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Jarzynka S, Makarewicz O, Weiss D, Minkiewicz-Zochniak A, Iwańska A, Skorupa W, Padzik M, Augustynowicz-Kopeć E, Olędzka G. The Impact of Pseudomonas aeruginosa Infection in Adult Cystic Fibrosis Patients-A Single Polish Centre Study. Pathogens 2023; 12:1440. [PMID: 38133323 PMCID: PMC10748198 DOI: 10.3390/pathogens12121440] [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: 11/15/2023] [Revised: 12/06/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Pseudomonas aeruginosa (PA) is one of the most predominant pathogens of lung infections, often causing exacerbations in adult patients with cystic fibrosis (CF). MATERIALS AND METHODS Microbiological characterization of 74 PA isolates and to evaluate the correlations between the bacterial features and 44 adult Polish CF cohort clinical parameters. RESULTS The most common variant in the CF transmembrane conductance regulator (CFTR) gene was F508del (76.3%), followed by 3849+10kbC>T (26.3%). A total of 39.4% of the PA isolates showed multiple resistances. In patients with parameters pointing to a decline in lung function, there was a statistically significant moderate correlation with β-lactam resistance and a weak correlation between hospital frequency and colistin resistance. The mucoidity did not correlate with the biofilm formation ability, which showed 41.9% of the isolates. Proteolytic activity, observed in 60.8% of the clinical isolates, was weakly associated with motility detected in 78.4% of the strains. The genetic profiles of the PA were highly heterogeneous, and a weak positive correlation was established between cluster group and biofilm formation. CONCLUSION The findings suggest that there is a high variety in P. aeruginosa populations in adult CF patients. There is a need to monitor PA strains in groups of patients with cystic fibrosis, in particular, in terms of the occurrence of antibiotic resistance related to a decline in lung function.
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Affiliation(s)
- Sylwia Jarzynka
- Department of Medical Biology, Medical University of Warsaw, Litewska 14/16, 00-575 Warsaw, Poland; (A.M.-Z.); (M.P.); (G.O.)
| | - Oliwia Makarewicz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, 07747 Jena, Germany; (O.M.); (D.W.)
| | - Daniel Weiss
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, 07747 Jena, Germany; (O.M.); (D.W.)
| | - Anna Minkiewicz-Zochniak
- Department of Medical Biology, Medical University of Warsaw, Litewska 14/16, 00-575 Warsaw, Poland; (A.M.-Z.); (M.P.); (G.O.)
| | - Agnieszka Iwańska
- Department of Microbiology, National Institute of Tuberculosis and Lung Diseases, Plocka 26, 01-138 Warsaw, Poland; (A.I.); (E.A.-K.)
| | - Wojciech Skorupa
- First Department of Lung Diseases, National Institute of Tuberculosis and Lung Diseases, Plocka 26, 01-138 Warsaw, Poland;
| | - Marcin Padzik
- Department of Medical Biology, Medical University of Warsaw, Litewska 14/16, 00-575 Warsaw, Poland; (A.M.-Z.); (M.P.); (G.O.)
| | - Ewa Augustynowicz-Kopeć
- Department of Microbiology, National Institute of Tuberculosis and Lung Diseases, Plocka 26, 01-138 Warsaw, Poland; (A.I.); (E.A.-K.)
| | - Gabriela Olędzka
- Department of Medical Biology, Medical University of Warsaw, Litewska 14/16, 00-575 Warsaw, Poland; (A.M.-Z.); (M.P.); (G.O.)
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Dadgostar A, Nassiri S, Quon BS, Manji J, Alsalihi S, Javer A. Effect of endoscopic sinus surgery on clinical outcomes in DeltaF508 cystic fibrosis patients. Clin Otolaryngol 2021; 46:941-947. [PMID: 33686728 DOI: 10.1111/coa.13751] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 01/22/2021] [Accepted: 02/07/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Chronic rhinosinusitis (CRS) is prevalent in the Cystic Fibrosis (CF) population. CRS exacerbations in CF are thought to contribute to pulmonary exacerbations. Literature regarding the impact of endoscopic sinus surgery (ESS) is inconclusive. This study examines rates of lung function decline and pulmonary exacerbation in CF patients who have undergone ESS. DESIGN Retrospective review of medical records. SETTING Academic Hospital. PARTICIPANTS 40 adult CF patients. MAIN OUTCOME MEASURES Rate of lung function decline (% predicted Forced Expiratory Volume in 1 second [ppFEV1 ]), number of pulmonary exacerbations (IV/oral antibiotic therapy ± hospital admission) and total number days hospitalised 2-year postoperatively was collected. CRS patients undergoing ESS were matched to those without ESS by gender, age, and F508del genotype. RESULTS Forty patients (mean age 37.4, 60% male) were reviewed. No significant difference was found between the surgical group and controls in baseline ppFEV1 (72.5% vs. 72.7%, P = .98), 2-year preoperative number of pulmonary exacerbations (3.05 vs. 1.65, P = .10), or Lund-Mackay scores (12.25 vs. 11.55, P = .71). No significant difference was found in 1-year (70.5% vs. 72.8%, P = .84) or 2-year (70.4% vs. 72.6% P = .80) postoperative ppFEV1 and 2-year postoperative pulmonary exacerbations (1.7 vs. 1.45, P = .87). A significant increase was identified in total number days hospitalised postoperatively (4.85, P = .02). In the surgical group, no significant difference was identified between preoperative and postoperative ppFEV1 , 1 year (-2.51%, P = .32) and 2 years after ESS (-3.10%, P = .51), postoperative rate of pulmonary exacerbations (-1.28, P = .11), or in total number days hospitalised (3.74, P = .14). CONCLUSIONS In this study, ESS does not appear to significantly improve ppFEV1 or decrease the number of pulmonary exacerbations postoperatively.
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Affiliation(s)
- Anali Dadgostar
- St. Paul's Sinus Centre, Division of Otolaryngology, University of British Columbia, Vancouver, BC, Canada
| | - Sepehr Nassiri
- St. Paul's Sinus Centre, Division of Otolaryngology, University of British Columbia, Vancouver, BC, Canada
| | - Bradley S Quon
- Adult Cystic Fibrosis Clinic, University of British Columbia, Vancouver, BC, Canada
| | - Jamil Manji
- St. Paul's Sinus Centre, Division of Otolaryngology, University of British Columbia, Vancouver, BC, Canada.,Faculty of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Salahuddin Alsalihi
- St. Paul's Sinus Centre, Division of Otolaryngology, University of British Columbia, Vancouver, BC, Canada
| | - Amin Javer
- St. Paul's Sinus Centre, Division of Otolaryngology, University of British Columbia, Vancouver, BC, Canada
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Zemke AC, Nouraie SM, Moore J, Gaston JR, Rowan NR, Pilewski JM, Bomberger JM, Lee SE. Clinical predictors of cystic fibrosis chronic rhinosinusitis severity. Int Forum Allergy Rhinol 2019; 9:759-765. [PMID: 31162888 DOI: 10.1002/alr.22332] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/05/2019] [Accepted: 02/24/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic rhinosinusitis (CRS) is a significant manifestation of cystic fibrosis (CF) with wide-ranging symptom and disease severity. The goal of the study was to determine clinical variables that correlate with outcome measures of disease severity. METHODS A prospective, longitudinal, observational study of 33 adults with symptomatic CRS treated in a CF-focused otolaryngology clinic was performed. Symptom severity, the presence of rhinosinusitis exacerbations, and endoscopic appearance were assessed, and regression analysis was used to determine clinical predictors of disease outcome. RESULTS Thirty-three adults with CF-CRS were included in the study and followed for a mean of 15 months. Rhinosinusitis exacerbations occurred in 61% of participants during the study, and female sex increased the odds of presenting with an exacerbation visit. Sinus disease exacerbations were associated with an odds ratio of 2.07 for presenting with a pulmonary exacerbation at the next visit. CF-related diabetes was found to be associated with worse symptoms and endoscopic appearance. Infection with Staphylococcus aureus predicted worsening of symptoms, whereas infections with Pseudomonas aeruginosa improved over time. Allergic rhinitis was associated with worse endoscopic appearance, and nasal steroid use was associated with improved endoscopic appearance. CONCLUSION Sex, CF-related diabetes, sinonasal infection status, allergic rhinitis, and nasal steroid use may all modulate severity of CF-CRS in adults. Sinusitis exacerbation may be a precursor to pulmonary exacerbation.
