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Cauwenberghs E, De Boeck I, Spacova I, Van Tente I, Bastiaenssen J, Lammertyn E, Verhulst S, Van Hoorenbeeck K, Lebeer S. Positioning the preventive potential of microbiome treatments for cystic fibrosis in the context of current therapies. Cell Rep Med 2024; 5:101371. [PMID: 38232705 PMCID: PMC10829789 DOI: 10.1016/j.xcrm.2023.101371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/24/2023] [Accepted: 12/14/2023] [Indexed: 01/19/2024]
Abstract
Antibiotics and cystic fibrosis transmembrane conductance regulator (CFTR) modulators play a pivotal role in cystic fibrosis (CF) treatment, but both have limitations. Antibiotics are linked to antibiotic resistance and disruption of the airway microbiome, while CFTR modulators are not widely accessible, and structural lung damage and pathogen overgrowth still occur. Complementary strategies that can beneficially modulate the airway microbiome in a preventive way are highly needed. This could be mediated via oral probiotics, which have shown some improvement of lung function and reduction of airway infections and exacerbations, as a cost-effective approach. However, recent data suggest that specific and locally administered probiotics in the respiratory tract might be a more targeted approach to prevent pathogen outgrowth in the lower airways. This review aims to summarize the current knowledge on the CF airway microbiome and possibilities of microbiome treatments to prevent bacterial and/or viral infections and position them in the context of current CF therapies.
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Affiliation(s)
- Eline Cauwenberghs
- University of Antwerp, Department of Bioscience Engineering, Groenenborgerlaan 171, 2020 Antwerp, Belgium
| | - Ilke De Boeck
- University of Antwerp, Department of Bioscience Engineering, Groenenborgerlaan 171, 2020 Antwerp, Belgium
| | - Irina Spacova
- University of Antwerp, Department of Bioscience Engineering, Groenenborgerlaan 171, 2020 Antwerp, Belgium
| | - Ilke Van Tente
- University of Antwerp, Department of Bioscience Engineering, Groenenborgerlaan 171, 2020 Antwerp, Belgium
| | - Joke Bastiaenssen
- University of Antwerp, Department of Bioscience Engineering, Groenenborgerlaan 171, 2020 Antwerp, Belgium
| | - Elise Lammertyn
- Belgian CF Association, Driebruggenstraat 124, 1160 Brussels, Belgium; Cystic Fibrosis Europe, Driebruggenstraat 124, 1160 Brussels, Belgium
| | - Stijn Verhulst
- University of Antwerp, Laboratory of Experimental Medicine and Pediatrics, Universiteitsplein 1, 2610 Wilrijk, Belgium; Antwerp University Hospital, Department of Pediatric Pulmonology, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Kim Van Hoorenbeeck
- University of Antwerp, Laboratory of Experimental Medicine and Pediatrics, Universiteitsplein 1, 2610 Wilrijk, Belgium; Antwerp University Hospital, Department of Pediatric Pulmonology, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Sarah Lebeer
- University of Antwerp, Department of Bioscience Engineering, Groenenborgerlaan 171, 2020 Antwerp, Belgium.
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Lindley B, Bhakta Z, Leclair L, Young DC. The pharmacokinetics and pharmacodynamics of continuous infusion vancomycin in adult people with cystic fibrosis. Pediatr Pulmonol 2024; 59:89-94. [PMID: 37792309 DOI: 10.1002/ppul.26714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/31/2023] [Accepted: 09/26/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND The American Thoracic Society Guidelines recommend vancomycin as first line option for treatment of methicillin-resistant Staphylococcus aureus. Two studies have described the pharmacokinetics (PK) of intermittent intravenous (IV) vancomycin in adult people with cystic fibrosis (PwCF). Currently, there have not been any studies describing the PK of continuous infusion vancomycin in PwCF. Our study aimed to describe the PK of continuous infusion vancomycin in adult PwCF. METHODS Included patients were adult PwCF, who were admitted to University of Utah Hospital between May 11, 2014 and August 31, 2020, and received continuous infusion vancomycin for the treatment of an pulmonary exacerbations. The primary outcome was to describe vancomycin clearance rate (CLvanco ) and total daily dose (TDD). Secondary outcomes included rates of acute kidney injury (AKI), liver injury, and infusion-related reactions. RESULTS Twenty patients were included in this study. The mean CLvanco was 5.08 L/h on Day 3 and 4.58 L/h on Day 7 (p = .04), and the TDD increased from 2444 mg on Day 3 to 2556 on Day 7, although not statistically significant (p = 0.26). Zero patients experienced an AKI, two patients experienced liver injury, and no patients experienced infusion-related reactions. CONCLUSIONS This study demonstrates that continuous infusion vancomycin PK, namely CLvanco , is similar to previously reported CLvanco for intermittent dosed IV vancomycin in adult PwCF. This study suggests that continuous infusion vancomycin is likely safe to use in adult PwCF.
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Affiliation(s)
- Bryn Lindley
- Department of Pharmacotherapy, University of North Texas Health Science Center College of Pharmacy, Fort Worth, Texas, USA
| | - Zubin Bhakta
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
| | - Laurie Leclair
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - David C Young
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
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Fischer AJ, Planet PJ. A birth cohort approach to understanding cystic fibrosis lung infections. J Cyst Fibros 2024; 23:8-11. [PMID: 37949746 DOI: 10.1016/j.jcf.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Anthony J Fischer
- Stead Family Department of Pediatrics, University of Iowa, 6314 PBDB, Iowa, IA 52242, United States.
| | - Paul J Planet
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States
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Svishchuk J, Ebbert K, Waddell B, Izydorczyk C, Acosta N, Somayaji R, Rabin HR, Bjornson CL, Lisboa L, Gregson DB, Conly JM, Surette MG, Parkins MD. Epidemiology and impact of methicillin-sensitive Staphylococcus aureus with β-lactam antibiotic inoculum effects in adults with cystic fibrosis. Antimicrob Agents Chemother 2023; 67:e0013623. [PMID: 37966229 PMCID: PMC10720481 DOI: 10.1128/aac.00136-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 08/22/2023] [Indexed: 11/16/2023] Open
Abstract
Staphylococcus aureus is the most prevalent cystic fibrosis (CF) pathogen. Several phenotypes are associated with worsened CF clinical outcomes including methicillin-resistance and small-colony-variants. The inoculum effect (IE) is characterized by reduced β-lactam susceptibility when assessed at high inoculum. The IE associates with worse outcomes in bacteremia and other high-density infections, and may therefore be relevant to CF. The prevalence of IE amongst a CF cohort (age ≥18 years), followed from 2013 to 2016, was investigated. Yearly methicillin-sensitive S. aureus (MSSA) isolates were screened at standard (5 × 105 CFU/mL) and high (5 × 107 CFU/mL) inoculum against narrow-spectrum anti-Staphylococcal β-lactams and those with anti-pseudomonal activity common to CF. A ≥ 4-fold increase in minimum inhibitory concentration between standard and high inoculum defined IE. Isolates underwent blaZ sequencing and genotyping and were compared against published genomes. Fifty-six percent (99/177) of individuals had MSSA infection. MSSA was observed at ≥105 CFU/mL in 44.8% of entry sputum samples. The prevalence of the IE was 25.0%-cefazolin; 13.5%-cloxacillin; 0%-meropenem; 1.0%-cefepime; 5.2%-ceftazidime; and 34.4%-piperacillin-tazobactam amongst baseline MSSA isolates assessed. blaZ A associated with cefazolin IE (P = 0.0011), whereas blaZ C associated with piperacillin-tazobactam IE (P < 0.0001). Baseline demographics did not reveal specific risk factors for IE-associated infections, nor were long-term outcomes different. Herein, we observed the IE in CF-derived MSSA disproportionally for cefazolin and piperacillin-tazobactam and this phenotype strongly associated with underlying blaZ genotype. The confirmation of CF being a high density infection, and the identification of high prevalence of MSSA with IE in CF supports the need for prospective pulmonary exacerbation treatment studies to understand the impact of this phenotype.
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Affiliation(s)
- J. Svishchuk
- Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - K. Ebbert
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - B. Waddell
- Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - C. Izydorczyk
- Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - N. Acosta
- Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - R. Somayaji
- Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - H. R. Rabin
- Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - C. L. Bjornson
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - L. Lisboa
- Department of Pathology and Laboratory Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - D. B. Gregson
- Department of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
- Department of Pathology and Laboratory Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - J. M. Conly
- Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
- Department of Pathology and Laboratory Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - M. G. Surette
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - M. D. Parkins
- Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
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Ludwig N, Thörner-van Almsick J, Mersmann S, Bardel B, Niemann S, Chasan AI, Schäfers M, Margraf A, Rossaint J, Kahl BC, Zarbock A, Block H. Nuclease activity and protein A release of Staphylococcus aureus clinical isolates determine the virulence in a murine model of acute lung infection. Front Immunol 2023; 14:1259004. [PMID: 37849760 PMCID: PMC10577289 DOI: 10.3389/fimmu.2023.1259004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/19/2023] [Indexed: 10/19/2023] Open
Abstract
Staphylococcus aureus is a common cause of hospital-acquired pneumonia associated with high mortality. Adequate clinical treatment is impeded by increasing occurrence of antibiotic resistances. Understanding the underlying mechanisms of its virulence during infections is a prerequisite to finding alternative treatments. Here, we demonstrated that an increased nuclease activity of a S. aureus isolate from a person with cystic fibrosis confers a growth advantage in a model of acute lung infection compared to the isogenic strain with low nuclease activity. Comparing these CF-isolates with a common MRSA-USA300 strain with similarly high nuclease activity but significantly elevated levels of Staphylococcal Protein A (SpA) revealed that infection with USA300 resulted in a significantly increased bacterial burden in a model of murine lung infection. Replenishment with the cell wall-bound SpA of S. aureus, which can also be secreted into the environment and binds to tumor necrosis factor receptor -1 (TNFR-1) to the CF-isolates abrogated these differences. In vitro experiments confirmed significant differences in spa-expression between USA300 compared to CF-isolates, thereby influencing TNFR-1 shedding, L-selectin shedding, and production of reactive oxygen species through activation of ADAM17.
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Affiliation(s)
- Nadine Ludwig
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Julia Thörner-van Almsick
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Sina Mersmann
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Bernadette Bardel
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Silke Niemann
- Institute for Medical Microbiology, University Hospital Muenster, Muenster, Germany
| | - Achmet Imam Chasan
- Institute of Immunology, University Hospital Muenster, Muenster, Germany
| | - Michael Schäfers
- European Institute for Molecular Imaging (EIMI), University of Muenster, Muenster, Germany
| | - Andreas Margraf
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Jan Rossaint
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Barbara C. Kahl
- Institute for Medical Microbiology, University Hospital Muenster, Muenster, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Helena Block
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
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Yadav R, Li QZ, Huang H, Bridges SL, Kahlenberg JM, Stecenko AA, Rada B. Cystic fibrosis autoantibody signatures associate with Staphylococcus aureus lung infection or cystic fibrosis-related diabetes. Front Immunol 2023; 14:1151422. [PMID: 37767091 PMCID: PMC10519797 DOI: 10.3389/fimmu.2023.1151422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 08/18/2023] [Indexed: 09/29/2023] Open
Abstract
Introduction While cystic fibrosis (CF) lung disease is characterized by persistent inflammation and infections and chronic inflammatory diseases are often accompanied by autoimmunity, autoimmune reactivity in CF has not been studied in depth. Methods In this work we undertook an unbiased approach to explore the systemic autoantibody repertoire in CF using autoantibody microarrays. Results and discussion Our results show higher levels of several new autoantibodies in the blood of people with CF (PwCF) compared to control subjects. Some of these are IgA autoantibodies targeting neutrophil components or autoantigens linked to neutrophil-mediated tissue damage in CF. We also found that people with CF with higher systemic IgM autoantibody levels have lower prevalence of S. aureus infection. On the other hand, IgM autoantibody levels in S. aureus-infected PwCF correlate with lung disease severity. Diabetic PwCF have significantly higher levels of IgA autoantibodies in their circulation compared to nondiabetic PwCF and several of their IgM autoantibodies associate with worse lung disease. In contrast, in nondiabetic PwCF blood levels of IgA autoantibodies correlate with lung disease. We have also identified other autoantibodies in CF that associate with P. aeruginosa airway infection. In summary, we have identified several new autoantibodies and associations of autoantibody signatures with specific clinical features in CF.
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Affiliation(s)
- Ruchi Yadav
- Department of Infectious Diseases, College of Veterinary Medicine, The University of Georgia, Athens, GA, United States
| | - Quan-Zhen Li
- Department of Immunology and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Hanwen Huang
- Department of Epidemiology & Biostatistics, College of Public Health, The University of Georgia, Athens, GA, United States
| | - S. Louis Bridges
- Department of Medicine, Hospital for Special Surgery, Division of Rheumatology, Weill Cornell Medical College, New York, NY, United States
| | - J. Michelle Kahlenberg
- Division of Rheumatology, University of Michigan, School of Medicine, Ann Arbor, MI, United States
| | - Arlene A. Stecenko
- Division of Pulmonology, Asthma, Cystic Fibrosis and Sleep, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Balázs Rada
- Department of Infectious Diseases, College of Veterinary Medicine, The University of Georgia, Athens, GA, United States
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Fantone KM, Goldberg JB, Stecenko AA, Rada B. Sputum from People with Cystic Fibrosis Reduces the Killing of Methicillin-Resistant Staphylococcus aureus by Neutrophils and Diminishes Phagosomal Production of Reactive Oxygen Species. Pathogens 2023; 12:1148. [PMID: 37764956 PMCID: PMC10538153 DOI: 10.3390/pathogens12091148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/23/2023] [Accepted: 08/27/2023] [Indexed: 09/29/2023] Open
Abstract
Cystic fibrosis (CF) airway disease is characterized by chronic polymicrobial infections and an infiltration of neutrophils (PMNs). Staphylococcus aureus has been the most prevalent respiratory pathogen in CF. In particular, methicillin-resistant S. aureus (MRSA) represents a huge clinical burden in CF due to its association with lung disease and increased resistance to antibiotics. In CF, PMNs are unable to kill and clear MRSA. The reason for this remains largely unknown. Our study found that CF PMNs are as equally capable of killing MRSA as healthy PMNs. We show that the CF sputum, however, significantly impairs the ability of human PMNs to kill CF MRSA isolates. In the absence of CF sputum, PMNs kill MRSA via intracellular mechanisms mediated by phagocytosis, rather than extracellular mechanisms via NET formation. CF sputum does not affect the phagocytosis of MRSA via healthy or CF PMNs. Our results demonstrate that CF sputum exposure impairs phagosomal levels of reactive oxygen species (ROS) in MRSA-phagocytosing PMNs. While phagosomal co-localizations of MRSA with primary granule markers, myeloperoxidase and cathepsin D, were significantly reduced upon CF sputum exposure, that of a third azurophilic granule marker, neutrophil elastase, remained unaffected. This suggests that CF sputum does not compromise the fusion of primary granules with phagosomes but diminishes phagosomal ROS levels via another, likely more specific, mechanism. Overall, we identified the airway environment as an important factor that restricts neutrophils' oxidative microbicidal activities in CF against MRSA. These results deliver new details of the complex host-pathogen interactions present in the CF lung.
