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Schwarz C, Bend J, Hebestreit H, Hogardt M, Hügel C, Illing S, Mainz JG, Rietschel E, Schmidt S, Schulte-Hubbert B, Sitter H, Wielpütz MO, Hammermann J, Baumann I, Brunsmann F, Dieninghoff D, Eber E, Ellemunter H, Eschenhagen P, Evers C, Gruber S, Koitschev A, Ley-Zaporozhan J, Düesberg U, Mentzel HJ, Nüßlein T, Ringshausen FC, Sedlacek L, Smaczny C, Sommerburg O, Sutharsan S, Vonberg RP, Weber AK, Zerlik J. [CF Lung Disease - a German S3 Guideline: Pseudomonas aeruginosa]. Pneumologie 2024; 78:367-399. [PMID: 38350639 DOI: 10.1055/a-2182-1907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
Cystic Fibrosis (CF) is the most common autosomal recessive genetic multisystemic disease. In Germany, it affects at least 8000 people. The disease is caused by mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene leading to dysfunction of CFTR, a transmembrane chloride channel. This defect causes insufficient hydration of the airway epithelial lining fluid which leads to reduction of the mucociliary clearance.Even if highly effective, CFTR modulator therapy has been available for some years and people with CF are getting much older than before, recurrent and chronic infections of the airways as well as pulmonary exacerbations still occur. In adult CF life, Pseudomonas aeruginosa (PA) is the most relevant pathogen in colonisation and chronic infection of the lung, leading to further loss of lung function. There are many possibilities to treat PA-infection.This is a S3-clinical guideline which implements a definition for chronic PA-infection and demonstrates evidence-based diagnostic methods and medical treatment in order to give guidance for individual treatment options.
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Affiliation(s)
- Carsten Schwarz
- Klinikum Westbrandenburg GmbH, Standort Potsdam, Deutschland
| | - Jutta Bend
- Mukoviszidose Institut gGmbH, Bonn, Deutschland
| | | | - Michael Hogardt
- Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Frankfurt, Deutschland
| | - Christian Hügel
- Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Deutschland
| | | | - Jochen G Mainz
- Klinikum Westbrandenburg, Standort Brandenburg an der Havel, Universitätsklinikum der Medizinischen Hochschule Brandenburg (MHB), Brandenburg an der Havel, Deutschland
| | - Ernst Rietschel
- Medizinische Fakultät der Universität zu Köln, Mukoviszidose-Zentrum, Klinik und Poliklinik für Kinder- und Jugendmedizin, Köln, Deutschland
| | - Sebastian Schmidt
- Ernst-Moritz-Arndt Universität Greifswald, Kinderpoliklinik, Allgemeine Pädiatrie, Greifswald, Deutschland
| | | | - Helmut Sitter
- Philipps-Universität Marburg, Institut für theoretische Medizin, Marburg, Deutschland
| | - Marc Oliver Wielpütz
- Universitätsklinikum Heidelberg, Klinik für Diagnostische und Interventionelle Radiologie, Heidelberg, Deutschland
| | - Jutta Hammermann
- Universitäts-Mukoviszidose-Zentrum "Christiane Herzog", Dresden, Deutschland
| | - Ingo Baumann
- Universität Heidelberg, Hals-Nasen-Ohrenklinik, Heidelberg, Deutschland
| | - Frank Brunsmann
- Allianz Chronischer Seltener Erkrankungen (ACHSE) e. V., Deutschland (Patient*innenvertreter)
| | | | - Ernst Eber
- Medizinische Universität Graz, Univ. Klinik für Kinder- und Jugendheilkunde, Klinische Abteilung für Pädiatrische Pulmonologie und Allergologie, Graz, Österreich
| | - Helmut Ellemunter
- Tirolkliniken GmbH, Department für Kinderheilkunde, Pädiatrie III, Innsbruck, Österreich
| | | | | | - Saskia Gruber
- Medizinische Universität Wien, Universitätsklinik für Kinder- und Jugendheilkunde, Wien, Österreich
| | - Assen Koitschev
- Klinikum Stuttgart - Standort Olgahospital, Klinik für Hals-Nasen-Ohrenkrankheiten, Stuttgart, Deutschland
| | - Julia Ley-Zaporozhan
- Klinik und Poliklinik für Radiologie, Kinderradiologie, LMU München, Deutschland
| | | | - Hans-Joachim Mentzel
- Universitätsklinikum Jena, Sektion Kinderradiologie, Institut für Diagnostische und Interventionelle Radiologie, Jena, Deutschland
| | - Thomas Nüßlein
- Gemeinschaftsklinikum Mittelrhein, Klinik für Kinder- und Jugendmedizin Koblenz und Mayen, Koblenz, Deutschland
| | - Felix C Ringshausen
- Medizinische Hochschule Hannover, Klinik für Pneumologie und Infektiologie und Deutsches Zentrum für Lungenforschung (DZL), Hannover, Deutschland
| | - Ludwig Sedlacek
- Medizinische Hochschule Hannover, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Hannover, Deutschland
| | - Christina Smaczny
- Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Deutschland
| | - Olaf Sommerburg
- Universitätsklinikum Heidelberg, Sektion Pädiatrische Pneumologie, Allergologie und Mukoviszidose-Zentrum, Heidelberg, Deutschland
| | | | - Ralf-Peter Vonberg
- Medizinische Hochschule Hannover, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Hannover, Deutschland
| | | | - Jovita Zerlik
- Altonaer Kinderkrankenhaus gGmbH, Abteilung Physiotherapie, Hamburg, Deutschland
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Conceição M, Shteinberg M, Goeminne P, Altenburg J, Chalmers JD. Eradication treatment for Pseudomonas aeruginosa infection in adults with bronchiectasis: a systematic review and meta-analysis. Eur Respir Rev 2024; 33:230178. [PMID: 38296344 PMCID: PMC10828832 DOI: 10.1183/16000617.0178-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/24/2023] [Indexed: 02/03/2024] Open
Abstract
INTRODUCTION Pseudomonas aeruginosa is the most commonly isolated pathogen in bronchiectasis and is associated with worse outcomes. Eradication treatment is recommended by guidelines, but the evidence base is limited. The expected success rate of eradication in clinical practice is not known. METHODS We conducted a systematic review and meta-analysis according to Meta-Analysis of Observational Studies in Epidemiology guidelines. PubMed, Embase, the Cochrane Database of Systematic Reviews and Clinicaltrials.gov were searched for studies investigating P. aeruginosa eradication treatment using antibiotics (systemic or inhaled) in patients with bronchiectasis. The primary outcome was the percentage of patients negative for P. aeruginosa at 12 months after eradication treatment. Cystic fibrosis was excluded. RESULTS Six observational studies including 289 patients were included in the meta-analysis. Our meta-analysis found a 12-month P. aeruginosa eradication rate of 40% (95% CI 34-45%; p<0.00001), with no significant heterogeneity (I2=0%). Combined systemic and inhaled antibiotic treatment was associated with a higher eradication rate (48%, 95% CI 41-55%) than systemic antibiotics alone (27%, 13-45%). CONCLUSION Eradication treatment in bronchiectasis results in eradication of P. aeruginosa from sputum in ∼40% of cases at 12 months. Combined systemic and inhaled antibiotics achieve higher eradication rates than systemic antibiotics alone.
