotension, preferably persistent hypotension, has been pretreated for at least 2 hours with at least one, preferably one vasopressor agent in a therapeutic dose.

[0071] In a preferred embodiment, the composition is for use in the treatment of hypotension, preferably persistent hypotension, in septic shock, sepsis, severe sepsis, acute respiratory distress syndrome or acute lung injury, preferably for use in the treatment of hypotension, preferably persistent hypotension, in septic shock, wherein said hypotension, preferably said persistent hypotension, is associated with a systolic blood pressure <90 mmHg or a mean arterial pressure <70 mmHg, and wherein said hypotension, preferably said persistent hypotension, has been pretreated for at least 2 hours with at least one, preferably one, vasopressor agent at a therapeutic dose, wherein said vasopressor agent is selected from dopamine, epinephrine, norepinephrine, phenylephrine or vasopressin.

[0072] In a preferred embodiment, the composition is for use in the treatment of hypotension, preferably persistent hypotension, in septic shock, sepsis, severe sepsis, acute respiratory distress syndrome or acute lung injury, preferably for use in the treatment of hypotension, preferably persistent hypotension, in septic shock, wherein the hypotension, preferably persistent hypotension, is associated with a systolic blood pressure <90 mmHg or a mean arterial pressure <70 mmHg, and wherein the hypotension, preferably persistent hypotension, has been pretreated for at least 2 hours with at least one, preferably one vasopressor agent at a therapeutic dose, wherein the therapeutic dose of the vasopressor agent is >5 mg / kg / min of dopamine or a corresponding dose of the vasopressor agent or, preferably, a corresponding dose of epinephrine, norepinephrine, phenylephrine or vasopressin.

[0073] In a preferred embodiment, the composition is for use in the treatment and prevention of septic shock. In a preferred embodiment, the composition is for use in the treatment of hypotension, preferably persistent hypotension. In a preferred embodiment, the hypotension, preferably persistent hypotension, is associated with septic shock. In a preferred embodiment, the composition is for use in the treatment of persistent hypotension. In a preferred embodiment, the persistent hypotension is associated with septic shock.

[0074] In a preferred embodiment, the hypotension, preferably the persistent hypotension, is associated with a systolic blood pressure <90 mmHg (or a mean arterial pressure <70 mmHg). In a preferred embodiment, the hypotension, preferably the persistent hypotension, is associated with a systolic blood pressure <90 mmHg (or a mean arterial pressure <70 mmHg) despite treatment with a therapeutic dose (i.e., dopamine >5 mg / kg / min or any dose of epinephrine, norepinephrine, phenylephrine or vasopressin) for at least 2 hours after adequate fluid resuscitation.

[0075] In a preferred embodiment, the treatment is adjunctive to antibiotic therapy, preferably standard antibiotic therapy. In a preferred embodiment, the antibiotic of the antibiotic therapy, preferably the standard antibiotic therapy, is selected from the group consisting of ceftriaxone, spiramycin, amoxicillin, amoxicillin / clavulanic acid, gentamicin, piperacillin / tazobactam, cefuroxime, penicillin, azithromycin, clarithromycin, erythromycin, doxycycline, cefotaxime, ampicillin, ertapenem, cefepime, imipenem, meropenem, Preferably, the antibiotic of the antibiotic therapy, preferably the antibiotic of the standard antibiotic therapy, is selected from ceftriaxone, spiramycin, amoxicillin, gentamicin, levofloxacin, piperacillin / tazobactam, amoxicillin / clavulanic acid, cefuroxime, and penicillin. In a preferred embodiment, the antibiotic therapy, preferably the standard antibiotic therapy, is intravenous (IV) or oral antibiotic therapy, preferably the standard antibiotic therapy.

[0076] In a preferred embodiment, the human patient has pneumonia, preferably the pneumonia is selected from community-acquired pneumonia (CAP), hospitalization-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP). In a preferred embodiment, the human patient has pneumonia, and the pneumonia is community-acquired pneumonia (CAP). In a preferred embodiment, the human patient has pneumonia, and the pneumonia is hospitalization-acquired pneumonia (HAP). In a preferred embodiment, the human patient has pneumonia, and the pneumonia is ventilator-associated pneumonia (VAP). In a preferred embodiment, the human patient has pneumonia, and the pneumonia is severe pneumonia, preferably severe community-acquired pneumonia (sCAP) or severe community-acquired pneumococcal pneumonia (sCAPP). In a preferred embodiment, the human patient has pneumonia, and the pneumonia is community-acquired pneumonia (CAP) or community-acquired pneumococcal pneumonia (CAPP).