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Affiliation(s)
- Kayla M. Fantone
- Department of Infectious Diseases, College of Veterinary Medicine, The University of Georgia, Athens, GA 30602, USA;
| | - Joanna B. Goldberg
- Division of Pulmonology, Asthma, Cystic Fibrosis and Sleep, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30602, USA; (J.B.G.); (A.A.S.)
| | - Arlene A. Stecenko
- Division of Pulmonology, Asthma, Cystic Fibrosis and Sleep, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30602, USA; (J.B.G.); (A.A.S.)
| | - Balázs Rada
- Department of Infectious Diseases, College of Veterinary Medicine, The University of Georgia, Athens, GA 30602, USA;
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McGarry ME, Huang CY, Ly NP. Ethnic differences in staphylococcus aureus acquisition in cystic fibrosis. J Cyst Fibros 2023; 22:909-915. [PMID: 37460380 PMCID: PMC10802839 DOI: 10.1016/j.jcf.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Hispanic people with CF (pwCF) have increased morbidity than non-Hispanic White pwCF, including increased risk of Pseudomonas aeruginosa. We aimed to determine if Staphylococcus aureus (S. aureus) acquisition varies between Hispanic and non-Hispanic White pwCF. METHODS This longitudinal cohort study of pwCF ages 0-25 years in the CF Foundation Patient Registry compared acquisition of methicillin-sensitive S. aureus (MSSA), methicillin-resistant S. aureus (MRSA), persistent MRSA between Hispanic and non-Hispanic White pwCF. Risk of acquisition was assessed by Kaplan-Meier survival curves and its association with ethnicity was evaluated using Cox regressions. Adjusted associations were evaluated using multivariate Cox models adjusting for sex, age of entry into CFFPR, CFTR variant severity, pancreatic insufficiency, CF-related diabetes, maternal education, insurance status. RESULTS Of 10,640 pwCF, 7.5% were Hispanic and 92.5% were non-Hispanic White. Hispanic pwCF had a 19% higher risk of acquiring MSSA (HR 1.19, 95% CI 1.10-1.28, p<0.001) and 13% higher risk of acquiring MRSA (HR 1.13, 95% CI 1.02-1.26, p = 0.02) than non-Hispanic White pwCF. The difference in persistent MRSA between ethnicities did not reach statistical significance. After adjusting for confounding variables, only the risk of MSSA was significantly associated with ethnicity. Compared to non-Hispanic White pwCF, Hispanic pwCF acquired MSSA and MRSA at younger median ages (4.9 vs. 3.8 years (p<0.001), 22.4 vs. 20.8 years (p = 0.02). CONCLUSION Hispanic pwCF <25 years of age have an increased risk of acquiring MSSA and acquired MSSA and MRSA at an earlier age. Differences in S. aureus acquisition may contribute to increased morbidity in Hispanic pwCF.
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Affiliation(s)
- Meghan E McGarry
- Division of Pediatric Pulmonology, Department of Pediatrics, University of California, 550 16th Ave, Box 0632, San Francisco, CA 94158, United States.
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, United States
| | - Ngoc P Ly
- Division of Pediatric Pulmonology, Department of Pediatrics, University of California, 550 16th Ave, Box 0632, San Francisco, CA 94158, United States
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Evaluation of the Efficiency of Random and Diblock Methacrylate-Based Amphiphilic Cationic Polymers against Major Bacterial Pathogens Associated with Cystic Fibrosis. Antibiotics (Basel) 2023; 12:antibiotics12010120. [PMID: 36671321 PMCID: PMC9854508 DOI: 10.3390/antibiotics12010120] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/02/2023] [Accepted: 01/05/2023] [Indexed: 01/11/2023] Open
Abstract
Cystic fibrosis (CF) is associated with repeated lung bacterial infection, mainly by Pseudomonas aeruginosa, Staphylococcus aureus, and Mycobacterium abscessus, all known to be or becoming resistant to several antibiotics, often leading to therapeutic failure and death. In this context, antimicrobial peptides and antimicrobial polymers active against resistant strains and less prompt to cause resistance, appear as a good alternative to conventional antibiotics. In the present study, methacrylate-based copolymers obtained by radical chemistry were evaluated against CF-associated bacterial strains. Results showed that the type (Random versus Diblock) and the size of the copolymers affected their antibacterial activity and toxicity. Among the different copolymers tested, four (i.e., Random10200, Random15000, Random23900, and Diblock9500) were identified as the most active and the safest molecules and were further investigated. Data showed that they inserted into bacterial lipids, leading to a rapid membranolytic effect and killing of the bacterial. In relation with their fast bactericidal action and conversely to conventional antibiotics, those copolymers did not induce a resistance and remained active against antibiotic-resistant strains. Finally, the selected copolymers possessed a preventive effect on biofilm formation, although not exhibiting disruptive activity. Overall, the present study demonstrates that methacrylate-based copolymers are an interesting alternative to conventional antibiotics in the treatment of CF-associated bacterial infection.
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Lo DK, Muhlebach MS, Smyth AR. Interventions for the eradication of meticillin-resistant Staphylococcus aureus (MRSA) in people with cystic fibrosis. Cochrane Database Syst Rev 2022; 12:CD009650. [PMID: 36511181 PMCID: PMC9745639 DOI: 10.1002/14651858.cd009650.pub5] [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: 12/15/2022]
Abstract
BACKGROUND Cystic fibrosis is an inherited recessive disorder of chloride transport that is characterised by recurrent and persistent pulmonary infections from resistant organisms that result in lung function deterioration and early mortality in sufferers. Meticillin-resistant Staphylococcus aureus (MRSA) has emerged not only as an important infection in people who are hospitalised, but also as a potentially harmful pathogen in cystic fibrosis. Chronic pulmonary infection with MRSA is thought to confer on people with cystic fibrosis a worse clinical outcome and result in an increased rate of lung function decline. Clear guidance for MRSA eradication in cystic fibrosis, supported by robust evidence, is urgently needed. This is an update of a previous review. OBJECTIVES To evaluate the effectiveness of treatment regimens designed to eradicate MRSA and to determine whether the eradication of MRSA confers better clinical and microbiological outcomes for people with cystic fibrosis. To ascertain whether attempts at eradicating MRSA can lead to increased acquisition of other resistant organisms (including Pseudomonas aeruginosa), increased adverse effects from drugs, or both. SEARCH METHODS We identified randomised and quasi-randomised controlled trials by searching the Cochrane Cystic Fibrosis and Genetic Disorders (CFGD) Group's Cystic Fibrosis Trials Register, PubMed, MEDLINE and three clinical trials registries; by handsearching article reference lists; and through contact with experts in the field. We last searched the CFGD Group's Cystic Fibrosis Trials Register on 4 October 2021, and the ongoing trials registries on 31 January 2022. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs of any combinations of topical, inhaled, oral or intravenous antimicrobials primarily aimed at eradicating MRSA compared with placebo, standard treatment or no treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane and used the GRADE methodology to assess the certainty of the evidence. MAIN RESULTS The review includes three RCTs with 135 participants with MRSA infection. Two trials compared active treatment versus observation only and one trial compared active treatment with placebo. Active treatment versus observation In both trials (106 participants), active treatment consisted of oral trimethoprim and sulfamethoxazole combined with rifampicin. One trial administered this combination for two weeks alongside nasal, skin and oral decontamination and a three-week environmental decontamination, while the second trial administered this drug combination for 21 days with five days intranasal mupirocin. Both trials reported successful eradication of MRSA in people with cystic fibrosis, but they used different definitions of eradication. One trial (45 participants) defined MRSA eradication as negative MRSA respiratory cultures at day 28, and reported that oral trimethoprim and sulfamethoxazole combined with rifampicin may lead to a higher proportion of negative cultures compared to control (odds ratio (OR) 12.6 (95% confidence interval (CI) 2.84 to 55.84; low-certainty evidence). However, by day 168 of follow-up, there was no difference between groups in the proportion of participants who remained MRSA-negative (OR 1.17, 95% CI 0.31 to 4.42; low-certainty evidence). The second trial defined successful eradication as the absence of MRSA following treatment in at least three cultures over a period of six months. We are uncertain if the intervention led to results favouring the treatment group as the certainty of the evidence was very low (OR 2.74, 95% CI 0.64 to 11.75). There were no differences between groups in the remaining outcomes for this comparison: quality of life, frequency of exacerbations or adverse effects (all low-certainty evidence) or the change from baseline in lung function or weight (both very low-certainty evidence). The time until next positive MRSA isolate was not reported. The included trials found no differences between groups in terms of nasal colonisation with MRSA. While not a specific outcome of this review, investigators from one study reported that the rate of hospitalisation from screening through day 168 was lower with oral trimethoprim and sulfamethoxazole combined with rifampicin compared to control (rate ratio 0.22, 95% CI 0.05 to 0.72; P = 0.01). Nebulised vancomycin with oral antibiotics versus nebulised placebo with oral antibiotics The third trial (29 participants) defined eradication as a negative respiratory sample for MRSA at one month following completion of treatment. No differences were reported in MRSA eradication between treatment arms (OR 1.00, 95% CI 0.14 to 7.39; low-certainty evidence). No differences between groups were seen in lung function or adverse effects (low-certainty evidence), in quality of life (very low-certainty evidence) or nasal colonisation with MRSA. The trial did not report on the change in weight or frequency of exacerbations. AUTHORS' CONCLUSIONS: Early eradication of MRSA is possible in people with cystic fibrosis, with one trial demonstrating superiority of active MRSA treatment compared with observation only in terms of the proportion of MRSA-negative respiratory cultures at day 28. However, follow-up at three or six months showed no difference between treatment and control in the proportion of participants remaining MRSA-negative. Moreover, the longer-term clinical consequences - in terms of lung function, mortality and cost of care - remain unclear. Using GRADE methodology, we judged the certainty of the evidence provided by this review to be very low to low, due to potential biases from the open-label design, high rates of attrition and small sample sizes. Based on the available evidence, we believe that whilst early eradication of respiratory MRSA in people with cystic fibrosis is possible, there is not currently enough evidence regarding the clinical outcomes of eradication to support the use of the interventions studied.
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Affiliation(s)
- David Kh Lo
- Ward 12, Leicester Royal Infirmary, Leicester, UK
| | - Marianne S Muhlebach
- Department of Pediatrics, Division of Pulmonary Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Alan R Smyth
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
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11
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Lindley B, Bhakta Z, Gray K, Watanabe A, Leclair L, Young DC. Pharmacokinetics of intermittent dosed intravenous vancomycin in adult persons with cystic fibrosis. Pediatr Pulmonol 2022; 57:2646-2651. [PMID: 35836330 DOI: 10.1002/ppul.26077] [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: 02/18/2022] [Revised: 05/23/2022] [Accepted: 06/12/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Antibiotics have altered pharmacokinetics (PK) in persons with cystic fibrosis (PwCF) during treatment for an acute pulmonary exacerbation (APE). The Cystic Fibrosis Foundation Pulmonary Guidelines-Treatment of Pulmonary Exacerbations do not provide specific recommendations for treatment of methicillin-resistant Staphylococcus aureus (MRSA) lung infections. However, the American Thoracic Society Guidelines recommend vancomycin as the first-line therapy. Only one study has previously described a single dose of intravenous (IV) vancomycin PK in adult PwCF. Our study aimed to describe intermittent IV vancomycin PK at steady-state in adult PwCF. METHODS Adult PwCF who were admitted to University of Utah Hospital between May 11, 2014 and August 31, 2020, and received intermittent IV vancomycin for the treatment of an APE were included in this study. The primary outcome was to describe the drug volume of distribution (Vd), drug clearance, elimination half-life, and total daily dose of vancomycin. Secondary outcomes were rates of acute kidney injury (AKI), liver injury, and infusion-related reactions. RESULTS Thirteen patients were included. The mean Vd was 0.54 L/kg on Day 3 and 0.53L/kg on Day 7. CLvanco was 5.11L/h on Day 3 and 4.69 L/h on Day 7. Zero patients experienced an AKI, two patients experienced liver injury, and no patients experienced infusion-related reactions. CONCLUSIONS Our results demonstrate that in PwCF intermittent IV vancomycin steady-state PK are similar to previously reported single-dose IV vancomycin. Additionally, CLvanco minimally changes from Day 3 to Day 7, although this study was not powered to detect a difference.
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Affiliation(s)
- Bryn Lindley
- Department of Pharmacy Services, University of Utah Health, Salt Lake City, Utah, USA
| | - Zubin Bhakta
- Department of Pharmacy Services, University of Utah Health, Salt Lake City, Utah, USA
| | - Kristine Gray
- Department of Pharmacy Services, University of Utah Health, Salt Lake City, Utah, USA.,Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
| | - Alexandre Watanabe
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
| | - Laurie Leclair
- Department of Pharmacy Services, University of Utah Health, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - David C Young
- Department of Pharmacy Services, University of Utah Health, Salt Lake City, Utah, USA.,Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
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12
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Stoudemire W, Jiang X, Zhou JJ, Kosorok MR, Saiman L, Muhlebach MS. Predicting risk-adjusted incidence rates of methicillin-resistant Staphylococcus Aureus and Pseudomonas Aeruginosa in cystic fibrosis programs in the United States. J Cyst Fibros 2022; 21:1013-1019. [PMID: 35963814 DOI: 10.1016/j.jcf.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 07/31/2022] [Accepted: 08/02/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Healthcare-associated transmission of methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa occurs for people with cystic fibrosis (CF), but CF programs lack a process to monitor incidence rates (IRs). We assessed predictors of incident infections and created a model to determine risk-adjusted IRs for CF programs. METHODS Using the CF Foundation Patient Registry data for all patients from 2012 to 2015, coefficients for variables that predicted IRs were estimated. Hazard functions were then used to predict IRs of MRSA and P. aeruginosa for CF programs based on their patient and program characteristics. Predicted IRs were compared with observed IRs over multiple time intervals. RESULTS Multiple patient and program characteristics were identified as predictors of observed IRs. Our model's predicted IRs closely aligned with observed IRs for most CF programs. Alarm values (defined as observed IR > 95% confidence interval of predicted IR) were found at 5.9%, 5.9%, 6.0% (adult, pediatric, affiliate) of programs for MRSA and 3.0%, 1.7%, 0.0% (adult, pediatric, affiliate) of programs for P. aeruginosa. CONCLUSIONS We found patient and program characteristics that predicted MRSA and P. aeruginosa IRs. Our model accurately predicted risk-adjusted IRs of MRSA and P. aeruginosa. CF programs could use our model to monitor their IRs and potentially improve infection prevention and control.
