1
|
Schwarz C, Bend J, Hebestreit H, Hogardt M, Hügel C, Illing S, Mainz JG, Rietschel E, Schmidt S, Schulte-Hubbert B, Sitter H, Wielpütz MO, Hammermann J, Baumann I, Brunsmann F, Dieninghoff D, Eber E, Ellemunter H, Eschenhagen P, Evers C, Gruber S, Koitschev A, Ley-Zaporozhan J, Düesberg U, Mentzel HJ, Nüßlein T, Ringshausen FC, Sedlacek L, Smaczny C, Sommerburg O, Sutharsan S, Vonberg RP, Weber AK, Zerlik J. [CF Lung Disease - a German S3 Guideline: Pseudomonas aeruginosa]. Pneumologie 2024. [PMID: 38350639 DOI: 10.1055/a-2182-1907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
Cystic Fibrosis (CF) is the most common autosomal recessive genetic multisystemic disease. In Germany, it affects at least 8000 people. The disease is caused by mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene leading to dysfunction of CFTR, a transmembrane chloride channel. This defect causes insufficient hydration of the airway epithelial lining fluid which leads to reduction of the mucociliary clearance.Even if highly effective, CFTR modulator therapy has been available for some years and people with CF are getting much older than before, recurrent and chronic infections of the airways as well as pulmonary exacerbations still occur. In adult CF life, Pseudomonas aeruginosa (PA) is the most relevant pathogen in colonisation and chronic infection of the lung, leading to further loss of lung function. There are many possibilities to treat PA-infection.This is a S3-clinical guideline which implements a definition for chronic PA-infection and demonstrates evidence-based diagnostic methods and medical treatment in order to give guidance for individual treatment options.
Collapse
Affiliation(s)
- Carsten Schwarz
- Klinikum Westbrandenburg GmbH, Standort Potsdam, Deutschland
| | - Jutta Bend
- Mukoviszidose Institut gGmbH, Bonn, Deutschland
| | | | - Michael Hogardt
- Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Frankfurt, Deutschland
| | - Christian Hügel
- Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Deutschland
| | | | - Jochen G Mainz
- Klinikum Westbrandenburg, Standort Brandenburg an der Havel, Universitätsklinikum der Medizinischen Hochschule Brandenburg (MHB), Brandenburg an der Havel, Deutschland
| | - Ernst Rietschel
- Medizinische Fakultät der Universität zu Köln, Mukoviszidose-Zentrum, Klinik und Poliklinik für Kinder- und Jugendmedizin, Köln, Deutschland
| | - Sebastian Schmidt
- Ernst-Moritz-Arndt Universität Greifswald, Kinderpoliklinik, Allgemeine Pädiatrie, Greifswald, Deutschland
| | | | - Helmut Sitter
- Philipps-Universität Marburg, Institut für theoretische Medizin, Marburg, Deutschland
| | - Marc Oliver Wielpütz
- Universitätsklinikum Heidelberg, Klinik für Diagnostische und Interventionelle Radiologie, Heidelberg, Deutschland
| | - Jutta Hammermann
- Universitäts-Mukoviszidose-Zentrum "Christiane Herzog", Dresden, Deutschland
| | - Ingo Baumann
- Universität Heidelberg, Hals-Nasen-Ohrenklinik, Heidelberg, Deutschland
| | - Frank Brunsmann
- Allianz Chronischer Seltener Erkrankungen (ACHSE) e. V., Deutschland (Patient*innenvertreter)
| | | | - Ernst Eber
- Medizinische Universität Graz, Univ. Klinik für Kinder- und Jugendheilkunde, Klinische Abteilung für Pädiatrische Pulmonologie und Allergologie, Graz, Österreich
| | - Helmut Ellemunter
- Tirolkliniken GmbH, Department für Kinderheilkunde, Pädiatrie III, Innsbruck, Österreich
| | | | | | - Saskia Gruber
- Medizinische Universität Wien, Universitätsklinik für Kinder- und Jugendheilkunde, Wien, Österreich
| | - Assen Koitschev
- Klinikum Stuttgart - Standort Olgahospital, Klinik für Hals-Nasen-Ohrenkrankheiten, Stuttgart, Deutschland
| | - Julia Ley-Zaporozhan
- Klinik und Poliklinik für Radiologie, Kinderradiologie, LMU München, Deutschland
| | | | - Hans-Joachim Mentzel
- Universitätsklinikum Jena, Sektion Kinderradiologie, Institut für Diagnostische und Interventionelle Radiologie, Jena, Deutschland
| | - Thomas Nüßlein
- Gemeinschaftsklinikum Mittelrhein, Klinik für Kinder- und Jugendmedizin Koblenz und Mayen, Koblenz, Deutschland
| | - Felix C Ringshausen
- Medizinische Hochschule Hannover, Klinik für Pneumologie und Infektiologie und Deutsches Zentrum für Lungenforschung (DZL), Hannover, Deutschland
| | - Ludwig Sedlacek
- Medizinische Hochschule Hannover, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Hannover, Deutschland
| | - Christina Smaczny
- Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Deutschland
| | - Olaf Sommerburg
- Universitätsklinikum Heidelberg, Sektion Pädiatrische Pneumologie, Allergologie und Mukoviszidose-Zentrum, Heidelberg, Deutschland
| | | | - Ralf-Peter Vonberg
- Medizinische Hochschule Hannover, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Hannover, Deutschland
| | | | - Jovita Zerlik
- Altonaer Kinderkrankenhaus gGmbH, Abteilung Physiotherapie, Hamburg, Deutschland
| |
Collapse
|
2
|
Conceição M, Shteinberg M, Goeminne P, Altenburg J, Chalmers JD. Eradication treatment for Pseudomonas aeruginosa infection in adults with bronchiectasis: a systematic review and meta-analysis. Eur Respir Rev 2024; 33:230178. [PMID: 38296344 PMCID: PMC10828832 DOI: 10.1183/16000617.0178-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/24/2023] [Indexed: 02/03/2024] Open
Abstract
INTRODUCTION Pseudomonas aeruginosa is the most commonly isolated pathogen in bronchiectasis and is associated with worse outcomes. Eradication treatment is recommended by guidelines, but the evidence base is limited. The expected success rate of eradication in clinical practice is not known. METHODS We conducted a systematic review and meta-analysis according to Meta-Analysis of Observational Studies in Epidemiology guidelines. PubMed, Embase, the Cochrane Database of Systematic Reviews and Clinicaltrials.gov were searched for studies investigating P. aeruginosa eradication treatment using antibiotics (systemic or inhaled) in patients with bronchiectasis. The primary outcome was the percentage of patients negative for P. aeruginosa at 12 months after eradication treatment. Cystic fibrosis was excluded. RESULTS Six observational studies including 289 patients were included in the meta-analysis. Our meta-analysis found a 12-month P. aeruginosa eradication rate of 40% (95% CI 34-45%; p<0.00001), with no significant heterogeneity (I2=0%). Combined systemic and inhaled antibiotic treatment was associated with a higher eradication rate (48%, 95% CI 41-55%) than systemic antibiotics alone (27%, 13-45%). CONCLUSION Eradication treatment in bronchiectasis results in eradication of P. aeruginosa from sputum in ∼40% of cases at 12 months. Combined systemic and inhaled antibiotics achieve higher eradication rates than systemic antibiotics alone.
Collapse
Affiliation(s)
- Mariana Conceição
- Pulmonology Department, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Michal Shteinberg
- Pulmonology Institute and CF Center, Carmel Medical Center, Haifa, Israel
| | - Pieter Goeminne
- Department of Respiratory Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Josje Altenburg
- Department of Respiratory Disease, AZ Nikolaas, Sint-Niklaas, Belgium
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| |
Collapse
|
3
|
Somayaji R, Wessels ME, Milinic T, Ramos KJ, Mayer-Hamblett N, Ramsey BW, Heltshe S, Khan U, Goss CH. Potential implicit bias in attribution of adverse events in randomized controlled trials in cystic fibrosis. J Cyst Fibros 2023; 22:669-673. [PMID: 37286384 PMCID: PMC10529796 DOI: 10.1016/j.jcf.2023.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 05/08/2023] [Accepted: 05/24/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Although work to date in cystic fibrosis (CF) has elucidated frequencies and characteristics of adverse events, the accuracy of attribution of relatedness to study drug by investigators has not been assessed. We aimed to determine whether there was an association of attribution by group allocation in CF clinical trials. METHODS We conducted a secondary analysis from 4 CF trials of all persons who experienced an AE. Our primary outcome was the odds of an AE related to active study drug and predictor of interest was the treatment allocation. We constructed a multivariable generalized estimating equation model allowing for repeated measures. RESULTS A total of 785 subjects (47.5% female, mean age 12 years) had 11,974 AEs, of which 430 were serious. AE attribution was greater with receipt of active study drug as compared to placebo but did not reach statistical significance (OR 1.38, 95% CI 0.98-1.82). Significantly associated factors included female sex (OR 0.58, 95% 0.39-0.87), age (OR 1.24, 95% CI 1.06-1.46) and baseline lung function (per 10%, OR 1.16, 95% CI 1.05-1.28). CONCLUSION In our large study, there was a non-significant but greater odds of AE attribution (a key element of clinical trial reporting) to active study drug based on assigned treatment to study drug or control which suggests that there is a trend in physicians to attribute blinded safety data to the active drug. Interestingly, females were less likely to have AE attribution to study drug and warrants further work in development and validation of monitoring guidelines and processes.
Collapse
Affiliation(s)
| | | | - Tijana Milinic
- Department of Medicine, University of Washington, Seattle, WA USA
| | - Kathleen J Ramos
- Department of Medicine, University of Washington, Seattle, WA USA
| | - Nicole Mayer-Hamblett
- Seattle Children's Research Institute, Seattle, WA USA; Department of Pediatrics, Division of Pulmonary, University of Washington, Seattle, WA USA
| | - Bonnie W Ramsey
- Seattle Children's Research Institute, Seattle, WA USA; Department of Pediatrics, Division of Pulmonary, University of Washington, Seattle, WA USA
| | - Sonya Heltshe
- Seattle Children's Research Institute, Seattle, WA USA; Department of Pediatrics, Division of Pulmonary, University of Washington, Seattle, WA USA
| | - Umer Khan
- Seattle Children's Research Institute, Seattle, WA USA
| | - Christopher H Goss
- Seattle Children's Research Institute, Seattle, WA USA; Department of Medicine, University of Washington, Seattle, WA USA; Department of Pediatrics, Division of Pulmonary, University of Washington, Seattle, WA USA.
| |
Collapse
|
4
|
Langton Hewer SC, Smith S, Rowbotham NJ, Yule A, Smyth AR. Antibiotic strategies for eradicating Pseudomonas aeruginosa in people with cystic fibrosis. Cochrane Database Syst Rev 2023; 6:CD004197. [PMID: 37268599 PMCID: PMC10237531 DOI: 10.1002/14651858.cd004197.pub6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Respiratory tract infections with Pseudomonas aeruginosa occur in most people with cystic fibrosis (CF). Established chronic P aeruginosa infection is virtually impossible to eradicate and is associated with increased mortality and morbidity. Early infection may be easier to eradicate. This is an updated review. OBJECTIVES Does giving antibiotics for P aeruginosa infection in people with CF at the time of new isolation improve clinical outcomes (e.g. mortality, quality of life and morbidity), eradicate P aeruginosa infection, and delay the onset of chronic infection, but without adverse effects, compared to usual treatment or an alternative antibiotic regimen? We also assessed cost-effectiveness. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and conference proceedings. Latest search: 24 March 2022. We searched ongoing trials registries. Latest search: 6 April 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) of people with CF, in whom P aeruginosa had recently been isolated from respiratory secretions. We compared combinations of inhaled, oral or intravenous (IV) antibiotics with placebo, usual treatment or other antibiotic combinations. We excluded non-randomised trials and cross-over trials. DATA COLLECTION AND ANALYSIS Two authors independently selected trials, assessed risk of bias and extracted data. We assessed the certainty of the evidence using GRADE. MAIN RESULTS We included 11 trials (1449 participants) lasting between 28 days and 27 months; some had few participants and most had relatively short follow-up periods. Antibiotics in this review are: oral - ciprofloxacin and azithromycin; inhaled - tobramycin nebuliser solution for inhalation (TNS), aztreonam lysine (AZLI) and colistin; IV - ceftazidime and tobramycin. There was generally a low risk of bias from missing data. In most trials it was difficult to blind participants and clinicians to treatment. Two trials were supported by the manufacturers of the antibiotic used. TNS versus placebo TNS may improve eradication; fewer participants were still positive for P aeruginosa at one month (odds ratio (OR) 0.06, 95% confidence interval (CI) 0.02 to 0.18; 3 trials, 89 participants; low-certainty evidence) and two months (OR 0.15, 95% CI 0.03 to 0.65; 2 trials, 38 participants). We are uncertain whether the odds of a positive culture decrease at 12 months (OR 0.02, 95% CI 0.00 to 0.67; 1 trial, 12 participants). TNS (28 days) versus TNS (56 days) One trial (88 participants) comparing 28 days to 56 days TNS treatment found duration of treatment may make little or no difference in time to next isolation (hazard ratio (HR) 0.81, 95% CI 0.37 to 1.76; low-certainty evidence). Cycled TNS versus culture-based TNS One trial (304 children, one to 12 years old) compared cycled TNS to culture-based therapy and also ciprofloxacin to placebo. We found moderate-certainty evidence of an effect favouring cycled TNS therapy (OR 0.51, 95% CI 0.31 to 0.82), although the trial publication reported age-adjusted OR and no difference between groups. Ciprofloxacin versus placebo added to cycled and culture-based TNS therapy One trial (296 participants) examined the effect of adding ciprofloxacin versus placebo to cycled and culture-based TNS therapy. There is probably no difference between ciprofloxacin and placebo in eradicating P aeruginosa (OR 0.89, 95% CI 0.55 to 1.44; moderate-certainty evidence). Ciprofloxacin and colistin versus TNS We are uncertain whether there is any difference between groups in eradication of P aeruginosa at up to six months (OR 0.43, 95% CI 0.15 to 1.23; 1 trial, 58 participants) or up to 24 months (OR 0.76, 95% CI 0.24 to 2.42; 1 trial, 47 participants); there was a low rate of short-term eradication in both groups. Ciprofloxacin plus colistin versus ciprofloxacin plus TNS One trial (223 participants) found there may be no difference in positive respiratory cultures at 16 months between ciprofloxacin with colistin versus TNS with ciprofloxacin (OR 1.28, 95% CI 0.72 to 2.29; low-certainty evidence). TNS plus azithromycin compared to TNS plus oral placebo Adding azithromycin may make no difference to the number of participants eradicating P aeruginosa after a three-month treatment phase (risk ratio (RR) 1.01, 95% CI 0.75 to 1.35; 1 trial, 91 participants; low-certainty evidence); there was also no evidence of any difference in the time to recurrence. Ciprofloxacin and colistin versus no treatment A single trial only reported one of our planned outcomes; there were no adverse effects in either group. AZLI for 14 days plus placebo for 14 days compared to AZLI for 28 days We are uncertain whether giving 14 or 28 days of AZLI makes any difference to the proportion of participants having a negative respiratory culture at 28 days (mean difference (MD) -7.50, 95% CI -24.80 to 9.80; 1 trial, 139 participants; very low-certainty evidence). Ceftazidime with IV tobramycin compared with ciprofloxacin (both regimens in conjunction with three months colistin) IV ceftazidime with tobramycin compared with ciprofloxacin may make little or no difference to eradication of P aeruginosa at three months, sustained to 15 months, provided that inhaled antibiotics are also used (RR 0.84, 95 % CI 0.65 to 1.09; P = 0.18; 1 trial, 255 participants; high-certainty evidence). The results do not support using IV antibiotics over oral therapy to eradicate P aeruginosa, based on both eradication rate and financial cost. AUTHORS' CONCLUSIONS We found that nebulised antibiotics, alone or with oral antibiotics, were better than no treatment for early infection with P aeruginosa. Eradication may be sustained in the short term. There is insufficient evidence to determine whether these antibiotic strategies decrease mortality or morbidity, improve quality of life, or are associated with adverse effects compared to placebo or standard treatment. Four trials comparing two active treatments have failed to show differences in rates of eradication of P aeruginosa. One large trial showed that intravenous ceftazidime with tobramycin is not superior to oral ciprofloxacin when inhaled antibiotics are also used. There is still insufficient evidence to state which antibiotic strategy should be used for the eradication of early P aeruginosa infection in CF, but there is now evidence that intravenous therapy is not superior to oral antibiotics.