[0077] In preferred embodiments, the human patient has pneumonia, and the pneumonia is caused by Streptococcus pneumoniae, Staphylococcus aureus, Pseudomonas aeruginosa, Enterococcus faecium, Legionella pneumophila, Haemophilus influenzae, Klebsiella pneumoniae, Escherichia coli, Acinetobacter baumannii, Bordetella pertussis, Serratia marcescens, Stenotrophomonas maltophilia, Moraxella catarrhalis, or Mycobacterium tuberculosis. In a preferred embodiment, the human patient has pneumonia, and the pneumonia is a severe pneumonia caused by Streptococcus pneumoniae, Staphylococcus aureus, Pseudomonas aeruginosa, Enterococcus faecium, Legionella pneumophila, Haemophilus influenzae, Klebsiella pneumoniae, Escherichia coli, Acinetobacter baumannii, Bordetella pertussis, Serratia marcescens, Stenotrophomonas maltophilia, Moraxella catarrhalis, or Mycobacterium tuberculosis, and preferably, the pneumonia, preferably the severe pneumonia, is ... Preferably, the pneumonia, preferably the severe pneumonia, is caused by Streptococcus pneumoniae, Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecium, Haemophilus influenzae, Klebsiella pneumoniae, Escherichia coli, Acinetobacter baumannii, Bordetella pertussis, Moraxella catarrhalis, or Mycobacterium tuberculosis, and more preferably, the pneumonia, preferably the severe pneumonia, is caused by Streptococcus pneumoniae, Staphylococcus aureus, Klebsiella pneumoniae, or Pseudomonas aeruginosa, and even more preferably, the pneumonia, preferably the severe pneumonia, is caused by Streptococcus pneumoniae.

[0078] In a preferred embodiment, the composition is in the form of a solution for intravenous administration, preferably intravenous infusion, and comprises 10 to 40 grams of the empty liposome mixture per liter of solution, preferably 10 to 20 grams of the empty liposome mixture per liter of solution.

[0079] In a preferred embodiment, the infusion time for the intravenous administration is up to 3 hours, and preferably, the infusion time for the intravenous administration is 10 minutes to 2 hours.

[0080] In a preferred embodiment, the composition is administered in at least two doses, a first dose and a second dose, and the interval between the first dose and the second dose is 6 to 96 hours, preferably 12 to 72 hours, more preferably 24 to 48 hours, and even more preferably 24 or 48 hours.

[0081] In a preferred embodiment, the composition is administered in two to four doses, preferably two doses over a 12 to 72 hour period, more preferably two doses over a 24 to 48 hour period, preferably 24 or 48 hour intervals.

[0082] In a preferred embodiment, the composition is administered to the human patient in at least two doses, a first dose and a second dose, the interval between the first dose and the second dose being 20 to 28 hours, preferably 24 hours.

[0083] In a preferred embodiment, the composition is administered to the human patient in at least two doses, a first dose and a second dose, with an interval of 20 to 28 hours, preferably 24 hours, between the administration of the first dose and the administration of the second dose.

[0084] In a preferred embodiment, each of the doses is 1 mg / kg to 64 mg / kg, preferably 2 mg / kg to 32 mg / kg, more preferably 3 to 25 mg / kg, and even more preferably 4 mg / kg to 16 mg / kg.

[0085] In a preferred embodiment, each of the doses is 2 mg / kg to 8 mg / kg, preferably 2 mg / kg to 6 mg / kg, more preferably 3 to 5 mg / kg, and even more preferably 4 mg / kg.

[0086] In a preferred embodiment, each of said doses is 10 mg / kg to 22 mg / kg, preferably 12 mg / kg to 20 mg / kg, more preferably 14 mg / kg to 18 mg / kg, and even more preferably 16 mg / kg.

[0087] In a preferred embodiment, the composition is administered in the form of an intravenous solution.