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Affiliation(s)
- William Stoudemire
- Department of Pediatrics, UNC School of Medicine, University of North Carolina, 450 MacNider Building, CB# 7217 321 S. Columbia Street, Chapel Hill, NC, United States.
| | - Xiaotong Jiang
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, United States
| | - Juyan J Zhou
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, United States
| | - Michael R Kosorok
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, United States
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, United States; Department of Infection Prevention & Control, New York-Presbyterian Hospital, New York, NY, United States
| | - Marianne S Muhlebach
- Department of Pediatrics, UNC School of Medicine, University of North Carolina, 450 MacNider Building, CB# 7217 321 S. Columbia Street, Chapel Hill, NC, United States
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13
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Esquivel MD, Monogue ML, Smith GS, Finklea JD, Sanders JM. Ceftaroline versus vancomycin for treatment of acute pulmonary exacerbations of cystic fibrosis in adults. J Glob Antimicrob Resist 2022; 28:67-70. [PMID: 34936925 DOI: 10.1016/j.jgar.2021.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/08/2021] [Accepted: 12/12/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Vancomycin remains a first-line treatment for methicillin-resistant Staphylococcus aureus (MRSA)-mediated acute pulmonary exacerbations (APEs) in adult cystic fibrosis (CF) patients; however, optimal alternatives remain poorly defined. The aim of this study was to determine the safety and efficacy of ceftaroline for MRSA-mediated APEs of CF in adults. METHODS We conducted a retrospective, observational cohort study comparing ceftaroline with vancomycin for the treatment of MRSA-mediated APEs in adult CF patients. The primary endpoint was the return to at least 90% of baseline lung function measured by discharge FEV1% predicted in comparison with baseline FEV1% predicted. RESULTS A total of 55 patients were included in the analysis (22 receiving ceftaroline and 33 receiving vancomycin). Of the patients included in the analysis, 13 patients (59%) in the ceftaroline group and 24 patients (73%) in the vancomycin group met the primary outcome (P = 0.38). FEV1 measurements at baseline, admission and discharge were not different between treatments. Secondary outcomes including 30-day re-admission rate, 30-day mortality, treatment duration and adverse events (neutropenia, Clostridioides difficile infection and acute kidney injury) were similar between groups. CONCLUSION Our small cohort study supports ceftaroline as an alternative treatment option for MRSA-mediated APE of CF in adults.
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Affiliation(s)
- Marc D Esquivel
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Marguerite L Monogue
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Greg S Smith
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James D Finklea
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James M Sanders
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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14
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Boudet A, Sorlin P, Pouget C, Chiron R, Lavigne JP, Dunyach-Remy C, Marchandin H. Biofilm Formation in Methicillin-Resistant Staphylococcus aureus Isolated in Cystic Fibrosis Patients Is Strain-Dependent and Differentially Influenced by Antibiotics. Front Microbiol 2021; 12:750489. [PMID: 34721354 PMCID: PMC8554194 DOI: 10.3389/fmicb.2021.750489] [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: 07/30/2021] [Accepted: 09/22/2021] [Indexed: 12/17/2022] Open
Abstract
Cystic fibrosis (CF) is a genetic disease with lung abnormalities making patients particularly predisposed to pulmonary infections. Staphylococcus aureus is the most frequently identified pathogen, and multidrug-resistant strains (MRSA, methicillin-resistant S. aureus) have been associated with more severe lung dysfunction leading to eradication recommendations. Diverse bacterial traits and adaptive skills, including biofilm formation, may, however, make antimicrobial therapy challenging. In this context, we compared the ability of a collection of genotyped MRSA isolates from CF patients to form biofilm with and without antibiotics (ceftaroline, ceftobiprole, linezolid, trimethoprim, and rifampicin). Our study used standardized approaches not previously applied to CF MRSA, the BioFilm Ring test® (BRT®), the Antibiofilmogram®, and the BioFlux™ 200 system which were adapted for use with the artificial sputum medium (ASM) mimicking conditions more relevant to the CF lung. We included 63 strains of 10 multilocus sequence types (STs) isolated from 35 CF patients, 16 of whom had chronic colonization. The BRT® showed that 27% of the strains isolated in 37% of the patients were strong biofilm producers. The Antibiofilmogram® performed on these strains showed that broad-spectrum cephalosporins had the lowest minimum biofilm inhibitory concentrations (bMIC) on a majority of strains. A focus on four chronically colonized patients with inclusion of successively isolated strains showed that ceftaroline, ceftobiprole, and/or linezolid bMICs may remain below the resistance thresholds over time. Studying the dynamics of biofilm formation by strains isolated 3years apart in one of these patients using BioFlux™ 200 showed that inhibition of biofilm formation was observed for up to 36h of exposure to bMIC and ceftaroline and ceftobiprole had a significantly greater effect than linezolid. This study has brought new insights into the behavior of CF MRSA which has been little studied for its ability to form biofilm. Biofilm formation is a common characteristic of prevalent MRSA clones in CF. Early biofilm formation was strain-dependent, even within a sample, and not only observed during chronic colonization. Ceftaroline and ceftobiprole showed a remarkable activity with a long-lasting inhibitory effect on biofilm formation and a conserved activity on certain strains adapted to the CF lung environment after years of colonization.
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Affiliation(s)
- Agathe Boudet
- VBIC, INSERM U1047, Université de Montpellier, Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, Nîmes, France
| | - Pauline Sorlin
- HydroSciences Montpellier, Université de Montpellier, CNRS, IRD, Département de Microbiologie, CHU de Nîmes, Montpellier, France
| | | | - Raphaël Chiron
- HydroSciences Montpellier, Université de Montpellier, CNRS, IRD, Centre de Ressources et de Compétences de la Mucoviscidose, CHU de Montpellier, Montpellier, France
| | - Jean-Philippe Lavigne
- VBIC, INSERM U1047, Université de Montpellier, Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, Nîmes, France
| | - Catherine Dunyach-Remy
- VBIC, INSERM U1047, Université de Montpellier, Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, Nîmes, France
| | - Hélène Marchandin
- HydroSciences Montpellier, Université de Montpellier, CNRS, IRD, Département de Microbiologie, CHU de Nîmes, Montpellier, France
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15
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Aljutayli A, El-Haffaf I, Marsot A, Nekka F. An Update on Population Pharmacokinetic Analyses of Vancomycin, Part II: In Pediatric Patients. Clin Pharmacokinet 2021; 61:47-70. [PMID: 34671937 DOI: 10.1007/s40262-021-01050-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 10/20/2022]
Abstract
Vancomycin is widely used in pediatric patients, however, large inter- and intraindividual variability are observed in vancomycin pharmacokinetics, affecting proper therapeutic monitoring. This review aimed at providing a comprehensive synthesis of the population pharmacokinetic models of vancomycin in pediatric patients and identifying potential factors responsible for the variability observed in various subpopulations. We conducted a literature search of the PubMed and EMBASE databases to obtain population pharmacokinetic studies for vancomycin published between January 2011 and January 2020, which resulted in a total of 33 studies. Vancomycin pharmacokinetics were generally characterized using a one-compartment model (n = 27), while a two-compartment model was used in six studies. The median (interquartile range) of the typical vancomycin clearance (CL) and the total volume of distribution adjusted to the median or mean body weight of the respective study was 0.103 L/h/kg (0.071-0.125) and 0.64 L/kg (0.59-1.03), respectively. Median weight-adjusted CL between different child age groups, such as infants and adolescents, did not appear to vary significantly, although the sample size for many age groups was very small. Examples of the conditions with relatively abnormal vancomycin pharmacokinetic values include renal insufficiency, sepsis, hematological and solid malignancy, and hypothermia treatment. Factors influencing pediatric vancomycin pharmacokinetics after adjusting for size and maturation include various renal function descriptors and some case-specific variables such as dialysate flow rate, ultrafiltrate output, and hypothermia. This review was able to document possible variables explaining the high variability observed in certain subpopulations and contrast vancomycin pharmacokinetics in different pediatric subpopulations.
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Affiliation(s)
- Abdullah Aljutayli
- Faculty of Pharmacy, Université de Montréal, 2940 chemin de polytechnique, Montreal, H3T 1J4, Canada.,Laboratoire de Pharmacométrie, Faculté de Pharmacie, Université de Montréal, 2940 chemin de polytechnique, Montreal, QC, H3T 1J4, Canada
| | - Ibrahim El-Haffaf
- Faculty of Pharmacy, Université de Montréal, 2940 chemin de polytechnique, Montreal, H3T 1J4, Canada.,Laboratoire de suivi thérapeutique pharmacologique et pharmacocinétique, Faculté de Pharmacie, Université de Montréal, 2940 chemin de polytechnique, Montreal, QC, H3T 1J4, Canada
| | - Amélie Marsot
- Faculty of Pharmacy, Université de Montréal, 2940 chemin de polytechnique, Montreal, H3T 1J4, Canada. .,Laboratoire de suivi thérapeutique pharmacologique et pharmacocinétique, Faculté de Pharmacie, Université de Montréal, 2940 chemin de polytechnique, Montreal, QC, H3T 1J4, Canada. .,Centre de recherche, CHU Sainte-Justine, 175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
| | - Fahima Nekka
- Faculty of Pharmacy, Université de Montréal, 2940 chemin de polytechnique, Montreal, H3T 1J4, Canada.,Laboratoire de Pharmacométrie, Faculté de Pharmacie, Université de Montréal, 2940 chemin de polytechnique, Montreal, QC, H3T 1J4, Canada.,Centre de recherches mathématiques, Université de Montréal, 2900 Boulevard Edouard-Montpetit, Montreal, QC, Canada, H3T 1J4
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16
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Evaluation of different phenotypic methods to detect methicillin resistance in Staphylococcus aureus isolates recovered from cystic fibrosis patients. Diagn Microbiol Infect Dis 2021; 102:115559. [PMID: 34662789 DOI: 10.1016/j.diagmicrobio.2021.115559] [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] [Received: 07/14/2020] [Revised: 09/12/2021] [Accepted: 09/18/2021] [Indexed: 11/03/2022]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) detection in cystic fibrosis (CF) is challenging. We compared different phenotypic methods among 157 S. aureus from 136 CF-patients: cefoxitin (FOX) and oxacillin (OXA) broth-microdilution; MicroScan-WalkAway®; FOX and OXA disk-diffusion (DD), and PBP2a-latex agglutination. PCR detection of mecA/mecC was the gold standard. Growth on ChromIDTM-MRSA agar was evaluated and compared with that of 157 blood culture (BC) isolates. ChromIDTM-MRSA was also tested on sputa from 111 CF-patients. 32 isolates (20%) were mecA-positive. Both FOX DD and MicroScan-WalkAway® (FOX/OXA) showed the highest sensitivity and specificity (100% and 100%, 96.9% and 99.2%, 96.9% and 100%). ChromIDTM-MRSA showed an excellent sensitivity for BC and CF-isolates (100% and 96.9%) but a poorer specificity for CF ones (95.5% vs. 73.7%), which was also observed when samples were seeded on this medium. FOX DD and MicroScan-WalkAway® are suitable for MRSA detection among CF-isolates and should be used to confirm ChromIDTM-MRSA positive CF-cultures.
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17
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Antistaphylococcal Activity of the FtsZ Inhibitor C109. Pathogens 2021; 10:pathogens10070886. [PMID: 34358036 PMCID: PMC8308607 DOI: 10.3390/pathogens10070886] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/08/2021] [Accepted: 07/10/2021] [Indexed: 01/22/2023] Open
Abstract
Staphylococcus aureus infections represent a great concern due to their versatility and involvement in different types of diseases. The shortage of available clinical options, especially to treat multiresistant strains, makes the discovery of new effective compounds essential. Here we describe the activity of the previously described cell division inhibitor C109 against methicillin-sensitive and -resistant S. aureus strains. Antibiofilm activity was assessed using microtiter plates, confocal microscopy, and in an in vitro biofilm wound model. The ability of C109 to block FtsZ GTPase activity and polymerization was tested in vitro. Altogether, the results show that the FtsZ inhibitor C109 has activity against a wide range of S. aureus strains and support its use as an antistaphylococcal compound.
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18
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Gilpin D, Hoffman LR, Ceppe A, Muhlebach MS. Phenotypic characteristics of incident and chronic MRSA isolates in cystic fibrosis. J Cyst Fibros 2021; 20:692-698. [PMID: 34103251 DOI: 10.1016/j.jcf.2021.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 05/19/2021] [Accepted: 05/22/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Chronic methicillin resistant Staphylococcus aureus (MRSA) in CF is associated with worse outcomes compared to early or intermittent infection. This observation could be related to adaptive bacterial changes such as biofilm formation or anaerobic growth. METHODS MRSA isolates stored from incident and during chronic (>2 years) infection were included at two study sites. MRSA isolates were characterised by spa-typing, antimicrobial susceptibility testing, biofilm formation and haemolysis under aerobic and anaerobic culture conditions. RESULTS Paired MRSA isolates from 49 patients were included. Mean age at incident infection was 9.7±1.2 years with mild to moderate lung disease (FEV1 74±4% predicted). Twenty-five subjects showed progression of disease/symptoms after onset of MRSA with significantly increased use of antibiotics. Most isolates belonged to t002 (38%) and t008 (36%) spa-types and 8 patients had a change in spa-type over time. Antimicrobial susceptibility testing showed few differences between incident and late isolates but significantly lower MIC under anaerobic vs. aerobic conditions for vancomycin, fusidic acid, rifampin but higher MIC for trimethoprim-sulfamethoxazole. Biofilm formation and haemolysis did not differ by stage of infection or disease course but both were lower under anaerobic conditions (biofilm p=0.018; haemolysis p=0.002) in multi-variate analyses that included study site, growth condition and stage of infection. CONCLUSIONS Persistent MRSA infection is frequently associated with clinical decline. Anaerobic growth conditions, which occur in CF airways, affect the expression of virulence factors and antibiotic susceptibility of MRSA more than duration of infection.
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Affiliation(s)
- Deirdre Gilpin
- Department of Pharmacy Services, Queens University, Belfast, UK.
| | - Lucas R Hoffman
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA, USA.
| | - Agathe Ceppe
- Marisco Lung Institute, University of North Carolina, Chapel Hill, NC, USA.
| | - Marianne S Muhlebach
- Marisco Lung Institute, University of North Carolina, Chapel Hill, NC, USA; Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA.
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19
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Fantone K, Tucker SL, Miller A, Yadav R, Bernardy EE, Fricker R, Stecenko AA, Goldberg JB, Rada B. Cystic Fibrosis Sputum Impairs the Ability of Neutrophils to Kill Staphylococcus aureus. Pathogens 2021; 10:pathogens10060703. [PMID: 34200034 PMCID: PMC8229215 DOI: 10.3390/pathogens10060703] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/26/2021] [Accepted: 05/26/2021] [Indexed: 02/06/2023] Open
Abstract
Cystic fibrosis (CF) airway disease is characterized by chronic microbial infections and infiltration of inflammatory polymorphonuclear (PMN) granulocytes. Staphylococcus aureus (S. aureus) is a major lung pathogen in CF that persists despite the presence of PMNs and has been associated with CF lung function decline. While PMNs represent the main mechanism of the immune system to kill S. aureus, it remains largely unknown why PMNs fail to eliminate S. aureus in CF. The goal of this study was to observe how the CF airway environment affects S. aureus killing by PMNs. PMNs were isolated from the blood of healthy volunteers and CF patients. Clinical isolates of S. aureus were obtained from the airways of CF patients. The results show that PMNs from healthy volunteers were able to kill all CF isolates and laboratory strains of S. aureus tested in vitro. The extent of killing varied among strains. When PMNs were pretreated with supernatants of CF sputum, S. aureus killing was significantly inhibited suggesting that the CF airway environment compromises PMN antibacterial functions. CF blood PMNs were capable of killing S. aureus. Although bacterial killing was inhibited with CF sputum, PMN binding and phagocytosis of S. aureus was not diminished. The S. aureus-induced respiratory burst and neutrophil extracellular trap release from PMNs also remained uninhibited by CF sputum. In summary, our data demonstrate that the CF airway environment limits killing of S. aureus by PMNs and provides a new in vitro experimental model to study this phenomenon and its mechanism.