Collapse
Affiliation(s)
- Simon C Langton Hewer
- Paediatric Respiratory Medicine, Bristol Royal Hospital for Children, Bristol, UK
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Sherie Smith
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nicola J Rowbotham
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Alexander Yule
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Alan R Smyth
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| |
Collapse
|
5
|
Thornton CS, Parkins MD. Microbial Epidemiology of the Cystic Fibrosis Airways: Past, Present, and Future. Semin Respir Crit Care Med 2023; 44:269-286. [PMID: 36623820 DOI: 10.1055/s-0042-1758732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Progressive obstructive lung disease secondary to chronic airway infection, coupled with impaired host immunity, is the leading cause of morbidity and mortality in cystic fibrosis (CF). Classical pathogens found in the airways of persons with CF (pwCF) include Pseudomonas aeruginosa, Staphylococcus aureus, the Burkholderia cepacia complex, Achromobacter species, and Haemophilus influenzae. While traditional respiratory-tract surveillance culturing has focused on this limited range of pathogens, the use of both comprehensive culture and culture-independent molecular approaches have demonstrated complex highly personalized microbial communities. Loss of bacterial community diversity and richness, counteracted with relative increases in dominant taxa by traditional CF pathogens such as Burkholderia or Pseudomonas, have long been considered the hallmark of disease progression. Acquisition of these classic pathogens is viewed as a harbinger of advanced disease and postulated to be driven in part by recurrent and frequent antibiotic exposure driven by frequent acute pulmonary exacerbations. Recently, CF transmembrane conductance regulator (CFTR) modulators, small molecules designed to potentiate or restore diminished protein levels/function, have been successfully developed and have profoundly influenced disease course. Despite the multitude of clinical benefits, structural lung damage and consequent chronic airway infection persist in pwCF. In this article, we review the microbial epidemiology of pwCF, focus on our evolving understanding of these infections in the era of modulators, and identify future challenges in infection surveillance and clinical management.
Collapse
Affiliation(s)
- Christina S Thornton
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Michael D Parkins
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Alberta, Canada
| |
Collapse
|
6
|
Schütz K, Grewendorf S, Kontsendorn J, Fuge J, Happle C, Rudolf I, Dopfer C, Sedlacek L, Hansen G, Junge S, Dittrich AM. Comparison of Three Eradication Treatment Protocols for Pseudomonas Aeruginosa in Children and Adolescents with Cystic Fibrosis. KLINISCHE PADIATRIE 2023; 235:75-83. [PMID: 36758577 DOI: 10.1055/a-1996-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
BACKGROUND Pseudomonas aeruginosa (Pa) continues to affect disease progression in cystic fibrosis (CF). However, the best eradication regimen remains unclear. This work compares three different antibiotic eradication regimens in pediatric CF: an administration according to a standard-operating procedure (SOP) order vs. administration outside of this order (ooSOP). METHODS This observational study includes all CF patients<18 years who received one of three Pa eradication treatments in the past eight years at our center: 1) inhaled high-dose tobramycin (Hi-TOBI), 2) inhaled colistin+oral ciprofloxacin (COL/Cip), 3) inhaled low-dose tobramycin+4 intravenous 14-day Pa active antibiotic treatments (lo-Tobra/IV). We compared eradication rates of the three treatment regimens performed according to the SOP-based order vs. ooSOP. Logistic regression analysis was performed to identify risk factors for eradication failure. RESULTS Performed according to SOP order, Hi-TOBI showed the greatest efficacy, followed by lo-Tobra/IV and finally COL/Cip, while ooSOP lo-Tobra/IV was most successful, followed by COL/Cip and Hi-TOBI. Previous Pa-infections and Pa-therapies along with age at CF diagnosis were risk factors for eradication failure. CONCLUSION Antibiotic treatment in SOP-based pre-defined order leads to significantly better eradication rates than individual modifications of the order of administration. A short course of inhalational high-dose Tobramycin is most successful at the first attempt. Prolonged antibiotic therapy seems to improve eradication after failed initial attempts.
Collapse
Affiliation(s)
- Katharina Schütz
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany.,Excellence Cluster RESIST - Resolving Infection Susceptibility, Hannover Medical School, Hannover, Germany
| | - Simon Grewendorf
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany
| | - Julia Kontsendorn
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany.,German Center for Lung Research, BREATH location, Hannover Medical School, Hannover, Germany
| | - Jan Fuge
- German Center for Lung Research, BREATH location, Hannover Medical School, Hannover, Germany
| | - Christine Happle
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany.,Excellence Cluster RESIST - Resolving Infection Susceptibility, Hannover Medical School, Hannover, Germany.,German Center for Lung Research, BREATH location, Hannover Medical School, Hannover, Germany
| | - Isa Rudolf
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany.,German Center for Lung Research, BREATH location, Hannover Medical School, Hannover, Germany
| | - Christian Dopfer
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany
| | - Ludwig Sedlacek
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - Gesine Hansen
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany.,Excellence Cluster RESIST - Resolving Infection Susceptibility, Hannover Medical School, Hannover, Germany.,German Center for Lung Research, BREATH location, Hannover Medical School, Hannover, Germany
| | - Sibylle Junge
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany
| | - Anna-Maria Dittrich
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany.,German Center for Lung Research, BREATH location, Hannover Medical School, Hannover, Germany
| |
Collapse
|
7
|
Casaredi IG, Shaw M, Waters V, Seeto R, Blanchard AC, Ratjen F. Impact of antibiotic eradication therapy of Pseudomonas aeruginosa on long term lung function in cystic fibrosis. J Cyst Fibros 2023; 22:98-102. [PMID: 35995678 DOI: 10.1016/j.jcf.2022.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 08/10/2022] [Accepted: 08/10/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION While antibiotic eradication therapy (AET) of early Pseudomonas aeruginosa infection is considered standard of care, its long-term effect on the subsequent course of cystic fibrosis (CF) lung disease remains unclear. METHODS CF patients who were P. aeruginosa-free for at least a year and had a minimum of 10 years of pulmonary function measurements were included. Subjects were categorized as Never if they never had P. aeruginosa isolated from a respiratory tract sample. Subjects changed to the Eradicated group if they had a P. aeruginosa infection, were treated with AET, and subsequently cleared their infection. Subjects changed to the Chronic group if AET did not clear their P. aeruginosa infection. The primary outcome was absolute FEV1 decline over time, with age as the time variable. Mixed-effects linear regression models were used to account for the repeated lung function measurements over time within each patient. RESULTS 205 CF subjects (48% female) were included; the median (IQR) age at first infection was 9.6 (5.6, 14.6) years. The median (IQR) follow-up was 10.2 (5.7, 14.7) years for the Eradicated group, 8.8 (4.5, 14.9) years for the Chronic group and 2.8 (1.0, 5.7) years for the Never group was among those patients that had at least one P. aeruginosa infection over the study period, annual lung function decline of FEV1 was significantly less (-1.11% predicted/year; 95% CI: -1.18, -1.04) in the Eradication group compared to the Chronic group (-1.57%; -1.64, -1.50) (p<0.001). CONCLUSIONS AET against P. aeruginosa improves lung function trajectory in CF patients.
Collapse
Affiliation(s)
- Isabel Gascon Casaredi
- Division of Respiratory Medicine, Department of Pediatrics, Hospital Sant Joan de Déu de Barcelona, Universidad de Barcelona, Barcelona, Spain; Division of Respiratory Medicine, Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Michelle Shaw
- Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Valerie Waters
- Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Canada; Division of Infectious Diseases, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Ryan Seeto
- Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Ana C Blanchard
- Division of Infectious Diseases, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics, Hospital Sant Joan de Déu de Barcelona, Universidad de Barcelona, Barcelona, Spain; Division of Respiratory Medicine, Department of Paediatrics, University of Toronto, Toronto, Canada; Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Canada.
| |
Collapse
|
8
|
Rakhshan A, Farahbakhsh N, Khanbabaee G, Tabatabaii SA, Sadr S, Hassanzad M, Sistanizad M, Dastan F, Hajipour M, Bahadori AR, Mirrahimi B. Evaluating the efficacy of inhaled amikacin as an adjunct to intravenous combination therapy (ceftazidime and amikacin) in pediatric cystic fibrosis pulmonary exacerbation. Front Pharmacol 2023; 14:1130374. [PMID: 36969859 PMCID: PMC10034196 DOI: 10.3389/fphar.2023.1130374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/22/2023] [Indexed: 03/29/2023] Open
Abstract
Background: Pseudomonas aeruginosa is the most common microorganism found in the sputum culture of Cystic fibrosis (CF) patients causing the pulmonary destruction. Aminoglycosides have a low diffuse rate from lipid membranes, and respiratory system secretions. Regarding the burden of pulmonary exacerbation caused by the pseudomonas aeruginosa in cystic fibrosis patients in the long term and the limited number of clinical trials focused on appropriate treatment strategies, the present study evaluated the concurrent inhaled and intravenous aminoglycoside antibiotics for pulmonary exacerbation caused by the pseudomonas aeruginosa as a safe and effective treatment in children. Method: This study was a blinded, randomized clinical trial phase conducted in a tertiary referral pediatric teaching hospital from May 2021 to May 2022. The patients were randomly allocated to receive intravenously administered ceftazidime and Amikacin alone or with inhaled Amikacin. Forced expiratory volume (FEV1), Amikacin via the level, kidney function tests, audiometry, inflammatory markers (erythrocyte sedimentation rate and C-reactive protein), hospital stay, and bacterial eradication rate were compared in two therapy groups. Results: the average FEV1 has increased by 47% in Neb + group compared to Neb- group following treatment. Hospital stay was lower in Neb + group. No renal toxicity or ototoxicity was observed in both therapy groups. Pseudomonas aeruginosa eradication rate Neb- and Neb + groups were 44% and 69%, respectively (p-value = 0.15). Conclusion: Concurrent inhaled and intravenous Amikacin is safe and effective to treat Pseudomonas aeruginosa exacerbation in CF patients. Moreover, co-delivery antibiotics' route treatment increased the eradication rate. Although not statistically significant, never the less, it is clinically relevant. The intervention reduced the length of hospitalization in this group. Clinical Trial Registration: clinicaltrials.gov, identifier [IRCT20120415009475N10].
Collapse
Affiliation(s)
- Amin Rakhshan
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nazanin Farahbakhsh
- Department of Pediatric Pulmonology, Mofid Children’s Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ghamartaj Khanbabaee
- Department of Pediatric Pulmonology, Mofid Children’s Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Ahmad Tabatabaii
- Department of Pediatric Pulmonology, Mofid Children’s Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeed Sadr
- Department of Pediatric Pulmonology, Mofid Children’s Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Hassanzad
- Pediatric Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Sistanizad
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzaneh Dastan
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahmoud Hajipour
- Children’s Gastroenterology, Liver and Nutrition Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Reza Bahadori
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Bahador Mirrahimi
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- *Correspondence: Bahador Mirrahimi,
| |
Collapse
|
9
|
Orenti A, Mei-Zahav M, Boracchi P, Lindblad A, Shteinberg M. Prevalence, trends and outcomes of long-term inhaled antibiotic treatment in people with cystic fibrosis without chronic Pseudomonas aeruginosa infection - A European cystic fibrosis patient registry data analysis. J Cyst Fibros 2023; 22:103-111. [PMID: 36045028 DOI: 10.1016/j.jcf.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 08/11/2022] [Accepted: 08/13/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Long-term treatment with inhaled antibiotics is recommended for people with cystic fibrosis (pwCF) chronically infected with Pseudomonas aeruginosa (PA). However, pwCF without chronic PA infection are also commonly treated with inhaled antibiotics. Using data from the European Cystic Fibrosis Patient Registry (ECFSPR) we aimed to determine the prevalence and factors associated with inhaled antibiotic treatment in pwCF without chronic PA infection, and long-term outcomes with inhaled antibiotics use. METHODS The ECFSPR was searched for pwCF 6 years of age and older who were not chronically infected with PA at baseline. Factors associated with inhaled antibiotic use were first assessed through a logistic regression. From this model a propensity score was computed for each individual, providing the likelihood of being treated with inhaled antibiotics. Long-term outcomes with and without inhaled antibiotics were assessed separately for propensity scores tertiles. RESULTS 7210 pwCF without chronic PA infection at baseline were included, with 2722 (37.75%) receiving long-term treatment with inhaled antibiotics. Treatment with inhaled antibiotics was more prevalent with severe genotype, diabetes, pancreatic insufficiency, and past infection with chronic PA (OR 3.8, 95% CI, 2.88-5.04). Treatment with inhaled antibiotics was not associated with a reduced risk for acquisition of PA or other resistant pathogens, or with improved lung function decline, mortality, or transplantation. CONCLUSIONS Many pwCF without chronic PA infection are receiving long-term treatment with inhaled antibiotics despite lack of support from clinical trials or practice guidelines. We did not observe improve outcomes with inhaled antibiotics. Our findings suggest controlled studies evaluating specific inhaled antibiotic regimens targeting specific pathogens or indications be performed to determine their effect.
