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Clinical relevance of antibiotic-induced endotoxin release

Considerable mortality is associated with gram-negative infections, especially when they are complicated by shock (45). Although appropriate antibiotic treatment significantly reduces this mortality (45), it was already known in the early days of antibiotic treatment that fatal vasomotor collapse may occur after administration of a loading dose of chloramphenicol for typhoid fever (13). James Reilly hypothesized that the adverse clinical effects that were associated with destruction of the typhoid bacilli could be caused by an overwhelming release of endotoxin. He subsequently advised that one should start with a low dose of antibiotics: "frappez doucement" ("hit gently") instead of "frappez fort et vite" ("hit vigorously") (13). During the last 10 years a renewed interest in the possible deleterious effects of liberation of endotoxin (lipopolysaccharide [LPS]) during bacterial cell death has emerged. In this minireview, we review the current knowledge of the mechanisms of antibiotic-induced endotoxin release as well as their possible clinical implications.