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Affiliation(s)
- Anna C Zemke
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Seyed Mehdi Nouraie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - John Moore
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Jordan R Gaston
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, PA
| | - Nicholas R Rowan
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Joseph M Pilewski
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Jennifer M Bomberger
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, PA
| | - Stella E Lee
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, PA
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Lazio MS, Luparello P, Mannelli G, Santoro GP, Bresci S, Braggion C, Gallo O, Maggiore G. Quality of Life and Impact of Endoscopic Sinus Surgery in Adult Patients With Cystic Fibrosis. Am J Rhinol Allergy 2019; 33:413-419. [DOI: 10.1177/1945892419839260] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Cystic fibrosis (CF) is the most common autosomal recessive disease in Caucasian population. Due to its pathological mechanism, chronic rhino sinusitis (CRS) associated or not with nasal polyposis usually occurs in adults and affects close to one-half of all CF patients. The goal of our work was to evaluate the impact of endoscopic sinus surgery (ESS) in the quality of life (QoL) of the CF patients and demonstrate an improvement of the functional outcomes in the patients undergoing the surgical procedure rather than in the not treated ones. Methodology: We studied 54 adult patients affected by CF. Lund–Kennedy, Lund–Mackay scores, and Sino-Nasal Outcome Test-22 (SNOT-22) were analyzed. Results Twenty-two (40.7%) of the 54 CF patients underwent ESS. This group presented more likely complaints consistent with CRS. Lund–Kennedy and Lund–Mackay scores appeared higher in the ESS group: 10 (range of 6–12) and 16 (range of 12–20), respectively. SNOT-22 showed median values for non-ESS and ESS group of 17.5 (range of 3–68) and 44 (range of 10–73), respectively. Conclusions ESS represents the best option to improve clinical QoL of CF patients who do not response to conventional medical therapy.
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Affiliation(s)
- Maria S. Lazio
- Clinic of Otolaryngology, Head and Neck Surgery, Department of Surgery and Translational Medicine, Careggi University Hospital, Florence, Italy
| | - Paolo Luparello
- Clinic of Otolaryngology, Head and Neck Surgery, Department of Surgery and Translational Medicine, Careggi University Hospital, Florence, Italy
| | - Giuditta Mannelli
- Clinic of Otolaryngology, Head and Neck Surgery, Department of Surgery and Translational Medicine, Careggi University Hospital, Florence, Italy
| | - Giovanni P. Santoro
- Clinic of Otolaryngology, Head and Neck Surgery, Department of Surgery and Translational Medicine, Careggi University Hospital, Florence, Italy
| | - Silvia Bresci
- Department of Infectious Disease, Careggi University and Hospital, Florence, Italy
| | | | - Oreste Gallo
- Clinic of Otolaryngology, Head and Neck Surgery, Department of Surgery and Translational Medicine, Careggi University Hospital, Florence, Italy
| | - Giandomenico Maggiore
- Clinic of Otolaryngology, Head and Neck Surgery, Department of Surgery and Translational Medicine, Careggi University Hospital, Florence, Italy
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Mauch RM, Rossi CL, Nolasco da Silva MT, Bianchi Aiello T, Ribeiro JD, Ribeiro AF, Høiby N, Levy CE. Secretory IgA-mediated immune response in saliva and early detection of Pseudomonas aeruginosa in the lower airways of pediatric cystic fibrosis patients. Med Microbiol Immunol 2019; 208:205-213. [PMID: 30706137 DOI: 10.1007/s00430-019-00578-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 01/08/2019] [Indexed: 12/14/2022]
Abstract
Pseudomonas aeruginosa (Pa) detection in the paranasal sinuses may help to prevent or postpone bacterial aspiration to the lower airways (LAW) and chronic lung infection in cystic fibrosis (CF). We assessed the ability of an ELISA test for measurement of specific Pa secretory IgA (sIgA) in saliva (a potential marker of sinus colonization) to early detect changes in the Pa LAW status (indicated by microbiological sputum or cough swab culture and specific serum IgG levels) of 65 patients for three years, in different investigation scenarios. Increased sIgA levels were detected in saliva up to 22 months before changes in culture/serology. Patients who remained Pa-positive had significantly increased sIgA levels than patients who remained Pa-negative, both at the baseline (39.6 U/mL vs. 19.2 U/mL; p = 0.02) and at the end of the follow-up (119.4 U/mL vs. 25.2 U/mL; p < 0.001). No association was found between sIgA levels in saliva and emergence or recurrence of Pa in the LAW. A positive median sIgA result in the first year of follow-up implied up to 12.5-fold increased risk of subsequent Pa exposure in the LAW. Our test detected early changes in the P. aeruginosa LAW status and risk of exposure to P. aeruginosa in the LAW with two years in advance. Comparison with sinus culture is needed to assess the test's ability to identify CF patients in need of a sinus approach for Pa investigation, which could provide opportunities of Pa eradication before its aspiration to the lungs.
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Affiliation(s)
- Renan Marrichi Mauch
- Department of Clinical Pathology, School of Medical Sciences, University of Campinas, Rua Vital Brasil 251, 2nd floor, Cidade Universitária, Barão Geraldo, Campinas, SP, 13083-888, Brazil.,Center for Investigation in Pediatrics, School of Medical Sciences, University of Campinas, Rua Tessália Vieira de Camargo 126, Campinas, SP, 13083-887, Brazil
| | - Claudio Lucio Rossi
- Department of Clinical Pathology, School of Medical Sciences, University of Campinas, Rua Vital Brasil 251, 2nd floor, Cidade Universitária, Barão Geraldo, Campinas, SP, 13083-888, Brazil
| | - Marcos Tadeu Nolasco da Silva
- Center for Investigation in Pediatrics, School of Medical Sciences, University of Campinas, Rua Tessália Vieira de Camargo 126, Campinas, SP, 13083-887, Brazil
| | - Talita Bianchi Aiello
- Laboratory of Microbiology, Centro Médico de Campinas, Rua Dr. Edilberto Luís Pereira da Silva 929, Campinas, SP, 13083-190, Brazil
| | - José Dirceu Ribeiro
- Center for Investigation in Pediatrics, School of Medical Sciences, University of Campinas, Rua Tessália Vieira de Camargo 126, Campinas, SP, 13083-887, Brazil
| | - Antônio Fernando Ribeiro
- Center for Investigation in Pediatrics, School of Medical Sciences, University of Campinas, Rua Tessália Vieira de Camargo 126, Campinas, SP, 13083-887, Brazil
| | - Niels Høiby
- Clinical Microbiology Department, Rigshospitalet (Copenhagen University Hospital), Juliane Maries Vej 22, 2100, Copenhagen, Denmark.,Costerton Biofilm Centre, Department of International Health, Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 24.1, 2200, Copenhagen, Denmark
| | - Carlos Emilio Levy
- Department of Clinical Pathology, School of Medical Sciences, University of Campinas, Rua Vital Brasil 251, 2nd floor, Cidade Universitária, Barão Geraldo, Campinas, SP, 13083-888, Brazil.