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Affiliation(s)
- Kayla Fantone
- Department of Infectious Diseases, College of Veterinary Medicine, The University of Georgia, Athens, GA 30602, USA; (K.F.); (S.L.T.); (A.M.); (R.Y.); (R.F.)
| | - Samantha L. Tucker
- Department of Infectious Diseases, College of Veterinary Medicine, The University of Georgia, Athens, GA 30602, USA; (K.F.); (S.L.T.); (A.M.); (R.Y.); (R.F.)
| | - Arthur Miller
- Department of Infectious Diseases, College of Veterinary Medicine, The University of Georgia, Athens, GA 30602, USA; (K.F.); (S.L.T.); (A.M.); (R.Y.); (R.F.)
| | - Ruchi Yadav
- Department of Infectious Diseases, College of Veterinary Medicine, The University of Georgia, Athens, GA 30602, USA; (K.F.); (S.L.T.); (A.M.); (R.Y.); (R.F.)
| | - Eryn E. Bernardy
- Division of Pulmonology, Allergy/Immunology, Cystic Fibrosis and Sleep, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA; (E.E.B.); (A.A.S.); (J.B.G.)
| | - Rachel Fricker
- Department of Infectious Diseases, College of Veterinary Medicine, The University of Georgia, Athens, GA 30602, USA; (K.F.); (S.L.T.); (A.M.); (R.Y.); (R.F.)
| | - Arlene A. Stecenko
- Division of Pulmonology, Allergy/Immunology, Cystic Fibrosis and Sleep, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA; (E.E.B.); (A.A.S.); (J.B.G.)
| | - Joanna B. Goldberg
- Division of Pulmonology, Allergy/Immunology, Cystic Fibrosis and Sleep, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA; (E.E.B.); (A.A.S.); (J.B.G.)
| | - Balázs Rada
- Department of Infectious Diseases, College of Veterinary Medicine, The University of Georgia, Athens, GA 30602, USA; (K.F.); (S.L.T.); (A.M.); (R.Y.); (R.F.)
- Correspondence:
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20
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Sex and Gender Differences in Lung Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1304:227-258. [PMID: 34019273 DOI: 10.1007/978-3-030-68748-9_14] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Sex differences in the anatomy and physiology of the respiratory system have been widely reported. These intrinsic sex differences have also been shown to modulate the pathophysiology, incidence, morbidity, and mortality of several lung diseases across the life span. In this chapter, we describe the epidemiology of sex differences in respiratory diseases including neonatal lung disease (respiratory distress syndrome, bronchopulmonary dysplasia) and pediatric and adult disease (including asthma, cystic fibrosis, idiopathic pulmonary fibrosis, chronic obstructive pulmonary disease, lung cancer, lymphangioleiomyomatosis, obstructive sleep apnea, pulmonary arterial hypertension, and respiratory viral infections such as respiratory syncytial virus, influenza, and SARS-CoV-2). We also discuss the current state of research on the mechanisms underlying the observed sex differences in lung disease susceptibility and severity and the importance of considering both sex and gender variables in research studies' design and analysis.
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21
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Bashir G, Bhat JI, Mohammad S, Fomda BA, Bali NK, Altaf I. Airway Microbiology in Children with Cystic Fibrosis: A Prospective Cohort Study from Northern India. J Trop Pediatr 2021; 67:6294507. [PMID: 34100087 DOI: 10.1093/tropej/fmab030] [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] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The objective of this study is to find the organism profile and antimicrobial susceptibility patterns in children with cystic fibrosis (CF). DESIGN Prospective cohort study. SETTING Hospital-based study. INTERVENTION Sputum cultures/throat swabs were collected from the study population. Relevant details like anthropometry, systemic examination findings and investigations were entered in a pre-designed format. Sputum culture was subjected to microbiological analysis at the hospital microbiology laboratory. MAIN OUTCOME MEASURE Prevalence of positive sputum/cough swab culture in CF patients, their organism profile and antibiotic sensitivity. RESULTS A total of 63 patients were enrolled in the study. A total of 136 organisms were grown in our study population. Thirteen different organisms were isolated, which included five gram-positive bacteria, six gram-negative bacteria, eight Candida spp. and one filamentous. Antibiotic sensitivity profile of the Pseudomonas aeruginosa showed excellent sensitivity to all the aminoglycosides, piperacillin-tazobacteum and polymixin, similarly methicillin-sensitive Staphylococcus aureus, methicillin-resistant S. aureus and Enterococcus spp. were uniformly sensitive to vancomycin, linezolid and teicoplanin. Fungal isolates showed 100% sensitivity to all the antifungals tested including azoles and amphotericin B. CONCLUSION We observed 61% of culture positivity for different organisms in our study. Staphylococcus aureus and P. aeruginosa were the most frequently isolated organisms. Pseudomonas aeruginosa isolates were largely sensitive to aminoglycosides, carbapenems and polymixin. We found an unusually higher incidence of enterococcal infection in our study cohort with few vancomycin-resistant isolates.
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Affiliation(s)
- Gulnaz Bashir
- Department of Microbiology, SKIMS, Soura, Jammu and Kashmir 190011, India
| | - Javeed Iqbal Bhat
- Department of Pediatrics, SKIMS, Soura, Jammu and Kashmir 190011, India
| | - Sozia Mohammad
- Department of Microbiology, SKIMS, Soura, Jammu and Kashmir 190011, India
| | - Bashir Ahmad Fomda
- Department of Microbiology, SKIMS, Soura, Jammu and Kashmir 190011, India
| | - Nargis K Bali
- Department of Microbiology, SKIMS, Soura, Jammu and Kashmir 190011, India
| | - Insha Altaf
- Department of Microbiology, SKIMS, Soura, Jammu and Kashmir 190011, India
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22
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Kos R, Brinkman P, Neerincx AH, Paff T, Gerritsen MG, Lammers A, Kraneveld AD, Heijerman HGM, Janssens HM, Davies JC, Majoor CJ, Weersink EJ, Sterk PJ, Haarman EG, Bos LD, Maitland-van der Zee AH. Targeted exhaled breath analysis for detection of Pseudomonas aeruginosa in cystic fibrosis patients. J Cyst Fibros 2021; 21:e28-e34. [PMID: 34016557 DOI: 10.1016/j.jcf.2021.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/08/2021] [Accepted: 04/23/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pseudomonas aeruginosa (PA) is an important respiratory pathogen for cystic fibrosis (CF) patients. Routine microbiology surveillance is time-consuming, and is best performed on expectorated sputum. As alternative, volatile organic compounds (VOCs) may be indicative of PA colonisation. In this study, we aimed to identify VOCs associated with PA in literature and perform targeted exhaled breath analysis to recognize PA positive CF patients non-invasively. METHODS This study consisted of 1) a literature review to select VOCs of interest, and 2) a cross-sectional CF study. Definitions used: A) PA positive, PA culture at visit/chronically; B) PA free, no PA culture in ≥12 months. Exhaled VOCs were identified via quadrupole MS. The primary endpoint was the area under the receiver operating characteristics curve (AUROCC) of individual VOCs as well as combined VOCs against PA culture. RESULTS 241 VOCs were identified in literature, of which 56 were further evaluated, and 13 could be detected in exhaled breath in our cohort. Exhaled breath of 25 pediatric and 28 adult CF patients, PA positive (n=16) and free (n=28) was available. 3/13 VOCs were significantly (p<0.05) different between PA groups in children; none were in adults. Notably, a composite model based on 5 or 1 VOC(s) showed an AUROCC of 0.86 (CI 0.71-1.0) and 0.87 (CI 0.72-1.0) for adults and children, respectively. CONCLUSIONS Targeted VOC analysis appears to discriminate children and adults with and without PA positive cultures with clinically acceptable sensitivity values.
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Affiliation(s)
- Renate Kos
- Department Respiratory Medicine, Amsterdam University Medical Centres - loc. AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Paul Brinkman
- Department Respiratory Medicine, Amsterdam University Medical Centres - loc. AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Anne H Neerincx
- Department Respiratory Medicine, Amsterdam University Medical Centres - loc. AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Tamara Paff
- Department Paediatric Respiratory Medicine and Allergy, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Marije G Gerritsen
- Department Respiratory Medicine, Amsterdam University Medical Centres - loc. AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Ariana Lammers
- Department Respiratory Medicine, Amsterdam University Medical Centres - loc. AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Aletta D Kraneveld
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, Netherlands; Institute for Risk Assessment Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
| | - Harry G M Heijerman
- Department Respiratory Medicine, University Medical Centre, Utrecht, Netherlands
| | - Hettie M Janssens
- Department of Paediatrics, Division Respiratory Medicine and Allergology, Erasmus MC/Sophia Children's Hospital, University Medical Centre, Rotterdam, Netherlands
| | - Jane C Davies
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Christof J Majoor
- Department Respiratory Medicine, Amsterdam University Medical Centres - loc. AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Els J Weersink
- Department Respiratory Medicine, Amsterdam University Medical Centres - loc. AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Peter J Sterk
- Department Respiratory Medicine, Amsterdam University Medical Centres - loc. AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Eric G Haarman
- Department Paediatric Respiratory Medicine and Allergy, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Lieuwe D Bos
- Department Respiratory Medicine, Amsterdam University Medical Centres - loc. AMC, University of Amsterdam, Amsterdam, Netherlands; Department of Intensive Care, Amsterdam University Medical Centres, University of Amsterdam, Netherlands
| | - Anke H Maitland-van der Zee
- Department Respiratory Medicine, Amsterdam University Medical Centres - loc. AMC, University of Amsterdam, Amsterdam, Netherlands; Department Paediatric Respiratory Medicine and Allergy, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, the Netherlands.
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23
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Konstan MW, Pasta DJ, VanDevanter DR, Wagener JS, Morgan WJ. Epidemiologic Study of Cystic Fibrosis: 25 years of observational research. Pediatr Pulmonol 2021; 56:823-836. [PMID: 33434406 PMCID: PMC9123916 DOI: 10.1002/ppul.25248] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/19/2020] [Accepted: 12/25/2020] [Indexed: 11/09/2022]
Abstract
The Epidemiologic Study of Cystic Fibrosis (ESCF) was a prospective observational study of over 32,000 people with cystic fibrosis (CF) from 250 clinical care sites in North America from 1994 to 2005. Begun as a pharmacovigilance study in connection with the approval of dornase alfa in 1993, ESCF was open to all people with CF treated at any participating site in the United States or Canada. In addition to obtaining safety and effectiveness data on dornase alfa, ESCF collected encounter-based data to characterize the natural history and management of CF with a special focus on lung disease. During the study, 32,178 patients reported at least one encounter, contributing 869,136 encounters, 622,592 pulmonary function tests, 432,896 cultures, and 118,563 pulmonary exacerbations treated with intravenous antibiotics. Although ESCF data collection concluded in 2005, through a collaboration with the U.S. Cystic Fibrosis Foundation Patient Registry, additional follow-up data through 2017 was available for two-thirds of patients. This allowed for updating of CF genotype and survival information. Fifty-six peer-reviewed publications (cited over 3600 times) resulted from this study. In this manuscript we summarize the published ESCF manuscripts in thematic groups with key study findings and brief comments, and speculate on how ESCF findings will inform future data registries and patient care practices.
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Affiliation(s)
- Michael W Konstan
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | | | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Jeffrey S Wagener
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Wayne J Morgan
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA
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24
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In-Host Emergence of Linezolid Resistance in a Complex Pattern of Toxic Shock Syndrome Toxin-1-Positive Methicillin-Resistant Staphylococcus aureus Colonization in Siblings with Cystic Fibrosis. Toxins (Basel) 2021; 13:toxins13050317. [PMID: 33925199 PMCID: PMC8146457 DOI: 10.3390/toxins13050317] [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: 03/29/2021] [Revised: 04/25/2021] [Accepted: 04/26/2021] [Indexed: 01/01/2023] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) can cause chronic lung infections in patients with Cystic Fibrosis (CF). One option for managing them is the use of linezolid. We hereby report the in-host emergence of linezolid resistance (LR) in MRSA in CF siblings via a population analysis. A collection of 171 MRSA strains from 68 samples were characterized by determining their linezolid Minimal Inhibitory Concentrations (MICs), analyzing the locus of staphylococcal protein A (spa) and whole genome sequencing. Courses of linezolid were retraced. Strains belonged to three spa types (t002, t045, t127) and two sequence types (ST1, ST5). Emergence of LR occurred under treatment, one year apart in both siblings, in the CC5-MRSA-I Geraldine clone harboring the toxic shock syndrome toxin-1-encoding gene. Resistance was related to a G2576T substitution present in a variable number of 23S rRNA gene copies. Susceptible and resistant strains were co-isolated within samples. Single Nucleotide Polymorphism-based analysis revealed complex colonizations by highly diversified, clonally related populations. LR remains rare in MRSA and there are very few longitudinal analyses documenting its emergence. Analyzing a large MRSA collection revealed new aspects of LR emergence: it emerges in specific subclonal lineages resulting from adaptive diversification of MRSA in the CF lung and this heterogeneity of intra-sample resistance may contribute to compromising antibiotic management.
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25
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Fischer AJ, Singh SB, LaMarche MM, Maakestad LJ, Kienenberger ZE, Peña TA, Stoltz DA, Limoli DH. Sustained Coinfections with Staphylococcus aureus and Pseudomonas aeruginosa in Cystic Fibrosis. Am J Respir Crit Care Med 2021; 203:328-338. [PMID: 32750253 DOI: 10.1164/rccm.202004-1322oc] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Rationale: Staphylococcus aureus and Pseudomonas aeruginosa often infect the airways in cystic fibrosis (CF). Because registry studies show higher prevalence of P. aeruginosa versus S. aureus in older patients with CF, a common assumption is that P. aeruginosa replaces S. aureus over time. In vitro, P. aeruginosa can outgrow and kill S. aureus. However, it is unknown how rapidly P. aeruginosa replaces S. aureus in patients with CF.Methods: We studied a longitudinal cohort of children and adults with CF who had quantitative sputum cultures. We determined the abundance of P. aeruginosa and S. aureus in cfu/ml. We determined the duration and persistence of infections and measured longitudinal changes in culture positivity and abundance for each organism.Measurements and Main Results: Between 2004 and 2017, 134 patients had ≥10 quantitative cultures, with median observation time of 10.15 years. One hundred twenty-four patients had at least one positive culture for P. aeruginosa, and 123 had at least one positive culture for S. aureus. Both species had median abundance of >106 cfu/ml. Culture abundance was stable over time for both organisms. There was an increase in the prevalence of S. aureus/P. aeruginosa coinfection but no decrease in S. aureus prevalence within individuals over time.Conclusions: S. aureus and P. aeruginosa are abundant in CF sputum cultures. Contrary to common assumption, we found no pattern of replacement of S. aureus by P. aeruginosa. Many patients with CF have durable long-term coinfection with these organisms. New strategies are needed to prevent and treat these infections.