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Affiliation(s)
- Mariana Conceição
- Pulmonology Department, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Michal Shteinberg
- Pulmonology Institute and CF Center, Carmel Medical Center, Haifa, Israel
| | - Pieter Goeminne
- Department of Respiratory Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Josje Altenburg
- Department of Respiratory Disease, AZ Nikolaas, Sint-Niklaas, Belgium
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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Gilchrist FJ, Bui S, Gartner S, McColley SA, Tiddens H, Ruiz G, Stehling F, Alani M, Gurtovaya O, Bresnik M, Watkins TR, Frankovic B, Skov M. ALPINE2: Efficacy and safety of 14-day vs 28-day inhaled aztreonam for Pa eradication in children with cystic fibrosis. J Cyst Fibros 2024; 23:80-86. [PMID: 37455237 DOI: 10.1016/j.jcf.2023.06.008] [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: 03/06/2023] [Revised: 06/06/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Antibiotic eradication therapies recommended for newly isolated Pseudomonas aeruginosa (Pa) in people with cystic fibrosis (pwCF) can be burdensome. ALPINE2 compared the efficacy and safety of a shortened 14-day course of aztreonam for inhalation solution (AZLI) with 28-day AZLI in paediatric pwCF. METHODS ALPINE2 (a double-blind, phase 3b study) included children aged 3 months to <18 years with CF and new-onset Pa infection. Participants were randomized to receive 75 mg AZLI three times daily for either 28 or 14 days followed by 14 days' matched placebo. The primary endpoint was rate of primary Pa eradication (no Pa detected during the 4 weeks post AZLI treatment). Non-inferiority was achieved if the lower 95% CI bound of the treatment difference between the two arms was above -20%. Secondary endpoints included assessments of Pa recurrence during 108 weeks of follow-up after primary eradication. Safety endpoints included treatment-emergent adverse events (TEAEs). RESULTS In total, 149 participants were randomized (14-day AZLI, n = 74; 28-day AZLI, n = 75) and 142 (95.3%) completed treatment. Median age: 6.0 years (range: 0.3-17.0). Baseline characteristics were similar between treatment arms. Primary Pa eradication rates: 14-day AZLI, 55.9%; 28-day AZLI, 63.4%; treatment difference (CI), -8.0% (-24.6, 8.6%). Pa recurrence rates at follow-up end: 14-day AZLI, 54.1% (n = 20/37); 28-day AZLI, 41.9% (n = 18/43). TEAEs were similar between treatment arms. No new safety signals were observed. CONCLUSIONS Non-inferiority of 14-day AZLI versus 28-day AZLI was not demonstrated. Both courses were well tolerated, further supporting AZLI short-term safety in paediatric and adolescent pwCF. CLINICALTRIALS GOV: NCT03219164.
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Affiliation(s)
- Francis J Gilchrist
- Paediatric Respiratory Services, Staffordshire Children's Hospital at Royal Stoke, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK; Institute of Applied Clinical Science, Keele University, Stoke-on-Trent, UK.
| | - Stephanie Bui
- Bordeaux University Hospital, Hôpital Pellegrin-Enfants, Paediatric Cystic Fibrosis Reference Center (CRCM), Centre d'Investigation Clinique (CIC 1401), Bordeaux, France.
| | - Silvia Gartner
- Paediatric Pulmonology and Cystic Fibrosis Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
| | - Susanna A McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pulmonary and Sleep Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Harm Tiddens
- Department of Pediatric Pulmonology and Allergology, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands.
| | - Gary Ruiz
- Department of Paediatric Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK.
| | - Florian Stehling
- Pediatric Pulmonology and Sleep Medicine, Cystic Fibrosis Center, Children's Hospital, University Duisburg-Essen, Essen, Germany.
| | - Muhsen Alani
- Gilead Sciences Inc., Foster City, CA, USA; Division of Rheumatology, University of Washington, Seattle, WA, USA.
| | | | | | | | | | - Marianne Skov
- CF Centre Copenhagen, Paediatric Pulmonary Service, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
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Dupont C, Aujoulat F, Benaoudia M, Jumas-Bilak E, Chiron R, Marchandin H. Highly diverse dynamics of Pseudomonas aeruginosa colonization from initial detection in cystic fibrosis patients: A 7-year longitudinal genetic diversity study. INFECTION, GENETICS AND EVOLUTION : JOURNAL OF MOLECULAR EPIDEMIOLOGY AND EVOLUTIONARY GENETICS IN INFECTIOUS DISEASES 2023; 115:105513. [PMID: 37832753 DOI: 10.1016/j.meegid.2023.105513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/04/2023] [Accepted: 10/10/2023] [Indexed: 10/15/2023]
Abstract
In cystic fibrosis (CF), Pseudomonas aeruginosa (Pa) is a major pathogen that can persistently colonize patients. Genetic studies showed a high diversity of Pa, the success of widespread or 'international' clones and described epidemic clones in CF and Epidemic High-Risk (ERH) clones. Here, we characterized Pa genetic diversity over time after first colonization in CF patients, with the aim of accurately describing the dynamics of colonization in a context of scarce longitudinal studies including the first isolated Pa strain. Results represent the first genotyping data available for CF Pa in France. Forty-four CF patients with a first Pa colonization were included; 265 strains collected over 7 years in these patients were genotyped by multiplex rep-PCR, multilocus sequence typing, pulsed-field gel electrophoresis and/or whole genome sequencing. Forty-one sequence types were identified: 4 were unknown, 22 never previously reported for CF patients, and 6 corresponded to widespread clones colonizing 16 patients (36%). Unrelated strains were identified in 41 patients (93%). Twenty-six patients (59%) presented a recurrence during the study period. No specific clones were associated with transient, recurrent or persistent colonization. Our longitudinal study revealed that 9 of the 26 patients with recurrence (35%) harbored strains of different genotypes. Great genetic diversity was observed among initial Pa isolates excluding any cross-transmission. Persistent colonization may appear more complex than expected, imitating persistence, with successive colonization events by unrelated Pa.
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Affiliation(s)
- Chloé Dupont
- HydroSciences Montpellier, Univ Montpellier, CNRS, IRD, Laboratoire de Bactériologie, CHU de Montpellier, France.
| | - Fabien Aujoulat
- HydroSciences Montpellier, Univ Montpellier, CNRS, IRD, France
| | | | - Estelle Jumas-Bilak
- HydroSciences Montpellier, Univ Montpellier, CNRS, IRD, Laboratoire d'Ecologie Microbienne Hospitalière, CHU de Montpellier, France
| | - Raphaël Chiron
- HydroSciences Montpellier, Univ Montpellier, CNRS, IRD, Centre de Ressources et de Compétences de la Mucoviscidose, CHU de Montpellier, France
| | - Hélène Marchandin
- HydroSciences Montpellier, Univ Montpellier, CNRS, IRD, Service de Microbiologie et Hygiène Hospitalière, CHU de Nîmes, France.
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Langton Hewer SC, Smith S, Rowbotham NJ, Yule A, Smyth AR. Antibiotic strategies for eradicating Pseudomonas aeruginosa in people with cystic fibrosis. Cochrane Database Syst Rev 2023; 6:CD004197. [PMID: 37268599 PMCID: PMC10237531 DOI: 10.1002/14651858.cd004197.pub6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Respiratory tract infections with Pseudomonas aeruginosa occur in most people with cystic fibrosis (CF). Established chronic P aeruginosa infection is virtually impossible to eradicate and is associated with increased mortality and morbidity. Early infection may be easier to eradicate. This is an updated review. OBJECTIVES Does giving antibiotics for P aeruginosa infection in people with CF at the time of new isolation improve clinical outcomes (e.g. mortality, quality of life and morbidity), eradicate P aeruginosa infection, and delay the onset of chronic infection, but without adverse effects, compared to usual treatment or an alternative antibiotic regimen? We also assessed cost-effectiveness. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and conference proceedings. Latest search: 24 March 2022. We searched ongoing trials registries. Latest search: 6 April 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) of people with CF, in whom P aeruginosa had recently been isolated from respiratory secretions. We compared combinations of inhaled, oral or intravenous (IV) antibiotics with placebo, usual treatment or other antibiotic combinations. We excluded non-randomised trials and cross-over trials. DATA COLLECTION AND ANALYSIS Two authors independently selected trials, assessed risk of bias and extracted data. We assessed the certainty of the evidence using GRADE. MAIN RESULTS We included 11 trials (1449 participants) lasting between 28 days and 27 months; some had few participants and most had relatively short follow-up periods. Antibiotics in this review are: oral - ciprofloxacin and azithromycin; inhaled - tobramycin nebuliser solution for inhalation (TNS), aztreonam lysine (AZLI) and colistin; IV - ceftazidime and tobramycin. There was generally a low risk of bias from missing data. In most trials it was difficult to blind participants and clinicians to treatment. Two trials were supported by the manufacturers of the antibiotic used. TNS versus placebo TNS may improve eradication; fewer participants were still positive for P aeruginosa at one month (odds ratio (OR) 0.06, 95% confidence interval (CI) 0.02 to 0.18; 3 trials, 89 participants; low-certainty evidence) and two months (OR 0.15, 95% CI 0.03 to 0.65; 2 trials, 38 participants). We are uncertain whether the odds of a positive culture decrease at 12 months (OR 0.02, 95% CI 0.00 to 0.67; 1 trial, 12 participants). TNS (28 days) versus TNS (56 days) One trial (88 participants) comparing 28 days to 56 days TNS treatment found duration of treatment