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6
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Morlacchi LC, Greer M, Tudorache I, Blasi F, Welte T, Haverich A, Mainz JG, Gottlieb J. The burden of sinus disease in cystic fibrosis lung transplant recipients. Transpl Infect Dis 2018; 20:e12924. [DOI: 10.1111/tid.12924] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 03/29/2018] [Accepted: 04/01/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Letizia Corinna Morlacchi
- Internal Medicine Department; Respiratory Unit and Cystic Fibrosis Adult Centre; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano; Milan Italy
- Department of Pathophysiology and Transplantation; Università degli Studi di Milano; Milan Italy
| | - Mark Greer
- Department of Respiratory Medicine; Lungentransplantation; Hannover Medical School; Hanover Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant and Vascular Surgery; Hannover Medical School; Hanover Germany
| | - Francesco Blasi
- Internal Medicine Department; Respiratory Unit and Cystic Fibrosis Adult Centre; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano; Milan Italy
- Department of Pathophysiology and Transplantation; Università degli Studi di Milano; Milan Italy
| | - Tobias Welte
- Department of Respiratory Medicine; Lungentransplantation; Hannover Medical School; Hanover Germany
- Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH); German Centre for Lung Research (DZL); Hanover Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery; Hannover Medical School; Hanover Germany
| | - Jochen G. Mainz
- CF-Centre for Children and Adults; Department of Paediatrics; Jena University Hospital; Jena Germany
| | - Jens Gottlieb
- Department of Respiratory Medicine; Lungentransplantation; Hannover Medical School; Hanover Germany
- Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH); German Centre for Lung Research (DZL); Hanover Germany
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7
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Mauch RM, Rossi CL, Aiello TB, Ribeiro JD, Ribeiro AF, Høiby N, Levy CE. Secretory IgA response against Pseudomonas aeruginosa in the upper airways and the link with chronic lung infection in cystic fibrosis. Pathog Dis 2018. [PMID: 28645157 DOI: 10.1093/femspd/ftx069] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
We assessed the diagnostic ability of an enzyme-linked immunosorbent assay test for measurement of specific secretory IgA (sIgA) in saliva to identify cystic fibrosis (CF) patients with Pseudomonas aeruginosa chronic lung infection and intermittent lung colonization. A total of 102 Brazilian CF patients and 53 healthy controls were included. Specific serum IgG response was used as a surrogate to distinguish CF patients according to their P. aeruginosa colonization/infection status. The rate of sIgA positivity was 87.1% in CF chronically infected patients (median value = 181.5 U/mL), 48.7% in intermittently colonized patients (median value = 45.8 U/mL) and 21.8% in free of infection patients (median value = 22.1 U/mL). sIgA levels in saliva were significantly associated with serum P. aeruginosa IgG and microbiological culture results. The sensitivity, specificity, PPV and NPV for differentiation between presence and absence of chronic lung infection were 87%, 63%, 51% and 92%, respectively. Measurement of sIgA in saliva may be used for screening patients in risk of developing P. aeruginosa chronic lung infection in CF and possibly also for paranasal sinusitis, and, most importantly, to efficiently rule out chronic P. aeruginosa lung infection.
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Affiliation(s)
- Renan M Mauch
- Department of Clinical Pathology, University of Campinas, School of Medical Sciences, Campinas, SP, 13083-888, Brazil
| | - Claudio L Rossi
- Department of Clinical Pathology, University of Campinas, School of Medical Sciences, Campinas, SP, 13083-888, Brazil
| | - Talita B Aiello
- Department of Clinical Pathology, University of Campinas, School of Medical Sciences, Campinas, SP, 13083-888, Brazil
| | - José D Ribeiro
- Department of Pediatrics, University of Campinas, School of Medical Sciences, Campinas, SP, 13083-888, Brazil
| | - Antônio F Ribeiro
- Department of Pediatrics, University of Campinas, School of Medical Sciences, Campinas, SP, 13083-888, Brazil
| | - Niels Høiby
- Department of International, Health, Immunology and Microbiology, University of Copenhagen; Department of Clinical Microbiology, Rigshospitalet (Copenhagen University Hospital), 2200 Copenhagen, Denmark
| | - Carlos E Levy
- Department of Clinical Pathology, University of Campinas, School of Medical Sciences, Campinas, SP, 13083-888, Brazil
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8
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Sobin L, Kawai K, Irace AL, Gergin O, Cunningham M, Sawicki GS, Adil EA. Microbiology of the Upper and Lower Airways in Pediatric Cystic Fibrosis Patients. Otolaryngol Head Neck Surg 2017; 157:302-308. [PMID: 28440108 DOI: 10.1177/0194599817702332] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective To evaluate the microbiology of the upper and lower airways in pediatric cystic fibrosis (CF) patients who underwent sinus surgery. Study Design Retrospective case series with chart review. Setting Tertiary care children's hospital. Subjects and Methods A total of 201 paired sinus and pulmonary cultures from 105 CF patients were identified between 1996 and 2014. Demographics and culture results were analyzed. Results The mean age of patients was 11.2 ± 5.4 years (range, 1-27 years), and approximately one-half were female. Methicillin-sensitive Staphylococcus aureus was the most common pathogen overall. A significantly higher prevalence of Pseudomonas aeruginosa (32% for pulmonary and 37% for sinus cultures) was observed in older patients versus younger patients ( P < .001). There was low to moderate agreement between sinus and pulmonary cultures (Kappa statistic range, 0.03-0.56). The prevalence of methicillin-resistant S aureus (MRSA) increased significantly for lower respiratory tract culture (from 5% to 16%) and sinus culture (from 5% to 27%) between 1996-2004 and 2010-2014 ( P = .016 and P < .001, respectively). The prevalence of positive sinus cultures increased from 40% to 85% between 1996-2004 and 2010-2014 ( P = .018). Patients with pulmonary MRSA were more likely to be coinfected with pulmonary P aeruginosa (risk ratio, 2.4; 95% CI, 1.2-4.8; P = .015) or Aspergillus fumigatus (risk ratio, 2.2; 95% CI, 1.2-4.8; P = .035). Conclusions There is low to moderate correlation between pulmonary and sinus pathogens in CF patients. This is important to consider when treating infections. The prevalence of MRSA in sinus cultures has increased over time and warrants further investigation.
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Affiliation(s)
- Lindsay Sobin
- 1 Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kosuke Kawai
- 1 Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,2 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexandria L Irace
- 1 Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ozgul Gergin
- 1 Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michael Cunningham
- 1 Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,2 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory S Sawicki
- 3 Division of Respiratory Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eelam A Adil
- 1 Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,2 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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9
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Moore JE, Mastoridis P. Clinical implications of Pseudomonas aeruginosa location in the lungs of patients with cystic fibrosis. J Clin Pharm Ther 2017; 42:259-267. [PMID: 28374433 DOI: 10.1111/jcpt.12521] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 03/05/2017] [Indexed: 12/18/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Pseudomonas aeruginosa is the leading cause of lung infection in patients with cystic fibrosis (CF) and is associated with significant morbidity and mortality. Antibiotics are regarded as the foundational pharmacological treatment for the suppressive management of chronic P. aeruginosa infections and to eradicate the first infection by P. aeruginosa. Inhalation remains a preferred route for drug administration, providing direct access to the site of infection while minimizing systemic side effects. Effective suppressive management of P. aeruginosa infections, however, requires an understanding of the location of the bacteria in the lungs and consideration of the factors that could limit access of the inhaled antibiotic to the infected area. This review provides a systematic assessment of the scientific literature to gain insight into the location of P. aeruginosa in the lungs of patients with CF and its clinical implications. The characteristics of antibiotic inhalation systems are also discussed in this context. METHODS We reviewed evidence-based literature from both human and animal studies in which P. aeruginosa lung location was reported. Relevant publications were identified through a screening strategy and summarized by reported P. aeruginosa location. RESULTS AND DISCUSSION Most areas of the conductive and respiratory zones of the lungs are susceptible to P. aeruginosa colonization. Deposition of an inhaled antibiotic is dependent on the device and formulation characteristics, as well as the ability of the patient to generate sufficient inhaled volume. As patients with CF often experience a decline in lung function, the challenge is to ensure that the inhaled antibiotic can be delivered throughout the bronchial tree. WHAT IS NEW AND CONCLUSION An effective drug delivery system that can target P. aeruginosa in both the respiratory and conductive zones is required. The chosen inhalation device should also offer a drug formulation that can be quickly and effectively delivered to specific lung locations, with minimal inspiratory effort from the patient.