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Affiliation(s)
| | | | | | | | | | - Tahuanty A Peña
- Stead Family Department of Pediatrics.,Department of Internal Medicine, and
| | | | - Dominique H Limoli
- Department of Immunology and Microbiology, University of Iowa Carver College of Medicine, Iowa City, Iowa
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26
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Two Siblings Homozygous for F508del-CFTR Have Varied Disease Phenotypes and Protein Biomarkers. Int J Mol Sci 2021; 22:ijms22052631. [PMID: 33807880 PMCID: PMC7961721 DOI: 10.3390/ijms22052631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/20/2021] [Accepted: 03/01/2021] [Indexed: 12/01/2022] Open
Abstract
Two siblings with CF are homozygous for F508del (referred to as Subject A and Subject B). Despite having the same CFTR genotype and similar environment, these two subjects exhibited different disease phenotypes. We analyzed their medical records and CF Foundation Registry data and measured inflammatory protein mediators in their sputum samples. Then, we examined the longitudinal relationships between inflammatory markers and disease severity for each subject and compared between them. Subject A presented a more severe disease than Subject B. During the study period, Subject A had two pulmonary exacerbations (PEs) whereas Subject B had one mild PE. The forced expiratory volume in 1 s (FEV1, % predicted) values for Subject A were between 34–45% whereas for Subject B varied between 48–90%. Inflammatory protein mediators associated with neutrophils, Th1, Th2, and Th17 responses were elevated in sputum of Subject A compared with Subject B, and also in samples collected prior to and during PEs for both subjects. Neutrophilic elastase (NE) seemed to be the most informative biomarkers. The infectious burden between these two subjects was different.
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27
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Banjar H, Al-Qahtani H, Yasin W, Al-wgait W, Al-Amer H, raja R, Al-Nakhli A, Karkour K. The first report of Methicillin-resistant Staphylococcus aureus (MRSA) in cystic fibrosis (CF) patients in Saudi Arabia. Int J Pediatr Adolesc Med 2020; 7:186-190. [PMID: 33319017 PMCID: PMC7729253 DOI: 10.1016/j.ijpam.2019.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 09/11/2019] [Accepted: 10/20/2019] [Indexed: 11/19/2022]
Abstract
Introduction Methicillin-resistant Staphylococcus aureus infections have been increasingly reported in patients with cystic fibrosis (CF) who have progressive deterioration in their pulmonary function. Objectives To determine the prevalence of MRSA infections in CF in a tertiary care center in Saudi Arabia. Methodology This is a retrospective chart review conducted as part of the CF registry data from 1 January 2002 to 1 June 2016. All patients with confirmed CF of all age groups who had a respiratory culture positive for MRSA were included in the study. Results Among 385 patients with CF who had respiratory samples, 43 (11%) were positive for MRSA at a mean age of 10.4 ± 7.2 years. Twenty-two patients out of the 43 (51%) were treated with different regimens: nasal Bactroban in 13/22 (59%); a combination of nasal Bactroban, oral vancomycin, and rifampicin for 2 weeks in 5 patients (23%); Bactroban and linezolid in one patient (5%); and oral vancomycin and rifampicin in 3 patients (14%). Eight out of the 22 treated patients (36%) achieved MRSA eradication. Six out of the 22 treated (27%) had experienced MRSA recurrence within 3–6 months, and another 5/22 (23%) continued to have MRSA colonization up to 2–4 years of follow-up despite using a proper eradication protocol. Twelve out of the 43 (28%) patients with MRSA infection died. Conclusion MRSA infection in our population with CF is common. Therefore, an eradication protocol should be instituted at an early stage to prevent chronic colonization. Children with persistent MRSA colonization have high morbidity and mortality rate.
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Affiliation(s)
- Hanaa Banjar
- Department of Pediatrics, King Specialist Hospital and Research Center (KFSHRC), Riyadh, Saudi Arabia
- Corresponding author. Al-Faisal University, Department of Pediatrics, (KFSHRC). P.O. Box. 3354, MBC-58, Riyadh, 11211, Saudi Arabia.
| | - Hend Al-Qahtani
- Department of Pediatrics, King Specialist Hospital and Research Center (KFSHRC), Riyadh, Saudi Arabia
| | - Waseem Yasin
- Department of Pediatrics, King Specialist Hospital and Research Center (KFSHRC), Riyadh, Saudi Arabia
- College of Medicine, Al-Faisal University, Riyadh, Saudi Arabia
- Alfaisal University, Saudi Arabia
| | - Waad Al-wgait
- Department of Pediatrics, King Specialist Hospital and Research Center (KFSHRC), Riyadh, Saudi Arabia
| | - Hanan Al-Amer
- Department of Pediatrics, King Specialist Hospital and Research Center (KFSHRC), Riyadh, Saudi Arabia
| | - Rawia raja
- College of Medicine, Al-Faisal University, Riyadh, Saudi Arabia
| | - Ali Al-Nakhli
- College of Medicine, Al-Faisal University, Riyadh, Saudi Arabia
| | - Kawthar Karkour
- College of Medicine, Al-Faisal University, Riyadh, Saudi Arabia
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28
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Papa R, Garzoli S, Vrenna G, Sabatino M, Sapienza F, Relucenti M, Donfrancesco O, Fiscarelli EV, Artini M, Selan L, Ragno R. Essential Oils Biofilm Modulation Activity, Chemical and Machine Learning Analysis. Application on Staphylococcus aureus Isolates from Cystic Fibrosis Patients. Int J Mol Sci 2020; 21:ijms21239258. [PMID: 33291608 PMCID: PMC7730550 DOI: 10.3390/ijms21239258] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 02/08/2023] Open
Abstract
Bacterial biofilm plays a pivotal role in chronic Staphylococcus aureus (S. aureus) infection and its inhibition may represent an important strategy to develop novel therapeutic agents. The scientific community is continuously searching for natural and “green alternatives” to chemotherapeutic drugs, including essential oils (EOs), assuming the latter not able to select resistant strains, likely due to their multicomponent nature and, hence, multitarget action. Here it is reported the biofilm production modulation exerted by 61 EOs, also investigated for their antibacterial activity on S. aureus strains, including reference and cystic fibrosis patients’ isolated strains. The EOs biofilm modulation was assessed by Christensen method on five S. aureus strains. Chemical composition, investigated by GC/MS analysis, of the tested EOs allowed a correlation between biofilm modulation potency and putative active components by means of machine learning algorithms application. Some EOs inhibited biofilm growth at 1.00% concentration, although lower concentrations revealed different biological profile. Experimental data led to select antibiofilm EOs based on their ability to inhibit S. aureus biofilm growth, which were characterized for their ability to alter the biofilm organization by means of SEM studies.
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Affiliation(s)
- Rosanna Papa
- Department of Public Health and Infectious Diseases, Sapienza University, p.le Aldo Moro 5, 00185 Rome, Italy; (R.P.); (G.V.); (M.A.)
| | - Stefania Garzoli
- Department of Drug Chemistry and Technology, Sapienza University, p.le Aldo Moro 5, 00185 Rome, Italy; (S.G.); (M.S.); (F.S.)
| | - Gianluca Vrenna
- Department of Public Health and Infectious Diseases, Sapienza University, p.le Aldo Moro 5, 00185 Rome, Italy; (R.P.); (G.V.); (M.A.)
| | - Manuela Sabatino
- Department of Drug Chemistry and Technology, Sapienza University, p.le Aldo Moro 5, 00185 Rome, Italy; (S.G.); (M.S.); (F.S.)
- Rome Center for Molecular Design, Department of Drug Chemistry and Technology, Sapienza University, p.le Aldo Moro 5, 00185 Rome, Italy
| | - Filippo Sapienza
- Department of Drug Chemistry and Technology, Sapienza University, p.le Aldo Moro 5, 00185 Rome, Italy; (S.G.); (M.S.); (F.S.)
- Rome Center for Molecular Design, Department of Drug Chemistry and Technology, Sapienza University, p.le Aldo Moro 5, 00185 Rome, Italy
| | - Michela Relucenti
- Department of Anatomy, Histology, Forensic Medicine and Orthopaedics, Sapienza University of Rome, via Alfonso Borelli 50, 00161 Rome, Italy; (M.R.); (O.D.)
| | - Orlando Donfrancesco
- Department of Anatomy, Histology, Forensic Medicine and Orthopaedics, Sapienza University of Rome, via Alfonso Borelli 50, 00161 Rome, Italy; (M.R.); (O.D.)
| | - Ersilia Vita Fiscarelli
- Paediatric and Laboratory Department, Children’s Hospital and Institure Research Bambino Gesù, 00165 Rome, Italy;
| | - Marco Artini
- Department of Public Health and Infectious Diseases, Sapienza University, p.le Aldo Moro 5, 00185 Rome, Italy; (R.P.); (G.V.); (M.A.)
| | - Laura Selan
- Department of Public Health and Infectious Diseases, Sapienza University, p.le Aldo Moro 5, 00185 Rome, Italy; (R.P.); (G.V.); (M.A.)
- Correspondence: (L.S.); (R.R.)
| | - Rino Ragno
- Department of Drug Chemistry and Technology, Sapienza University, p.le Aldo Moro 5, 00185 Rome, Italy; (S.G.); (M.S.); (F.S.)
- Rome Center for Molecular Design, Department of Drug Chemistry and Technology, Sapienza University, p.le Aldo Moro 5, 00185 Rome, Italy
- Correspondence: (L.S.); (R.R.)
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29
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Branstetter J, Searcy H, Benner K, Yarbrough A, Crowder C, Troxler B. Ceftaroline vs vancomycin for the treatment of acute pulmonary exacerbations in pediatric patients with cystic fibrosis. Pediatr Pulmonol 2020; 55:3337-3342. [PMID: 32803907 DOI: 10.1002/ppul.25029] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Respiratory infection with methicillin-resistant Staphylococcus aureus (MRSA) is an increasing complication in cystic fibrosis (CF) that results in accelerated lung function decline and mortality. Vancomycin is considered a first-line intravenous treatment agent for MRSA associated acute pulmonary exacerbations (APEs); however, rates of vancomycin intolerance and resistance have been observed. These factors have led to the exploration of additional treatment options for treating MRSA associated APEs. METHODS This is a retrospective chart review conducted at a CF center including patients 0 to 21 years of age with CF admitted for an APE and treated with either vancomycin or ceftaroline between January 2016 and August 2018. The primary endpoint was to determine ceftaroline efficacy compared to vancomycin in the treatment of MRSA associated APEs. RESULTS There were 180 patients included in the study with 90 patients in each antibiotic group. Admission to discharge forced expiratory volume in 1 second (FEV1 ) improved in the ceftaroline (66.5% vs 81.1%; P < .001) and vancomycin (65.5% vs 77.3%; P < .001) treatment groups. No difference existed in mean change in FEV1 (14.1% vs 13.5%; P = .25) or readmissions (15% vs 22; P = .27) between ceftaroline and vancomycin groups, respectively. DISCUSSION In this retrospective study, no difference existed between ceftaroline and vancomycin with regard to observed improvement in lung function from admission to discharge. Additionally, no difference was observed in mean FEV1 or readmission rate between the two groups. Ceftaroline may represent an effective and safe intravenous antimicrobial option for targeting MRSA in pediatric CF patients with APEs.
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Affiliation(s)
- Joshua Branstetter
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Heather Searcy
- Department of Pharmacy, Children's of Alabama, Birmingham, Alabama
| | - Kim Benner
- Department of Pharmacy Practice, McWhorter School of Pharmacy, Samford University, Birmingham, Alabama
| | - April Yarbrough
- Department of Pharmacy, Children's of Alabama, Birmingham, Alabama
| | - Carly Crowder
- Department of Pharmacy, Intermountain Healthcare, Taylorsville, Utah
| | - Brad Troxler
- Division of Pediatric Pulmonology, University of Alabama at Birmingham, Birmingham, Alabama
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30
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Marsteller NL, Nussbaum E, Morphew T, Randhawa IS. Cystic fibrosis patients at risk for disease progression marked by decline in FEV1% predicted: development of the cystic fibrosis risk of disease progression score. J Thorac Dis 2020; 11:5557-5565. [PMID: 32030275 DOI: 10.21037/jtd.2019.11.22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Cystic fibrosis (CF) is one of the most common recessively inherited disorders diagnosed in early childhood in the United States. Determining the phenotype of CF patients likely to experience a significant drop in FEV1% predicted will help target efforts for mitigating this deleterious disorder. Methods This retrospective cohort study evaluated potential risk variables that account for the decline in FEV1% predicted in 81 CF patients treated at Miller Children's and Women's Hospital, CA. Cystic fibrosis risk of disease progression (CF RD-Pro) score was evaluated as a tool to identify high-risk patients for accelerated disease progression (event = drop in FEV1% predicted ≥10 percentage points) based on risk variables identified as significant. Results ROC analysis determined classification of high versus low-moderate risk of FEV1% decline during year two based on RD-Pro score. Scores ≥2 applied as threshold for high-risk revealed relatively good validity estimates: sensitivity =82.8%, specificity =66.7%, PVP =77.4%, PVN =73.7%, and correct classification =76%. Patients with CF RD-Pro scores suggestive of high (≥2 points) vs. low-moderate (<2 points) risk were nearly 10 times more likely to experience significant disease progression (OR 9.6, 95% CI, 2.6-36.1, P=0.001). Conclusions Identification of patients at high risk for significant decline in lung function will enable address of potential therapeutic modalities, environmental exposures, and behavioral variants that may improve outcomes in these patients. The power of the CF RD-Pro Score lies in its simplicity. Our study provides a novel readily available score, which incorporates body mass index (BMI) and Staphylococcus aureus infection, both being alterable targets for slowing CF progression.
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Affiliation(s)
- Nathan L Marsteller
- The Translational Pulmonary and Immunology Research Center (TPIRC), Long Beach, CA, USA.,MemorialCare Health System, Long Beach, CA, USA
| | - Eliezer Nussbaum
- MemorialCare Health System, Long Beach, CA, USA.,Pediatric Pulmonology Division, Miller Children's Hospital, Long Beach, CA, USA.,University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Tricia Morphew
- MemorialCare Health System, Long Beach, CA, USA.,Morphew Consulting, LLC, Bothell, WA, USA
| | - Inderpal S Randhawa
- The Translational Pulmonary and Immunology Research Center (TPIRC), Long Beach, CA, USA.,MemorialCare Health System, Long Beach, CA, USA.,Pediatric Pulmonology Division, Miller Children's Hospital, Long Beach, CA, USA.,University of California, Irvine School of Medicine, Irvine, CA, USA
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31
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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.