Collapse
Affiliation(s)
- Annalisa Orenti
- Department of Clinical Sciences and Community Health, Laboratory of Medical Statistics, Biometry and Epidemiology "G. A. Maccacaro", University of Milan, Milan, Italy
| | - Meir Mei-Zahav
- Pulmonary Institute, Schneider Children's Medical Center of Israel, Sackler School of Medicine, Tel Aviv University, Petach Tikva, Tel Aviv, Israel
| | - Patrizia Boracchi
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
| | - Anders Lindblad
- Department of pediatrics, Queen Silvia Childrens Hospital, Gothenburg, Sweden
| | - Michal Shteinberg
- The B. Rappaport Faculty of Medicine, Pulmonology Institute and CF Center, Carmel Medical Center, The Technion-Israel Institute of Technology, 7 Michal St., Haifa 34362, Israel.
| | | |
Collapse
|
10
|
Dolce D, Claut L, Colombo C, Tosco A, Castaldo A, Padoan R, Timpano S, Fabrizzi B, Bonomi P, Taccetti G, Terlizzi V. Different management approaches and outcome for infants with an inconclusive diagnosis following newborn screening for cystic fibrosis (CRMS/CFSPID) and Pseudomonas aeruginosa isolation. J Cyst Fibros 2023; 22:73-78. [PMID: 35869019 DOI: 10.1016/j.jcf.2022.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/17/2022] [Accepted: 07/12/2022] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Evidence is currently lacking to guide the management of cystic fibrosis (CF) transmembrane conductance regulator-related metabolic syndrome CF screen-positive inconclusive diagnosis (CRMS/CFSPID) with Pseudomonas aeruginosa (Pa)-positive respiratory culture. This study assessed the clinical data, management, and outcomes of an Italian cohort of CRMS/CFSPID infants with Pa isolated from their airways. METHODS Data of Pa-positive CRMS/CFSPID infants born between January 2011 and August 2018 and followed at five CF Italian centres were retrospectively extracted. Further data were collected until June 2021 to assess outcomes, prevalence of subjects treated with antimicrobials, and treatment type and duration. RESULTS Forty-three asymptomatic CRMS/CFSPID patients (median age on 30 June 2021, 82 months; interquartile range [IQR], 63-98 months) with at least one positive airway culture for non-mucoid Pa (median age at first isolation, 18.7 months; IQR, 7-25 months) were enrolled. Of them, 24 (55.8%) underwent anti-Pa therapy. Pa clearance occurred in 22 (91.6%) of 24 patients versus spontaneous clearance in 16 of 19 (84.2%) untreated patients (chi-square, 0.5737; p = 0.44878). After a median follow-up of 6.2 years (IQR, 3.0-9.9), 7 (16.3%) were diagnosed with CF after a pathological sweat test (median age, 43 months; IQR, 28-77 months), 3 (7%) developed recurrent pancreatitis or isolated bronchiectasis consistent with CFTR-related disorder, and the CRMS/CFSPID classification remained in 33 (76.7%). CONCLUSIONS Pa detection frequently occurs in asymptomatic infants with CRMS/CFSPID but tends to clear spontaneously. More studies are needed to determine if Pa isolation can predict evolution.
Collapse
Affiliation(s)
- Daniela Dolce
- Meyer Children's Hospital, Cystic Fibrosis Regional Reference Center, Department of Paediatric Medicine, Florence, Italy
| | - Laura Claut
- Cystic Fibrosis Regional Reference Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Carla Colombo
- Cystic Fibrosis Regional Reference Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Antonella Tosco
- Paediatric Unit, Department of Translational Medical Sciences, Cystic Fibrosis Regional Reference Center, University of Naples Federico II, Naples, Italy
| | - Alice Castaldo
- Paediatric Unit, Department of Translational Medical Sciences, Cystic Fibrosis Regional Reference Center, University of Naples Federico II, Naples, Italy
| | - Rita Padoan
- Cystic Fibrosis Regional Support Center, Department of Pediatrics, University of Brescia, ASST Spedali Civili Brescia, Brescia, Italy
| | - Silviana Timpano
- Cystic Fibrosis Regional Support Center, Department of Pediatrics, University of Brescia, ASST Spedali Civili Brescia, Brescia, Italy
| | - Benedetta Fabrizzi
- Cystic Fibrosis Regional Reference Center, Mother - Child Department, United Hospitals, Ancona, Italy
| | | | - Giovanni Taccetti
- Meyer Children's Hospital, Cystic Fibrosis Regional Reference Center, Department of Paediatric Medicine, Florence, Italy
| | - Vito Terlizzi
- Meyer Children's Hospital, Cystic Fibrosis Regional Reference Center, Department of Paediatric Medicine, Florence, Italy.
| |
Collapse
|
11
|
Smith S, Rowbotham NJ. Inhaled anti-pseudomonal antibiotics for long-term therapy in cystic fibrosis. Cochrane Database Syst Rev 2022; 11:CD001021. [PMID: 36373968 PMCID: PMC9662285 DOI: 10.1002/14651858.cd001021.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Inhaled antibiotics are commonly used to treat persistent airway infection with Pseudomonas aeruginosa that contributes to lung damage in people with cystic fibrosis. Current guidelines recommend inhaled tobramycin for individuals with cystic fibrosis and persistent Pseudomonas aeruginosa infection who are aged six years or older. The aim is to reduce bacterial load in the lungs so as to reduce inflammation and deterioration of lung function. This is an update of a previously published review. OBJECTIVES To evaluate the effects of long-term inhaled antibiotic therapy in people with cystic fibrosis on clinical outcomes (lung function, frequency of exacerbations and nutrition), quality of life and adverse events (including drug-sensitivity reactions and survival). SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries. Date of last search: 28 June 2022. SELECTION CRITERIA We selected trials where people with cystic fibrosis received inhaled anti-pseudomonal antibiotic treatment for at least three months, treatment allocation was randomised or quasi-randomised, and there was a control group (either placebo, no placebo or another inhaled antibiotic). DATA COLLECTION AND ANALYSIS Two authors independently selected trials, judged the risk of bias, extracted data from these trials and judged the certainty of the evidence using the GRADE system. MAIN RESULTS The searches identified 410 citations to 125 trials; 18 trials (3042 participants aged between five and 45 years) met the inclusion criteria. Limited data were available for meta-analyses due to the variability of trial design and reporting of results. A total of 11 trials (1130 participants) compared an inhaled antibiotic to placebo or usual treatment for a duration between three and 33 months. Five trials (1255 participants) compared different antibiotics, two trials (585 participants) compared different regimens of tobramycin and one trial (90 participants) compared intermittent tobramycin with continuous tobramycin alternating with aztreonam. One trial (18 participants) compared an antibiotic to placebo and also to a different antibiotic and so fell into both groups. The most commonly studied antibiotic was tobramycin which was studied in 12 trials. Inhaled antibiotics compared to placebo We found that inhaled antibiotics may improve lung function measured in a variety of ways (4 trials, 814 participants). Compared to placebo, inhaled antibiotics may also reduce the frequency of exacerbations (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.47 to 0.93; 3 trials, 946 participants; low-certainty evidence). Inhaled antibiotics may lead to fewer days off school or work (quality of life measure) (mean difference (MD) -5.30 days, 95% CI -8.59 to -2.01; 1 trial, 245 participants; low-certainty evidence). There were insufficient data for us to be able to report an effect on nutritional outcomes and there was no effect on survival. There was no effect on antibiotic resistance seen in the two trials that were included in meta-analyses. We are uncertain of the effect of the intervention on adverse events (very low-certainty evidence), but tinnitus and voice alteration were the only events occurring more often in the inhaled antibiotics group. The overall certainty of evidence was deemed to be low for most outcomes due to risk of bias within the trials and imprecision due to low event rates. Different antibiotics or regimens compared Of the eight trials comparing different inhaled antibiotics or different antibiotic regimens, there was only one trial for each unique comparison. We found no differences between groups for any outcomes except for the following. Aztreonam lysine for inhalation probably improved forced expiratory volume at one second (FEV1) % predicted compared to tobramycin (MD -3.40%, 95% CI -6.63 to -0.17; 1 trial, 273 participants; moderate-certainty evidence). However, the method of defining the endpoint was different to the remaining trials and the participants were exposed to tobramycin for a long period making interpretation of the results problematic. We found no differences in any measure of lung function in the remaining comparisons. Trials measured pulmonary exacerbations in different ways and showed no differences between groups except for aztreonam lysine probably leading to fewer people needing treatment with additional antibiotics than with tobramycin (RR 0.66, 95% CI 0.51 to 0.86; 1 trial, 273 participants; moderate-certainty evidence); and there were fewer hospitalisations due to respiratory exacerbations with levofloxacin compared to tobramycin (RR 0.62, 95% CI 0.40 to 0.98; 1 trial, 282 participants; high-certainty evidence). Important treatment-related adverse events were not very common across comparisons, but were reported less often in the tobramycin group compared to both aztreonam lysine and colistimethate. We found the certainty of evidence for these comparisons to be directly related to the risk of bias within the individual trials and varied from low to high. AUTHORS' CONCLUSIONS Long-term treatment with inhaled anti-pseudomonal antibiotics probably improves lung function and reduces exacerbation rates, but pooled estimates of the level of benefit were very limited. The best evidence available is for inhaled tobramycin. More evidence from trials measuring similar outcomes in the same way is needed to determine a better measure of benefit. Longer-term trials are needed to look at the effect of inhaled antibiotics on quality of life, survival and nutritional outcomes.
Collapse
Affiliation(s)
- Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
| | - Nicola J Rowbotham
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
| |
Collapse
|
12
|
Blanchard AC, Waters VJ. Opportunistic Pathogens in Cystic Fibrosis: Epidemiology and Pathogenesis of Lung Infection. J Pediatric Infect Dis Soc 2022; 11:S3-S12. [PMID: 36069904 DOI: 10.1093/jpids/piac052] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022]
Abstract
Cystic fibrosis (CF) is one of the most common life-shortening genetic diseases in Caucasians. Due to abnormal accumulation of mucus, respiratory failure caused by chronic infections is the leading cause of mortality in this patient population. The microbiology of these respiratory infections includes a distinct set of opportunistic pathogens, including Pseudomonas aeruginosa, Burkholderia spp., Achromobacter spp., Stenotrophomonas maltophilia, anaerobes, nontuberculous mycobacteria, and fungi. In recent years, culture-independent methods have shown the polymicrobial nature of lung infections, and the dynamics of microbial communities. The unique environment of the CF airway predisposes to infections caused by opportunistic pathogens. In this review, we will highlight how the epidemiology and role in disease of these pathogens in CF differ from that in individuals with other medical conditions. Infectious diseases (ID) physicians should be aware of these differences and the specific characteristics of infections associated with CF.
Collapse
Affiliation(s)
- Ana C Blanchard
- Department of Pediatrics, Division of Infectious Diseases, CHU Sainte-Justine, Université de Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada
| | - Valerie J Waters
- Department of Pediatrics, Division of Infectious Diseases, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
| |
Collapse
|
13
|
Lloyd EC, Cogen JD, Maples H, Bell SC, Saiman L. Antimicrobial Stewardship in Cystic Fibrosis. J Pediatric Infect Dis Soc 2022; 11:S53-S61. [PMID: 36069899 DOI: 10.1093/jpids/piac071] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
The chronic airway infection and inflammation characteristic of cystic fibrosis (CF) ultimately leads to progressive lung disease, the primary cause of death in persons with CF (pwCF). Despite many recent advances in CF clinical care, efforts to preserve lung function in many pwCF still necessitate frequent antimicrobial use. Incorporating antimicrobial stewardship (AMS) principles into management of pulmonary exacerbations (PEx) would facilitate development of best practices for antimicrobial utilization at CF care centers. However, AMS can be challenging in CF given the unique aspects of chronic, polymicrobial infection in the CF airways, lack of evidence-based guidelines for managing PEx, limited utility for antimicrobial susceptibility testing, and increased frequency of adverse drug events in pwCF. This article describes current evidence-based antimicrobial treatment strategies for pwCF, highlights the potential for AMS to beneficially impact CF care, and provides practical strategies for integrating AMS programs into the management of PEx in pwCF.
Collapse
Affiliation(s)
- Elizabeth C Lloyd
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jonathan D Cogen
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Holly Maples
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas, USA.,Quality and Safety Division, Arkansas Children's, Little Rock, Arkansas, USA
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia.,Children's Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Brisbane, Queensland, Australia
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA.,Department of Infection Prevention and Control, NewYork-Presbyterian Hospital, New York, New York, USA
| |
Collapse
|
14
|
LiPuma JJ. The Sense and Nonsense of Antimicrobial Susceptibility Testing in Cystic Fibrosis. J Pediatric Infect Dis Soc 2022; 11:S46-S52. [PMID: 36069902 DOI: 10.1093/jpids/piac040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/03/2022] [Indexed: 11/13/2022]
Abstract
Antimicrobial susceptibility testing (AST) has been used to guide therapy of airway infection in persons with cystic fibrosis (CF) for decades. However, evidence that AST adds benefit to treatment outcomes in CF is lacking. In fact, the routine use of AST has potential to exacerbate inappropriate antibiotic use. Several features of airway infection in CF contribute to the limitations of AST in predicting treatment outcomes, providing rationale for abandoning this practice altogether. Other features of CF infection suggest, however, that select use of AST can provide worthwhile guidance to antibiotic selection.