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Affiliation(s)
- J E Moore
- Northern Ireland Public Health Laboratory, Department of Bacteriology, Belfast City Hospital, Belfast, UK
| | - P Mastoridis
- Respiratory Department, Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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10
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Tipirneni KE, Woodworth BA. Medical and Surgical Advancements in the Management of Cystic Fibrosis Chronic Rhinosinusitis. CURRENT OTORHINOLARYNGOLOGY REPORTS 2017; 5:24-34. [PMID: 28989817 PMCID: PMC5626435 DOI: 10.1007/s40136-017-0139-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide otolaryngologists with the most up-to-date advancements in both the medical and surgical management of CF-related sinus disease. RECENT FINDINGS Recent studies have supported more aggressive CRS management, often with a combination of both medical and surgical therapies. Comprehensive treatment strategies have been shown to reduce hospital admissions secondary to pulmonary exacerbations in addition to improving CRS symptoms. Still, current management strategies are lacking in both high-level evidence and standardized guidelines. SUMMARY The unified airway model describes the bi-directional relationship between the upper and lower airways as a single functional unit and suggests that CRS may play a pivotal role in both the development and progression of lower airway disease. Current strategies for CF CRS focus primarily on amelioration of symptoms with antibiotics, nasal saline and/or topical medicated irrigations, and surgery. However, there are no definitive management guidelines and there remains a persistent need for additional studies. Nevertheless, otolaryngologists have a significant role in the overall management of CF, which requires a multi-disciplinary approach and a combination of both surgical and medical interventions for optimal outcomes of airway disease. Here we present a review of currently available literature and summarize medical and surgical therapies best suited for the management of CF-related sinus disease.
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11
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Kłodzińska SN, Priemel PA, Rades T, Mørck Nielsen H. Inhalable Antimicrobials for Treatment of Bacterial Biofilm-Associated Sinusitis in Cystic Fibrosis Patients: Challenges and Drug Delivery Approaches. Int J Mol Sci 2016; 17:E1688. [PMID: 27735846 PMCID: PMC5085720 DOI: 10.3390/ijms17101688] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 08/05/2016] [Accepted: 08/29/2016] [Indexed: 02/07/2023] Open
Abstract
Bacterial biofilm-associated chronic sinusitis in cystic fibrosis (CF) patients caused by Pseudomonas aeruginosa infections and the lack of available treatments for such infections constitute a critical aspect of CF disease management. Currently, inhalation therapies to combat P. aeruginosa infections in CF patients are focused mainly on the delivery of antimicrobials to the lower respiratory tract, disregarding the sinuses. However, the sinuses constitute a reservoir for P. aeruginosa growth, leading to re-infection of the lungs, even after clearing an initial lung infection. Eradication of P. aeruginosa from the respiratory tract after a first infection has been shown to delay chronic pulmonary infection with the bacteria for up to two years. The challenges with providing a suitable treatment for bacterial sinusitis include: (i) identifying a suitable antimicrobial compound; (ii) selecting a suitable device to deliver the drug to the sinuses and nasal cavities; and (iii) applying a formulation design, which will mediate delivery of a high dose of the antimicrobial directly to the site of infection. This review highlights currently available inhalable antimicrobial formulations for treatment and management of biofilm infections caused by P. aeruginosa and discusses critical issues related to novel antimicrobial drug formulation design approaches.
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Affiliation(s)
- Sylvia Natalie Kłodzińska
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Universitetsparken 2, DK-2100 Copenhagen, Denmark.
| | - Petra Alexandra Priemel
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Universitetsparken 2, DK-2100 Copenhagen, Denmark.
| | - Thomas Rades
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Universitetsparken 2, DK-2100 Copenhagen, Denmark.
| | - Hanne Mørck Nielsen
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Universitetsparken 2, DK-2100 Copenhagen, Denmark.
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Metabolism and Pathogenicity of Pseudomonas aeruginosa Infections in the Lungs of Individuals with Cystic Fibrosis. Microbiol Spectr 2016; 3. [PMID: 26350318 DOI: 10.1128/microbiolspec.mbp-0003-2014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Individuals with the genetic disease cystic fibrosis (CF) accumulate mucus or sputum in their lungs. This sputum is a potent growth substrate for a range of potential pathogens, and the opportunistic bacterium Pseudomonas aeruginosa is generally most difficult of these to eradicate. As a result, P. aeruginosa infections are frequently maintained in the CF lung throughout life, and are the leading cause of death for these individuals. While great effort has been expended to better understand and treat these devastating infections, only recently have researchers begun to rigorously examine the roles played by specific nutrients in CF sputum to cue P. aeruginosa pathogenicity. This chapter summarizes the current state of knowledge regarding how P. aeruginosa metabolism in CF sputum affects initiation and maintenance of these infections. It contains an overview of CF lung disease and the mechanisms of P. aeruginosa pathogenicity. Several model systems used to study these infections are described with emphasis on the challenge of replicating the chronic infections observed in humans with CF. Nutrients present in CF sputum are surveyed, and the impacts of these nutrients on the infection are discussed. The chapter concludes by addressing the future of this line of research including the use of next-generation technologies and the potential for metabolism-based therapeutics.
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Adappa ND, Workman AD, Hadjiliadis D, Dorgan DJ, Frame D, Brooks S, Doghramji L, Palmer JN, Mansfield C, Reed DR, Cohen NA. T2R38 genotype is correlated with sinonasal quality of life in homozygous ΔF508 cystic fibrosis patients. Int Forum Allergy Rhinol 2015; 6:356-61. [PMID: 26678226 DOI: 10.1002/alr.21675] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/15/2015] [Accepted: 10/04/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chronic rhinosinusitis (CRS) is very prevalent in the cystic fibrosis (CF) patient population, and leads to high morbidity and markedly decreased quality of life (QOL). Identification of genetic markers that contribute to CRS symptoms in these patients can allow for risk stratification and tailoring of medical and surgical treatments. T2R38 is a bitter taste receptor expressed in the sinonasal tract, and nonfunctional alleles of this receptor have been implicated in treatment-refractory CRS in non-CF patients. The purpose of this study is to investigate the significance of T2R38 genotype in the variability of sinonasal QOL and CRS disease severity in a sample of CF patients. METHODS ΔF508 homozygous CF patients were recruited from the University of Pennsylvania Cystic Fibrosis Center and were genotyped for the TAS2R38 locus. To assess sinonasal symptom severity, a 22-item Sino-Nasal Outcome Test (SNOT-22) was collected from each patient. Additional demographic and medical history data was obtained at the time of patient enrollment. RESULTS A total of 49 ΔF508 homozygous CF patients aged 18 to 32 years were included in the final SNOT-22 score analysis. Individuals with 2 functional T2R38 alleles (PAV/PAV) had significantly lower SNOT-22 scores (n = 49, p < 0.05). On further breakdown of SNOT-22 subcategories, rhinologic symptoms specifically were less severe in PAV/PAV patients than patients with other genotypes (n = 47, p < 0.05). CONCLUSION Our investigation indicates that T2R38 genotype correlates both with SNOT-22 scores and rhinologic-specific QOL in ΔF508 homozygous CF patients.