[0088] In a preferred embodiment, the composition is administered to the human patient in at least two doses, preferably a first dose and a second dose, with an interval of 20 to 48 hours, preferably 24 hours, between the administration of the first dose and the administration of the second dose, and the composition is in the form of a solution for intravenous administration.

[0089] In a preferred embodiment the composition is for use in the treatment of sepsis, severe sepsis, septic shock or prolonged and severe hypotension, preferably persistent hypotension, preferably the composition is for use in the treatment of septic shock in an animal, preferably a human, wherein the sepsis, severe sepsis, septic shock or prolonged and severe hypotension, preferably persistent hypotension, preferably septic shock requires hospitalization.

[0090] In a preferred embodiment, the composition is for use in the treatment of sepsis, septic shock, or hypotension, preferably persistent hypotension, in an animal, preferably a human.

[0091] In a preferred embodiment, the composition is for use in treating sepsis, septic shock, or hypotension, preferably persistent hypotension, in a human. In a highly preferred embodiment, the composition is for use in treating sepsis in a human. In a highly preferred embodiment, the composition is for use in treating septic shock in a human. In a highly preferred embodiment, the composition is for use in treating hypotension, preferably persistent hypotension, in a human. In a preferred embodiment, the sepsis, septic shock, or the hypotension, preferably persistent hypotension, requires hospitalization of the human, preferably in an intensive care unit (ICU) of a hospital.

[0092] In a preferred embodiment the composition is for use in the treatment of sepsis, severe sepsis, septic shock or prolonged and severe hypotension, preferably persistent hypotension, preferably the composition is for use in the treatment of septic shock in an animal, preferably a human, wherein the sepsis, severe sepsis, septic shock or prolonged and severe hypotension, preferably persistent hypotension, preferably septic shock requires admission to an intensive care unit (ICU), preferably in an intensive care unit (ICU) of a hospital.

[0093] In a preferred embodiment, the composition is for use in the treatment of sepsis, severe sepsis, septic shock, or prolonged and severe hypotension, preferably persistent hypotension, preferably the composition is for use in the treatment of septic shock in an animal, preferably a human, wherein the sepsis, severe sepsis, septic shock, or prolonged and severe hypotension, preferably persistent hypotension, preferably septic shock, requires hospitalization and wherein the treatment shortens the duration of the hospitalization compared to hospitalization in the absence of such treatment.

[0094] In a preferred embodiment, the treatment reduces hospital stay by at least 1 day, preferably 2 days, more preferably 3 days, even more preferably 4 days, even more preferably 5 days, even more preferably 6 days, even more preferably 7 days, even more preferably 8 days, and even more preferably 9 days. In a preferred embodiment, the hospital stay is at most 18 days.

[0095] In a preferred embodiment, the composition is for use in the treatment of sepsis, severe sepsis, septic shock, or prolonged and severe hypotension, preferably persistent hypotension, preferably the composition is for use in the treatment of septic shock in an animal, preferably a human, wherein the sepsis, severe sepsis, septic shock, or prolonged and severe hypotension, preferably persistent hypotension, preferably septic shock, requires admission to an intensive care unit (ICU), preferably to an intensive care unit (ICU) of a hospital, and wherein the treatment reduces the length of stay in the intensive care unit (ICU) compared to admission to the intensive care unit (ICU) in the absence of such treatment.

[0096] In a preferred embodiment, the reduction in length of stay in the intensive care unit (ICU) is at least 1 day, preferably 2 days, more preferably 3 days, even more preferably 4 days, even more preferably 5 days, even more preferably 6 days, and even more preferably 7 days. In a preferred embodiment, the length of stay in the intensive care unit (ICU) is at most 18 days.

[0097] In a preferred embodiment, the composition is for use in the treatment of sepsis, severe sepsis, septic shock, or prolonged and severe hypotension, preferably persistent hypotension, preferably the composition is for use in the treatment of septic shock in an animal, preferably a human, wherein the sepsis, severe sepsis, septic shock, or prolonged and severe hypotension, preferably persistent hypotension, preferably septic shock, is cured in a shorter time compared to in the absence of such treatment.

[0098] In preferred embodiments, the shorter healing time is at least 1 day shorter, preferably 2 days shorter, or more preferably at least 3 days shorter, even more preferably at least 4 days, even more preferably at least 5 days, even more preferably at least 6 days, and even more preferably at least 7 days shorter.