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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
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32
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Edwards BD, Somayaji R, Greysson-Wong J, Izydorczyk C, Waddell B, Storey DG, Rabin HR, Surette MG, Parkins MD. Clinical Outcomes Associated With Escherichia coli Infections in Adults With Cystic Fibrosis: A Cohort Study. Open Forum Infect Dis 2019; 7:ofz476. [PMID: 31976352 PMCID: PMC6966422 DOI: 10.1093/ofid/ofz476] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 11/14/2019] [Indexed: 11/13/2022] Open
Abstract
Background Analysis of “emerging” pathogens in cystic fibrosis (CF) lung disease has focused on unique pathogens that are rare in other human diseases or are drug resistant. Escherichia coli is recovered in the sputum of up to 25% of patients with CF, yet little is known about the epidemiology or clinical impact of infection. Methods We studied patients attending a Canadian adult CF clinic who had positive sputum cultures for E coli from 1978 to 2016. Infection was categorized as transient or persistent (≥3 positive sputum cultures, spanning >6 months). Those with persistent infection were matched 2:1 with age, sex, and time-period controls without history of E coli infection, and mixed-effects models were used to assess pulmonary exacerbation (PEx) frequency, lung function decline, hospitalization, and intravenous antibiotic days. Results Forty-five patients (12.3%) had E coli recovered from sputum samples between 1978 and 2016, and 18 patients (40%) developed persistent infection. Nine patients (24%) had PEx at incident infection, and increased bioburden was predictive of exacerbation (P = .03). Risk factors for persistent infection included lower nutritional status (P < .001) and lower lung function (P = .009), but chronic infection with Pseudomonas aeruginosa was protective. There was no difference in annual lung function decline, need for hospitalization or intravenous antibiotics, or risk of PEx in patients with persistent infection. Conclusions Persistent E coli infection was frequent and was more common in CF patients with low nutritional status and lung function. However, this does not predict clinical decline. Multicenter studies would allow better characterization of the epidemiology and clinical impact of E coli infection.
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Affiliation(s)
- B D Edwards
- Department of Medicine, University of Calgary
| | - R Somayaji
- Department of Medicine, University of Calgary.,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary.,Department of Community Health Sciences, University of Calgary
| | - J Greysson-Wong
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary
| | - C Izydorczyk
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary
| | - B Waddell
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary
| | - D G Storey
- Department of Biological Sciences, University of Calgary
| | - H R Rabin
- Department of Medicine, University of Calgary.,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary
| | - M G Surette
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary.,Department of Medicine, McMaster University.,Biochemistry and Biomedical Sciences, the Farncombe Family Digestive Health Research Institute, McMaster University
| | - M D Parkins
- Department of Medicine, University of Calgary.,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary
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Wolter DJ, Onchiri FM, Emerson J, Precit MR, Lee M, McNamara S, Nay L, Blackledge M, Uluer A, Orenstein DM, Mann M, Hoover W, Gibson RL, Burns JL, Hoffman LR. Prevalence and clinical associations of Staphylococcus aureus small-colony variant respiratory infection in children with cystic fibrosis (SCVSA): a multicentre, observational study. THE LANCET RESPIRATORY MEDICINE 2019; 7:1027-1038. [PMID: 31727592 DOI: 10.1016/s2213-2600(19)30365-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 08/08/2019] [Accepted: 09/05/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Staphylococcus aureus is the bacterium cultured most often from respiratory secretions of people with cystic fibrosis. Both meticillin-susceptible S aureus and meticillin-resistant S aureus (MRSA) can adapt to form slow-growing, antibiotic-resistant isolates known as small-colony variants that are not routinely identified by clinical laboratories. We aimed to determine the prevalence and clinical significance of S aureus small-colony variants and their subtypes among children with cystic fibrosis. METHODS The Small Colony Variant Staphylococcus aureus (SCVSA) study was a 2-year longitudinal study of children aged 6-16 years at five US cystic fibrosis centres, using culture methods sensitive for small-colony variants. Children were eligible if they had a documented diagnosis of cystic fibrosis and a minimum of two cystic fibrosis clinic visits and two respiratory cultures in the previous 12 months at enrolment. Participants attended clinic visits quarterly, at which respiratory tract samples were taken and measures of lung function (percentage of predicted forced expiratory volume in 1 s [FEV1] and frequency of respiratory exacerbations) were recorded. We determined the prevalence of small-colony variants and their subtypes, and assessed their independent associations with lung function and respiratory exacerbations using linear mixed-effects and generalised estimating equation logistic regression models. Analyses included both univariate models (unadjusted) and multivariate models that adjusted for potential confounders, including age, sex, race, baseline microbiology, treatment with CFTR modulator, and CTFR genotype. FINDINGS Between July 1, 2014, and May 26, 2015, we enrolled 230 children. Participants were followed-up for 2 years, with a mean of 6·4 visits (SD 1·14) per participant (range 2-9 visits) and a mean interval between visits of 3·94 months (SD 1·77). Across the 2-year period, S aureus small-colony variants were detected in 64 (28%) participants. Most (103 [56%] of 185) of the small-colony variants detected in these participants were thymidine dependent. Children with small-colony variants had significantly lower mean percentage of predicted FEV1 at baseline than did children without small-colony variants (85·5 [SD 19] vs 92·4 [SD 18·6]; p=0·0145). Small-colony variants were associated with significantly lower percentage of predicted FEV1 throughout the study in regression models, both in univariate analyses (regression coefficient -7·07, 95% CI -12·20 to -1·95; p=0·0068) and in multivariate analyses adjusting for potential confounders (-5·50, -10·51 to -0·48; p=0·0316). Small colony variants of the thymidine-dependent subtype had the strongest association with lung function in multivariate regression models (regression coefficient -10·49, -17·25 to -3·73; p=0·0024). Compared with children without small-colony variants, those with small-colony variants had significantly increased odds of respiratory exacerbations in univariate analyses (odds ratio 1·73, 95% CI 1·19 to 2·52; p=0·0045). Children with thymidine-dependent small-colony variants had significantly increased odds of respiratory exacerbations (2·81, 1·69-4·67; p=0·0001), even after adjusting for age, sex, race, genotype, CFTR modulator, P aeruginosa culture status, and baseline percentage of predicted FEV1 (2·17, 1·33-3·57; p=0·0021), whereas those with non-thymidine-dependent small-colony variants did not. In multivariate models including small-colony variants and MRSA status, P aeruginosa was not independently associated with lung function (regression coefficient -4·77, 95% CI -10·36 to 0·83; p=0·10) and was associated with reduced odds of exacerbations (0·54, 0·36 to 0·81; p=0·0028). Only the small-colony variant form of MRSA was associated with reduced lung function (-8·44, -16·15 to -0·72; p=0·0318) and increased odds of exacerbations (2·15, 1·24 to 3·71; p=0·0061). INTERPRETATION Infection with small-colony variants, and particularly thymidine-dependent small-colony variants, was common in a multicentre paediatric population with cystic fibrosis and associated with reduced lung function and increased risk of respiratory exacerbations. The adoption of small-colony variant identification and subtyping methods by clinical laboratories, and the inclusion of small-colony variant prevalence data in cystic fibrosis registries, should be considered for ongoing surveillance and study. FUNDING The Cystic Fibrosis Foundation and the National Institutes of Health.
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Affiliation(s)
- Daniel J Wolter
- Department of Pediatrics and Department of Microbiology, University of Washington, Seattle, WA, USA; Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Julia Emerson
- Department of Pediatrics and Department of Microbiology, University of Washington, Seattle, WA, USA; Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | - Mimi R Precit
- Department of Pediatrics and Department of Microbiology, University of Washington, Seattle, WA, USA
| | - Michael Lee
- Department of Pediatrics and Department of Microbiology, University of Washington, Seattle, WA, USA
| | - Sharon McNamara
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | - Laura Nay
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Ahmet Uluer
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
| | - David M Orenstein
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michelle Mann
- Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Wynton Hoover
- Department of Pediatrics, University of Alabama, Tuscaloosa, AL, USA
| | - Ronald L Gibson
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | - Jane L Burns
- Department of Pediatrics and Department of Microbiology, University of Washington, Seattle, WA, USA; Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | - Lucas R Hoffman
- Department of Pediatrics and Department of Microbiology, University of Washington, Seattle, WA, USA; Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA.
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Area Deprivation as a Risk Factor for Methicillin-resistant Staphylococcus aureus Infection in Pediatric Cystic Fibrosis. Pediatr Infect Dis J 2019; 38:e285-e289. [PMID: 31568067 PMCID: PMC6802275 DOI: 10.1097/inf.0000000000002419] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In US cystic fibrosis (CF) patients, methicillin-resistant Staphylococcus aureus (MRSA) rates have tripled in the past 2 decades. Known clinical risk factors include exposure to a healthcare setting, Pseudomonas aeruginosa and CF-related diabetes. Area-level socio-environmental exposures have not been evaluated. We explored the association of area-level deprivation with MRSA prevalence in a pediatric CF Center in the Southeastern United States. METHODS Patients' residential addresses were geocoded and linked to a composite Area Deprivation Index and Rural-Urban Commuting Area scores. The association of MRSA with Area Deprivation Index and Rural-Urban Commuting Area scores was evaluated using logistic regression with robust standard errors adjusted for sociodemographic covariates (age, sex, race, mother's and father's education and household income), clinical risk factors (P. aeruginosa, CF-related diabetes, hospitalizations and number of clinic visits) and clustering. RESULTS The study included all pediatric patients (N = 231; mean age 12) at a single CF Center. MRSA was present in 44% of subjects. Higher area-level deprivation was correlated with rural residence, lack of parental college education and lower household income (P < 0.001 for each). In a multiple regression model fully adjusted for patient-level sociodemographic covariates, clinical risk factors and clustering, neighborhood deprivation was associated with more than 2-fold increase in the odds of having MRSA [OR 2.26 (1.14-4.45), P < 0.05]. CONCLUSIONS Neighborhood deprivation is a risk factor for MRSA in pediatric CF, doubling the odds of infection. Community-level socioeconomic risk factors should be considered when developing prevention strategies and treatment plans for MRSA infection in pediatric patients with CF.
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Fusco NM, Meaney CJ, Frederick CA, Prescott WA. Comparative Effectiveness of Vancomycin Versus Linezolid for the Treatment of Acute Pulmonary Exacerbations of Cystic Fibrosis. Ann Pharmacother 2019; 54:197-204. [DOI: 10.1177/1060028019885651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Data are limited regarding the preferred antibiotics for treatment of acute pulmonary exacerbations (APEs) of cystic fibrosis (CF), when methicillin-resistant Staphylococcus aureus (MRSA) is suspected. Objective: To compare the rate of return to baseline lung function among individuals with APEs of CF treated with either vancomycin or linezolid. Methods: This retrospective study included individuals hospitalized for APEs of CF from May 1, 2015, to April 30, 2017 who were infected with MRSA and treated with vancomycin or linezolid. The primary outcome was the return to baseline lung function, as measured by forced expiratory volume in 1 s (FEV1). Descriptive and inferential statistics were used. All tests were 2-tailed with α set at 0.05. Results: A total of 122 encounters were included (vancomycin: n = 66; linezolid: n = 66). No difference existed in return to baseline FEV1 between vancomycin (53 [80.3%]) and linezolid (50 [75.8%]; P = 0.53); nor was there a difference in median percentage change in FEV1 from admission to follow-up between vancomycin (24.7%) and linezolid (20.7%; P = 0.61). Adverse drug events occurred more frequently in patient encounters treated with vancomycin (10 [15.2%]) compared with linezolid (2 [3%]; P = 0.002). Conclusion and Relevance: Our study observed no difference in the effectiveness of vancomycin compared with linezolid in terms of change in lung function for APEs of CF. The rate of adverse drug events was low. In individuals with CF infected with MRSA who are experiencing an APE, either vancomycin or linezolid appear to be viable treatment options.
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Affiliation(s)
- Nicholas M. Fusco
- University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA
| | - Calvin J. Meaney
- University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA
| | | | - William A. Prescott
- University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA
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Chronic Azithromycin Use in Cystic Fibrosis and Risk of Treatment-Emergent Respiratory Pathogens. Ann Am Thorac Soc 2019; 15:702-709. [PMID: 29474110 DOI: 10.1513/annalsats.201801-012oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Azithromycin has been shown to improve lung function and reduce the number of pulmonary exacerbations in patients with cystic fibrosis. Concerns remain, however, regarding the potential emergence of treatment-related respiratory pathogens. OBJECTIVES To determine whether chronic azithromycin use (defined as three-times weekly administration) is associated with increased rates of detection of eight specific respiratory pathogens. METHODS We performed a new-user, propensity score-matched retrospective cohort study utilizing data from the Cystic Fibrosis Foundation Patient Registry. Incident azithromycin users were propensity score matched 1:1 with contemporaneous nonusers. Kaplan-Meier curves and Cox proportional hazards regression were used to evaluate the association between chronic azithromycin use and incident respiratory pathogen detection. Analyses were performed separately for each pathogen, limited to patients among whom that pathogen had not been isolated in the 2 years before cohort entry. RESULTS After propensity score matching, the mean age of the cohorts was approximately 12 years. Chronic azithromycin users had a significantly lower risk of detection of new methicillin-resistant Staphylococcus aureus, nontuberculous mycobacteria, and Burkholderia cepacia complex compared with nonusers. The risk of acquiring the remaining five pathogens was not significantly different between users and nonusers. CONCLUSIONS Using an innovative new-user, propensity score-matched study design to minimize indication and selection biases, we found in a predominantly pediatric cohort that chronic azithromycin users had a lower risk of acquiring several cystic fibrosis-related respiratory pathogens. These results may ease concerns that chronic azithromycin exposure increases the risk of acquiring new respiratory pathogens among pediatric patients with cystic fibrosis.
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Esposito S, Pennoni G, Mencarini V, Palladino N, Peccini L, Principi N. Antimicrobial Treatment of Staphylococcus aureus in Patients With Cystic Fibrosis. Front Pharmacol 2019; 10:849. [PMID: 31447669 PMCID: PMC6692479 DOI: 10.3389/fphar.2019.00849] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/03/2019] [Indexed: 11/13/2022] Open
Abstract
Staphylococcus aureus is a ubiquitous human commensal pathogen. It is commonly isolated in cystic fibrosis (CF) patients and is considered one of the main causes of the recurrent acute pulmonary infections and progressive decline in lung function that characterize this inherited life-threatening multisystem disorder. However, the true role of S. aureus in CF patients is not completely understood. The main aim of this narrative review is to discuss the present knowledge of the role of S. aureus in CF patients. Literature review showed that despite the fact that the availability and use of drugs effective against S. aureus have coincided with a significant improvement in the prognosis of lung disease in CF patients, clearly evidencing the importance of S. aureus therapy, how to use old and new drugs to obtain the maximal effectiveness has not been precisely defined. The most important problem remains that the high frequency with which S. aureus is carried in healthy subjects prevents the differentiation of simple colonization from infection. Moreover, although experts recommend antibiotic administration in CF patients with symptoms and in those with persistent detection of S. aureus, the best antibiotic approach has not been defined. All these problems are complicated by the evidence that the most effective antibiotic against methicillin-resistant S. aureus (MRSA) cannot be used in patients with CF with the same schedules used in patients without CF. Further studies are needed to solve these problems and to assure CF patients the highest level of care.