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Affiliation(s)
- Nithin D Adappa
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alan D Workman
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Denis Hadjiliadis
- Paul F. Harron Jr. Lung Center, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel J Dorgan
- Paul F. Harron Jr. Lung Center, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Danielle Frame
- Paul F. Harron Jr. Lung Center, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Steven Brooks
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Laurel Doghramji
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - James N Palmer
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Noam A Cohen
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Monell Smell and Taste Center, Philadelphia, PA.,Philadelphia Veterans Affairs Medical Center, Philadelphia, PA
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Dosanjh A. The microbiology of the cystic fibrosis upper and lower airway. J Cyst Fibros 2015; 14:e35. [DOI: 10.1016/j.jcf.2015.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/04/2015] [Indexed: 11/29/2022]
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A case of failed eradication of cystic fibrosis-related sinus colonisation by Pseudomonas aeruginosa. BMC Pulm Med 2015; 15:114. [PMID: 26445233 PMCID: PMC4596362 DOI: 10.1186/s12890-015-0113-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 09/28/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pseudomonas aeruginosa is a pathogen associated with cystic fibrosis that has potential to decrease lung function and cause respiratory failure. Paranasal sinuses are increasingly recognised as potential reservoirs for intermittent colonisation by P. aeruginosa. This case documents investigation and outcome of P. aeruginosa recurrence in a male paediatric patient over an eight year period. CASE PRESENTATION A 12 year old Irish male paediatric cystic fibrosis patient experienced intermittent culturing of P. aeruginosa from the oropharyngeal region, indicating chronic infection of the sinuses despite absence of symptoms, retaining good lung function, and normal bronchoscopy and bronchoalveolar lavage. However, P. aeruginosa was isolated from a sinus wash-out and was identified as a unique strain of P. aeruginosa that was also cultured from cough swabs. Despite treatment, successful eradication from the paranasal sinuses was not achieved. CONCLUSIONS Few reports have addressed the paranasal sinuses as a reservoir for lung infection in cystic fibrosis patients despite increased recognition of the need to investigate this niche. In this case, attempts at eradication of P. aeruginosa present in paranasal sinuses including oral and nebulised antimicrobials proved unsuccessful. However, detection of P. aeruginosa in the paranasal sinuses instigated antimicrobial treatment which may have contributed to prevention of migration to the lower airways. Our outcome provides additional insight and may indicate utility of nasal lavage or nasal endoscopy in paediatric cystic fibrosis patients' annual review clinic visits.
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Abstract
PURPOSE OF REVIEW Upper airway disease engenders significant morbidity for patients with cystic fibrosis and is increasingly recognized as having a much greater role in pulmonary outcomes and quality of life than originally believed. Widespread disparate therapeutic strategies for cystic fibrosis chronic rhinosinusitis underscore the absence of a standardized treatment paradigm. This review outlines the most recent evidence-based trends in the management of upper airway disease in cystic fibrosis. RECENT FINDINGS The unified airway theory proposes that the sinuses are a focus of initial bacterial colonization which seeds the lower airway and may play a large role in maintaining lung infections. Mounting evidence suggests more aggressive treatment of the sinuses may confer significant improvement in pulmonary disease and quality of life outcomes in cystic fibrosis patients. However, there is a lack of high-level evidence regarding medical and surgical management of cystic fibrosis chronic rhinosinusitis that makes generalizations difficult. SUMMARY Well designed clinical trials with long-term follow-up concerning medical and surgical interventions for cystic fibrosis sinus disease are required to establish standardized treatment protocols, but increased interest in the sinuses as a bacterial reservoir for pulmonary infections has generated considerable attention.
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Affiliation(s)
- Elisa A Illing
- Department of Surgery/Division of Otolaryngology and the Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Aanæs K. Bacterial sinusitis can be a focus for initial lung colonisation and chronic lung infection in patients with cystic fibrosis. J Cyst Fibros 2014; 12 Suppl 2:S1-20. [PMID: 24064077 DOI: 10.1016/s1569-1993(13)00150-1] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A major purpose of treating patients with cystic fibrosis (CF) is to prevent or delay chronic lung infections with CF-pathogenic Gram-negative bacteria. In the intermittent stage, bacteria can usually be eradicated from the lungs with antibiotics, but following eradication, the next lung colonisations often occur with bacteria of identical genotype. This may be due to re-colonisation from the patient's paranasal sinuses. In our study, we found that approximately two-thirds of CF patients having sinus surgery (FESS) had growth of CF-lung-pathogenic Gram-negative bacteria in their sinuses (Pseudomonas aeruginosa, Achromobacter xylosoxidans, Burkholderia cepacia complex). The environment in the sinuses is in many ways similar to that of the lower respiratory tract, e.g. low oxygen concentration in secretions. Sinus bacteria are more difficult to eradicate than in the lungs, thus, having good conditions for adapting to the environment in the lungs. In the presence of bacteria, the environment of the sinuses differs from that of the lower respiratory tract by having a higher immunoglobulin A (IgA): IgG ratio, and reduced inflammation. We found a significant correlation between the concentration of IgA against P. aeruginosa (standard antigen and alginate) in nasal secretions and saliva and CF patients' infection status (not lung colonised, intermittently colonised or chronically lung-infected with P. aeruginosa). This supports the hypothesis that infections often originate in the sinuses and can be a focus for initial lung colonisation or for maintaining lung infections in CF patients. We are confident that anti-P. aeruginosa IgA can be used as an early supplementary tool to diagnose P. aeruginosa colonisation; P. aeruginosa being the microorganism causing most morbidity and mortality in CF patients. This is important since urgent treatment reduces morbidity when CF patients are early colonised with P. aeruginosa, however, there is a lack of diagnostic tools for detecting the early colonisation in the lungs and in the sinuses. We initiated a treatment strategy for CF patients to prevent sino-nasal bacteria being seeded into the lower airways: we recommended extensive functional endoscopic FESS with creation of sufficient drainage from all involved sinuses with subsequent i.v. antibiotics and at least 6 months of twice daily nasal irrigation with saline and antibiotics. By this strategy, sinus bacteria could be eradicated in a large proportion of patients. Essentially, growth of CF-pathogenic bacteria from the lower respiratory tract was decreased following the treatment. Furthermore, a number of patients have been free from CF-pathogenic bacteria for more than one year after FESS, and thus re-classified as "not lung colonised". We also corroborated that CF patients obtain an improved quality of life and reduction in their symptoms of chronic rhinosinusitis after FESS. It is primarily intermittently lung colonised CF patients with CF-pathogenic bacteria in their sinuses that seem to benefit from the treatment strategy. This is in accordance with the fact that we did not see a significant increase in lung function and only a small decrease in specific antibodies after FESS; a high systemic immune and inflammatory response and a decreasing lung function is generally not present in patients who primarily have sinus CF-pathogenic bacteria. It is important that guidelines are created for how CF patients with CF-pathogenic bacteria in the sinuses are to be treated, including criteria for who may likely benefit from FESS, and who may be treated exclusively with conservative therapy, e.g. saline and antibiotic irrigations.