[0099] In a preferred embodiment, the composition is for use in the treatment of sepsis, severe sepsis, septic shock, or prolonged and severe hypotension, preferably persistent hypotension, preferably the composition is for use in the treatment of septic shock in an animal, preferably a human, wherein the treatment reduces the cardiovascular SOFA score compared to the cardiovascular SOFA score in the absence of such treatment.

[0100] In a preferred embodiment, the composition is for use in the treatment of sepsis, severe sepsis, septic shock, or prolonged and severe hypotension, preferably persistent hypotension, preferably the composition is for use in the treatment of septic shock in an animal, preferably a human, wherein the treatment reduces the cardiovascular SOFA score compared to the cardiovascular SOFA in the absence of such treatment, wherein the reduction is at least 50%, preferably at least 60%, more preferably at least 70%, and even more preferably at least 80% 7 days after initiation of the treatment, 6 days after initiation of the treatment, and more preferably 5 days after initiation of the treatment. [Example]

[0101] Liposomes: Sphingomyelin from egg yolk (CAS No. 85187-10-6) was purchased from Sigma (S0756), Avanti Polar Lipids (860061) or Lipoid GmbH. Cholesterol from wool grease (CAS No. 57-88-5) was purchased from Sigma (C-8667), Avanti Polar Lipids (70000) or Dishman Netherlands BV. According to the present invention, the sphingomyelin and cholesterol contained in or consisting of the inventive mixture of empty liposomes can be obtained from the above natural sources or by chemical synthesis.

[0102] Liposome preparation: Unilamellar sphingomyelin:cholesterol (35:65 molar ratio) and sphingomyelin-only (100%) liposomes were prepared using sonication or microfluidization (e.g., high-pressure homogenization or following a hydration, extrusion, and diafiltration process protocol).

[0103] Sonication: Lipids were individually dissolved in chloroform at a concentration of 1 mg / ml and stored at -20°C. For liposome preparation, chloroform solutions of individual lipids were routinely mixed in the appropriate proportions to produce a final solution of 50–500 μl. The chloroform was allowed to completely evaporate at 60°C for 20–50 min. 50 μl or 100 μl of Tyrode's buffer (140 mM NaCl, 5 mM KCl, 1 mM MgCl, 10 mM glucose, 10 mM HEPES, pH = 7.4) containing 2.5 mM CaCl was added to the tube containing the dried lipid film and vortexed vigorously. The lipid suspension was incubated in an Eppendorf thermomixer at 45°C for 20–30 min with vigorous shaking. To produce liposomes, the final lipid suspension was sonicated for 3 x 5 s at 6°C at 70% power in a Bandelin Sonopuls sonicator. The liposome preparation was left at 6°C for at least 1 hour before use in experiments.

[0104] Hydration, Extrusion, and Diafiltration Process Protocol: Alternatively, each liposome formulation was produced by ethanol hydration and extrusion. Lipids were dissolved separately in ethanol and t-butanol and mixed at elevated temperatures (approximately 55 °C). The lipid solution was then added to PBS buffer (sodium chloride, monosodium phosphate, dihydrate, and disodium phosphate, dihydrate, dissolved in water for injection during mixing, adjusted to pH 7.0-7.4 with either hydrochloric acid (HCl) or sodium hydroxide (NaOH), as needed, and filtered through a 0.2 µm filter) and mixed at elevated temperatures (approximately 65 °C) for approximately 30 minutes. The resulting process fluid was then repeatedly extruded through a series of polycarbonate track-etched membranes at elevated pressures and temperatures (approximately 65 °C) until the desired particle size, as measured by dynamic light scattering, was achieved (example extruder: LIPEX® extruder). The resulting process fluid was then concentrated approximately two-fold using a 100,000 molecular weight cutoff hollow fiber cartridge and then diafiltered against approximately 10 volume changes of PBS buffer solution to remove ethanol and t-butanol. At the end of diafiltration, the process fluid was concentrated approximately 30% and then diluted to the target lipid concentration. Prior to dilution, the process fluid was filtered through a 0.2 μm sterilizing-grade filter to remove any large liposomes that could clog the filter during sterile filtration. The process fluid was then diluted to a target of 40 mg / mL total lipid using PBS buffer. The final formulation was aseptically filtered through two 0.2 μm sterilizing-grade filters in series and aseptically filled into glass vials.