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Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Cystic Fibrosis Center of Umbria Region, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Guido Pennoni
- Pediatric Unit, Cystic Fibrosis Center of Umbria Region, Branca Hospital, Branca, Italy
| | - Valeria Mencarini
- Pediatric Unit, Cystic Fibrosis Center of Umbria Region, Branca Hospital, Branca, Italy
| | - Nicola Palladino
- Pediatric Unit, Cystic Fibrosis Center of Umbria Region, Branca Hospital, Branca, Italy
| | - Laura Peccini
- Pediatric Clinic, Cystic Fibrosis Center of Umbria Region, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
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38
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Heirali AA, Acosta N, Storey DG, Workentine ML, Somayaji R, Laforest-Lapointe I, Leung W, Quon BS, Berthiaume Y, Rabin HR, Waddell BJ, Rossi L, Surette MG, Parkins MD. The effects of cycled inhaled aztreonam on the cystic fibrosis (CF) lung microbiome. J Cyst Fibros 2019; 18:829-837. [PMID: 30857926 DOI: 10.1016/j.jcf.2019.02.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND To improve clinical outcomes, cystic fibrosis (CF) patients with chronic Pseudomonas aeruginosa infections are prescribed inhaled anti-pseudomonal antibiotics. Although, a diverse microbial community exists within CF airways, little is known about how the CF microbiota influences patient outcomes. We hypothesized that organisms within the CF microbiota are affected by inhaled-antibiotics and baseline microbiome may be used to predict therapeutic response. METHODS Adults with chronic P. aeruginosa infection from four clinics were observed during a single 28-day on/off inhaled-aztreonam cycle. Patients performed serial sputum collection, CF-respiratory infection symptom scores (CRISS), and spirometry. Patients achieving a decrease of ≥2 CRISS by day 28 were categorized as subjective responders (SR). The airway microbiome was defined by Illumina MiSeq analysis of the 16S rRNA gene. RESULTS Thirty-seven patients (median 37.4 years and FEV1 44% predicted) were enrolled. No significant cohort-wide changes in the microbiome were observed between on/off AZLI cycles in either alpha- or beta-diversity metrics. However, at an individual level shifts were apparent. Twenty-one patients (57%) were SR and fourteen patients did not subjectively respond. While alpha-diversity metrics did not associate with response, patients who did not subjectively respond had a higher abundance of Staphylococcus and Streptococcus, and lower abundance of Haemophilus. CONCLUSIONS The CF microbiome is relatively resilient to AZLI perturbations. However, associated changes were observed at the individual patient level. The relative abundance of key "off-target" organisms associated with subjective improvements suggesting that the microbiome may be used as a tool to predict patient response - potentially improving outcomes.
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Affiliation(s)
- Alya A Heirali
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada
| | - Nicole Acosta
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada
| | - Douglas G Storey
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada; Department of Biological Sciences, University of Calgary, Calgary, AB, Canada
| | | | - Ranjani Somayaji
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada; Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Isabelle Laforest-Lapointe
- Departments of Physiology & Pharmacology, University of Calgary, Calgary, AB, Canada; Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Winnie Leung
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Bradley S Quon
- Department of Medicine and Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Yves Berthiaume
- Institut de recherches cliniques de Montreal and Department of Medicine, Universite de Montreal, QB, Canada
| | - Harvey R Rabin
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada; Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Barbara J Waddell
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada
| | - Laura Rossi
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Michael G Surette
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Michael D Parkins
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada; Department of Medicine, University of Calgary, Calgary, AB, Canada.
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Refining the Application of Microbial Lipids as Tracers of Staphylococcus aureus Growth Rates in Cystic Fibrosis Sputum. J Bacteriol 2018; 200:JB.00365-18. [PMID: 30249710 DOI: 10.1128/jb.00365-18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 09/19/2018] [Indexed: 02/04/2023] Open
Abstract
Chronic lung infections in cystic fibrosis (CF) could be treated more effectively if the effects of antimicrobials on pathogens in situ were known. Here, we compared changes in the microbial community composition and pathogen growth rates in longitudinal studies of seven pediatric CF patients undergoing intravenous antibiotic administration during pulmonary exacerbations. The microbial community composition was determined by counting rRNA with NanoString DNA analysis, and growth rates were obtained by incubating CF sputum with heavy water and tracing incorporation of deuterium into two branched-chain ("anteiso") fatty acids (a-C15:0 and a-C17:0) using gas chromatography-mass spectrometry (GC/MS). Prior to this study, both lipids were thought to be specific for Staphylococcaceae; hence, their isotopic enrichment was interpreted as a growth proxy for Staphylococcus aureus Our experiments revealed, however, that Prevotella is also a relevant microbial producer of a-C17:0 fatty acid in some CF patients; thus, deuterium incorporation into these lipids is better interpreted as a more general pathogen growth rate proxy. Even accounting for a small nonmicrobial background source detected in some patient samples, a-C15:0 fatty acid still appears to be a relatively robust proxy for CF pathogens, revealing a median generation time of ∼1.5 days, similar to prior observations. Contrary to our expectation, pathogen growth rates remained relatively stable throughout exacerbation treatment. We suggest two straightforward "best practices" for application of stable-isotope probing to CF sputum metabolites: (i) parallel determination of microbial community composition in CF sputum using culture-independent tools and (ii) assessing background levels of the diagnostic metabolite.IMPORTANCE In chronic lung infections, populations of microbial pathogens change and mature in ways that are often unknown, which makes it challenging to identify appropriate treatment options. A promising tool to better understand the physiology of microorganisms in a patient is stable-isotope probing, which we previously developed to estimate the growth rates of S. aureus in cystic fibrosis (CF) sputum. Here, we tracked microbial communities in a cohort of CF patients and found that anteiso fatty acids can also originate from other sources in CF sputum. This awareness led us to develop a new workflow for the application of stable-isotope probing in this context, improving our ability to estimate pathogen generation times in clinical samples.
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40
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Akil N, Muhlebach MS. Biology and management of methicillin resistant Staphylococcus aureus in cystic fibrosis. Pediatr Pulmonol 2018; 53:S64-S74. [PMID: 30073802 DOI: 10.1002/ppul.24139] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/20/2018] [Indexed: 02/06/2023]
Abstract
Staphylococcus aureus is one of the earliest bacteria isolated from the respiratory tract in people with cystic fibrosis (CF). Its methicillin resistant form, MRSA, has gained attention due to the rapid increase in the last decades and worse outcomes with chronic infection. In the United States, prevalence of MRSA in CF is around 27%, but is much lower (3-18%) in most other countries. Methicillin is typically genetically encoded by the mecA gene, which encodes for an alternative penicillin binding protein (PRBa). This PRBa has low affinity to β-lactams, thereby enabling growth of S. aureus in the presence of penicillinase resistant penicillins and most other β-lactams. Non-mecA positive strains of MRSA, so-called borderline resistant (BORSA) have also been described. In addition to production of toxins, the virulence of S. aureus is conferred by its adaptability allowing persistence in face of antibiotic therapies and host defense. These adaptive growth mechanisms include small colony variants, biofilms, and growth under anaerobic conditions. Several reports have described successful eradication of MRSA, yet only two randomized trials of eradication during early infection have been conducted. A list of MRSA specific antibiotics with dosing relevant to CF patients is presented here. Many of these require special dosing in people with CF. Novel antibiotics are in trials for skin and soft tissue infections and it is unclear if and when those might be available for lung infections. Thus the best strategies for MRSA would be primary prevention.
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Affiliation(s)
- Nour Akil
- Division of Pulmonology, Department of Pediatrics, University of NC at Chapel Hill, Chapel Hill, North Carolina
| | - Marianne S Muhlebach
- Division of Pulmonology, Department of Pediatrics, University of NC at Chapel Hill, Chapel Hill, North Carolina.,Marisco Lung Institute, University of NC at Chapel Hill, Chapel Hill, North Carolina
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41
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Stockmann C, Olson J, Rashid J, Lubsch L, Young DC, Hersh AL, Frymoyer A, Ampofo K, Liu X, Wang Y, Sherwin CMT, Zobell JT. An Evaluation of Vancomycin Area Under the Curve Estimation Methods for Children Treated for Acute Pulmonary Exacerbations of Cystic Fibrosis Due to Methicillin-Resistant Staphylococcus aureus. J Clin Pharmacol 2018; 59:198-205. [PMID: 30371946 DOI: 10.1002/jcph.1323] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 09/14/2018] [Indexed: 11/12/2022]
Abstract
The prevalence of pulmonary methicillin-resistant Staphylococcus aureus infections in patients with cystic fibrosis (CF) has increased over the last 2 decades. Two concentrations-a postdistributive and a trough-are currently used to estimate the area under the curve (AUC) of vancomycin, an antibiotic routinely used to treat these infections, to achieve the target AUC/minimum inhibitory concentration of ≥400 mg·h/L in ensuring optimal dosing of this drug. This study evaluated precision and bias in estimating vancomycin AUCs obtained either from a population pharmacokinetic (PK) model by using a single trough concentration or from standard PK equation-based 2-point monitoring approach. AUCs were either obtained from a single trough concentration-fitted model or derived from a model fitted by 2 concentration points. Children ≥2 years of age with CF received intravenous vancomycin at 2 centers from June 2012 to December 2014. A population PK model was developed in Pmetrics to quantify the between-subject variability in vancomycin PK parameters, define the sources of PK variability, and leverage information from the population to improve individual AUC estimates. Twenty-three children with CF received 27 courses of vancomycin. The median age was 12.3 (interquartile range [IQR] 8.5-16.6) years. From the individual vancomycin PK parameter estimates from the population PK model, median AUC was 622 (IQR 529-680) mg·h/L. Values were not significantly different from the AUC calculated using the standard PK equation-based approach (median 616 [IQR 540-663] mg·h/L) (P = .89). A standard PK equation-based approach using 2 concentrations and a population PK model-based approach using a single trough concentration yielded unbiased and precise AUC estimates. Findings suggest that options exist to implement AUC-based pediatric vancomycin dosing in patients with CF. The findings of this study reveal that several excellent options exist for centers to implement AUC-based pediatric vancomycin dosing for patients with CF.
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Affiliation(s)
- Chris Stockmann
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA.,University of Utah College of Pharmacy, Salt Lake City, UT, USA.,Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jared Olson
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA.,Department of Pharmacy, Intermountain Primary Children's Hospital, Salt Lake City, UT, USA
| | - Jahidur Rashid
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Lisa Lubsch
- School of Pharmacy, Southern Illinois University Edwardsville, Edwardsville, IL, USA
| | - David C Young
- University of Utah College of Pharmacy, Salt Lake City, UT, USA.,University of Utah Adult Cystic Fibrosis Center, Salt Lake City, UT, USA
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Adam Frymoyer
- Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Krow Ampofo
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Xiaoxi Liu
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Yuhuan Wang
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Catherine M T Sherwin
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA.,University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Jeffery T Zobell
- University of Utah College of Pharmacy, Salt Lake City, UT, USA.,Department of Pharmacy, Intermountain Primary Children's Hospital, Salt Lake City, UT, USA.,Intermountain Cystic Fibrosis Pediatric Center, Salt Lake City, UT, USA
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Lo DKH, Muhlebach MS, Smyth AR. Interventions for the eradication of meticillin-resistant Staphylococcus aureus (MRSA) in people with cystic fibrosis. Cochrane Database Syst Rev 2018; 7:CD009650. [PMID: 30030966 PMCID: PMC6513544 DOI: 10.1002/14651858.cd009650.pub4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cystic fibrosis is an inherited recessive disorder of chloride transport that is characterised by recurrent and persistent pulmonary infections from resistant organisms that result in lung function deterioration and early mortality in sufferers.Meticillin-resistant Staphylococcus aureus (MRSA) has emerged as, not only an important infection in people who are hospitalised, but also as a potentially harmful pathogen in cystic fibrosis. Chronic pulmonary infection with MRSA is thought to confer people with cystic fibrosis with a worse clinical outcome and result in an increased rate of lung function decline. Clear guidance for MRSA eradication in cystic fibrosis, supported by robust evidence, is urgently needed. This is an update of a previous review. OBJECTIVES To evaluate the effectiveness of treatment regimens designed to eradicate MRSA and to determine whether the eradication of MRSA confers better clinical and microbiological outcomes for people with cystic fibrosis. To ascertain whether attempts at eradicating MRSA can lead to increased acquisition of other resistant organisms (including P aeruginosa) or increased adverse effects from drugs, or both. SEARCH METHODS Randomised and quasi-randomised controlled trials were identified by searching the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register, PubMed, MEDLINE, clinical trial registries (Clinicaltrials.gov, WHO ICTRP, ISRCTN Registry), handsearching article reference lists and through contact with experts in the field.Date of the last search of the Group's Cystic Fibrosis Trials Register: 27 July 2017.Ongoing trials registries were last searched: 07 August 2017. SELECTION CRITERIA Randomised or quasi-randomised controlled trials comparing any combinations of topical, inhaled, oral or intravenous antimicrobials with the primary aim of eradicating MRSA compared with placebo, standard treatment or no treatment. DATA COLLECTION AND ANALYSIS The authors independently assessed all search results for eligibility. They used the GRADE methodology to assess the quality of the evidence. MAIN RESULTS The review includes two trials with a total of 106 participants with MRSA infection. In both trials the active treatment was oral trimethoprim and sulfamethoxazole combined with rifampicin; however, one trial administered this combination for two weeks alongside nasal, skin and oral decontamination and a three-week environmental decontamination, while the second trial administered this drug combination for 21 days with five days intranasal mupirocin. In both trials the control arm was observation only.Both trials reported successful eradication of MRSA in people with CF as an outcome; however, the definition used for MRSA eradication differed. The first trial (n = 45) defined MRSA eradication as negative MRSA respiratory cultures at day 28, and reported that, when compared to control, oral trimethoprim and sulfamethoxazole combined with rifampicin may lead to a higher proportion of negative cultures, odds ratio (OR) 12.6 (95% confidence interval (CI) 2.84 to 55.84; low-certainty evidence); however, by day 168 of follow-up there was no difference in the proportion of participants who remained MRSA-negative in either treatment arm, OR 1.17 (95% CI 0.31 to 4.42) (low-quality evidence). In the second trial, successful eradication was defined as the absence of MRSA following treatment (oral co-trimoxazole and rifampicin with intranasal mupirocin or observation) in at least three cultures over a period of six months. At the time of reporting, 40 out of 61 participants had completed follow-up, but results showed no difference between groups. Eradication was achieved in 12 out 29 participants (41%) receiving active treatment, and in 9 out of 32 participants (28%) on the observation arm, OR 1.80 (95% CI 0.62 to 5.25) (very low-quality evidence).With regards to this review's secondary outcomes, these were reported in the first trial only. The trial reports that no differences were observed between the two arms in terms of pulmonary exacerbations (from screening to day 28), nasal colonisation, lung function, weight or participant-reported outcomes. While not a specific outcome of this review, investigators reported that the rate of hospitalisation from screening through day 168 was lower with oral trimethoprim and sulfamethoxazole combined with rifampicin compared to control, rate ratio 0.22 (95% CI 0.05 to 0.72) (P = 0.0102). AUTHORS' CONCLUSIONS Early eradication of MRSA is possible in people with cystic fibrosis, with one trial demonstrating superiority of active MRSA treatment compared with observation only in terms of the proportion of MRSA-negative respiratory cultures at day 28. However, by six months, the proportion of participants who remained MRSA-negative did not differ between treatment arms in either trial. Moreover, the longer-term clinical consequences in terms of lung function, mortality and cost of care, remain unclear.Using GRADE methodology, we judged the quality of the evidence provided by this review to be very low to low, due to potential biases from the open-label design and unclear detail reported in one trial. Based on the available evidence, it is the opinion of the authors that whilst early eradication of respiratory MRSA in people with cystic fibrosis is possible, there is not currently enough evidence regarding the clinical outcomes of eradication to support the use of the interventions studied.