Collapse
Affiliation(s)
- John J LiPuma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| |
Collapse
|
15
|
Cogen JD, Nichols DP, Goss CH, Somayaji R. Drugs, Drugs, Drugs: Current Treatment Paradigms in Cystic Fibrosis Airway Infections. J Pediatric Infect Dis Soc 2022; 11:S32-S39. [PMID: 36069901 DOI: 10.1093/jpids/piac061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/23/2022] [Indexed: 12/15/2022]
Abstract
Airway infections have remained a prominent feature in persons living with cystic fibrosis (CF) despite the dramatic improvements in survival in the past decades. Antimicrobials are a cornerstone of infection management for both acute and chronic maintenance indications. Historic clinical trials of antimicrobials in CF have led to the adoption of consensus guidelines for their use in clinical care. More recently, however, there are efforts to re-think the optimal use of antimicrobials for care with the advent of novel and highly effective CF transmembrane conductance regulator modulator therapies. Encouragingly, however, drug development has remained active concurrently in this space. Our review focuses on the evidence for and perspectives regarding antimicrobial use in both acute and maintenance settings in persons with CF. The therapeutic innovations in CF and how this may affect antimicrobial approaches are also discussed.
Collapse
Affiliation(s)
- Jonathan D Cogen
- Department of Pediatrics, University of Washington , Seattle, Washington, USA
| | - David P Nichols
- Department of Pediatrics, University of Washington , Seattle, Washington, USA.,Seattle Children's Research Institute, Seattle, Washington , USA
| | - Christopher H Goss
- Department of Pediatrics, University of Washington , Seattle, Washington, USA.,Seattle Children's Research Institute, Seattle, Washington , USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Ranjani Somayaji
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
16
|
Abstract
BACKGROUND Cystic fibrosis is a genetic disorder in which abnormal mucus in the lungs is associated with susceptibility to persistent infection. Pulmonary exacerbations are when symptoms of infection become more severe. Antibiotics are an essential part of treatment for exacerbations and inhaled antibiotics may be used alone or in conjunction with oral antibiotics for milder exacerbations or with intravenous antibiotics for more severe infections. Inhaled antibiotics do not cause the same adverse effects as intravenous antibiotics and may prove an alternative in people with poor access to their veins. This is an update of a previously published review. OBJECTIVES To determine if treatment of pulmonary exacerbations with inhaled antibiotics in people with cystic fibrosis improves their quality of life, reduces time off school or work, and improves their long-term lung function. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Group's Cystic Fibrosis Trials Register. Date of the last search: 7 March 2022. We also searched ClinicalTrials.gov, the Australia and New Zealand Clinical Trials Registry and WHO ICTRP for relevant trials. Date of last search: 3 May 2022. SELECTION CRITERIA Randomised controlled trials in people with cystic fibrosis with a pulmonary exacerbation in whom treatment with inhaled antibiotics was compared to placebo, standard treatment or another inhaled antibiotic for between one and four weeks. DATA COLLECTION AND ANALYSIS Two review authors independently selected eligible trials, assessed the risk of bias in each trial and extracted data. They assessed the certainty of the evidence using the GRADE criteria. Authors of the included trials were contacted for more information. MAIN RESULTS Five trials with 183 participants are included in the review. Two trials (77 participants) compared inhaled antibiotics alone to intravenous antibiotics alone and three trials (106 participants) compared a combination of inhaled and intravenous antibiotics to intravenous antibiotics alone. Trials were heterogenous in design and two were only available in abstract form. Risk of bias was difficult to assess in most trials but, for four out of five trials, we judged there to be a high risk from lack of blinding and an unclear risk with regards to randomisation. Results were not fully reported and only limited data were available for analysis. One trial was a cross-over design and we only included data from the first intervention arm. Inhaled antibiotics alone versus intravenous antibiotics alone Only one trial (18 participants) reported a perceived improvement in lifestyle (quality of life) in both groups (very low-certainty evidence). Neither trial reported on time off work or school. Both trials measured lung function, but there was no difference reported between treatment groups (very low-certainty evidence). With regards to our secondary outcomes, one trial (18 participants) reported no difference in the need for additional antibiotics and the second trial (59 participants) reported on the time to next exacerbation. In neither case was a difference between treatments identified (both very low-certainty evidence). The single trial (18 participants) measuring adverse events and sputum microbiology did not observe any in either treatment group for either outcome (very low-certainty evidence). Inhaled antibiotics plus intravenous antibiotics versus intravenous antibiotics alone Inhaled antibiotics plus intravenous antibiotics may make little or no difference to quality of life compared to intravenous antibiotics alone. None of the trials reported time off work or school. All three trials measured lung function, but found no difference between groups in forced expiratory volume in one second (two trials; 44 participants; very low-certainty evidence) or vital capacity (one trial; 62 participants). None of the trials reported on the need for additional antibiotics. Inhaled plus intravenous antibiotics may make little difference to the time to next exacerbation; however, one trial (28 participants) reported on hospital admissions and found no difference between groups. There is likely no difference between groups in adverse events (very low-certainty evidence) and one trial (62 participants) reported no difference in the emergence of antibiotic-resistant organisms (very low-certainty evidence). AUTHORS' CONCLUSIONS We identified only low- or very low-certainty evidence to judge the effectiveness of inhaled antibiotics for the treatment of pulmonary exacerbations in people with cystic fibrosis. The included trials were not sufficiently powered to achieve their goals. Hence, we are unable to demonstrate whether one treatment was superior to the other or not. Further research is needed to establish whether inhaled tobramycin may be used as an alternative to intravenous tobramycin for some pulmonary exacerbations.
Collapse
Affiliation(s)
- Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
| | - Nicola J Rowbotham
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, The University of Nottingham, Nottingham, UK
| | - Edward Charbek
- Division of Pulmonary, Critical Care and Sleep Medicine, St Louis University School of Medicine, St Louis, MO, USA
| |
Collapse
|
17
|
Green HD, Jones AM. Managing Pulmonary Infection in Adults With Cystic Fibrosis: Adult Cystic Fibrosis Series. Chest 2022; 162:66-75. [PMID: 35167860 DOI: 10.1016/j.chest.2022.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 02/04/2022] [Accepted: 02/04/2022] [Indexed: 12/17/2022] Open
Abstract
Cystic fibrosis (CF) is characterized by chronic airway infection and progressive respiratory decline. Historically, a narrow spectrum of bacterial pathogens was believed to comprise the bulk of respiratory infections in CF, with Haemophilus influenzae and Staphylococcus aureus dominating childhood infections, and Pseudomonas aeruginosa or, less commonly, a member of the Burkholderia cepacia complex becoming the dominant infecting organism in adulthood. Today, the landscape is changing for airway infection in CF. The prevalence of "less typical" gram-negative bacterial infections are rising due to a number of factors: the CF population is aging; new therapies are being introduced; antibiotic usage is increasing; diagnostic tests are evolving; and taxonomic changes are being made as new bacterial species are being discovered. Less is known about the clinical relevance and evidence for treatment strategies for many of the other lower prevalence organisms that are encountered in CF. The aim of this article was to discuss the current evidence and recommended strategies for treating airway infection in CF, focusing on bacterial infections.
Collapse
Affiliation(s)
- Heather D Green
- Manchester Adult Cystic Fibrosis Centre, Manchester University NHS Foundation Trust, Manchester, England
| | - Andrew M Jones
- Manchester Adult Cystic Fibrosis Centre, Manchester University NHS Foundation Trust, Manchester, England; Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, England.
| |
Collapse
|
18
|
Sunman B, Emiralioglu N, Hazirolan G, Şener B, Ozsezen B, Tural DA, Buyuksahin HN, Guzelkas I, Yalcin E, Dogru D, Özçelik U, Kiper N. Effectiveness of different eradication treatment protocols for new-onset Pseudomonas aeruginosa in children with cystic fibrosis. Pediatr Pulmonol 2022; 57:1456-1465. [PMID: 35229497 DOI: 10.1002/ppul.25876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/31/2022] [Accepted: 02/27/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES While eradicating new-onset Pseudomonas aeruginosa in children with cystic fibrosis is an important issue, there is no clear evidence about the best treatment approach. This retrospective observational cohort study aims to compare the effectiveness of intravenous therapy versus inhalation with/without oral therapy in the eradication of new-onset P. aeruginosa, determine the factors affecting the treatment success and assess lung function at baseline and posttreatment. METHODS Of 399 children, 110 (140 episodes) with either the first P. aeruginosa isolation or a new isolation after at least 1 year free of infection were included. Different eradication regimens (intravenous therapy or inhaled tobramycin or inhaled tobramycin plus oral ciprofloxacin) were compared. Eradication success was accepted as remaining free of infection with a negative culture for 12 months. Demographic, clinical, and microbiological characteristics of children, effectiveness of different eradication strategies, time to a new P. aeruginosa isolation, and the relationship between lung function and the type of eradication regimen were determined. RESULTS Of 140 episodes, intravenous therapy was administered in 53 and inhalation therapy (in combination with or without oral ciprofloxacin) in 87. Total success rate of eradication was 60.7%. Eradication was achieved in 56.6% of children with intravenous therapy, 59.7% with inhaled tobramycin therapy, and 72% with inhaled tobramycin plus oral ciprofloxacin therapy. Success rates of different eradication regimens did not differ significantly (p = 0.419). Lung function by the end of the first year was worse in the intravenous group compared to the inhalation group (p = 0.017 for forced expiratory volume in 1 s, p = 0.015 for forced vital capacity). CONCLUSION No advantage of intravenous therapy was demonstrated compared to inhalation therapy in terms of eradication success.
Collapse
Affiliation(s)
- Birce Sunman
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nagehan Emiralioglu
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Gülsen Hazirolan
- Department of Medical Microbiology, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Burçin Şener
- Department of Medical Microbiology, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Beste Ozsezen
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Dilber A Tural
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Halime N Buyuksahin
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ismail Guzelkas
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ebru Yalcin
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Deniz Dogru
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Uğur Özçelik
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nural Kiper
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
19
|
Magaret AS, Warden M, Simon N, Heltshe S, Retsch-Bogart GZ, Ramsey BW, Mayer-Hamblett N. A new path for CF clinical trials through the use of historical controls. J Cyst Fibros 2022; 21:293-299. [PMID: 34879997 PMCID: PMC8957493 DOI: 10.1016/j.jcf.2021.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 09/24/2021] [Accepted: 11/15/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Given future challenges in conducting large randomized, placebo controlled trials for future CF therapeutics development, we evaluated the potential for using external historical controls to either enrich or replace traditional concurrent placebo groups in CF trials. METHODS The study included data from sequentially completed, randomized, controlled clinical trials, EPIC and OPTIMIZE respectively, evaluating optimal antibiotic therapy to reduce the risk of pulmonary exacerbation in children with early Pseudomonas aeruginosa infection. The primary treatment effect in OPTIMIZE, the risk of pulmonary exacerbation associated with azithromycin, was re-estimated in alternative designs incorporating varying numbers of participants from the earlier trial (EPIC) as historical controls. Bias and precision of these estimates were characterized. Propensity scores were derived to adjust for baseline differences across study populations, and both Poisson and Cox regression were used to estimate treatment efficacy. RESULTS Replacing 86 OPTIMIZE placebo participants with 304 controls from EPIC to mimic a fully historically controlled trial resulted an 8% reduction in risk of pulmonary exacerbations (Hazard ratio (HR):0.92 95% CI 0.61, 1.34) when not adjusting for key baseline differences between study populations. After adjustment, a 37% decrease in risk of exacerbation (HR:0.63, 95% CI 0.50, 0.80) was estimated, comparable to the estimate from the original trial comparing the 86 placebo participants to 77 azithromycin participants on azithromycin (45%, HR:0.55, 95% CI: 0.34, 0.86). Other adjusted approaches provided similar estimates for the efficacy of azithromycin in reducing exacerbation risk: pooling all controls from both studies provided a HR of 0.60 (95% x`CI 0.46, 0.77) and augmenting half the OPTIMIZE placebo participants with EPIC controls gave a HR 0.63 (95% CI 0.48, 0.82). CONCLUSIONS The potential exists for future CF trials to utilize historical control data. Careful consideration of both the comparability of controls and of optimal methods can reduce the potential for biased estimation of treatment effects.
Collapse
Affiliation(s)
- Amalia S. Magaret
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children’s Hospital, Seattle, WA, USA,Department of Pediatrics, University of Washington, Seattle, WA, USA,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Mark Warden
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Noah Simon
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children’s Hospital, Seattle, WA, USA,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Sonya Heltshe
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children’s Hospital, Seattle, WA, USA,Department of Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Bonnie W. Ramsey
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children’s Hospital, Seattle, WA, USA,Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Nicole Mayer-Hamblett
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children’s Hospital, Seattle, WA, USA,Department of Pediatrics, University of Washington, Seattle, WA, USA,Department of Biostatistics, University of Washington, Seattle, WA, USA
| |
Collapse
|
20
|
Schwarz C, Taccetti G, Burgel PR, Mulrennan S. Tobramycin safety and efficacy review article. Respir Med 2022; 195:106778. [DOI: 10.1016/j.rmed.2022.106778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 12/27/2022]
|
21
|
Lahiri T, Sullivan JS. Recent advances in the early treatment of cystic fibrosis: Bridging the gap to highly effective modulator therapy. Pediatr Pulmonol 2022; 57 Suppl 1:S60-S74. [PMID: 34473419 DOI: 10.1002/ppul.25660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/22/2021] [Accepted: 09/01/2021] [Indexed: 11/08/2022]
Abstract
Highly effective modulator therapy (HEMT) for cystic fibrosis (CF) has been touted as one of the greatest advances to date in CF care. As these therapies are now available for many older children and adults with CF, marked improvement of their nutritional status, pulmonary and gastrointestinal symptoms has been observed. However, most infants and younger children are not current candidates for HEMT due to age and/or cystic fibrosis transmembrane conductance regulator (CFTR) mutation. For these young children, it is essential to provide rigorous monitoring and care to avoid potential disease sequelae while awaiting HEMT availability. The following article highlights recent advances in the care of infants and young children with CF with regard to surveillance and treatment of nutritional, pulmonary, and gastrointestinal disorders. Recent clinical trials in this population are also reviewed.