may make little or no difference in time to next isolation (hazard ratio (HR) 0.81, 95% CI 0.37 to 1.76; low-certainty evidence). Cycled TNS versus culture-based TNS One trial (304 children, one to 12 years old) compared cycled TNS to culture-based therapy and also ciprofloxacin to placebo. We found moderate-certainty evidence of an effect favouring cycled TNS therapy (OR 0.51, 95% CI 0.31 to 0.82), although the trial publication reported age-adjusted OR and no difference between groups. Ciprofloxacin versus placebo added to cycled and culture-based TNS therapy One trial (296 participants) examined the effect of adding ciprofloxacin versus placebo to cycled and culture-based TNS therapy. There is probably no difference between ciprofloxacin and placebo in eradicating P aeruginosa (OR 0.89, 95% CI 0.55 to 1.44; moderate-certainty evidence). Ciprofloxacin and colistin versus TNS We are uncertain whether there is any difference between groups in eradication of P aeruginosa at up to six months (OR 0.43, 95% CI 0.15 to 1.23; 1 trial, 58 participants) or up to 24 months (OR 0.76, 95% CI 0.24 to 2.42; 1 trial, 47 participants); there was a low rate of short-term eradication in both groups. Ciprofloxacin plus colistin versus ciprofloxacin plus TNS One trial (223 participants) found there may be no difference in positive respiratory cultures at 16 months between ciprofloxacin with colistin versus TNS with ciprofloxacin (OR 1.28, 95% CI 0.72 to 2.29; low-certainty evidence). TNS plus azithromycin compared to TNS plus oral placebo Adding azithromycin may make no difference to the number of participants eradicating P aeruginosa after a three-month treatment phase (risk ratio (RR) 1.01, 95% CI 0.75 to 1.35; 1 trial, 91 participants; low-certainty evidence); there was also no evidence of any difference in the time to recurrence. Ciprofloxacin and colistin versus no treatment A single trial only reported one of our planned outcomes; there were no adverse effects in either group. AZLI for 14 days plus placebo for 14 days compared to AZLI for 28 days We are uncertain whether giving 14 or 28 days of AZLI makes any difference to the proportion of participants having a negative respiratory culture at 28 days (mean difference (MD) -7.50, 95% CI -24.80 to 9.80; 1 trial, 139 participants; very low-certainty evidence). Ceftazidime with IV tobramycin compared with ciprofloxacin (both regimens in conjunction with three months colistin) IV ceftazidime with tobramycin compared with ciprofloxacin may make little or no difference to eradication of P aeruginosa at three months, sustained to 15 months, provided that inhaled antibiotics are also used (RR 0.84, 95 % CI 0.65 to 1.09; P = 0.18; 1 trial, 255 participants; high-certainty evidence). The results do not support using IV antibiotics over oral therapy to eradicate P aeruginosa, based on both eradication rate and financial cost. AUTHORS' CONCLUSIONS We found that nebulised antibiotics, alone or with oral antibiotics, were better than no treatment for early infection with P aeruginosa. Eradication may be sustained in the short term. There is insufficient evidence to determine whether these antibiotic strategies decrease mortality or morbidity, improve quality of life, or are associated with adverse effects compared to placebo or standard treatment. Four trials comparing two active treatments have failed to show differences in rates of eradication of P aeruginosa. One large trial showed that intravenous ceftazidime with tobramycin is not superior to oral ciprofloxacin when inhaled antibiotics are also used. There is still insufficient evidence to state which antibiotic strategy should be used for the eradication of early P aeruginosa infection in CF, but there is now evidence that intravenous therapy is not superior to oral antibiotics.
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Affiliation(s)
- Simon C Langton Hewer
- Paediatric Respiratory Medicine, Bristol Royal Hospital for Children, Bristol, UK
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Sherie Smith
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nicola J Rowbotham
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Alexander Yule
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Alan R Smyth
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
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Møller R, Pressler T, Qvist T. Antimicrobial Strategies for Cystic Fibrosis. Semin Respir Crit Care Med 2023; 44:297-306. [PMID: 36535665 DOI: 10.1055/s-0042-1758733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Lung infection is the leading cause of death in cystic fibrosis (CF), and antimicrobial therapies are the backbone of infection management. While many different strategies may be applied, rigorous microbiological surveillance, intensive eradication therapy, and long-term maintenance therapy based on inhaled antibiotics may be considered the main strategy for infection control in individuals with CF. While most of the existing evidence is based on infection with Pseudomonas aeruginosa, other important pathogens causing lung inflammation and deterioration exist and should be treated despite the evidence gap. In this chapter, we describe the approaches to the antimicrobial treatment of the most important pathogens in CF and the evidence behind.
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Affiliation(s)
- Rikke Møller
- Department of Infectious Diseases, Cystic Fibrosis Center Copenhagen, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Tacjana Pressler
- Department of Infectious Diseases, Cystic Fibrosis Center Copenhagen, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Tavs Qvist
- Department of Infectious Diseases, Cystic Fibrosis Center Copenhagen, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
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Thornton CS, Parkins MD. Microbial Epidemiology of the Cystic Fibrosis Airways: Past, Present, and Future. Semin Respir Crit Care Med 2023; 44:269-286. [PMID: 36623820 DOI: 10.1055/s-0042-1758732] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Progressive obstructive lung disease secondary to chronic airway infection, coupled with impaired host immunity, is the leading cause of morbidity and mortality in cystic fibrosis (CF). Classical pathogens found in the airways of persons with CF (pwCF) include Pseudomonas aeruginosa, Staphylococcus aureus, the Burkholderia cepacia complex, Achromobacter species, and Haemophilus influenzae. While traditional respiratory-tract surveillance culturing has focused on this limited range of pathogens, the use of both comprehensive culture and culture-independent molecular approaches have demonstrated complex highly personalized microbial communities. Loss of bacterial community diversity and richness, counteracted with relative increases in dominant taxa by traditional CF pathogens such as Burkholderia or Pseudomonas, have long been considered the hallmark of disease progression. Acquisition of these classic pathogens is viewed as a harbinger of advanced disease and postulated to be driven in part by recurrent and frequent antibiotic exposure driven by frequent acute pulmonary exacerbations. Recently, CF transmembrane conductance regulator (CFTR) modulators, small molecules designed to potentiate or restore diminished protein levels/function, have been successfully developed and have profoundly influenced disease course. Despite the multitude of clinical benefits, structural lung damage and consequent chronic airway infection persist in pwCF. In this article, we review the microbial epidemiology of pwCF, focus on our evolving understanding of these infections in the era of modulators, and identify future challenges in infection surveillance and clinical management.
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Affiliation(s)
- Christina S Thornton
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Michael D Parkins
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Alberta, Canada
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Schütz K, Grewendorf S, Kontsendorn J, Fuge J, Happle C, Rudolf I, Dopfer C, Sedlacek L, Hansen G, Junge S, Dittrich AM. Comparison of Three Eradication Treatment Protocols for Pseudomonas Aeruginosa in Children and Adolescents with Cystic Fibrosis. KLINISCHE PADIATRIE 2023; 235:75-83. [PMID: 36758577 DOI: 10.1055/a-1996-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
BACKGROUND Pseudomonas aeruginosa (Pa) continues to affect disease progression in cystic fibrosis (CF). However, the best eradication regimen remains unclear. This work compares three different antibiotic eradication regimens in pediatric CF: an administration according to a standard-operating procedure (SOP) order vs. administration outside of this order (ooSOP). METHODS This observational study includes all CF patients<18 years who received one of three Pa eradication treatments in the past eight years at our center: 1) inhaled high-dose tobramycin (Hi-TOBI), 2) inhaled colistin+oral ciprofloxacin (COL/Cip), 3) inhaled low-dose tobramycin+4 intravenous 14-day Pa active antibiotic treatments (lo-Tobra/IV). We compared eradication rates of the three treatment regimens performed according to the SOP-based order vs. ooSOP. Logistic regression analysis was performed to identify risk factors for eradication failure. RESULTS Performed according to SOP order, Hi-TOBI showed the greatest efficacy, followed by lo-Tobra/IV and finally COL/Cip, while ooSOP lo-Tobra/IV was most successful, followed by COL/Cip and Hi-TOBI. Previous Pa-infections and Pa-therapies along with age at CF diagnosis were risk factors for eradication failure. CONCLUSION Antibiotic treatment in SOP-based pre-defined order leads to significantly better eradication rates than individual modifications of the order of administration. A short course of inhalational high-dose Tobramycin is most successful at the first attempt. Prolonged antibiotic therapy seems to improve eradication after failed initial attempts.