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Affiliation(s)
- Kasper Aanæs
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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Wilson P, Lambert C, Carr SB, Pao C. Paranasal sinus pathogens in children with cystic fibrosis: do they relate to lower respiratory tract pathogens and is eradication successful? J Cyst Fibros 2014; 13:449-54. [PMID: 24713592 DOI: 10.1016/j.jcf.2014.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 02/21/2014] [Accepted: 03/11/2014] [Indexed: 01/21/2023]
Abstract
BACKGROUND The study aims were to assess the association of microflora between the paranasal sinus and the lower airways of children attending a regional paediatric cystic fibrosis centre and to determine the performance of an eradication treatment protocol for positive paranasal sinus samples. METHOD Paired nasal lavage and lower airway samples (cough swabs or sputum) were taken from 54 children with cystic fibrosis (median age 11 years). Positive paranasal sinus samples received eradication treatment, using oral and sinonasal nebulised antibiotics. RESULTS A correlation between paranasal sinus and lower airways was detected in 33/54 paired timed samples (p<0.02). Of 4/54 children who reported sinus symptoms, only 2 had paranasal sinus positive samples. 28 positive nasal lavage samples cultured 8 Pseudomonas aeruginosa (PA), 8 Staphylococcus aureus (SA) and 12 other bacterial pathogens. Eradication using sinonasal nebulised antibiotics and oral antibiotics showed a success of 14/21 (67%) treated paranasal sinus positive samples at 1 month & 3 months after treatment. Success rate was 75% in the PA group and 71% in the SA group. Ongoing monitoring with nasal lavage will continue. CONCLUSION There was agreement between pathogens or lack of them found in the paranasal sinus and lower airways. Paranasal infection is often asymptomatic in children with cystic fibrosis. The eradication protocol for paranasal sinus pathogens had a good success rate.
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Affiliation(s)
- P Wilson
- Paediatric Cystic Fibrosis Team, Royal London Children's Hospital, Royal London Hospital, Whitechapel Road, London E1 1BB, United Kingdom.
| | - C Lambert
- Paediatric Cystic Fibrosis Team, Royal London Children's Hospital, Royal London Hospital, Whitechapel Road, London E1 1BB, United Kingdom
| | - S B Carr
- Paediatric Respiratory Department, Royal Brompton Hospital, Sydney Street, London SW3 6NP, United Kingdom
| | - C Pao
- Paediatric Cystic Fibrosis Team, Royal London Children's Hospital, Royal London Hospital, Whitechapel Road, London E1 1BB, United Kingdom
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Chang EH. New insights into the pathogenesis of cystic fibrosis sinusitis. Int Forum Allergy Rhinol 2013; 4:132-7. [PMID: 24282147 DOI: 10.1002/alr.21252] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 10/11/2013] [Accepted: 10/15/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND People with cystic fibrosis (CF) sinus disease have developmental sinus abnormalities with airway bacterial infection, inflammation, impaired mucociliary clearance and thick obstructive mucus. The pathophysiology of airway disease in CF is not completely understood, and current treatments in CF sinus disease ameliorate symptoms but do not provide a cure. METHODS This manuscript reviews the history of CF, its manifestations in sinus disease, and the potential impact and relationship of CF on the upper and lower airway. RESULTS There is increasing evidence that CF sinus disease may affect CF lung disease, the most common cause of mortality in CF. We have been limited in treating the symptoms of advanced CF sinus disease with our current therapies. CONCLUSIONS Recent discoveries in the pathophysiology of CF using the CF porcine animal model and exciting treatments that address the primary gene defect that may translate into improved outcomes in CF and non-CF sinusitis in humans.
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Affiliation(s)
- Eugene H Chang
- Department of Otolaryngology-Head and Neck Surgery, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
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20
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Lavin J, Bhushan B, Schroeder JW. Correlation between respiratory cultures and sinus cultures in children with cystic fibrosis. Int J Pediatr Otorhinolaryngol 2013; 77:686-9. [PMID: 23415069 DOI: 10.1016/j.ijporl.2013.01.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 01/15/2013] [Accepted: 01/18/2013] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Patients with cystic fibrosis (CF) have chronic pulmonary infections and, in many cases, chronic rhinosinusitis (CRS). In patients who have CRS without CF, the causative pathogens are well established, and empiric therapy is prescribed. In patients with CF, organisms are different, decreasing the efficacy of empiric therapy. Furthermore, obtaining accurate sinus cultures is invasive, making culture directed therapy more challenging. Some physicians use respiratory cultures to guide antibiotic selection for treatment of sinusitis. Previous studies have had varying results on the correlation between respiratory and sinus cultures so further investigation is warranted. METHODS Bacterial growth from preoperative sputum, bronchoalveolar lavage, and oropharyngeal cultures were compared to the bacterial growth from intraoperative sinus cultures in patients with cystic fibrosis undergoing endoscopic sinus surgery. RESULTS In the patients over eight years of age, 16 of 26 sputum cultures matched sinus cultures (p=0.4). When sputum cultures with normal flora and no growth were eliminated, 16 of 21 matched sinus cultures (p=0.02). No statistically significant associations were found for sputum cultures in patients under eight years of age. No statistically significant associations were found between oropharyngeal or bronchoalveolar lavage cultures and intraoperative sinus cultures from patients of any age. When Staphylococcus aureus was cultured from sputum in patients over eight years of age the positive and negative predictive values that S. aureus would be cultured from the sinuses were 100% and 75% respectively. The positive and negative predictive values for Pseudomonas aeruginosa were 73% and 86% respectively. CONCLUSION In children with CF who are over eight years of age, organisms grown from sputum cultures are similar to organisms grown from sinus cultures when bacterial growth is present.
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Affiliation(s)
- Jennifer Lavin
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, IL, United States
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Vital D, Hofer M, Benden C, Holzmann D, Boehler A. Impact of Sinus Surgery on Pseudomonal Airway Colonization, Bronchiolitis Obliterans Syndrome and Survival in Cystic Fibrosis Lung Transplant Recipients. Respiration 2013; 86:25-31. [DOI: 10.1159/000339627] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 05/21/2012] [Indexed: 11/19/2022] Open
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Beiersdorf N, Schien M, Hentschel J, Pfister W, Markert UR, Mainz JG. Soluble inflammation markers in nasal lavage from CF patients and healthy controls. J Cyst Fibros 2012; 12:249-57. [PMID: 22990051 DOI: 10.1016/j.jcf.2012.08.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 08/16/2012] [Accepted: 08/19/2012] [Indexed: 01/13/2023]
Abstract
BACKGROUND CF sinonasal and bronchial mucosa reveal identical ion channel defects. Nasal Lavage (NL) allows non-invasive repeated sampling of airway surface liquid. We compared inflammatory mediators in NL from CF-patients and healthy controls, and in CF in relation to sinonasal pathogen colonization. METHODS From 40 CF-patients (mean age 21.8yrs, SD 11.8yrs.) and 52 healthy controls (mean age 31.9yrs., SD 13.7yrs.) NL-fluid (10ml/nostril) concentrations of MPO, IL-8, IL-17A, sICAM-1, IL-1β, IL-6, TNF-α, IL-10 and IL-5 were determined using cytometric bead arrays for flow cytometry. RESULTS CF-patients showed significantly higher MPO-concentrations in NL-fluid and higher IL-8-levels (n.s.) than controls. MPO, IL-8, IL-17A, sICAM-1, IL-1β and IL-6 were significantly more often detectable in CF-patients than in controls. CF-patients with S. aureus colonization in both upper and lower airways had significantly elevated MPO and IL-8 levels in NL-fluid compared to S. aureus negatives. CONCLUSION NL-fluid differed substantially between CF-patients and healthy controls with most promising results for IL-8 and MPO, a primarily in CF-NL assessed mediator. Further studies are required to assess effects of sample collection and processing on concentrations of inflammatory markers and to evaluate potentials of NL analysis in research and clinical routine.