Collapse
Affiliation(s)
- Thomas Lahiri
- Divisions of Pediatric Pulmonology and Gastroenterology, University of Vermont Children's Hospital, Burlington, Vermont, USA
| | - Jillian S Sullivan
- Divisions of Pediatric Pulmonology and Gastroenterology, University of Vermont Children's Hospital, Burlington, Vermont, USA
| |
Collapse
|
22
|
Mursaloglu HH, Akın C, Yılmaz Yeğit C, Ergenekon AP, Suzer Uzunoglu B, Taştan G, Gökdemir Y, Erdem Eralp E, Karahasan Yağcı A, Karakoç F, Karadağ B. Comparison of intravenous and non-intravenous antibiotic regimens in eradication of P. aeruginosa and MRSA in cystic fibrosis. Pediatr Pulmonol 2021; 56:3745-3751. [PMID: 34436829 DOI: 10.1002/ppul.25646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/30/2021] [Accepted: 08/22/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Chronic pulmonary infection is the leading cause of mortality and morbidity in patients with cystic fibrosis (CF). The most common pathogens isolated in CF are Staphylococcus aureus (SA) and Pseudomonas aeruginosa (PA). Chronic infection of PA and methicillin-resistant S. aureus (MRSA) are associated with worse survival and antibiotic eradication treatment is recommended for both. This study compared the outcomes between intravenous (IV) and non-IV antibiotics in eradication of PA and MRSA. METHODS This was a single-center retrospective study. All respiratory specimen cultures of 309 CF patients and eradication regimens between 2015 and 2019 were reviewed. Patients received eradication treatment in case of first ever isolation or new isolation after being infection-free ≥1 year. The primary analysis was the comparison of the percentage of successful eradication after receiving IV and non-IV eradication regimens. Demographic and clinical risk factors for eradication failure were also analyzed. RESULTS One hundred and two patients with PA isolations and 48 patients with MRSA were analyzed. At 1 year, 21.6% in PA group and 35.4% in MRSA group were successfully eradicated. There was not any statistically significant difference between IV versus non-IV antibiotic regimens on eradication in either group. Additionally, none of the clinical risk factors was significantly associated with eradication failure in PA and MRSA groups. CONCLUSION In the eradication of PA and MRSA, IV and non-IV treatment regimens did not show any superiority to one another. Non-parenteral eradication could be a better option considering the cost-effectiveness and the treatment burden of IV treatments due to hospitalization and the need for IV access.
Collapse
Affiliation(s)
- H Hakan Mursaloglu
- Department of Pediatric Pulmonology, Selim Coremen Cystic Fibrosis Center, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Can Akın
- Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Cansu Yılmaz Yeğit
- Department of Pediatric Pulmonology, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Almala P Ergenekon
- Department of Pediatric Pulmonology, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Burcu Suzer Uzunoglu
- Department of Pediatric Pulmonology, Selim Coremen Cystic Fibrosis Center, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Gamze Taştan
- Department of Pediatric Pulmonology, Selim Coremen Cystic Fibrosis Center, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Yasemin Gökdemir
- Department of Pediatric Pulmonology, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Ela Erdem Eralp
- Department of Pediatric Pulmonology, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Ayşegül Karahasan Yağcı
- Department of Medical Microbiology, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Fazilet Karakoç
- Department of Pediatric Pulmonology, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Bulent Karadağ
- Department of Pediatric Pulmonology, Faculty of Medicine, Marmara University, Istanbul, Turkey
| |
Collapse
|
23
|
The Epidemiology and Pathogenesis and Treatment of Pseudomonas aeruginosa Infections: An Update. Drugs 2021; 81:2117-2131. [PMID: 34743315 PMCID: PMC8572145 DOI: 10.1007/s40265-021-01635-6] [Citation(s) in RCA: 135] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2021] [Indexed: 12/20/2022]
Abstract
Pseudomonas aeruginosa is a Gram-negative bacterial pathogen that is a common cause of nosocomial infections, particularly pneumonia, infection in immunocompromised hosts, and in those with structural lung disease such as cystic fibrosis. Epidemiological studies have
identified increasing trends of antimicrobial resistance, including multi-drug resistant (MDR) isolates in recent years. P. aeruginosa has several virulence mechanisms that increase its ability to cause severe infections, such as secreted toxins, quorum sensing and biofilm formation. Management of P. aeruginosa infections focuses on prevention when possible, obtaining cultures, and prompt initiation of antimicrobial therapy, occasionally with combination therapy depending on the clinical scenario to ensure activity against P. aeruginosa. Newer anti-pseudomonal antibiotics are available and are increasingly being used in the management of MDR P. aeruginosa.
Collapse
|
24
|
Pittman JE, Khan U, Laguna TA, Heltshe S, Goss CH, Sanders DB. Rates of adverse and serious adverse events in children with cystic fibrosis. J Cyst Fibros 2021; 20:972-977. [PMID: 33745860 PMCID: PMC8448791 DOI: 10.1016/j.jcf.2021.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/29/2021] [Accepted: 02/26/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) is an autosomal recessive disease characterized by chronic sinopulmonary symptoms and chronic gastrointestinal symptoms that begins in infancy. Children with CF are increasingly being included in clinical trials. In order to fully evaluate the impact of new therapies in future clinical trials, an understanding of baseline adverse event (AE) rates in children with CF is needed. To address this, we determined the rates of common AEs in pediatric patients with CF who participated in two clinical trials. METHODS We reviewed AEs for placebo recipients in the AZ0004 study and inhaled tobramycin recipients in the Early Pseudomonas Infection Control (EPIC) clinical trial. AEs were categorized based on Medical Dictionary for Regulatory Activities (MedDRA) coding classifications and pooled into common, batched AE descriptors. AE rates were estimated from negative binomial models according to age groups, severity of lung disease, and season. RESULTS A total of 433 children had 8,266 total AEs reported, or 18.1 (95% CI 17.0, 19.2) AEs per person per year. Respiratory AEs were the most commonly reported AEs, with a rate of 7.6 events per person-year. The total SAE rate was 0.33 per person per-year. Cough was the most commonly reported respiratory AE, with 61% of subjects reporting at least one episode of cough within 4 months. The rate ratio of any AE was higher in Spring, Fall, and Winter, compared with Summer. CONCLUSIONS AEs occur commonly in pediatric CF clinical trial participants. Season of enrollment could affect AE rates.
Collapse
Affiliation(s)
- Jessica E Pittman
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Umer Khan
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States
| | - Theresa A Laguna
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Sonya Heltshe
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Christopher H Goss
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Don B Sanders
- Division of Pediatric Pulmonary, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States.
| |
Collapse
|
25
|
Ratjen F, VanDevanter DR. Retracing changes in cystic fibrosis understanding and management over the past twenty years. J Cyst Fibros 2021; 21:3-9. [PMID: 34602342 DOI: 10.1016/j.jcf.2021.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Felix Ratjen
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Canada
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH USA.
| |
Collapse
|
26
|
Karki K, Sigdel S, Kafle S. Is it Worth Adding Systemic Antibiotics to Inhalational Tobramycin Therapy to Treat Pseudomonas Infections in Cystic Fibrosis? Cureus 2021; 13:e17326. [PMID: 34567873 PMCID: PMC8451513 DOI: 10.7759/cureus.17326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2021] [Indexed: 11/19/2022] Open
Abstract
Pseudomonas aeruginosa (PA), a gram-negative rod-shaped bacterium, is one of the most common pathogens causing colonization and infection of the respiratory tract and lungs in patients with cystic fibrosis (CF). Antibiotic therapy is the mainstay treatment for PA infection, and tobramycin is one of the widely used antibiotics in intravenous or inhalation form. This review aims to explore if there is any advantage of adding systemic antibiotics to tobramycin inhalation therapy by comparing the combination regimen to tobramycin inhalation monotherapy in CF patients with PA infection. We collected studies relevant to our review topic by doing a literature search on multiple databases. According to the currently available studies, the addition of oral antibiotics such as fluoroquinolones and azithromycin to tobramycin inhalation solution (TIS) provides no additional benefit in eradicating PA infection or producing clinical improvement in cystic fibrosis patients. However, adding intravenous antibiotics to TIS has not produced conclusive results and thus requires further research. We recommend conducting more randomized controlled trials comparing different treatment regimens, which may help discover the most beneficial treatment regimen with decreased systemic side effects.
Collapse
Affiliation(s)
- Kumar Karki
- Internal Medicine, Larkin Community Hospital, Miami, USA
| | - Santosh Sigdel
- Internal Medicine, Avera McKennan Hospital and University Health Center, Sioux Falls, USA
| | - Sunam Kafle
- Internal Medicine, College of Medical Sciences, Bharatpur, NPL
| |
Collapse
|
27
|
Cogen JD, Onchiri FM, Hamblett NM, Gibson RL, Morgan WJ, Rosenfeld M. Association of Intensity of Antipseudomonal Antibiotic Therapy With Risk of Treatment-Emergent Organisms in Children With Cystic Fibrosis and Newly Acquired Pseudomonas Aeruginosa. Clin Infect Dis 2021; 73:987-993. [PMID: 33693586 DOI: 10.1093/cid/ciab208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND While Pseudomonas aeruginosa (Pa) eradication regimens have contributed to a decline in Pa prevalence in people with cystic fibrosis (CF), this antibiotic exposure might increase the risk of acquisition of drug-resistant organisms. This study evaluated the association between antipseudomonal antibiotic exposure intensity and acquisition risk of drug-resistant organisms among children with CF and new Pa infection. METHODS We utilized data from the Early Pseudomonas Infection Control Clinical Trial (EPIC CT), a randomized controlled trial comparing Pa eradication strategies in children with CF and new Pa. The exposure was the number of weeks of oral or inhaled antipseudomonal antibiotics or ever versus never treatment with intravenous antipseudomonal antibiotics during the 18 months of EPIC CT participation. Primary outcomes were risks of acquisition of several respiratory organisms during 5 years of follow-up after EPIC CT estimated using Cox proportional hazards models separately for each specific organism. RESULTS Among 249 participants, there was no increased acquisition risk of any organism associated with greater inhaled antibiotic exposure. With each additional week of oral antibiotics, there was an increased hazard of Achromobacter xylosoxidans acquisition (HR, 1.24; 95% CI: 1.02-1.50; P = .03). Treatment with intravenous antibiotics was associated with an increased hazard of acquisition of multidrug-resistant Pa (HR, 2.47; 95% CI: 1.28-4.78; P = .01) and MRSA (HR, 1.57; 95% CI: 1.03-2.40; P = .04). CONCLUSIONS Results from this study illustrate the importance of making careful antibiotic choices to balance the benefits of antibiotics in people with CF while minimizing risk of acquisition of drug-resistant organisms.
Collapse
Affiliation(s)
- Jonathan D Cogen
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Seattle Children's Research Institute, Seattle, Washington, USA
| | | | - Nicole Mayer Hamblett
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Biostatistics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ronald L Gibson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Wayne J Morgan
- Department of Pediatrics, The University of Arizona, Tucson, Arizona, USA
| | - Margaret Rosenfeld
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Seattle Children's Research Institute, Seattle, Washington, USA
| |
Collapse
|
28
|
Current and Emerging Therapies to Combat Cystic Fibrosis Lung Infections. Microorganisms 2021; 9:microorganisms9091874. [PMID: 34576767 PMCID: PMC8466233 DOI: 10.3390/microorganisms9091874] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/26/2021] [Accepted: 08/30/2021] [Indexed: 11/30/2022] Open
Abstract
The ultimate aim of any antimicrobial treatment is a better infection outcome for the patient. Here, we review the current state of treatment for bacterial infections in cystic fibrosis (CF) lung while also investigating potential new treatments being developed to see how they may change the dynamics of antimicrobial therapy. Treatment with antibiotics coupled with regular physical therapy has been shown to reduce exacerbations and may eradicate some strains. Therapies such as hypertonic saline and inhaled PulmozymeTM (DNase-I) improve mucus clearance, while modifier drugs, singly and more successfully in combination, re-open certain mutant forms of the cystic fibrosis transmembrane conductance regulator (CFTR) to enable ion passage. No current method, however, completely eradicates infection, mainly due to bacterial survival within biofilm aggregates. Lung transplants increase lifespan, but reinfection is a continuing problem. CFTR modifiers normalise ion transport for the affected mutations, but there is conflicting evidence on bacterial clearance. Emerging treatments combine antibiotics with novel compounds including quorum-sensing inhibitors, antioxidants, and enzymes, or with bacteriophages, aiming to disrupt the biofilm matrix and improve antibiotic access. Other treatments involve bacteriophages that target, infect and kill bacteria. These novel therapeutic approaches are showing good promise in vitro, and a few have made the leap to in vivo testing.
Collapse
|
29
|
Effect of Concomitant Azithromycin and Tobramycin Use on Cystic Fibrosis Pulmonary Exacerbation Treatment. Ann Am Thorac Soc 2021; 18:266-272. [PMID: 32810412 DOI: 10.1513/annalsats.202002-176oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Pulmonary exacerbations (PExs) are associated with significant morbidity in people with cystic fibrosis (CF). Severe PExs are treated with intravenous antibiotics, including tobramycin. CF care guidelines recommend continuing chronic maintenance medications during PEx treatment. Azithromycin (AZM) is one of the most widely prescribed chronic medications for CF in the United States. Recent evidence has identified a potential antagonistic relationship between AZM and tobramycin.Objectives: To determine whether, among PEx treated with intravenous tobramycin, concomitant AZM use is associated with worse clinical outcomes.Methods: Retrospective cohort study using the CF Foundation Patient Registry-Pediatric Health Information System (CFFPR-PHIS)-linked dataset. People with CF age 6-21 years were included if they were hospitalized between 2006 and 2016 for a PEx. Inverse probability of treatment weighing was used to minimize the effects of confounders, including indication bias. Associations of concomitant treatment with AZM and lung function outcomes were determined using linear mixed-effect models and generalized estimating equations. Cox proportional hazard regression models were used to evaluate associations with time to next PEx.Results: Among the 10,660 people with CF included in the CFFPR-PHIS-linked dataset, 2,294 children and adolescents with 5,022 PExs that had intravenous tobramycin use were identified. A little less than half (n = 2,247; 45%) of all PExs were treated concomitantly with AZM and intravenous tobramycin. AZM use both at the most recent outpatient clinic encounter and during PEx treatment in combination with intravenous tobramycin was associated with a significantly lower absolute improvement in percentage-predicted forced expiratory volume in 1 second (ppFEV1) (-0.93%; 95% confidence interval [CI], -1.78 to -0.07; P = 0.033), a lesser odds of returning to 90% or more of baseline ppFEV1 (odds ratio, 0.79; 95% CI, 0.68-0.93; P = 0.003), and a shorter time to next PEx requiring intravenous antibiotics (hazard ratio, 1.22; 95% CI, 1.14-1.31; P < 0.001) compared with intravenous tobramycin use without concomitant AZM.Conclusions: Concomitant AZM and intravenous tobramycin use for in-hospital PEx treatment was associated with poorer clinical outcomes than treatment with intravenous tobramycin without AZM. These results support the hypothesis that an antagonistic relationship between these two medications might exist.