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Affiliation(s)
- Katharina Schütz
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany.,Excellence Cluster RESIST - Resolving Infection Susceptibility, Hannover Medical School, Hannover, Germany
| | - Simon Grewendorf
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany
| | - Julia Kontsendorn
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany.,German Center for Lung Research, BREATH location, Hannover Medical School, Hannover, Germany
| | - Jan Fuge
- German Center for Lung Research, BREATH location, Hannover Medical School, Hannover, Germany
| | - Christine Happle
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany.,Excellence Cluster RESIST - Resolving Infection Susceptibility, Hannover Medical School, Hannover, Germany.,German Center for Lung Research, BREATH location, Hannover Medical School, Hannover, Germany
| | - Isa Rudolf
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany.,German Center for Lung Research, BREATH location, Hannover Medical School, Hannover, Germany
| | - Christian Dopfer
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany
| | - Ludwig Sedlacek
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - Gesine Hansen
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany.,Excellence Cluster RESIST - Resolving Infection Susceptibility, Hannover Medical School, Hannover, Germany.,German Center for Lung Research, BREATH location, Hannover Medical School, Hannover, Germany
| | - Sibylle Junge
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany
| | - Anna-Maria Dittrich
- Dep. of Paediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany.,German Center for Lung Research, BREATH location, Hannover Medical School, Hannover, Germany
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9
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Casaredi IG, Shaw M, Waters V, Seeto R, Blanchard AC, Ratjen F. Impact of antibiotic eradication therapy of Pseudomonas aeruginosa on long term lung function in cystic fibrosis. J Cyst Fibros 2023; 22:98-102. [PMID: 35995678 DOI: 10.1016/j.jcf.2022.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 08/10/2022] [Accepted: 08/10/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION While antibiotic eradication therapy (AET) of early Pseudomonas aeruginosa infection is considered standard of care, its long-term effect on the subsequent course of cystic fibrosis (CF) lung disease remains unclear. METHODS CF patients who were P. aeruginosa-free for at least a year and had a minimum of 10 years of pulmonary function measurements were included. Subjects were categorized as Never if they never had P. aeruginosa isolated from a respiratory tract sample. Subjects changed to the Eradicated group if they had a P. aeruginosa infection, were treated with AET, and subsequently cleared their infection. Subjects changed to the Chronic group if AET did not clear their P. aeruginosa infection. The primary outcome was absolute FEV1 decline over time, with age as the time variable. Mixed-effects linear regression models were used to account for the repeated lung function measurements over time within each patient. RESULTS 205 CF subjects (48% female) were included; the median (IQR) age at first infection was 9.6 (5.6, 14.6) years. The median (IQR) follow-up was 10.2 (5.7, 14.7) years for the Eradicated group, 8.8 (4.5, 14.9) years for the Chronic group and 2.8 (1.0, 5.7) years for the Never group was among those patients that had at least one P. aeruginosa infection over the study period, annual lung function decline of FEV1 was significantly less (-1.11% predicted/year; 95% CI: -1.18, -1.04) in the Eradication group compared to the Chronic group (-1.57%; -1.64, -1.50) (p<0.001). CONCLUSIONS AET against P. aeruginosa improves lung function trajectory in CF patients.
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Affiliation(s)
- Isabel Gascon Casaredi
- Division of Respiratory Medicine, Department of Pediatrics, Hospital Sant Joan de Déu de Barcelona, Universidad de Barcelona, Barcelona, Spain; Division of Respiratory Medicine, Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Michelle Shaw
- Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Valerie Waters
- Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Canada; Division of Infectious Diseases, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Ryan Seeto
- Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Ana C Blanchard
- Division of Infectious Diseases, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics, Hospital Sant Joan de Déu de Barcelona, Universidad de Barcelona, Barcelona, Spain; Division of Respiratory Medicine, Department of Paediatrics, University of Toronto, Toronto, Canada; Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Canada.
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10
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Athanazio RA, Tanni SE, Ferreira J, Dalcin PDTR, Fuccio MBD, Esposito C, Canan MGM, Coelho LS, Firmida MDC, Almeida MBD, Marostica PJC, Monte LDFV, Souza EL, Pinto LA, Rached SZ, Oliveira VSBD, Riedi CA, Silva Filho LVRFD. Brazilian guidelines for the pharmacological treatment of the pulmonary symptoms of cystic fibrosis. Official document of the Sociedade Brasileira de Pneumologia e Tisiologia (SBPT, Brazilian Thoracic Association). J Bras Pneumol 2023; 49:e20230040. [PMID: 37194817 DOI: 10.36416/1806-3756/e20230040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 03/31/2023] [Indexed: 05/18/2023] Open
Abstract
Cystic fibrosis (CF) is a genetic disease that results in dysfunction of the CF transmembrane conductance regulator (CFTR) protein, which is a chloride and bicarbonate channel expressed in the apical portion of epithelial cells of various organs. Dysfunction of that protein results in diverse clinical manifestations, primarily involving the respiratory and gastrointestinal systems, impairing quality of life and reducing life expectancy. Although CF is still an incurable pathology, the therapeutic and prognostic perspectives are now totally different and much more favorable. The purpose of these guidelines is to define evidence-based recommendations regarding the use of pharmacological agents in the treatment of the pulmonary symptoms of CF in Brazil. Questions in the Patients of interest, Intervention to be studied, Comparison of interventions, and Outcome of interest (PICO) format were employed to address aspects related to the use of modulators of this protein (ivacaftor, lumacaftor+ivacaftor, and tezacaftor+ivacaftor), use of dornase alfa, eradication therapy and chronic suppression of Pseudomonas aeruginosa, and eradication of methicillin-resistant Staphylococcus aureus and Burkholderia cepacia complex. To formulate the PICO questions, a group of Brazilian specialists was assembled and a systematic review was carried out on the themes, with meta-analysis when applicable. The results obtained were analyzed in terms of the strength of the evidence compiled, the recommendations being devised by employing the GRADE approach. We believe that these guidelines represent a major advance to be incorporated into the approach to patients with CF, mainly aiming to favor the management of the disease, and could become an auxiliary tool in the definition of public policies related to CF.
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Affiliation(s)
- Rodrigo Abensur Athanazio
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Suzana Erico Tanni
- . Faculdade de Medicina de Botucatu, Universidade Estadual Paulista Julio de Mesquita Filho - UNESP - Botucatu (SP) Brasil
| | - Juliana Ferreira
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Paulo de Tarso Roth Dalcin
- . Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
- . Serviço de Pneumologia, Hospital de Clínicas de Porto Alegre - HCPA - Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | - Marcelo B de Fuccio
- . Hospital Júlia Kubitschek, Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | | | | | - Liana Sousa Coelho
- . Faculdade de Medicina de Botucatu, Universidade Estadual Paulista Julio de Mesquita Filho - UNESP - Botucatu (SP) Brasil
| | | | - Marina Buarque de Almeida
- . Unidade de Pneumologia, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Paulo José Cauduro Marostica
- . Unidade de Pneumologia Infantil, Hospital de Clínicas de Porto Alegre - HCPA - Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | | | - Edna Lúcia Souza
- . Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador (BA) Brasil
| | | | - Samia Zahi Rached
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Verônica Stasiak Bednarczuk de Oliveira
- . Hospital de Clínicas, Universidade Federal do Paraná, Curitiba (PR) Brasil
- . Unidos Pela Vida - Instituto Brasileiro de Atenção à Fibrose Cística, Curitiba (PR) Brasil
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11
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Rakhshan A, Farahbakhsh N, Khanbabaee G, Tabatabaii SA, Sadr S, Hassanzad M, Sistanizad M, Dastan F, Hajipour M, Bahadori AR, Mirrahimi B. Evaluating the efficacy of inhaled amikacin as an adjunct to intravenous combination therapy (ceftazidime and amikacin) in pediatric cystic fibrosis pulmonary exacerbation. Front Pharmacol 2023; 14:1130374. [PMID: 36969859 PMCID: PMC10034196 DOI: 10.3389/fphar.2023.1130374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/22/2023] [Indexed: 03/29/2023] Open
Abstract
Background: Pseudomonas aeruginosa is the most common microorganism found in the sputum culture of Cystic fibrosis (CF) patients causing the pulmonary destruction. Aminoglycosides have a low diffuse rate from lipid membranes, and respiratory system secretions. Regarding the burden of pulmonary exacerbation caused by the pseudomonas aeruginosa in cystic fibrosis patients in the long term and the limited number of clinical trials focused on appropriate treatment strategies, the present study evaluated the concurrent inhaled and intravenous aminoglycoside antibiotics for pulmonary exacerbation caused by the pseudomonas aeruginosa as a safe and effective treatment in children. Method: This study was a blinded, randomized clinical trial phase conducted in a tertiary referral pediatric teaching hospital from May 2021 to May 2022. The patients were randomly allocated to receive intravenously administered ceftazidime and Amikacin alone or with inhaled Amikacin. Forced expiratory volume (FEV1), Amikacin via the level, kidney function tests, audiometry, inflammatory markers (erythrocyte sedimentation rate and C-reactive protein), hospital stay, and bacterial eradication rate were compared in two therapy groups. Results: the average FEV1 has increased by 47% in Neb + group compared to Neb- group following treatment. Hospital stay was lower in Neb + group. No renal toxicity or ototoxicity was observed in both therapy groups. Pseudomonas aeruginosa eradication rate Neb- and Neb + groups were 44% and 69%, respectively (p-value = 0.15). Conclusion: Concurrent inhaled and intravenous Amikacin is safe and effective to treat Pseudomonas aeruginosa exacerbation in CF patients. Moreover, co-delivery antibiotics' route treatment increased the eradication rate. Although not statistically significant, never the less, it is clinically relevant. The intervention reduced the length of hospitalization in this group. Clinical Trial Registration: clinicaltrials.gov, identifier [IRCT20120415009475N10].