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Affiliation(s)
- Natalie Beiersdorf
- Department of Obstetrics, Placenta Laboratory, Jena University Hospital, D-07740 Jena, Germany
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Digoy GP, Dunn JD, Stoner JA, Christie A, Jones DT. Bacteriology of the paranasal sinuses in pediatric cystic fibrosis patients. Int J Pediatr Otorhinolaryngol 2012; 76:934-8. [PMID: 22513080 DOI: 10.1016/j.ijporl.2012.02.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 02/13/2012] [Accepted: 02/14/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To review the characteristic microbiology of the paranasal sinuses in patients with cystic fibrosis who undergo endoscopic sinus surgery. To examine the subtypes of organisms cultured from the maxillary sinuses and determine their sensitivity to antibiotic therapy. STUDY DESIGN Retrospective chart review. SETTING Tertiary care children's hospital. METHODS Sinus cultures were obtained from 51 patients with cystic fibrosis during endoscopic sinus procedures between 2000 and 2004 at a tertiary care children's hospital. A retrospective chart review was undertaken to obtain culture and sensitivity data of the sinus contents. RESULTS The most common bacteria isolated was Staphylococcus aureus (71%), followed by Pseudomonas aeruginosa (PSA) (27%), Haemophilus influenzae (21%), Staphylococcus non-aureus (16%) and Streptococcus viridans (12%). Streptococcus pneumoniae and Moraxella catarrhalis were rarely isolated (2% and 0% respectively). Twenty-nine percent of the patients with cultures positive for PSA were of the mucoid variant. Only one patient had culture positive Escherichia coli. Antibiotic resistance among the more common organisms cultured from the sinus samples is also listed. CONCLUSION Staph. aureus is the most common isolate in the sinuses of this pediatric CF population followed by P. aeruginosa and H. influenzae. Although many isolates are pansensitive, some isolates are panresistant.
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Affiliation(s)
- G Paul Digoy
- Department of Otolaryngology, OU Medical Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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Vital D, Hofer M, Boehler A, Holzmann D. Posttransplant sinus surgery in lung transplant recipients with cystic fibrosis: a single institutional experience. Eur Arch Otorhinolaryngol 2012; 270:135-9. [PMID: 22460525 DOI: 10.1007/s00405-012-2002-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Accepted: 03/14/2012] [Indexed: 11/29/2022]
Abstract
Chronic rhinosinusitis is hypothesised to play a major role in lung transplant recipients with cystic fibrosis. Paranasal sinuses are considered to accumulate a significant bacterial load, potentially leading to lung allograft infection with ensuing complications such as bronchiolitis obliterans syndrome, i.e. allograft rejection. We therefore would like to present our combined medical and surgical treatment plan, which consists of an endoscopic fronto-spheno-ethmoidectomy as well as a meticulous daily nasal care program. The microbiological results show that our combined concept is effective, whereas especially daily nasal care with isotonic saline solution is the cornerstone in preventing significant colonisation of the sinuses and spreading bacteria to the lower respiratory tract causing lung allograft infection. Regarding the surgical part of our treatment, it should be emphasised that all sinuses and ethmoidal air cells should be widely opened. Edges such as bony overhangs should be smoothened to avoid mucus retention and consecutive bacterial recolonisation requiring subsequent revision surgery.
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Affiliation(s)
- Domenic Vital
- Division of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Frauenklinikstrasse 24, 8091, Zurich, Switzerland.
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Hansen SK, Rau MH, Johansen HK, Ciofu O, Jelsbak L, Yang L, Folkesson A, Jarmer HØ, Aanæs K, von Buchwald C, Høiby N, Molin S. Evolution and diversification of Pseudomonas aeruginosa in the paranasal sinuses of cystic fibrosis children have implications for chronic lung infection. ISME JOURNAL 2011; 6:31-45. [PMID: 21716309 DOI: 10.1038/ismej.2011.83] [Citation(s) in RCA: 164] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The opportunistic pathogen Pseudomonas aeruginosa is a frequent colonizer of the airways of patients suffering from cystic fibrosis (CF). Depending on early treatment regimens, the colonization will, with high probability, develop into chronic infections sooner or later, and it is important to establish under which conditions the switch to chronic infection takes place. In association with a recently established sinus surgery treatment program for CF patients at the Copenhagen CF Center, colonization of the paranasal sinuses with P. aeruginosa has been investigated, paralleled by sampling of sputum from the same patients. On the basis of genotyping and phenotypic characterization including transcription profiling, the diversity of the P. aeruginosa populations in the sinuses and the lower airways was investigated and compared. The observations made from several children show that the paranasal sinuses constitute an important niche for the colonizing bacteria in many patients. The paranasal sinuses often harbor distinct bacterial subpopulations, and in the early colonization phases there seems to be a migration from the sinuses to the lower airways, suggesting that independent adaptation and evolution take place in the sinuses. Importantly, before the onset of chronic lung infection, lineages with mutations conferring a large fitness benefit in CF airways such as mucA and lasR as well as small colony variants and antibiotic-resistant clones are part of the sinus populations. Thus, the paranasal sinuses potentially constitute a protected niche of adapted clones of P. aeruginosa, which can intermittently seed the lungs and pave the way for subsequent chronic lung infections.
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Bonestroo HJC, de Winter-de Groot KM, van der Ent CK, Arets HGM. Upper and lower airway cultures in children with cystic fibrosis: do not neglect the upper airways. J Cyst Fibros 2010; 9:130-4. [PMID: 20110197 DOI: 10.1016/j.jcf.2010.01.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Revised: 12/23/2009] [Accepted: 01/04/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND Airways of cystic fibrosis (CF) patients are colonised with bacteria early in life. We aimed to analyse differences between results of simultaneously taken upper airway (UAW) and lower airway (LAW) cultures, to describe clinical characteristics of patients with positive versus negative cultures and to follow up the patients with P. aeruginosa positive UAW cultures. METHODS Bacteriological and clinical data from 157 children were collected during annual check up. The number of positive UAW and LAW cultures and correspondence between these results and clinical characteristics were analysed. RESULTS Positive LAW and UAW cultures were found in 79.6% and 43.9% of patients respectively (p<0.001). Patients with positive LAW cultures were significantly older (11.9 vs. 9.8years, p<0.05) and had more LAW symptoms (73.6% vs. 46.7%, p<0.05), especially when P. aeruginosa was found. Patients with positive UAW cultures (especially S. aureus) had more nasal discharge (50.7% vs. 25.0%, p<0.001). In 65% of patients with positive UAW and negative LAW culture for P. aeruginosa the next LAW became P. aeruginosa positive. CONCLUSION UAW cultures and LAW cultures differ in children with CF and there are differences in clinical characteristics between patients with positive versus negative culture results. P. aeruginosa positive UAW cultures appeared to precede positive LAW cultures in a substantial part of patients, suggesting some kind of cross-infection between the UAW and LAW.