Collapse
|
30
|
Morris AJ, Jackson L, Cw Yau Y, Reichhardt C, Beaudoin T, Uwumarenogie S, Guttman KM, Lynne Howell P, Parsek MR, Hoffman LR, Nguyen D, DiGiandomenico A, Guttman DS, Wozniak DJ, Waters VJ. The role of Psl in the failure to eradicate Pseudomonas aeruginosa biofilms in children with cystic fibrosis. NPJ Biofilms Microbiomes 2021; 7:63. [PMID: 34349133 PMCID: PMC8338932 DOI: 10.1038/s41522-021-00234-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 07/01/2021] [Indexed: 11/09/2022] Open
Abstract
The exopolysaccharide Psl contributes to biofilm structure and antibiotic tolerance and may play a role in the failure to eradicate Pseudomonas aeruginosa from cystic fibrosis (CF) airways. The study objective was to determine whether there were any differences in Psl in P. aeruginosa isolates that were successfully eradicated compared to those that persisted, despite inhaled tobramycin treatment, in children with CF. Initial P. aeruginosa isolates were collected from children with CF undergoing eradication treatment, grown as biofilms and labeled with 3 anti-Psl monoclonal antibodies (Cam003/Psl0096, WapR001, WapR016) before confocal microscopy visualization. When grown as biofilms, P. aeruginosa isolates from children who failed antibiotic eradication therapy, had significantly increased Psl0096 binding compared to isolates from those who cleared P. aeruginosa. This was confirmed in P. aeruginosa isolates from the SickKids Eradication Cohort as well as the Early Pseudomonas Infection Control (EPIC) trial. Increased anti-Psl antibody binding was associated with bacterial aggregation and tobramycin tolerance. The biofilm matrix represents a potential therapeutic target to improve P. aeruginosa eradication treatment.
Collapse
Affiliation(s)
- Amanda J Morris
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Lindsay Jackson
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Yvonne Cw Yau
- Division of Microbiology, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Trevor Beaudoin
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Stephanie Uwumarenogie
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Kevin M Guttman
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - P Lynne Howell
- Program in Molecular Medicine, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Biochemistry, University of Toronto, Toronto, ON, Canada
| | - Matthew R Parsek
- Department of Microbiology, University of Washington, Seattle, WA, USA
| | - Lucas R Hoffman
- Departments of Pediatrics and Microbiology, University of Washington, Seattle, WA, USA
| | - Dao Nguyen
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Antonio DiGiandomenico
- Discovery Microbiome, Microbial Sciences, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, USA
| | - David S Guttman
- Department of Cell and Systems Biology, University of Toronto, Toronto, ON, Canada
| | - Daniel J Wozniak
- Departments of Microbial Infection and Immunity, Microbiology, Ohio State University, Columbus, OH, USA
| | - Valerie J Waters
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada. .,Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada. .,Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
31
|
Cystic Fibrosis: Recent Insights into Inhaled Antibiotic Treatment and Future Perspectives. Antibiotics (Basel) 2021; 10:antibiotics10030338. [PMID: 33810116 PMCID: PMC8004710 DOI: 10.3390/antibiotics10030338] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 02/08/2023] Open
Abstract
Although new inhaled antibiotics have profoundly improved respiratory diseases in cystic fibrosis (CF) patients, lung infections are still the leading cause of death. Inhaled antibiotics, i.e., colistin, tobramycin, aztreonam lysine and levofloxacin, are used as maintenance treatment for CF patients after the development of chronic Pseudomonas aeruginosa (P. aeruginosa) infection. Their use offers advantages over systemic therapy since a relatively high concentration of the drug is delivered directly to the lung, thus, enhancing the pharmacokinetic/pharmacodynamic parameters and decreasing toxicity. Notably, alternating treatment with inhaled antibiotics represents an important strategy for improving patient outcomes. The prevalence of CF patients receiving continuous inhaled antibiotic regimens with different combinations of the anti-P. aeruginosa antibiotic class has been increasing over time. Moreover, these antimicrobial agents are also used for preventing acute pulmonary exacerbations in CF. In this review, the efficacy and safety of the currently available inhaled antibiotics for lung infection treatment in CF patients are discussed, with a particular focus on strategies for eradicating P. aeruginosa and other pathogens. Moreover, the effects of long-term inhaled antibiotic therapy for chronic P. aeruginosa infection and for the prevention of pulmonary exacerbations is reviewed. Finally, how the mucus environment and microbial community richness can influence the efficacy of aerosolized antimicrobial agents is discussed.
Collapse
|
32
|
Kwong K, Benedetti A, Yau Y, Waters V, Nguyen D. Failed eradication therapy of new onset Pseudomonas aeruginosa infections in cystic fibrosis children is associated with bacterial resistance to neutrophil functions. J Infect Dis 2021; 225:1886-1895. [PMID: 33606875 PMCID: PMC9159338 DOI: 10.1093/infdis/jiab102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/12/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Antibiotics, such as inhaled tobramycin are used to eradicate new onset Pseudomonas aeruginosa (PA) infections in cystic fibrosis (CF) patients but frequently fail due to reasons poorly understood. We hypothesized that PA isolates' resistance to neutrophil antibacterial functions was associated with failed eradication in patients harboring those strains. METHODS We analyzed all PA isolates from a cohort of 39 CF children with new onset PA infections undergoing tobramycin eradication therapy, where N=30 patients had eradicated and N=9 patients had persistent infection. We characterized several bacterial phenotypes and measured the isolates' susceptibility to neutrophil antibacterial functions using in vitro assays of phagocytosis and intracellular bacterial killing. RESULTS PA isolates from persistent infections were more resistant to neutrophil functions, with lower phagocytosis and intracellular bacterial killing compared to those from eradicated infections. In multivariable analyses, in vitro neutrophil responses were positively associated with twitching motility, and negatively with mucoidy. In vitro neutrophil phagocytosis was a predictor of persistent infection following tobramycin even after adjustment for clinical risk factors. CONCLUSIONS PA isolates from new onset CF infection show strain-specific susceptibility to neutrophil antibacterial functions, and infection with PA isolates resistant to neutrophil phagocytosis is an independent risk factor for failed tobramycin eradication.
Collapse
Affiliation(s)
- K Kwong
- Department of Microbiology and Immunology, McGill University, Montreal, CA.,Meakins Christie Laboratories, Research Institute of the McGill University Health Centre, Montreal, CA
| | - A Benedetti
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, CA.,Centre for Health Outcome Research, Research Institute of the McGill University Health Centre, Montreal, CA
| | - Y Yau
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, CA.,Division of Microbiology, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, CA
| | - V Waters
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, CA.,Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, CA
| | - D Nguyen
- Department of Microbiology and Immunology, McGill University, Montreal, CA.,Meakins Christie Laboratories, Research Institute of the McGill University Health Centre, Montreal, CA.,Department of Medicine, McGill University, Montreal, CA
| |
Collapse
|
33
|
Pseudomonas aeruginosa Resistance to Bacteriophages and Its Prevention by Strategic Therapeutic Cocktail Formulation. Antibiotics (Basel) 2021; 10:antibiotics10020145. [PMID: 33540528 PMCID: PMC7912912 DOI: 10.3390/antibiotics10020145] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/23/2021] [Accepted: 01/27/2021] [Indexed: 12/12/2022] Open
Abstract
Antimicrobial resistance poses a significant threat to modern healthcare as it limits treatment options for bacterial infections, particularly impacting those with chronic conditions such as cystic fibrosis (CF). Viscous mucus accumulation in the lungs of individuals genetically predisposed to CF leads to recurrent bacterial infections, necessitating prolonged antimicrobial chemotherapy. Pseudomonas aeruginosa infections are the predominant driver of CF lung disease, and airway isolates are frequently resistant to multiple antimicrobials. Bacteriophages, or phages, are viruses that specifically infect bacteria and are a promising alternative to antimicrobials for CF P. aeruginosa infections. However, the narrow host range of P. aeruginosa-targeting phages and the rapid evolution of phage resistance could limit the clinical efficacy of phage therapy. A promising approach to overcome these issues is the strategic development of mixtures of phages (cocktails). The aim is to combine phages with broad host ranges and target multiple distinct bacterial receptors to prevent the evolution of phage resistance. However, further research is required to identify and characterize phage resistance mechanisms in CF-derived P. aeruginosa, which differ from their non-CF counterparts. In this review, we consider the mechanisms of P. aeruginosa phage resistance and how these could be overcome by an effective future phage therapy formulation.
Collapse
|
34
|
Choi J, Novak K, Thompson R. Evaluation of Inhaled Tobramycin in Early Eradication of Pseudomonas aeruginosa in Infants With Cystic Fibrosis. J Pediatr Pharmacol Ther 2020; 25:709-716. [PMID: 33214782 DOI: 10.5863/1551-6776-25.8.709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Early antibiotic therapy has the potential to eradicate initial Pseudomonas aeruginosa infection and postpone chronic infection. There are limited data evaluating the efficacy and safety of inhaled tobramycin in patients with cystic fibrosis (CF) who are younger than 1 year. The objective of this study was to evaluate the effectiveness of inhaled tobramycin in early eradication of P aeruginosa in infants with CF. METHODS This retrospective study evaluated patients with CF younger than 1 year with first time infection with P aeruginosa. The primary outcome was the frequency of P aeruginosa eradication. Secondary outcomes were sustained culture negativity at 12 and 18 months and safety assessments. RESULTS Of 18 patients included in the study, 9 received inhaled tobramycin and an enteral fluoroquinolone and 9 received inhaled tobramycin alone. Microbiologic clearance of respiratory cultures was observed in 83% patients at end of therapy and 78% of patients at 1 month posttherapy. Eradication of P aeruginosa was observed in 56% of patients at 6 months posttreatment with sustained culture negativity observed in 39% of patients up to 18 months. CONCLUSIONS Inhaled-tobramycin therapy is effective in early eradication of P aeruginosa infection and is well tolerated in infants younger than 1 year.
Collapse
Affiliation(s)
- Jane Choi
- Department of Pharmacy (JC, KN), Nationwide Children's Hospital, Columbus OH
| | - Kimberly Novak
- Department of Pharmacy (JC, KN), Nationwide Children's Hospital, Columbus OH.,Section of Pulmonary Medicine (KN, RT), Nationwide Children's Hospital, Columbus OH
| | - Rohan Thompson
- Section of Pulmonary Medicine (KN, RT), Nationwide Children's Hospital, Columbus OH
| |
Collapse
|
35
|
Hewer SCL, Smyth AR, Brown M, Jones AP, Hickey H, Kenna D, Ashby D, Thompson A, Williamson PR. Intravenous versus oral antibiotics for eradication of Pseudomonas aeruginosa in cystic fibrosis (TORPEDO-CF): a randomised controlled trial. THE LANCET RESPIRATORY MEDICINE 2020; 8:975-986. [PMID: 33007285 PMCID: PMC7606906 DOI: 10.1016/s2213-2600(20)30331-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 05/05/2020] [Accepted: 06/08/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Chronic pulmonary infection with Pseudomonas aeruginosa is one of the most important causes of mortality and morbidity in cystic fibrosis. If antibiotics are commenced promptly, infection can be eradicated. The aim of the trial was to compare the effectiveness and safety of intravenous ceftazidime and tobramycin versus oral ciprofloxacin in the eradication of P aeruginosa. METHODS We did a multicentre, parallel group, open-label, randomised controlled trial in 72 cystic fibrosis centres (70 in the UK and two in Italy). Eligible participants were older than 28 days with an isolate of P aeruginosa (either the first ever isolate or a new isolate after at least 1 year free of infection). Participants were excluded if the P aeruginosa was resistant to, or they had a contraindication to, one or more of the trial antibiotics; if they were already receiving P aeruginosa suppressive therapy; if they had received any P aeruginosa eradication therapy within the previous 9 months; or if they were pregnant or breastfeeding. We used web-based randomisation to assign patients to 14 days intravenous ceftazidime and tobramycin or 12 weeks oral ciprofloxacin. Both were combined with 12 weeks inhaled colistimethate sodium. Randomisation lists were generated by a statistician, who had no involvement in the trial, using a computer-generated list. Randomisation was stratified by centre and because of the nature of the interventions, blinding was not possible. Our primary outcome was eradication of P aeruginosa at 3 months and remaining free of infection to 15 months. Primary analysis used intention to treat (powered for superiority). Safety analysis included patients who received at least one dose of study drug. TORPEDO-CF was registered on the ISRCTN register, ISRCTN02734162, and EudraCT, 2009-012575-10. FINDINGS Between Oct 5, 2010, and Jan 27, 2017, 286 patients were randomly assigned to treatment: 137 to intravenous antibiotics and 149 to oral antibiotics. 55 (44%) of 125 participants in the intravenous group and 68 (52%) of 130 participants in the oral group achieved the primary outcome. Participants randomly assigned to the intravenous group were less likely to achieve the primary outcome, although the difference between groups was not statistically significant (relative risk 0·84, 95% CI 0·65-1·09; p=0·18). 11 serious adverse events occurred in ten (8%) of 126 participants in the intravenous antibiotics group and 17 serious adverse events in 12 (8%) of 146 participants in the oral antibiotics group. INTERPRETATION Compared with oral therapy, intravenous antibiotics did not achieve sustained eradication of P aeruginosa in a greater proportion of patients with cystic fibrosis and was more expensive. Although there were fewer hospitalisations in the intravenous group than the oral group during follow-up, this confers no advantage over oral treatment because intravenous eradication frequently requires hospitalisation. These results do not support the use of intravenous antibiotics to eradicate P aeruginosa in cystic fibrosis. FUNDING National Institute for Health Research Health Technology Assessment Programme.