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Affiliation(s)
- David KH Lo
- Leicester Royal InfirmaryWard 12Infirmary SquareLeicesterUKLE1 5WW
| | - Marianne S Muhlebach
- University of North CarolinaDepartment of Pediatrics, Division of Pulmonary Medicine5 Bioinformatics, CB 7217Chapel HillNorth CarolinaUSANC 27514
| | - Alan R Smyth
- School of Medicine, University of NottinghamDivision of Child Health, Obstetrics & Gynaecology (COG)Queens Medical CentreDerby RoadNottinghamUKNG7 2UH
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Abstract
The number of published articles on Cystic Fibrosis (CF) continues to increase year on year. The evidence base for small molecule therapies in CF has continued to expand, with evidence for lumacaftor/ivacaftor in younger patients and longer-term evidence in adults, and pivotal studies on tezacaftor/ivacaftor. There were reports on emerging CFTR mutation agnostic therapies, and new evidence for long standing therapies.
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Affiliation(s)
- Iolo Doull
- Department of Paediatric Respiratory Medicine and Paediatric Cystic Fibrosis Centre, Children's Hospital for Wales, Cardiff CF14 4XN, UK.
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Kiefer A, Bogdan C, Melichar VO. Successful eradication of newly acquired MRSA in six of seven patients with cystic fibrosis applying a short-term local and systemic antibiotic scheme. BMC Pulm Med 2018; 18:20. [PMID: 29370836 PMCID: PMC5785857 DOI: 10.1186/s12890-018-0588-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 01/15/2018] [Indexed: 11/20/2022] Open
Abstract
Background In individuals with cystic fibrosis (CF), colonization with methicillin-resistant Staphylococcus aureus (MRSA) was reported to be associated with a deterioration of pulmonary disease as reflected by an accelerated decline in lung function. Thus, an early eradication of MRSA could be beneficial in these patients. Here, we report on an intensified MRSA eradication protocol. Methods Since 2012 a protocol for the eradication of newly acquired MRSA has been used in our CF Clinic, combining oral rifampicin and fusidic acid, inhaled vancomycin, nasal mupirocin, local antiseptic treatment and hygienic directives all of which are applied for only 7 days during an inpatient hospital stay. Results Since 2012 seven patients (3 male, 4 female; age range 4 to 30 years) newly acquired MRSA. In 6 of the 7 patients (86%) successful eradication of MRSA was achieved upon first treatment using the protocol described above. In one patient a second course of treatment was performed which, however, also failed to eliminate the colonizing MRSA. Conclusions Our protocol led to an eradication rate of 86%. The impact of each individual component of the protocol remains to be determined.
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Affiliation(s)
- Alexander Kiefer
- Department of Pediatrics and Adolescent Medicine, Clinic for Cystic Fibrosis, Universitätsklinikum Erlangen, Loschgestraße 15, 91054, Erlangen, Germany.
| | - Christian Bogdan
- Microbiology Institute - Clinical Microbiology, Immunology and Hygiene, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Wasserturmstraße 3/5, 91054, Erlangen, Germany
| | - Volker O Melichar
- Department of Pediatrics and Adolescent Medicine, Clinic for Cystic Fibrosis, Universitätsklinikum Erlangen, Loschgestraße 15, 91054, Erlangen, Germany
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45
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Lung transplantation in cystic fibrosis patients with difficult to treat lung infections. Curr Opin Pulm Med 2017; 23:574-579. [DOI: 10.1097/mcp.0000000000000431] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Cohen RWF, Folescu TW, Daltro P, Boechat MCB, Lima DF, Marques EA, Leão RS. Methicillin-resistant Staphylococcus aureus in cystic fibrosis patients: do we need to care? A cohort study. SAO PAULO MED J 2017; 135:420-427. [PMID: 28832807 PMCID: PMC10027246 DOI: 10.1590/1516-3180.2016.0350240317] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 03/24/2017] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE The prevalence of a variety of potentially pathogenic microorganisms in cystic fibrosis patients, such as methicillin-resistant Staphylococcus aureus (MRSA), has increased over the past decade. Given the increasing prevalence of MRSA and the few data available in the literature, better understanding of the clinical repercussions of colonization by this bacterium in cystic fibrosis patients becomes essential. This study aimed to evaluate the repercussions of chronic colonization by MRSA in cystic fibrosis patients. DESIGN AND SETTING Retrospective cohort study from January 2004 to December 2013 in a cystic fibrosis reference center. METHODS Each patient with cystic fibrosis was evaluated for nutritional status (body mass index, BMI, and BMI percentile), pulmonary function and tomographic abnormalities (modified Bhalla scores) at the time of chronic colonization by MRSA or methicillin-susceptible Staphylococcus aureus (MSSA) and throughout the study period. RESULTS Twenty pairs of patients were included. There were no significant differences between the groups regarding nutritional characteristics. Spirometric data showed a trend towards greater obstruction of the airways in patients with MRSA. Patients with MRSA presented greater structural damage to their lungs, demonstrated not only by the total Bhalla score but also by its parameters individually. CONCLUSIONS Patients colonized by MRSA presented greater functional and structural respiratory impairment at the time of chronic colonization. Disease progression was also faster in patients chronically colonized by MRSA than in those with MSSA. This was shown through comparisons that avoided possible confounding variables.
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Affiliation(s)
- Renata Wrobel Folescu Cohen
- Assistant Professor of Pediatrics, School of Medical Sciences, Universidade do Estado do Rio de Janeiro (UERJ), and Pediatric Pulmonologist, Instituto Nacional de Saúde da Mulher da Criança e do Adolescente Fernandes Figueira, Fundação Instituto Oswaldo Cruz (IFF/Fiocruz), Rio de Janeiro (RJ), Brazil.
| | - Tânia Wrobel Folescu
- Head of Pediatric Pulmonology, Instituto Nacional de Saúde da Mulher da Criança e do Adolescente Fernandes Figueira, Fundação Instituto Oswaldo Cruz (IFF/Fiocruz), Rio de Janeiro (RJ), Brazil.
| | - Pedro Daltro
- Radiologist, Instituto Nacional de Saúde da Mulher da Criança e do Adolescente Fernandes Figueira, Fundação Instituto Oswaldo Cruz (IFF/Fiocruz), Rio de Janeiro (RJ), Brazil.
| | - Marcia Cristina Bastos Boechat
- Head of Radiology, Instituto Nacional de Saúde da Mulher da Criança e do Adolescente Fernandes Figueira, Fundação Instituto Oswaldo Cruz (IFF/Fiocruz), Rio de Janeiro (RJ), Brazil.
| | - Danielle Ferreira Lima
- Fellow, Department of Microbiology, Immunology and Parasitology, School of Medical Sciences, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro (RJ), Brazil.
| | - Elizabeth Andrade Marques
- Professor, Department of Microbiology, Immunology and Parasitology, School of Medical Sciences, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro (RJ), Brazil.
| | - Robson Souza Leão
- Professor, Department of Microbiology, Immunology and Parasitology, School of Medical Sciences, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro (RJ), Brazil.
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Fusco NM, Francisconi R, Meaney CJ, Duman D, Frederick CA, Prescott WA. Association of Vancomycin Trough Concentration With Response to Treatment for Acute Pulmonary Exacerbation of Cystic Fibrosis. J Pediatric Infect Dis Soc 2017; 6:e103-e108. [PMID: 28903517 DOI: 10.1093/jpids/pix043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 05/11/2017] [Indexed: 11/14/2022]
Abstract
BACKGROUND Our goal was to determine the relationship between serum vancomycin trough concentrations (VTCs) and changes in pulmonary function among individuals with an acute pulmonary exacerbation (APE) of cystic fibrosis (CF). METHODS We included subjects who were ≥6 years of age, were hospitalized for an APE of CF between May 1, 2012, and April 30, 2014, were administered vancomycin for ≥48 hours, and had a history of airway infection with methicillin-resistant Staphylococcus aureus. Pearson correlations were performed to characterize the relationship between VTC and pulmonary function. RESULTS The mean final VTC (± standard deviation) was 12.6 ± 3.3 µg/mL; 40 (81.6%) of 49 final VTCs were in the range of 10 to <15 µg/mL. The mean change in forced expiratory volume in 1 second (FEV1) between admission and discharge was 24.5% ± 24.4% (P < .001) of predicted values. Forty-two (85.7%) patients returned to their baseline FEV1. No correlation between the change in FEV1 and VTC (Pearson r = -0.10; P = .49) was identified. Similarly, VTC, daily weight-adjusted vancomycin dose, and vancomycin area under the concentration-time curve normalized to the minimum inhibitory concentration (AUC/MIC) were not significant predictors of change in FEV1 or return to baseline FEV1 on multivariate analysis. One (2%) subject experienced acute kidney injury. CONCLUSIONS The majority of patients experienced improvement in pulmonary function and a return to their baseline FEV1 while achieving a VTC in the range of 10 to <15 µg/mL. We were unable to identify a correlation between markers of vancomycin exposure and change in pulmonary function test results. Additional studies are needed to reinforce the efficacy of VTCs of 10 to 15 µg/mL for treating APEs of CF.
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Affiliation(s)
- Nicholas M Fusco
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, New York
| | | | - Calvin J Meaney
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, New York
| | - Desiree Duman
- Department of Pharmacy, Women and Children's Hospital of Buffalo, New York
| | - Carla A Frederick
- Pulmonary and Critical Care Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - William A Prescott
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, New York
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Ankrum A, Hall BG. Population Dynamics of Staphylococcus aureus in Cystic Fibrosis Patients To Determine Transmission Events by Use of Whole-Genome Sequencing. J Clin Microbiol 2017; 55:2143-2152. [PMID: 28446577 PMCID: PMC5483916 DOI: 10.1128/jcm.00164-17] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 04/21/2017] [Indexed: 01/14/2023] Open
Abstract
Strict infection control practices have been implemented for health care visits by cystic fibrosis (CF) patients in an attempt to prevent transmission of important pathogens. This study used whole-genome sequencing (WGS) to determine strain relatedness and assess population dynamics of Staphylococcus aureus isolates from a cohort of CF patients as assessed by strain relatedness. A total of 311 S. aureus isolates were collected from respiratory cultures of 115 CF patients during a 22-month study period. Whole-genome sequencing was performed, and using single nucleotide polymorphism (SNP) analysis, phylogenetic trees were assembled to determine relatedness between isolates. Methicillin-resistant Staphylococcus aureus (MRSA) phenotypes were predicted using PPFS2 and compared to the observed phenotype. The accumulation of SNPs in multiple isolates obtained over time from the same patient was examined to determine if a genomic molecular clock could be calculated. Pairs of isolates with ≤71 SNP differences were considered to be the "same" strain. All of the "same" strain isolates were either from the same patient or siblings pairs. There were 47 examples of patients being superinfected with an unrelated strain. The predicted MRSA phenotype was accurate in all but three isolates. Mutation rates were unable to be determined because the branching order in the phylogenetic tree was inconsistent with the order of isolation. The observation that transmissions were identified between sibling patients shows that WGS is an effective tool for determining transmission between patients. The observation that transmission only occurred between siblings suggests that Staphylococcus aureus acquisition in our CF population occurred outside the hospital environment and indicates that current infection prevention efforts appear effective.
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Affiliation(s)
- Andrea Ankrum
- Department of Infection Prevention and Control, Infectious Diseases Division, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Barry G Hall
- Bellingham Research Institute, Portland, Oregon, USA
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Psoter KJ, De Roos AJ, Wakefield J, Mayer JD, Rosenfeld M. Seasonality of acquisition of respiratory bacterial pathogens in young children with cystic fibrosis. BMC Infect Dis 2017; 17:411. [PMID: 28599639 PMCID: PMC5466772 DOI: 10.1186/s12879-017-2511-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 06/01/2017] [Indexed: 12/30/2022] Open
Abstract
Background Seasonal variations are often observed for respiratory tract infections; however, limited information is available regarding seasonal patterns of acquisition of common cystic fibrosis (CF)-related respiratory pathogens. We previously reported differential seasonal acquisition of Pseudomonas aeruginosa in young children with CF and no such variation for methicillin-susceptible Staphylococcus aureus acquisition. The purpose of this study was to describe and compare the seasonal incidence of acquisition of other respiratory bacterial pathogens in young children with CF. Methods We conducted a retrospective study to describe and compare the seasonal incidence of methicillin-resistant Staphylococcus aureus (MRSA), Stenotrophomonas maltophilia, Achromobacter xylosoxidans, and Haemophilus influenzae acquisition in young CF patients residing in the U.S. using the Cystic Fibrosis Foundation National Patient Registry, 2003-2009. Log-linear overdispersed Poisson regression was used to evaluate seasonal acquisition of each of these pathogens. Results A total of 4552 children met inclusion criteria. During follow-up 910 (20%), 1161 (26%), 228 (5%), and 2148 (47%) children acquired MRSA, S. maltophilia, A. xylosoxidans and H. influenzae, respectively. Compared to winter season, MRSA was less frequently acquired in spring (Incidence Rate Ratio [IRR]: 0.79; 95% Confidence Interval [CI]: 0.65, 0.96) and summer (IRR: 0.69; 95% CI: 0.57, 0.84) seasons. Similarly, a lower rate of A. xylosoxidans acquisition was observed in spring (IRR: 0.59; 95% CI: 0.39, 0.89). For H. influenzae, summer (IRR: 0.88; 95% CI: 0.78, 0.99) and autumn (IRR: 0.78; 95% CI: 0.69, 0.88) seasons were associated with lower acquisition rates compared to winter. No seasonal variation was observed for S. maltophilia acquisition. Conclusion Acquisition of CF-related respiratory pathogens displays seasonal variation in young children with CF, with the highest rate of acquisition for most pathogens occurring in the winter. Investigation of factors underlying these observed associations may contribute to our understanding of the aetiology of these infections and guide future infection control strategies. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2511-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kevin J Psoter
- Department of Pediatrics, School of Medicine, The Johns Hopkins University Bayview Medical Center, 5200 Eastern Ave, Mason F. Lord Bldg, Suite 4200, Baltimore, MD, 21224, USA.
| | - Anneclaire J De Roos
- Department of Environmental and Occupational Health, Drexel University School of Public Health, Philadelphia, PA, USA
| | - Jon Wakefield
- Departments of Biostatistics and Statistics, University of Washington, Seattle, WA, USA
| | - Jonathan D Mayer
- Departments of Epidemiology, Geography, Global Health, Medicine (Allergy and Infectious Diseases), Family Medicine, and Health Services, University of Washington, Seattle, WA, USA
| | - Margaret Rosenfeld
- Division of Pulmonary Medicine, University of Washington School of Medicine, Seattle, WA, USA.,Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
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