[0105] The concentrations of individual lipids in liposomes are always given as a weight-per-weight ratio. For liposomes containing sphingomyelin and cholesterol, a 1:1 (weight-per-weight) ratio corresponds to 50% (weight-per-weight) or a 35:65 molar ratio. Specifications are shown in Table 1. JPEG2025165965000001.jpg35170

[0106] CURB-65 score: The CURB-65, also known as the CURB criteria, is a clinical prediction rule well known to those skilled in the art that has been validated to predict mortality in community-acquired pneumonia (Lim WS, et al. (2003) Thorax 58(5):377-82). The CURB-65 is recommended by the British Thoracic Society for assessing the severity of pneumonia (British Thoracic Society Standards of Care Committee (2001). "BTS Guidelines for the Management of Community-Acquired Pneumonia in Adults". Thorax. 56. Suppl 4:IV1-64).

[0107] The score is an acronym for each risk factor measured. Each risk factor has a score of 1, with a maximum score of 5. -First episode confusion (defined as AMTS ≤ 8) Blood urea nitrogen greater than 7 mmol / l (19 mg / dL) Respiratory rate of 30 breaths per minute or more Systolic blood pressure less than 90mmHg or diastolic blood pressure less than 60mmHg - Over 65 years old.

[0108] APACHE II: APACHE II is an acronym for Acute Physiology and Chronic Health Evaluation and is calculated according to Table 2 (Knaus WA et al. APACHE II: a severity of disease classification system. Crit Care Med. 1985 Oct;13(10):818-29): JPEG2025165965000002.jpg255145JPEG2025165965000003.jpg255149JPEG2025165965000004.jpg238170

[0109] The APACHE II score is intended to provide an estimate of mortality for a patient or group of patients based on the total score obtained. Mortality interpretation of the score is shown in Table 3. JPEG2025165965000005.jpg84170

[0110] Sofa: The SOFA score is an acronym for Sequential Organ Failure Assessment and is calculated according to Table 4 (S. Vosylius, J. Sipylaite and J. Ivaskevicius, Croat Med J, 45 (2004), 715-20). JPEG2025165965000006.jpg186170

[0111] Cardiovascular hypotension: Cardiovascular hypotension is a major feature of septic shock. It may be due to low cardiac output or low systemic vascular resistance. Its severity can be assessed using the cardiovascular Sequential Organ Failure Assessment (SOFA) score, defined by mean arterial pressure or the need for vasopressor administration, as shown in Table 5 (S. Vosylius, J. Sipylaite and J. Ivaskevicius, Croat Med J, 45 (2004), 715-20). JPEG2025165965000007.jpg69170

[0112] Example 1 Treating sepsis and septic shock in severely infected patients In a subsequently reported study, a highly preferred mixture of empty liposomes of the present invention, designated CAL02, was administered intravenously (IV) as an adjunctive treatment to standard antibiotic therapy in patients admitted to the intensive care unit (ICU) for severe community-acquired pneumonia (CAP) due to Streptococcus pneumoniae. The highly preferred mixture of empty liposomes of the present invention (CAL02) consisted of a 1:1 (weight per weight - w / w) mixture of the first empty liposomes and the second empty liposomes, where the first empty liposomes were composed of sphingomyelin and cholesterol in a 1:1 weight ratio (1:1 w / w, 35:65 molar ratio) and the second empty liposomes were composed solely of sphingomyelin.

[0113] In addition to standard antibiotic therapy (Mandell et al., CID 2007:44 (Suppl 2), S27-S72), each patient received two infusions of CAL02 or placebo (physiological 0.9% NaCl solution) separated by 24 or 48 hours. The first infusion was administered immediately after the diagnosis of severity. A diagnosis of severity was defined as meeting at least one of the following severity criteria: i. Invasive mechanical ventilatory support ii. After adequate fluid resuscitation, treatment with vasopressors at therapeutic doses (i.e., dopamine >5 mg / kg / min or any dose of epinephrine, norepinephrine, phenylephrine, or vasopressin) to maintain or attempt to maintain a systolic blood pressure >90 mmHg (or mean arterial pressure >70 mmHg) for at least 2 hours. or was based on at least three of the following minor severity criteria: i.Respiration rate ≧30 breaths / min ii.PaO2 / FiO2 ratio≦250mmHg iii.Multilobular infiltrate iv. Confusion / disorientation (must be documented prior to use of sedatives or other new psychotropic medications) v.Urea>7mM(>40mg / dL) vi. Leukopenia (white blood cell count <4'000 cells / mm 3 ) vii. Thrombocytopenia (platelet count <100'000 cells / mm 3 ) viii. Hypothermia (core temperature <36°C) ix. Systolic blood pressure <90mmHg or mean arterial pressure <70mmHg and received fluid resuscitation of ≥40mL / kg for at least 2 hours