Collapse
Affiliation(s)
- Simon C Langton Hewer
- Department of Paediatric Respiratory Medicine, Bristol Royal Hospital for Children, University of Bristol, Bristol, UK.
| | - Alan R Smyth
- Division of Child Health, Obstetrics & Gynaecology, University of Nottingham, Nottingham, UK
| | - Michaela Brown
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - Ashley P Jones
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - Helen Hickey
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - Dervla Kenna
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, London, UK
| | - Deborah Ashby
- School of Public Health, Imperial College London, London, UK
| | - Alexander Thompson
- The University of Manchester, Manchester Centre for Health Economics, Manchester, UK
| | - Paula R Williamson
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | | |
Collapse
|
36
|
Jablonski L, Lee CKK, Rosenstein BJ, Mogayzel PJ, Paranjape S, Pan A. Real World Experience of Pseudomonas aeruginosa Eradication at an Urban Pediatric Cystic Fibrosis Center. J Pediatr Pharmacol Ther 2020; 25:623-628. [PMID: 33041717 DOI: 10.5863/1551-6776-25.7.623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Clinical practice guidelines for eradication of Pseudomonas aeruginosa (PA) in patients with cystic fibrosis (CF) have been established, but current studies have not assessed how these guidelines translate into clinical practice. This study aimed to characterize the real-world eradication strategies, eradication rates, and microbiologic outcomes of patients with first acquisition of PA at an urban pediatric CF center. METHODS The Cystic Fibrosis Foundation Patient Registry was used to identify patients with CF who received care between January 2014 and September 2018 and had PA isolated from an airway culture. Patients were included if they had a first positive PA culture or the first positive culture in 2 years. Data regarding patient demographics, timing and results of airway cultures, and treatment regimens were collected. RESULTS Over a 3.75-year period, 75 patients had an initial positive culture for PA. Of those patients, 74 (98.7%) received eradication treatment. Tobramycin inhalation solution (TIS) monotherapy was the most common regimen prescribed (52.7%) followed by TIS plus an oral fluoroquinolone (28.4%) (TIS + FQ). Of those treated, 62 (83.8%) patients had eradication of PA at first follow-up culture (median, 58 days; IQR, 49-77 days). Eradication rates (84.6% vs 76.2%, p = 0.421) and times to recurrence (6.37 months vs 5.1 months, p = 0.726) were comparable between TIS and TIS + FQ cohorts. CONCLUSIONS The eradication rate for PA in clinical practice is similar to that published in the literature. Consistent with published guidelines, these microbiologic outcomes do not support the addition of an oral FQ to TIS for initial PA eradication.
Collapse
|
37
|
Riquena B, Silva Filho LVRFD, Nakaie CMA, Almeida MBD, Rodrigues JC, Adde FV. Effectiveness of a multistep Pseudomonas aeruginosa eradication treatment protocol in children with cystic fibrosis in Brazil. J Bras Pneumol 2020; 46:e20180294. [PMID: 32696837 PMCID: PMC7567631 DOI: 10.36416/1806-3756/e20180294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 06/21/2019] [Indexed: 11/24/2022] Open
Abstract
Objective: Although various strategies have been proposed for eradicating Pseudomonas aeruginosa in patients with cystic fibrosis (CF), only a few employ multistep treatment in children colonized by that pathogen for the first time. The aim of this study was to describe the effectiveness of a three-phase eradication protocol, initiated after the first isolation of P. aeruginosa, in children with CF in Brazil. Methods: This was a retrospective real-life study in which we reviewed the medical records of pediatric CF patients in whom the eradication protocol was applied between June of 2004 and December of 2012. The three-phase protocol was guided by positive cultures for P. aeruginosa in airway secretions, and the treatment consisted of inhaled colistimethate and oral ciprofloxacin. Success rates were assessed after each phase, as well as cumulatively. Results: During the study period, 47 episodes of P. aeruginosa colonization, in 29 patients, were eligible for eradication. Among the 29 patients, the median age was 2.7 years, 17 (59%) were male, and 19 (65%) had at least one F508del allele. All 29 patients completed the first phase of the protocol, whereas only 12 and 6 completed the second and third phases, respectively. Success rates for eradication in the three treatment phases were 58.6% (95% CI: 40.7-74.5), 50.0% (95% CI: 25.4-74.6), and 66.7% (95% CI: 30.0-90.3), respectively. The cumulative success rate was 93.1% (95% CI: 78.0-98.1). Treatment failure in all three phases occurred in only 2 patients. Conclusions: In this sample of patients, the multistep eradication protocol was effective and had a high success rate.
Collapse
Affiliation(s)
- Barbara Riquena
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | | | | | - Fabíola Villac Adde
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| |
Collapse
|
38
|
Maintenance of Pulmonary Therapies. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
39
|
Taccetti G, Denton M, Hayes K, Drevinek P, Sermet-Gaudelus I, Bilton D, Campana S, Dolce D, Ferroni A, Héry-Arnaud G, Martin-Gomez MT, Nash E, Pereira L, Pressler T, Tümmler B. A critical review of definitions used to describe Pseudomonas aeruginosa microbiological status in patients with cystic fibrosis for application in clinical trials. J Cyst Fibros 2020; 19:52-67. [DOI: 10.1016/j.jcf.2019.08.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/23/2019] [Accepted: 08/15/2019] [Indexed: 01/23/2023]
|
40
|
Palser S, Smith S, Nash EF, Agarwal A, Smyth AR. Treatments for preventing recurrence of infection with Pseudomonas aeruginosa in people with cystic fibrosis. Cochrane Database Syst Rev 2019; 12:CD012300. [PMID: 31845758 PMCID: PMC6916140 DOI: 10.1002/14651858.cd012300.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Chronic infection with Pseudomonas aeruginosa (PA) in cystic fibrosis (CF) is a source of much morbidity and mortality. Eradication of early PA infection is possible, but can recur in many individuals. We sought to examine strategies to delay the time to PA recurrence in people with CF. OBJECTIVES To establish whether secondary prevention strategies, using antibiotics or other therapies, increase the chances of people with CF remaining free from PA infection following successful eradication therapy. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries and the reference lists of relevant articles and reviews. Date of last search: 21 August 2019. SELECTION CRITERIA Randomised controlled trials (and quasi-randomised trials where the risk of bias was low) comparing any treatment modality aimed at preventing recurrence of PA infection with placebo, standard therapy or any other treatment modality in people with CF who have undergone successful eradication of PA. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias. Quality of the evidence was assessed using GRADE. Conflicts were resolved by discussion and the opinion of a third review author was sought where necessary. Only a subset of participants in the included trial were eligible, therefore individual participant data were requested and obtained from the trial investigators. MAIN RESULTS We included one trial (n = 306) in the review; however, only 253 participants had undergone successful eradication of PA, so fulfilling the inclusion criteria for our review. Information presented relates only to the included subset of participants. The trial recruited children aged one to 12 years (mean (standard deviation (SD)) age of 5.8 (3.5) years), 129 participants (51.0%) were female and the median follow-up was 494 days. We compared cycled therapy with tobramycin inhalation solution (TIS), in which participants underwent 28 days of TIS every three months, with culture-based therapy, in which participants were only prescribed medication when a quarterly sputum sample was positive for PA. Reasons for downgrading the quality of the evidence included applicability (only included children), incomplete outcome data and a small number of participants. The time to next isolation of PA was probably shorter with cycled TIS therapy than with culture-based therapy, hazard ratio (HR) 2.04 days (95% confidence interval (CI) 1.28 to 3.26) (moderate-quality evidence). This is in contrast to the main publication of the only included trial, which examined rate of PA positivity rather than time to PA infection and included participants not eligible for inclusion in this review. At the end of the trial, there was no difference between the cycled and culture-based groups in the change from baseline in forced expiratory volume in one second (FEV1) L, mean difference (MD) 0.0 L (95% CI -0.09 to 0.09) or in FEV1 % predicted, MD 0.70% (95% CI -4.33 to 5.73) (both very low-quality evidence). There was no difference in the change from baseline for FVC between the groups. There was also no difference in the frequency of pulmonary exacerbations between groups, MD -0.18 (95% CI -0.51 to 0.14) (moderate-quality evidence). Similarly, there was no difference between groups in the risk of participants developing novel resistant bacteria, RR 1.00 (95% CI 0.67 to 1.5) (moderate-quality evidence). There were more severe adverse events in the cycled group, but the type of treatment probably makes little or no difference to the results, RR 0.65 (95% CI 0.39 to 1.11) (moderate-quality evidence). There was no difference between groups in the change in weight or height from baseline or in rates of adherence to tobramycin or all trial medicines. The included trial did not assess changes in quality of life, the time to chronic infection with PA or the cost-effectiveness of treatment. AUTHORS' CONCLUSIONS Cycled TIS therapy may be beneficial in prolonging the time to recurrence of PA after successful eradication, but further trials are required, specifically addressing this question and in both adults and children.
Collapse
Affiliation(s)
- Sally Palser
- School of Medicine, University of NottinghamDivision of Child Health, Obstetrics & Gynaecology (COG)Queen's Medical CentreDerby RoadNottinghamUKNG7 2UH
| | - Sherie Smith
- University of NottinghamDivision of Child Health, Obstetrics & Gynaecology (COG), School of Medicine1701 E FloorEast Block Queens Medical CentreNottinghamNG7 2UHUK
| | - Edward F Nash
- University Hospitals Birmingham NHS Foundation TrustWest Midlands Adult Cystic Fibrosis CentreBordesley Green EastBirminghamUKB9 5SS
| | - Arnav Agarwal
- University of TorontoDepartment of MedicineTorontoCanada
| | - Alan R Smyth
- School of Medicine, University of NottinghamDivision of Child Health, Obstetrics & Gynaecology (COG)Queen's Medical CentreDerby RoadNottinghamUKNG7 2UH
| | | |
Collapse
|
41
|
Claude F, Rochat I, Hafen GM. No benefit of longer eradication therapy of Pseudomonas aeruginosa primoinfections in pediatric cystic fibrosis. BMC Res Notes 2019; 12:115. [PMID: 30832714 PMCID: PMC6398262 DOI: 10.1186/s13104-019-4157-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 02/22/2019] [Indexed: 11/18/2022] Open
Abstract
Objective Patients with cystic fibrosis are more susceptible than members of the general population to lung infections. Infections with Pseudomonas aeruginosa require particular attention, because they may accelerate the deterioration of lung function if not adequately treated. This study assessed the eradication rate of P. aeruginosa primoinfections, with a protocol of inhaled tobramycin and oral ciprofloxacin over a 3 months’ period. Results Retrospective single-center study from June 1st, 2007 to December 31st, 2015. Inclusion of 28 pediatric patients (11 females, 17 males), with a total of 49 primoinfections. Overall success rate of 67.3%, which is similar or even inferior to figures published in the literature.
Collapse
|
42
|
Abstract
Although survival of individuals with cystic fibrosis (CF) has been continuously improving for the past 40 years, respiratory failure secondary to recurrent pulmonary infections remains the leading cause of mortality in this patient population. Certain pathogens such as Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and species of the Burkholderia cepacia complex continue to be associated with poorer clinical outcomes including accelerated lung function decline and increased mortality. In addition, other organisms such as anaerobes, viruses, and fungi are increasingly recognized as potential contributors to disease progression. Culture-independent molecular methods are also being used for diagnostic purposes and to examine the interaction of microorganisms in the CF airway. Given the importance of CF airway infections, ongoing initiatives to promote understanding of the epidemiology, clinical course, and treatment options for these infections are needed.
Collapse
Affiliation(s)
- Ana C Blanchard
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Valerie J Waters
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
43
|
Saiman L. Improving outcomes of infections in cystic fibrosis in the era of CFTR modulator therapy. Pediatr Pulmonol 2019; 54 Suppl 3:S18-S26. [PMID: 31715086 DOI: 10.1002/ppul.24522] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 09/06/2019] [Indexed: 12/14/2022]
Abstract
Currently, available single and dual-combination cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies have favorably altered the life course of individuals with cystic fibrosis (CF) by decreasing morbidities and increasing survival. However, even with CFTR modulator use, questions and challenges remain to optimize the management of lung infections. This review (a) identifies these ongoing challenges and discusses the current understanding of the potential impact of CFTR modulator therapy on infections; (b) describes ongoing research to optimize detection, diagnosis, and treatment of CF microorganisms; and (c) discusses strategies to develop new anti-infective therapies. The CF Foundation has launched the Infection Research Initiative to fund research that will improve our understanding of the complex microbial ecology within the CF lung, improve detection of CF pathogens, optimize current treatment, including long-term chronic therapies, and develop new anti-infective therapies. Ongoing clinical trials to determine the optimal duration of treatment of pulmonary exacerbations and to diagnose and treat nontuberculous mycobacteria represent clinical research paradigms that could be used to answer other complex treatment questions. The anti-infective pipeline includes both existing anti-infective and non-anti-infective agents, many of which are proposed to have unique mechanisms of action in CF. Future studies plan to evaluate short- and long-term clinical effectiveness and impact on infections, of the next generation of CFTR modulator therapy, the highly effective triple-combination therapy, for individuals with CF, homozygous or heterozygous for F508del.
Collapse
Affiliation(s)
- Lisa Saiman
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| |
Collapse
|
44
|
Ratjen F, Davis SD, Stanojevic S, Kronmal RA, Hinckley Stukovsky KD, Jorgensen N, Rosenfeld M, Kerby G, Kopecky C, Anthony M, Mogayzel P, Walker D, Zeglin B, Hoover W, Hathorne H, Slaten K, Dorkin H(H, Fowler R, Fenton C(N, Ulles M, Goetz D, Caci N, Cahill B, Roach C, Retsch-Bogart G, Johnson R, Cunnion R, McColley S, Ward S, Bell E, McPhail G, Keller K, Thornton K, Parsons A, Chmiel J, Schaefer C, Tribout M, Consiglio B, Tribout H, McCoy K, Johnson T, Olson P, Raterman L, Hiatt P, Walker B, Schaap N, Davis M, Davis S, Clem C, Bendy L, Starner T, Lux C, Carver T, Thompson R, Williams A, Schmoll C, Hastings PM, Noe J, Roth L, Kump T, McNamara J, Franck Thompson E, Yousef S, Wezel G(G, Oquendo O, Darling A, Valencia W, Milla C, Zirbes J, Rubenstein R, Donnelly E, Malpass J, Weiner D, Agostini B, Hartigan E, Cornell A, Klein B, Bucher J, Nusbaum P, Rosenfeld M, McNamara S, Genatossio A, Pittman J, Hicks T, Bauer I, Siegel M, Isaac S, Jensen R, Au J, Stanojevic S, Ratjen F, McDonald N, Prentice C, Chilvers M, Richmond M. Inhaled hypertonic saline in preschool children with cystic fibrosis (SHIP): a multicentre, randomised, double-blind, placebo-controlled trial. THE LANCET RESPIRATORY MEDICINE 2019; 7:802-809. [DOI: 10.1016/s2213-2600(19)30187-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/25/2019] [Accepted: 04/30/2019] [Indexed: 01/25/2023]
|
45
|
Pereira MC, Athanazio RA, Dalcin PDTR, Figueiredo MRFD, Gomes M, Freitas CGD, Ludgren F, Paschoal IA, Rached SZ, Maurici R. Brazilian consensus on non-cystic fibrosis bronchiectasis. ACTA ACUST UNITED AC 2019; 45:e20190122. [PMID: 31411280 PMCID: PMC6733718 DOI: 10.1590/1806-3713/e20190122] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/16/2019] [Indexed: 12/16/2022]
Abstract
Bronchiectasis is a condition that has been increasingly diagnosed by chest HRCT. In the literature, bronchiectasis is divided into bronchiectasis secondary to cystic fibrosis and bronchiectasis not associated with cystic fibrosis, which is termed non-cystic fibrosis bronchiectasis. Many causes can lead to the development of bronchiectasis, and patients usually have chronic airway symptoms, recurrent infections, and CT abnormalities consistent with the condition. The first international guideline on the diagnosis and treatment of non-cystic fibrosis bronchiectasis was published in 2010. In Brazil, this is the first review document aimed at systematizing the knowledge that has been accumulated on the subject to date. Because there is insufficient evidence on which to base recommendations for various treatment topics, here the decision was made to prepare an expert consensus document. The Brazilian Thoracic Association Committee on Respiratory Infections summoned 10 pulmonologists with expertise in bronchiectasis in Brazil to conduct a critical assessment of the available scientific evidence and international guidelines, as well as to identify aspects that are relevant to the understanding of the heterogeneity of bronchiectasis and to its diagnostic and therapeutic management. Five broad topics were established (pathophysiology, diagnosis, monitoring of stable patients, treatment of stable patients, and management of exacerbations). After this subdivision, the topics were distributed among the authors, who conducted a nonsystematic review of the literature, giving priority to major publications in the specific areas, including original articles, review articles, and systematic reviews. The authors reviewed and commented on all topics, producing a single final document that was approved by consensus.