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Affiliation(s)
- Amin Rakhshan
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nazanin Farahbakhsh
- Department of Pediatric Pulmonology, Mofid Children’s Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ghamartaj Khanbabaee
- Department of Pediatric Pulmonology, Mofid Children’s Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Ahmad Tabatabaii
- Department of Pediatric Pulmonology, Mofid Children’s Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeed Sadr
- Department of Pediatric Pulmonology, Mofid Children’s Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Hassanzad
- Pediatric Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Sistanizad
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzaneh Dastan
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahmoud Hajipour
- Children’s Gastroenterology, Liver and Nutrition Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Reza Bahadori
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Bahador Mirrahimi
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- *Correspondence: Bahador Mirrahimi,
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12
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Smith S, Rowbotham NJ. Inhaled anti-pseudomonal antibiotics for long-term therapy in cystic fibrosis. Cochrane Database Syst Rev 2022; 11:CD001021. [PMID: 36373968 PMCID: PMC9662285 DOI: 10.1002/14651858.cd001021.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Inhaled antibiotics are commonly used to treat persistent airway infection with Pseudomonas aeruginosa that contributes to lung damage in people with cystic fibrosis. Current guidelines recommend inhaled tobramycin for individuals with cystic fibrosis and persistent Pseudomonas aeruginosa infection who are aged six years or older. The aim is to reduce bacterial load in the lungs so as to reduce inflammation and deterioration of lung function. This is an update of a previously published review. OBJECTIVES To evaluate the effects of long-term inhaled antibiotic therapy in people with cystic fibrosis on clinical outcomes (lung function, frequency of exacerbations and nutrition), quality of life and adverse events (including drug-sensitivity reactions and survival). SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched ongoing trials registries. Date of last search: 28 June 2022. SELECTION CRITERIA We selected trials where people with cystic fibrosis received inhaled anti-pseudomonal antibiotic treatment for at least three months, treatment allocation was randomised or quasi-randomised, and there was a control group (either placebo, no placebo or another inhaled antibiotic). DATA COLLECTION AND ANALYSIS Two authors independently selected trials, judged the risk of bias, extracted data from these trials and judged the certainty of the evidence using the GRADE system. MAIN RESULTS The searches identified 410 citations to 125 trials; 18 trials (3042 participants aged between five and 45 years) met the inclusion criteria. Limited data were available for meta-analyses due to the variability of trial design and reporting of results. A total of 11 trials (1130 participants) compared an inhaled antibiotic to placebo or usual treatment for a duration between three and 33 months. Five trials (1255 participants) compared different antibiotics, two trials (585 participants) compared different regimens of tobramycin and one trial (90 participants) compared intermittent tobramycin with continuous tobramycin alternating with aztreonam. One trial (18 participants) compared an antibiotic to placebo and also to a different antibiotic and so fell into both groups. The most commonly studied antibiotic was tobramycin which was studied in 12 trials. Inhaled antibiotics compared to placebo We found that inhaled antibiotics may improve lung function measured in a variety of ways (4 trials, 814 participants). Compared to placebo, inhaled antibiotics may also reduce the frequency of exacerbations (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.47 to 0.93; 3 trials, 946 participants; low-certainty evidence). Inhaled antibiotics may lead to fewer days off school or work (quality of life measure) (mean difference (MD) -5.30 days, 95% CI -8.59 to -2.01; 1 trial, 245 participants; low-certainty evidence). There were insufficient data for us to be able to report an effect on nutritional outcomes and there was no effect on survival. There was no effect on antibiotic resistance seen in the two trials that were included in meta-analyses. We are uncertain of the effect of the intervention on adverse events (very low-certainty evidence), but tinnitus and voice alteration were the only events occurring more often in the inhaled antibiotics group. The overall certainty of evidence was deemed to be low for most outcomes due to risk of bias within the trials and imprecision due to low event rates. Different antibiotics or regimens compared Of the eight trials comparing different inhaled antibiotics or different antibiotic regimens, there was only one trial for each unique comparison. We found no differences between groups for any outcomes except for the following. Aztreonam lysine for inhalation probably improved forced expiratory volume at one second (FEV1) % predicted compared to tobramycin (MD -3.40%, 95% CI -6.63 to -0.17; 1 trial, 273 participants; moderate-certainty evidence). However, the method of defining the endpoint was different to the remaining trials and the participants were exposed to tobramycin for a long period making interpretation of the results problematic. We found no differences in any measure of lung function in the remaining comparisons. Trials measured pulmonary exacerbations in different ways and showed no differences between groups except for aztreonam lysine probably leading to fewer people needing treatment with additional antibiotics than with tobramycin (RR 0.66, 95% CI 0.51 to 0.86; 1 trial, 273 participants; moderate-certainty evidence); and there were fewer hospitalisations due to respiratory exacerbations with levofloxacin compared to tobramycin (RR 0.62, 95% CI 0.40 to 0.98; 1 trial, 282 participants; high-certainty evidence). Important treatment-related adverse events were not very common across comparisons, but were reported less often in the tobramycin group compared to both aztreonam lysine and colistimethate. We found the certainty of evidence for these comparisons to be directly related to the risk of bias within the individual trials and varied from low to high. AUTHORS' CONCLUSIONS Long-term treatment with inhaled anti-pseudomonal antibiotics probably improves lung function and reduces exacerbation rates, but pooled estimates of the level of benefit were very limited. The best evidence available is for inhaled tobramycin. More evidence from trials measuring similar outcomes in the same way is needed to determine a better measure of benefit. Longer-term trials are needed to look at the effect of inhaled antibiotics on quality of life, survival and nutritional outcomes.
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Affiliation(s)
- Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
| | - Nicola J Rowbotham
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
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13
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Blanchard AC, Waters VJ. Opportunistic Pathogens in Cystic Fibrosis: Epidemiology and Pathogenesis of Lung Infection. J Pediatric Infect Dis Soc 2022; 11:S3-S12. [PMID: 36069904 DOI: 10.1093/jpids/piac052] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022]
Abstract
Cystic fibrosis (CF) is one of the most common life-shortening genetic diseases in Caucasians. Due to abnormal accumulation of mucus, respiratory failure caused by chronic infections is the leading cause of mortality in this patient population. The microbiology of these respiratory infections includes a distinct set of opportunistic pathogens, including Pseudomonas aeruginosa, Burkholderia spp., Achromobacter spp., Stenotrophomonas maltophilia, anaerobes, nontuberculous mycobacteria, and fungi. In recent years, culture-independent methods have shown the polymicrobial nature of lung infections, and the dynamics of microbial communities. The unique environment of the CF airway predisposes to infections caused by opportunistic pathogens. In this review, we will highlight how the epidemiology and role in disease of these pathogens in CF differ from that in individuals with other medical conditions. Infectious diseases (ID) physicians should be aware of these differences and the specific characteristics of infections associated with CF.