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Affiliation(s)
- Hilde J C Bonestroo
- Department of Paediatric Respiratory Disease, Cystic Fibrosis Centre Utrecht, Wilhelmina Children's Hospital, KH 01.419.0, University Medical Centre Utrecht, PO Box 85090, 3508 AB Utrecht, The Netherlands
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Dosanjh A, Koziol J. A comparison of CF and non-CF school-age children undergoing lung transplantation. Transpl Int 2009; 22:725-9. [DOI: 10.1111/j.1432-2277.2009.00865.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Paranasal and sinus disease is present in almost every patient with cystic fibrosis. However, symptoms are rarely reported. Some aspects including polyposis and microbial flora change with patient age. Endoscopy and computerised tomography have broadened our understanding of how this disease affects the sinuses, including an increased recognition of polyposis than previously thought and identification of several disease specific entities such as abnormalities of the lateral nasal wall and uncinate process. Few randomised, controlled trials evaluating medical or surgical treatments of CF sinus disease exist. Sinus surgery may provide some benefit, though there are no established selection criteria for appropriate candidates. A link between sinus disease and lower respiratory tract function may contribute to general health and survival following lung transplantation. Complications of sinonasal disease in CF are rare and include mucoceles and periorbital abscesses.
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Affiliation(s)
- John M Robertson
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas 77030, USA
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Roby BB, McNamara J, Finkelstein M, Sidman J. Sinus surgery in cystic fibrosis patients: comparison of sinus and lower airway cultures. Int J Pediatr Otorhinolaryngol 2008; 72:1365-9. [PMID: 18602167 DOI: 10.1016/j.ijporl.2008.05.011] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Accepted: 05/21/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study is to determine whether cross-infection occurs between infections in the sinuses and lower airways in Cystic Fibrosis patients, and to determine whether the infections begin in the sinuses before spreading to the lungs. METHODS Retrospective study of pediatric Cystic Fibrosis patients who underwent simultaneous sinus surgery and bronchial washings. The results of the cultures were reviewed to determine if the same organisms colonized both the sinuses and lower airways. RESULTS Staphylococcus aureus (Staph. Aureus) was found in 40.7% of the sinuses but only 33.3% of the lower airways. One patient had Staph. Aureus in the lower airway but not the sinuses. Pseudomonas, Hemophilus Influenza, and Moraxella showed similar patterns: multiple instances of positive sinus cultures and negative bronchial cultures, but only a small number of cases with positive lower airway cultures and negative sinus cultures. CONCLUSION The data showed that as patients age, they are more likely to have infections in both upper and lower airways, but infections start in the upper airways at a younger age. In many cases, organisms were cultured from sinuses in patients who had negative lower airway cultures. In only a few instances, organisms grew in the lower airways and not the sinuses. In most cases, the bacteria that caused sinus infections at a young age caused the lung infections in older patients. This is the paper to show that bacteria spread from the sinuses to the lungs to cause infections in Cystic Fibrosis patients, and not vice-versa.
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Affiliation(s)
- Brianne Barnett Roby
- Children's Hospitals and Clinics of Minnesota-Otolaryngology, 910 E 26th Street, Suite 323, Minneapolis, MN 55404, United States.
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Sakano E, Ribeiro AF, Barth L, Condino Neto A, Ribeiro JD. Nasal and paranasal sinus endoscopy, computed tomography and microbiology of upper airways and the correlations with genotype and severity of cystic fibrosis. Int J Pediatr Otorhinolaryngol 2007; 71:41-50. [PMID: 17007941 DOI: 10.1016/j.ijporl.2006.08.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2006] [Revised: 08/19/2006] [Accepted: 08/19/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Many studies have assessed clinical and functional aspects of lower airway affections in cystic fibrosis. Conversely, few studies have been performed to assess the clinical and functional affections of upper airways. The objective of the present study was to correlate the variables obtained by nasal and paranasal sinuses endoscopy, paranasal sinus laboratory and computed tomography (CT) scan findings, and to check the association with severity and genotype of cystic fibrosis patients. METHODS Clinical and laboratory study of 50 patients with cystic fibrosis at a university center. All patients were submitted to CT scan, nasal and paranasal endoscopy and bacterioscopy of maxillary sinus, trachea and oropharynx secretion. Severity of cystic fibrosis was assessed by Shwachman score and the most frequent genetic mutations were identified. RESULTS The prevalence of polyposis in the studied population was 36% and it was greater among homozygote for DeltaF 508. Shwachman score was correlated with age (p=0.003). The genotype was correlated with presence of nasal polyposis (p=0.006). There was no association between affections in CT scan and severity of cystic fibrosis (CF). Patients presented high prevalence of early colonization of Pseudomonas aeruginosa. CONCLUSIONS Sinus disease in CF patients presents several clinical, endoscopic and tomographic affections. Although most of them are not correlated with severity and disease genotype, severity of CF is correlated with age and presence of polyposis is genotype-dependent.
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Affiliation(s)
- Eulalia Sakano
- Department of Otorhinolaryngology Head Neck Surgery, School of Medical Sciences, Campinas State University, SP, Brazil.
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Muhlebach MS, Miller MB, Moore C, Wedd JP, Drake AF, Leigh MW. Are lower airway or throat cultures predictive of sinus bacteriology in cystic fibrosis? Pediatr Pulmonol 2006; 41:445-51. [PMID: 16547960 DOI: 10.1002/ppul.20396] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The choice of antibiotics for sinusitis in children with cystic fibrosis (CF) is empirical or based on lower airway cultures, because sinus cultures are difficult to obtain. The aim of this study was to identify the main organisms cultured from CF children with chronic sinusitis, and to evaluate the concordance of concomitant sinus, oropharyngeal swab (OP), and bronchoalveolar lavage fluid (BALF) cultures. OP and BALF cultures were done preoperatively, and sinus cultures were obtained during clinically indicated sinus surgery. The genetic identity of the bacteria was compared if the same organisms were present in upper and lower airway cultures. In total, 45 paired sinus-BALF cultures from 31 patients were included. Twenty-four of these had matched OP cultures. The mean age of patients was 9.5 +/- 4.3 years, and 19 patients were DeltaF508 homozygous. Bacterial sinus infection was present in 96%, caused by S. aureus (49%), P. aeruginosa (42%), and H. influenzae (22%). The diagnostic accuracy of BALF or OP cultures was low in predicting sinus infection, particularly at younger ages. Positive and negative predictive values (PPV and NPV) of BALF for P. aeruginosa infection were 65% and 67%, and for S. aureus, 76% and 63%, respectively. Predictive values for OP cultures were similar. Bacterial species were the same in sinus and OP or BALF samples of 12 patients of these bacteria 83% showed genetic identity. We conclude that S. aureus is an important pathogen in pediatric CF sinusitis, and that BALF or oropharyngeal cultures are poor predictors for organisms present in the sinuses.
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Holzmann D, Speich R, Kaufmann T, Laube I, Russi EW, Simmen D, Weder W, Boehler A. Effects of sinus surgery in patients with cystic fibrosis after lung transplantation: a 10-year experience. Transplantation 2004; 77:134-6. [PMID: 14724449 DOI: 10.1097/01.tp.0000100467.74330.49] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Chronic infectious rhinosinusitis with Pseudomonas aeruginosa is common in cystic fibrosis and may result in allograft infection after lung transplantation. Sinus surgery followed by nasal care may reduce these adverse effects. Sinus surgery was performed in 37 patients with cystic fibrosis after transplantation. Bacteriology of sinus aspirates (n=771) and bronchoalveolar lavage (BAL) (n=256) was correlated with clinical data. Sinus surgery was successful in 54% and partially successful in 27% of patients. A significant correlation between negative sinus aspirates and negative BAL and between positive sinus aspirates and positive BAL (P<0.0001) was found. Successful sinus management led to a lower incidence of tracheobronchitis and pneumonia (P=0.009) and a trend toward a lower incidence of bronchiolitis obliterans syndrome (P=0.23). Sinus surgery followed by daily nasal douching may control posttransplant lower airway colonization and infection. In the long term, this concept may lead to less bronchiolitis obliterans syndrome by decreasing bronchiolar inflammation.
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Affiliation(s)
- David Holzmann
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Zurich, Switzerland
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