Collapse
Affiliation(s)
- Mônica Corso Pereira
- . Departamento de Clínica Médica, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
| | - Rodrigo Abensur Athanazio
- . Divisão de Pneumologia, Instituto do Coração - InCor - Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Paulo de Tarso Roth Dalcin
- . Departamento de Medicina Interna, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS) Brasil.,. Serviço de Pneumologia, Hospital de Clínicas de Porto Alegre, Porto Alegre (RS) Brasil
| | | | - Mauro Gomes
- . Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo (SP) Brasil.,. Equipe de Pneumologia, Hospital Samaritano, São Paulo (SP) Brasil
| | | | | | - Ilma Aparecida Paschoal
- . Departamento de Clínica Médica, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
| | - Samia Zahi Rached
- . Divisão de Pneumologia, Instituto do Coração - InCor - Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Rosemeri Maurici
- . Programa de Pós-Graduação em Ciências Médicas, Universidade Federal de Santa Catarina, Florianópolis (SC) Brasil
| |
Collapse
|
46
|
Harun SN, Holford NHG, Grimwood K, Wainwright CE, Hennig S. Pseudomonas aeruginosa eradication therapy and risk of acquiring Aspergillus in young children with cystic fibrosis. Thorax 2019; 74:740-748. [DOI: 10.1136/thoraxjnl-2018-211548] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/31/2019] [Accepted: 05/08/2019] [Indexed: 12/20/2022]
Abstract
BackgroundWhile Aspergillus detection rates in adults, adolescents and older children with cystic fibrosis (CF) have increased, the risk of acquiring this fungal pathogen in young children is unknown.AimTo determine the risk and explanatory factors of acquiring Aspergillus in children with CF by age 5 years.MethodsCross-sectional analysis of clinical, bronchoalveolar lavage and treatment data from the Australasian Cystic Fibrosis Bronchoalveolar Lavage study was used to identify predictive factors for detecting Aspergillus at age 5 years. A parametric repeated time-to-event model quantitatively described the risk and factors associated with acquiring Aspergillus and Pseudomonas aeruginosa from birth until age 5 years.ResultsCross-sectional analysis found that the number of P. aeruginosa eradication courses increased the odds of detecting Aspergillus at age 5 years (OR 1.61, 95% CI 1.23 to 2.12). The median (IQR) age for the first P. aeruginosa positive culture was 2.38 (1.32–3.79) years and 3.69 (1.68–4.74) years for the first Aspergillus positive culture. The risk of P. aeruginosa and Aspergillus events changes with time after the first year of study entry. It also decreases for P. aeruginosa after completing P. aeruginosa eradication (HR 0.15, 95% CI 0.00 to 0.79), but increases for Aspergillus events (HR 2.75, 95% CI 1.45 to 5.41). The risk of acquiring both types of events increases after having had a previous event.ConclusionIn young children with CF, completing P. aeruginosa eradication therapy and previous Aspergillus events are associated with increased risk of acquiring Aspergillus.
Collapse
|
47
|
Van Stormbroek B, Zampoli M, Morrow BM. Nebulized gentamicin in combination with systemic antibiotics for eradicating early Pseudomonas aeruginosa infection in children with cystic fibrosis. Pediatr Pulmonol 2019; 54:393-398. [PMID: 30656856 DOI: 10.1002/ppul.24254] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 12/26/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Chronic Pseudomonas aeruginosa (Pa) infection in cystic fibrosis (CF) can be prevented with early eradication treatment. In resource-constrained environments, low-cost, off-label nebulized antibiotics, including intravenous gentamicin solution, are often used for eradication therapy. This study aimed to describe the characteristics and clinical course of children with CF and early Pa infection, treated with a Pa eradication protocol combining inhaled gentamicin and systemic antibiotics. STUDY DESIGN Retrospective descriptive study. PATIENT-SUBJECT SELECTION All children (0-18 years) attending a CF clinic in South Africa, with early Pa infections between January 2005 and March 2015, who received nebulized gentamicin-based Pa eradication treatment. METHODOLOGY Data were described and compared between those with successful versus unsuccessful eradication, using descriptive and inferential statistics appropriate to normality of distribution. RESULTS One hundred and forty-nine children were managed in the CF Clinic over the study period, of whom 44 (29.5%; 28 [63.6%] male) had early Pa infections treated with a gentamicin-based eradication regimen. Thirty-nine (88.6%) patients had successful Pa eradication at 12 months follow-up; of which 28 (71.8%) had Pa reinfection at a median of 37.0 (21.0-101.0) months after initial treatment. Six patients (13%) acquired chronic Pa infection during the median follow-up period of 77 months. Older age was associated with Pa eradication failure and chronic Pa infection. There were no clinically significant adverse events associated with gentamicin inhalational therapy. CONCLUSIONS Nebulized gentamicin solution combined with systemic antibiotics appears to be safe and has comparable efficacy to other strategies in eradicating early Pa infections in children with CF.
Collapse
Affiliation(s)
- Ben Van Stormbroek
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa.,Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Marco Zampoli
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa.,Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Brenda M Morrow
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
48
|
Dolce D, Neri S, Grisotto L, Campana S, Ravenni N, Miselli F, Camera E, Zavataro L, Braggion C, Fiscarelli EV, Lucidi V, Cariani L, Girelli D, Faelli N, Colombo C, Lucanto C, Lombardo M, Magazzù G, Tosco A, Raia V, Manara S, Pasolli E, Armanini F, Segata N, Biggeri A, Taccetti G. Methicillin-resistant Staphylococcus aureus eradication in cystic fibrosis patients: A randomized multicenter study. PLoS One 2019; 14:e0213497. [PMID: 30901344 PMCID: PMC6430412 DOI: 10.1371/journal.pone.0213497] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 02/24/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Few studies, based on a limited number of patients using non-uniform therapeutic protocols, have analyzed Methicillin-resistant Staphylococcus aureus (MRSA) eradication. METHODS In a randomized multicenter trial conducted on patients with new-onset MRSA infection we evaluated the efficacy of an early eradication treatment (arm A) compared with an observational group (B). Arm A received oral rifampicin and trimethoprim/sulfamethoxazole (21 days). Patients' microbiological status, FEV1, BMI, pulmonary exacerbations and use of antibiotics were assessed. RESULTS Sixty-one patients were randomized. Twenty-nine (47.5%) patients were assigned to active arm A and 32 (52.5%) patients to observational arm B. Twenty-nine (47.5%) patients, 10 patients in arm A and 19 in arm B, dropped out of the study. At 6 months MRSA was eradicated in 12 (63.2%) out of 19 patients in arm A while spontaneous clearance was observed in 5 (38.5%) out of 13 patients in arm B. A per-protocol analysis showed a 24.7% difference in the proportion of MRSA clearance between the two groups (z = 1.37, P(Z>z) = 0.08). Twenty-seven patients, 15 (78.9%) out of 19 in arm A and 12 (92.3%) out of 13 in arm B, were able to perform spirometry. The mean (±SD) FEV1 change from baseline was 7.13% (±14.92) in arm A and -1.16% (±5.25) in arm B (p = 0.08). In the same period the BMI change (mean ±SD) from baseline was 0.54 (±1.33) kg/m2 in arm A and -0.38 (±1.56) kg/m2 in arm B (p = 0.08). At 6 months no statistically significant differences regarding the number of pulmonary exacerbations, days spent in hospital and use of antibiotics were observed between the two arms. CONCLUSIONS Although the statistical power of the study is limited, we found a 24.7% higher clearance of MRSA in the active arm than in the observational arm at 6 months. Patients in the active arm A also had favorable FEV1 and BMI tendencies.
Collapse
Affiliation(s)
- Daniela Dolce
- Cystic Fibrosis Center, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Stella Neri
- Cystic Fibrosis Center, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy.,Department of Health Sciences, University of Florence, Florence, Italy
| | - Laura Grisotto
- Department of Statistics, Computer Science and Applications "G. Parenti", University of Florence, Florence, Italy
| | - Silvia Campana
- Cystic Fibrosis Center, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Novella Ravenni
- Cystic Fibrosis Center, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Francesca Miselli
- Cystic Fibrosis Center, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy.,Department of Health Sciences, University of Florence, Florence, Italy
| | - Erica Camera
- Cystic Fibrosis Center, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Lucia Zavataro
- Cystic Fibrosis Center, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Cesare Braggion
- Cystic Fibrosis Center, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Ersilia V Fiscarelli
- Cystic Fibrosis Microbiology and Cystic Fibrosis Center, Children's Hospital and Research Institute Bambino Gesù, Rome, Italy
| | - Vincenzina Lucidi
- Cystic Fibrosis Microbiology and Cystic Fibrosis Center, Children's Hospital and Research Institute Bambino Gesù, Rome, Italy
| | - Lisa Cariani
- Laboratory for Cystic Fibrosis Microbiology, Fondazione IRCCS, Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniela Girelli
- Laboratory for Cystic Fibrosis Microbiology, Fondazione IRCCS, Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Nadia Faelli
- Cystic Fibrosis Center, University of Milan, Fondazione IRCCS, Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Carla Colombo
- Cystic Fibrosis Center, University of Milan, Fondazione IRCCS, Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Cristina Lucanto
- Cystic Fibrosis and Pediatric Gastroenterology Unit, University of Messina, Messina, Italy
| | - Mariangela Lombardo
- Cystic Fibrosis and Pediatric Gastroenterology Unit, University of Messina, Messina, Italy
| | - Giuseppe Magazzù
- Cystic Fibrosis and Pediatric Gastroenterology Unit, University of Messina, Messina, Italy
| | - Antonella Tosco
- Department of Translational Medical Sciences, Pediatric Cystic Fibrosis Center, Federico II University, Naples, Italy
| | - Valeria Raia
- Department of Translational Medical Sciences, Pediatric Cystic Fibrosis Center, Federico II University, Naples, Italy
| | - Serena Manara
- Center for Integrative Biology, University of Trento, Trento, Italy
| | - Edoardo Pasolli
- Center for Integrative Biology, University of Trento, Trento, Italy
| | | | - Nicola Segata
- Center for Integrative Biology, University of Trento, Trento, Italy
| | - Annibale Biggeri
- Department of Statistics, Computer Science and Applications "G. Parenti", University of Florence, Florence, Italy
| | - Giovanni Taccetti
- Cystic Fibrosis Center, Anna Meyer Children's University Hospital, University of Florence, Florence, Italy
| |
Collapse
|
49
|
Skov M, Hansen CR, Pressler T. Cystic fibrosis - an example of personalized and precision medicine. APMIS 2019; 127:352-360. [PMID: 30761610 DOI: 10.1111/apm.12915] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 11/28/2018] [Indexed: 12/13/2022]
Abstract
Cystic fibrosis (CF) is a severe, monogenic, autosomal recessive disease caused by mutations in the CFTR (cystic fibrosis transmembrane regulator) gene, where disturbed chloride and bicarbonate transportation in epithelial cells results in a multiorgan disease with primarily pulmonary infections and pancreatic insufficiency. In 1968, the Copenhagen CF Center was established, and centralized care of CF patients with monthly control was introduced. Close monitoring and treatment of Pseudomonas lung infection as well as segregation of patients with different infection status improved the clinical outcome as well as survival. Prophylactic basic treatment as well as infection treatments follow specific algorithms. A variety of comorbidities have all along the pulmonary infection control necessitated personalized care, adjusted to the patients' phenotype. With the introduction of CFTR modulators, the treatment has shifted from prophylactic, symptomatic type toward a new era of precision medicine targeting the basic defect according to the patients' CFTR genotype. Future directions will focus on further improvement of the CFTR modulators and gene therapy, as well as modifier genes and CF phenotype.
Collapse
Affiliation(s)
- Marianne Skov
- Department of Pediatrics, Rigshospitalet, Copenhagen, Denmark
| | | | | |
Collapse
|
50
|
Shanthikumar S, Robertson C, Ranganathan S. Azithromycin for Early Pseudomonas Infection in Cystic Fibrosis: Do the Benefits Outweigh the Harms? Am J Respir Crit Care Med 2018; 198:1348-1349. [PMID: 30138568 DOI: 10.1164/rccm.201807-1329le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Shivanthan Shanthikumar
- 1 Royal Children's Hospital Melbourne, Australia.,2 Murdoch Children's Research Institute Melbourne, Australia and.,3 The University of Melbourne Melbourne, Australia
| | - Colin Robertson
- 1 Royal Children's Hospital Melbourne, Australia.,2 Murdoch Children's Research Institute Melbourne, Australia and.,3 The University of Melbourne Melbourne, Australia
| | - Sarath Ranganathan
- 1 Royal Children's Hospital Melbourne, Australia.,2 Murdoch Children's Research Institute Melbourne, Australia and.,3 The University of Melbourne Melbourne, Australia
| |
Collapse
|