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Affiliation(s)
- Ana C Blanchard
- Department of Pediatrics, Division of Infectious Diseases, CHU Sainte-Justine, Université de Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada
| | - Valerie J Waters
- Department of Pediatrics, Division of Infectious Diseases, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
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14
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Thornton CS, Acosta N, Surette MG, Parkins MD. Exploring the Cystic Fibrosis Lung Microbiome: Making the Most of a Sticky Situation. J Pediatric Infect Dis Soc 2022; 11:S13-S22. [PMID: 36069903 PMCID: PMC9451016 DOI: 10.1093/jpids/piac036] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/16/2022] [Indexed: 01/02/2023]
Abstract
Chronic lower respiratory tract infections are a leading contributor to morbidity and mortality in persons with cystic fibrosis (pwCF). Traditional respiratory tract surveillance culturing has focused on a limited range of classic pathogens; however, comprehensive culture and culture-independent molecular approaches have demonstrated complex communities highly unique to each individual. Microbial community structure evolves through the lifetime of pwCF and is associated with baseline disease state and rates of disease progression including occurrence of pulmonary exacerbations. While molecular analysis of the airway microbiome has provided insight into these dynamics, challenges remain including discerning not only "who is there" but "what they are doing" in relation to disease progression. Moreover, the microbiome can be leveraged as a multi-modal biomarker for both disease activity and prognostication. In this article, we review our evolving understanding of the role these communities play in pwCF and identify challenges in translating microbiome data to clinical practice.
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Affiliation(s)
- Christina S Thornton
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nicole Acosta
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Michael G Surette
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Michael D Parkins
- Corresponding Author: Michael D. Parkins, MD, MSc, FRCPC, Associate Professor, Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada; Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada; Snyder Institute for Chronic Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada. E-mail:
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15
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Lloyd EC, Cogen JD, Maples H, Bell SC, Saiman L. Antimicrobial Stewardship in Cystic Fibrosis. J Pediatric Infect Dis Soc 2022; 11:S53-S61. [PMID: 36069899 DOI: 10.1093/jpids/piac071] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
The chronic airway infection and inflammation characteristic of cystic fibrosis (CF) ultimately leads to progressive lung disease, the primary cause of death in persons with CF (pwCF). Despite many recent advances in CF clinical care, efforts to preserve lung function in many pwCF still necessitate frequent antimicrobial use. Incorporating antimicrobial stewardship (AMS) principles into management of pulmonary exacerbations (PEx) would facilitate development of best practices for antimicrobial utilization at CF care centers. However, AMS can be challenging in CF given the unique aspects of chronic, polymicrobial infection in the CF airways, lack of evidence-based guidelines for managing PEx, limited utility for antimicrobial susceptibility testing, and increased frequency of adverse drug events in pwCF. This article describes current evidence-based antimicrobial treatment strategies for pwCF, highlights the potential for AMS to beneficially impact CF care, and provides practical strategies for integrating AMS programs into the management of PEx in pwCF.
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Affiliation(s)
- Elizabeth C Lloyd
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jonathan D Cogen
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Holly Maples
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas, USA.,Quality and Safety Division, Arkansas Children's, Little Rock, Arkansas, USA
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia.,Children's Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Brisbane, Queensland, Australia
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA.,Department of Infection Prevention and Control, NewYork-Presbyterian Hospital, New York, New York, USA
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16
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LiPuma JJ. The Sense and Nonsense of Antimicrobial Susceptibility Testing in Cystic Fibrosis. J Pediatric Infect Dis Soc 2022; 11:S46-S52. [PMID: 36069902 DOI: 10.1093/jpids/piac040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/03/2022] [Indexed: 11/13/2022]
Abstract
Antimicrobial susceptibility testing (AST) has been used to guide therapy of airway infection in persons with cystic fibrosis (CF) for decades. However, evidence that AST adds benefit to treatment outcomes in CF is lacking. In fact, the routine use of AST has potential to exacerbate inappropriate antibiotic use. Several features of airway infection in CF contribute to the limitations of AST in predicting treatment outcomes, providing rationale for abandoning this practice altogether. Other features of CF infection suggest, however, that select use of AST can provide worthwhile guidance to antibiotic selection.
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Affiliation(s)
- John J LiPuma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
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17
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Cogen JD, Nichols DP, Goss CH, Somayaji R. Drugs, Drugs, Drugs: Current Treatment Paradigms in Cystic Fibrosis Airway Infections. J Pediatric Infect Dis Soc 2022; 11:S32-S39. [PMID: 36069901 DOI: 10.1093/jpids/piac061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/23/2022] [Indexed: 12/15/2022]
Abstract
Airway infections have remained a prominent feature in persons living with cystic fibrosis (CF) despite the dramatic improvements in survival in the past decades. Antimicrobials are a cornerstone of infection management for both acute and chronic maintenance indications. Historic clinical trials of antimicrobials in CF have led to the adoption of consensus guidelines for their use in clinical care. More recently, however, there are efforts to re-think the optimal use of antimicrobials for care with the advent of novel and highly effective CF transmembrane conductance regulator modulator therapies. Encouragingly, however, drug development has remained active concurrently in this space. Our review focuses on the evidence for and perspectives regarding antimicrobial use in both acute and maintenance settings in persons with CF. The therapeutic innovations in CF and how this may affect antimicrobial approaches are also discussed.
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Affiliation(s)
- Jonathan D Cogen
- Department of Pediatrics, University of Washington , Seattle, Washington, USA
| | - David P Nichols
- Department of Pediatrics, University of Washington , Seattle, Washington, USA.,Seattle Children's Research Institute, Seattle, Washington , USA
| | - Christopher H Goss
- Department of Pediatrics, University of Washington , Seattle, Washington, USA.,Seattle Children's Research Institute, Seattle, Washington , USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Ranjani Somayaji
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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18
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Abstract
BACKGROUND Cystic fibrosis is a genetic disorder in which abnormal mucus in the lungs is associated with susceptibility to persistent infection. Pulmonary exacerbations are when symptoms of infection become more severe. Antibiotics are an essential part of treatment for exacerbations and inhaled antibiotics may be used alone or in conjunction with oral antibiotics for milder exacerbations or with intravenous antibiotics for more severe infections. Inhaled antibiotics do not cause the same adverse effects as intravenous antibiotics and may prove an alternative in people with poor access to their veins. This is an update of a previously published review. OBJECTIVES To determine if treatment of pulmonary exacerbations with inhaled antibiotics in people with cystic fibrosis improves their quality of life, reduces time off school or work, and improves their long-term lung function. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Group's Cystic Fibrosis Trials Register. Date of the last search: 7 March 2022. We also searched ClinicalTrials.gov, the Australia and New Zealand Clinical Trials Registry and WHO ICTRP for relevant trials. Date of last search: 3 May 2022. SELECTION CRITERIA Randomised controlled trials in people with cystic fibrosis with a pulmonary exacerbation in whom treatment with inhaled antibiotics was compared to placebo, standard treatment or another inhaled antibiotic for between one and four weeks. DATA COLLECTION AND ANALYSIS Two review authors independently selected eligible trials, assessed the risk of bias in each trial and extracted data. They assessed the certainty of the evidence using the GRADE criteria. Authors of the included trials were contacted for more information. MAIN RESULTS Five trials with 183 participants are included in the review. Two trials (77 participants) compared inhaled antibiotics alone to intravenous antibiotics alone and three trials (106 participants) compared a combination of inhaled and intravenous antibiotics to intravenous antibiotics alone. Trials were heterogenous in design and two were only available in abstract form. Risk of bias was difficult to assess in most trials but, for four out of five trials, we judged there to be a high risk from lack of blinding and an unclear risk with regards to randomisation. Results were not fully reported and only limited data were available for analysis. One trial was a cross-over design and we only included data from the first intervention arm. Inhaled antibiotics alone versus intravenous antibiotics alone Only one trial (18 participants) reported a perceived improvement in lifestyle (quality of life) in both groups (very low-certainty evidence). Neither trial reported on time off work or school. Both trials measured lung function, but there was no difference reported between treatment groups (very low-certainty evidence). With regards to our secondary outcomes, one trial (18 participants) reported no difference in the need for additional antibiotics and the second trial (59 participants) reported on the time to next exacerbation. In neither case was a difference between treatments identified (both very low-certainty evidence). The single trial (18 participants) measuring adverse events and sputum microbiology did not observe any in either treatment group for either outcome (very low-certainty evidence). Inhaled antibiotics plus intravenous antibiotics versus intravenous antibiotics alone Inhaled antibiotics plus intravenous antibiotics may make little or no difference to quality of life compared to intravenous antibiotics alone. None of the trials reported time off work or school. All three trials measured lung function, but found no difference between groups in forced expiratory volume in one second (two trials; 44 participants; very low-certainty evidence) or vital capacity (one trial; 62 participants). None of the trials reported on the need for additional antibiotics. Inhaled plus intravenous antibiotics may make little difference to the time to next exacerbation; however, one trial (28 participants) reported on hospital admissions and found no difference between groups. There is likely no difference between groups in adverse events (very low-certainty evidence) and one trial (62 participants) reported no difference in the emergence of antibiotic-resistant organisms (very low-certainty evidence). AUTHORS' CONCLUSIONS We identified only low- or very low-certainty evidence to judge the effectiveness of inhaled antibiotics for the treatment of pulmonary exacerbations in people with cystic fibrosis. The included trials were not sufficiently powered to achieve their goals. Hence, we are unable to demonstrate whether one treatment was superior to the other or not. Further research is needed to establish whether inhaled tobramycin may be used as an alternative to intravenous tobramycin for some pulmonary exacerbations.
