Ketone and glycolytic metabolism are key modulators of inflammation during neonatal sepsis

Neonatal sepsis is a life-threatening condition in preterm infants, primarily due to a dysregulated immunometabolic response to infection. Sepsis and infection mortality are associated with excessive glycolysis-induced inflammation, impaired mitochondrial oxidative phosphorylation (OXPHOS) and loss of disease tolerance. Reduced glucose intake can reverse these dysregulations, but it is unclear how the mechanistic control of glycolysis-OXPHOS balance drives defense strategies and infection outcomes. Here, in a preterm piglet model of neonatal sepsis, glycolysis inhibition with 2-deoxyglucose (2-DG) completely prevents acute infection mortality, reduces systemic inflammation and markers of liver injury, accompanied by enhanced mitochondrial metabolism and disease tolerance. Strikingly, this protection by 2-DG is conferred despite elevated blood glucose levels and higher bacterial burdens than the infected controls. Alternatively, partial replacement of glucose intake with the ketone beta-hydroxybutyrate (BHB) abolishes sepsis-related mortality via improving disease tolerance and clinical parameters. This intervention also shifts the hepatic transcriptome away from inflammatory signaling and towards mitochondrial metabolism. In macrophages in vitro, BHB also exerts anti-inflammatory effects independently of metabolic modulation via the HCAR2 receptor. Finally, data from a cohort of 700 infants confirm an association of plasma BHB levels and anti-inflammatory state. These findings demonstrate that metabolic reprogramming through glycolysis inhibition or ketone supplementation is a promising therapeutic strategy to enhance disease tolerance and improve sepsis outcomes in neonates.