[0114] Two dose levels of CAL02 were tested: 4 mg / kg (low dose) and 16 mg / kg (high dose). Five patients were randomly assigned to the placebo group, 11 to the high-dose CAL02 group, and 3 to the low-dose CAL02 group. At the time of treatment, 56% of patients were already in septic shock: two patients in the placebo group, five in the high-dose CAL02 group, and all three patients in the low-dose CAL02 group.

[0115] Survey results JPEG2025165965000008.jpg199170

[0116] A faster reduction in cardiovascular SOFA scores was observed in the CAL02 group compared with the placebo group, both when considering the entire study population and when evaluating only patients presenting with septic shock at baseline: a 100% reduction in SOFA scores was achieved already at 6 days in the CAL02 group, whereas the reduction in the placebo group did not reach 40% at the same time point (Figures 1 and 2).

[0117] Among patients presenting with septic shock, all patients in the CAL02 high-dose group (5 / 5, 100%) and 66% of patients in the CAL02 low-dose group (2 / 3) had complete resolution of hypotension and septic shock on the 8th day after treatment, compared with none in the placebo group (0 / 2, 0%).

[0118] Of the three patients in the placebo group who were not in septic shock at baseline, one was hypotensive at baseline and developed septic shock on day 4, and two were not hypotensive at baseline but developed hypotension within the first 8 days. In contrast, in the CAL02 group, three patients were not hypotensive at baseline and did not develop hypotension, and all other patients improved to resolution by day 6. This suggests that CAL02 prevented hypotension and hemodynamic instability and protected against the development of septic shock.

[0119] Resolution of septic shock was accompanied by a significant reduction in mean ICU stay, from 32 days for patients in the placebo group to 5.4 and 15 days for patients in the CAL02 high-dose and CAL02 low-dose groups, respectively. Furthermore, mortality was lower in the CAL02 group (20% and 33% mortality in the CAL02 high-dose and CAL02 low-dose groups, respectively) compared with the placebo group (50%) (Table 7). [Table 7]

[0120] The effect of CAL02 treatment was also assessed on vital signs (including heart rate, systolic and diastolic blood pressure, and core body temperature) and lactate levels.

Claims

1. 1. A composition for use in the treatment of sepsis in an animal, preferably a human, comprising, preferably consisting of, a mixture of empty liposomes, said mixture of empty liposomes comprising: (a) a first empty liposome comprising cholesterol, the first empty liposome having an amount of cholesterol of at least 30% (weight per weight); (b) a second empty liposome comprising sphingomyelin, preferably comprising only said sphingomyelin as a lipid component.

2. 2. The composition for use according to claim 1, wherein said composition is for use in the treatment of septic shock in said animal, preferably said human.

3. 2. The composition for use according to claim 1, wherein said composition is for use in treating hypotension, preferably persistent hypotension, in said animal, preferably said human, with sepsis.

4. 3. The composition for use according to claim 2, wherein said composition is for use in treating hypotension, preferably persistent hypotension, in said animal, preferably said human, with septic shock.

5. 5. The composition for use according to any one of claims 1 to 4, wherein the amount of cholesterol in the empty liposome (a) is between 45% and 55% (weight per weight) and the second empty liposome (b) consists of sphingomyelin.

6. 6. The composition for use according to any one of claims 1 to 5, wherein the first empty liposome (a) consists of cholesterol and sphingomyelin, the amount of cholesterol in the empty liposome (a) is about 50% (weight per weight), and the mixture of empty liposomes comprises at least 40%, preferably at least 45% (weight per weight) of the first (a) and second (b) empty liposomes.