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Affiliation(s)
- Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
| | - Nicola J Rowbotham
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, The University of Nottingham, Nottingham, UK
| | - Edward Charbek
- Division of Pulmonary, Critical Care and Sleep Medicine, St Louis University School of Medicine, St Louis, MO, USA
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Sunman B, Emiralioglu N, Hazirolan G, Şener B, Ozsezen B, Tural DA, Buyuksahin HN, Guzelkas I, Yalcin E, Dogru D, Özçelik U, Kiper N. Effectiveness of different eradication treatment protocols for new-onset Pseudomonas aeruginosa in children with cystic fibrosis. Pediatr Pulmonol 2022; 57:1456-1465. [PMID: 35229497 DOI: 10.1002/ppul.25876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/31/2022] [Accepted: 02/27/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES While eradicating new-onset Pseudomonas aeruginosa in children with cystic fibrosis is an important issue, there is no clear evidence about the best treatment approach. This retrospective observational cohort study aims to compare the effectiveness of intravenous therapy versus inhalation with/without oral therapy in the eradication of new-onset P. aeruginosa, determine the factors affecting the treatment success and assess lung function at baseline and posttreatment. METHODS Of 399 children, 110 (140 episodes) with either the first P. aeruginosa isolation or a new isolation after at least 1 year free of infection were included. Different eradication regimens (intravenous therapy or inhaled tobramycin or inhaled tobramycin plus oral ciprofloxacin) were compared. Eradication success was accepted as remaining free of infection with a negative culture for 12 months. Demographic, clinical, and microbiological characteristics of children, effectiveness of different eradication strategies, time to a new P. aeruginosa isolation, and the relationship between lung function and the type of eradication regimen were determined. RESULTS Of 140 episodes, intravenous therapy was administered in 53 and inhalation therapy (in combination with or without oral ciprofloxacin) in 87. Total success rate of eradication was 60.7%. Eradication was achieved in 56.6% of children with intravenous therapy, 59.7% with inhaled tobramycin therapy, and 72% with inhaled tobramycin plus oral ciprofloxacin therapy. Success rates of different eradication regimens did not differ significantly (p = 0.419). Lung function by the end of the first year was worse in the intravenous group compared to the inhalation group (p = 0.017 for forced expiratory volume in 1 s, p = 0.015 for forced vital capacity). CONCLUSION No advantage of intravenous therapy was demonstrated compared to inhalation therapy in terms of eradication success.
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Affiliation(s)
- Birce Sunman
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nagehan Emiralioglu
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Gülsen Hazirolan
- Department of Medical Microbiology, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Burçin Şener
- Department of Medical Microbiology, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Beste Ozsezen
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Dilber A Tural
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Halime N Buyuksahin
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ismail Guzelkas
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ebru Yalcin
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Deniz Dogru
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Uğur Özçelik
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nural Kiper
- Department of Pediatric Pulmonology, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Wijers CDM, Pham L, Douglass MV, Skaar EP, Palmer LD, Noto MJ. Gram-negative bacteria act as a reservoir for aminoglycoside antibiotics that interact with host factors to enhance bacterial killing in a mouse model of pneumonia. FEMS MICROBES 2022; 3:xtac016. [PMID: 35909464 PMCID: PMC9326624 DOI: 10.1093/femsmc/xtac016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 05/04/2022] [Accepted: 05/11/2022] [Indexed: 01/28/2023] Open
Abstract
In vitro exposure of multiple Gram-negative bacteria to an aminoglycoside (AG) antibiotic has previously been demonstrated to result in bacterial alterations that interact with host factors to suppress Gram-negative pneumonia. However, the mechanisms resulting in suppression are not known. Here, the hypothesis that Gram-negative bacteria bind and retain AGs, which are introduced into the lung and interact with host defenses to affect bacterial killing, was tested. Following in vitro exposure of one of several, pathogenic Gram-negative bacteria to the AG antibiotics kanamycin or gentamicin, AGs were detected in bacterial cell pellets (up to 208 μg/mL). Using inhibitors of AG binding and internalization, the bacterial outer membrane was implicated as the predominant kanamycin and gentamicin reservoir. Following intranasal administration of gentamicin-bound bacteria or gentamicin solution at the time of infection with live, AG-naïve bacteria, gentamicin was detected in the lungs of infected mice (up to 8 μg/g). Co-inoculation with gentamicin-bound bacteria resulted in killing of AG-naïve bacteria by up to 3-log10, mirroring the effects of intranasal gentamicin treatment. In vitro killing of AG-naïve bacteria mediated by kanamycin-bound bacteria required the presence of detergents or pulmonary surfactant, suggesting that increased bacterial killing inside the murine lung is facilitated by the detergent component of pulmonary surfactant. These findings demonstrate that Gram-negative bacteria bind and retain AGs that can interact with host-derived pulmonary surfactant to enhance bacterial killing in the lung. This may help explain why AGs appear to have unique efficacy in the lung and might expand their clinical utility.
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Affiliation(s)
- Christiaan D M Wijers
- Department of Pathology, Microbiology, and Immunology, Vanderbilt
University Medical Center, 1161 21st Avenue South, Nashville, TN 37232,
United States,Vanderbilt Institute for Infection, Immunology, and Inflammation,
Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville,
TN 37232, United States
| | - Ly Pham
- Department of Pathology, Microbiology, and Immunology, Vanderbilt
University Medical Center, 1161 21st Avenue South, Nashville, TN 37232,
United States,Vanderbilt Institute for Infection, Immunology, and Inflammation,
Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville,
TN 37232, United States
| | - Martin V Douglass
- Department of Pathology, Microbiology, and Immunology, Vanderbilt
University Medical Center, 1161 21st Avenue South, Nashville, TN 37232,
United States,Vanderbilt Institute for Infection, Immunology, and Inflammation,
Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville,
TN 37232, United States
| | - Eric P Skaar
- Department of Pathology, Microbiology, and Immunology, Vanderbilt
University Medical Center, 1161 21st Avenue South, Nashville, TN 37232,
United States,Vanderbilt Institute for Infection, Immunology, and Inflammation,
Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville,
TN 37232, United States
| | - Lauren D Palmer
- Department of Microbiology and Immunology, University of Illinois
Chicago, 835 South Wolcott Avenue, Chicago, IL 60612, United States
| | - Michael J Noto
- Corresponding author: Room 205H Whitehead Biomedical Research Building, Emory
University, 615 Michael Street, Atlanta, GA 30322, United States. Tel: (+404)712-2988;
E-mail:
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21
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Mora Cuesta VM, Vargas NB, Fernández DI, Mena ST, Cifrián Martínez JM. Exacerbation of chronic renal failure because of inhaled tobramycin in a lung transplant patient. Respir Med Case Rep 2022; 36:101584. [PMID: 35127435 PMCID: PMC8803646 DOI: 10.1016/j.rmcr.2022.101584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/04/2022] [Accepted: 01/12/2022] [Indexed: 10/31/2022] Open
Abstract
61-year-old man, with a history of years of unknown etiology bronchiectasis, with chronic bronchial infection by Burkholderia multivorans, who received treatment with a double lung transplant on 08/20/2020. Persistent positive cultures of Burkholderia multivorans after transplant in respiratory samples was observed, and treatment with inhaled tobramycin 300 mg/12 hours was started. One month after treatment, a significant worsening of renal function was observed, which was already altered, and toxic levels of tobramycin were measured in blood samples 12 hours after the last inhaled administration. After stopping treatment, kidney function returned to its baseline values.