7. 7. The composition for use according to any one of claims 1 to 6, wherein the first empty liposome (a) consists of a 1:1 (weight per weight - w / w) mixture of the first empty liposome and the second liposome, the first empty liposome being composed of cholesterol and sphingomyelin in a 1:1 weight ratio (1:1 w / w, 35:65 molar ratio), the second empty liposome being composed solely of sphingomyelin, the first empty liposome (a) comprising only the cholesterol and the sphingomyelin as lipid components, and the second empty liposome (b) comprising only the sphingomyelin as lipid component.

8. The composition for use according to any one of claims 3 to 7, wherein said hypotension, preferably said sustained hypotension, is associated with a mean arterial pressure <70 mmHg.

9. 9. The composition for use according to claim 8, wherein said hypotension, preferably said sustained hypotension, is pretreated with a vasopressor for at least 2 hours.

10. The composition for use according to any one of claims 1 to 9, wherein the treatment is adjunctive to antibiotic therapy.

11. 11. The composition for use according to claim 10, wherein the antibiotic therapy is intravenous (IV) or oral antibiotic therapy.

12. 12. The composition for use according to any one of claims 1 to 11, wherein said animal is a human patient, and said human patient has pneumonia, preferably said pneumonia selected from Community Acquired Pneumonia (CAP), Hospitalization Acquired Pneumonia (HAP) and Ventilator Associated Pneumonia (VAP).

13. 13. The composition for use according to claim 12, wherein the pneumonia is severe pneumonia, preferably severe community-acquired pneumonia (sCAP) or severe community-acquired pneumococcal pneumonia (sCAPP).

14. The pneumonia or the severe pneumonia is caused by Streptococcus pneumoniae, Staphylococcus aureus, Pseudomonas aeruginosa, Enterococcus faecium, Legionella pneumophila, Haemophilus influenzae, Klebsiella pneumoniae, Escherichia coli, or the like.

14. The composition for use according to claim 12 or 13, wherein the pneumonia or the severe pneumonia is caused by E. coli, Acinetobacter baumannii, Bordetella pertussis, Serratia marcescens, Stenotrophomonas maltophilia, Moraxella catarrhalis, or Mycobacterium tuberculosis, preferably wherein the pneumonia or the severe pneumonia is caused by Streptococcus pneumoniae.

15. The composition for use according to any one of claims 1 to 14, wherein the composition is in the form of a solution for intravenous administration.

16. 16. The composition for use according to any one of claims 1 to 15, wherein said composition is administered to said animal, preferably said human, in at least two doses, a first dose and a second dose, and the interval between said first dose and said second dose is between 6 and 96 hours, preferably between 12 and 72 hours, more preferably between 24 and 48 hours, even more preferably 24 or 48 hours.

17. 17. The composition for use according to any one of claims 1 to 16, wherein said sepsis, septic shock or said hypotension, preferably persistent hypotension, requires hospitalisation, preferably in the intensive care unit (ICU) of a hospital.

18. 18. The composition for use according to claim 17, wherein said treatment reduces the duration of said hospitalization compared to a hospitalization in the absence of such treatment.

19. 19. A composition for use according to claim 17 or 18, wherein said reduction in length of hospital stay due to said treatment is at least 1 day, preferably 2 days, more preferably 3 days, even more preferably 4 days, even more preferably 5 days, even more preferably 6 days, even more preferably 7 days, even more preferably 8 days, even more preferably 9 days.

20. 20. The composition for use according to any one of claims 1 to 19, wherein said sepsis, septic shock or said hypotension, preferably persistent hypotension, is cured in a shorter time compared to in the absence of such treatment.

21. 21. The composition for use according to claim 20, wherein said shorter healing time is at least 1 day shorter, preferably 2 days shorter, or more preferably at least 3 days shorter, even more preferably at least 4 days shorter, even more preferably at least 5 days shorter, even more preferably at least 6 days shorter, and even more preferably at least 7 days shorter.

22. 22. The composition for use according to any one of claims 1 to 21, wherein said treatment reduces the cardiovascular SOFA score compared to the cardiovascular SOFA score in the absence of such treatment.

23. 23. The composition for use according to claim 22, wherein said reduction is at least 50%, preferably at least 60%, more preferably at least 70%, even more preferably at least 80% 7 days after the start of said treatment, preferably 6 days after the start of said treatment, more preferably 5 days after the start of said treatment.

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