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22
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Alhajj N, O'Reilly NJ, Cathcart H. Developing ciprofloxacin dry powder for inhalation: A story of challenges and rational design in the treatment of cystic fibrosis lung infection. Int J Pharm 2021; 613:121388. [PMID: 34923051 DOI: 10.1016/j.ijpharm.2021.121388] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/08/2021] [Accepted: 12/12/2021] [Indexed: 12/11/2022]
Abstract
Cystic fibrosis (CF) is an inherited multisystem disease affecting the lung which leads to a progressive decline in lung function as a result of malfunctioning mucociliary clearance and subsequent chronic bacterial infections. Pseudomonas aeruginosa is the predominant cause of lung infection in CF patients and is associated with significant morbidity and mortality. Thus, antibiotic therapy remains the cornerstone of the treatment of CF. Pulmonary delivery of antibiotics for lung infections significantly reduces the required dose and the associated systemic side effects while improving therapeutic outcomes. Ciprofloxacin is one of the most widely used antibiotics against P. aeruginosa and the most effective fluoroquinolone. However, in spite of the substantial amount of research aimed at developing ciprofloxacin powder for inhalation, none of these formulations has been commercialized. Here, we present an integrated view of the diverse challenges associated with delivering ciprofloxacin dry particles to the lungs of CF patients and the rationales behind recent formulations of ciprofloxacin dry powder for inhalation. This review will discuss the challenges in developing ciprofloxacin powder for inhalation along with the physiological and pathophysiological challenges such as ciprofloxacin lung permeability, overproduction of viscous mucus and bacterial biofilms. The review will also discuss the current and emerging particle engineering approaches to overcoming these challenges. By doing so, we believe the review will help the reader to understand the current limitations in developing an inhalable ciprofloxacin powder and explore new opportunities of rational design strategies.
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Affiliation(s)
- Nasser Alhajj
- Pharmaceutical and Molecular Biotechnology Research Centre (PMBRC), Waterford Institute of Technology, Waterford, Ireland.
| | - Niall J O'Reilly
- Pharmaceutical and Molecular Biotechnology Research Centre (PMBRC), Waterford Institute of Technology, Waterford, Ireland; SSPC - The Science Foundation Ireland Research Centre for Pharmaceuticals, Ireland
| | - Helen Cathcart
- Pharmaceutical and Molecular Biotechnology Research Centre (PMBRC), Waterford Institute of Technology, Waterford, Ireland
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The Epidemiology and Pathogenesis and Treatment of Pseudomonas aeruginosa Infections: An Update. Drugs 2021; 81:2117-2131. [PMID: 34743315 PMCID: PMC8572145 DOI: 10.1007/s40265-021-01635-6] [Citation(s) in RCA: 182] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2021] [Indexed: 12/20/2022]
Abstract
Pseudomonas aeruginosa is a Gram-negative bacterial pathogen that is a common cause of nosocomial infections, particularly pneumonia, infection in immunocompromised hosts, and in those with structural lung disease such as cystic fibrosis. Epidemiological studies have
identified increasing trends of antimicrobial resistance, including multi-drug resistant (MDR) isolates in recent years. P. aeruginosa has several virulence mechanisms that increase its ability to cause severe infections, such as secreted toxins, quorum sensing and biofilm formation. Management of P. aeruginosa infections focuses on prevention when possible, obtaining cultures, and prompt initiation of antimicrobial therapy, occasionally with combination therapy depending on the clinical scenario to ensure activity against P. aeruginosa. Newer anti-pseudomonal antibiotics are available and are increasingly being used in the management of MDR P. aeruginosa.
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24
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Ratjen F, VanDevanter DR. Retracing changes in cystic fibrosis understanding and management over the past twenty years. J Cyst Fibros 2021; 21:3-9. [PMID: 34602342 DOI: 10.1016/j.jcf.2021.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Felix Ratjen
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Canada
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH USA.
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25
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Karki K, Sigdel S, Kafle S. Is it Worth Adding Systemic Antibiotics to Inhalational Tobramycin Therapy to Treat Pseudomonas Infections in Cystic Fibrosis? Cureus 2021; 13:e17326. [PMID: 34567873 PMCID: PMC8451513 DOI: 10.7759/cureus.17326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2021] [Indexed: 11/19/2022] Open
Abstract
Pseudomonas aeruginosa (PA), a gram-negative rod-shaped bacterium, is one of the most common pathogens causing colonization and infection of the respiratory tract and lungs in patients with cystic fibrosis (CF). Antibiotic therapy is the mainstay treatment for PA infection, and tobramycin is one of the widely used antibiotics in intravenous or inhalation form. This review aims to explore if there is any advantage of adding systemic antibiotics to tobramycin inhalation therapy by comparing the combination regimen to tobramycin inhalation monotherapy in CF patients with PA infection. We collected studies relevant to our review topic by doing a literature search on multiple databases. According to the currently available studies, the addition of oral antibiotics such as fluoroquinolones and azithromycin to tobramycin inhalation solution (TIS) provides no additional benefit in eradicating PA infection or producing clinical improvement in cystic fibrosis patients. However, adding intravenous antibiotics to TIS has not produced conclusive results and thus requires further research. We recommend conducting more randomized controlled trials comparing different treatment regimens, which may help discover the most beneficial treatment regimen with decreased systemic side effects.
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Affiliation(s)
- Kumar Karki
- Internal Medicine, Larkin Community Hospital, Miami, USA
| | - Santosh Sigdel
- Internal Medicine, Avera McKennan Hospital and University Health Center, Sioux Falls, USA
| | - Sunam Kafle
- Internal Medicine, College of Medical Sciences, Bharatpur, NPL
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26
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Cogen JD, Onchiri FM, Hamblett NM, Gibson RL, Morgan WJ, Rosenfeld M. Association of Intensity of Antipseudomonal Antibiotic Therapy With Risk of Treatment-Emergent Organisms in Children With Cystic Fibrosis and Newly Acquired Pseudomonas Aeruginosa. Clin Infect Dis 2021; 73:987-993. [PMID: 33693586 DOI: 10.1093/cid/ciab208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND While Pseudomonas aeruginosa (Pa) eradication regimens have contributed to a decline in Pa prevalence in people with cystic fibrosis (CF), this antibiotic exposure might increase the risk of acquisition of drug-resistant organisms. This study evaluated the association between antipseudomonal antibiotic exposure intensity and acquisition risk of drug-resistant organisms among children with CF and new Pa infection. METHODS We utilized data from the Early Pseudomonas Infection Control Clinical Trial (EPIC CT), a randomized controlled trial comparing Pa eradication strategies in children with CF and new Pa. The exposure was the number of weeks of oral or inhaled antipseudomonal antibiotics or ever versus never treatment with intravenous antipseudomonal antibiotics during the 18 months of EPIC CT participation. Primary outcomes were risks of acquisition of several respiratory organisms during 5 years of follow-up after EPIC CT estimated using Cox proportional hazards models separately for each specific organism. RESULTS Among 249 participants, there was no increased acquisition risk of any organism associated with greater inhaled antibiotic exposure. With each additional week of oral antibiotics, there was an increased hazard of Achromobacter xylosoxidans acquisition (HR, 1.24; 95% CI: 1.02-1.50; P = .03). Treatment with intravenous antibiotics was associated with an increased hazard of acquisition of multidrug-resistant Pa (HR, 2.47; 95% CI: 1.28-4.78; P = .01) and MRSA (HR, 1.57; 95% CI: 1.03-2.40; P = .04). CONCLUSIONS Results from this study illustrate the importance of making careful antibiotic choices to balance the benefits of antibiotics in people with CF while minimizing risk of acquisition of drug-resistant organisms.
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Affiliation(s)
- Jonathan D Cogen
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Seattle Children's Research Institute, Seattle, Washington, USA
| | | | - Nicole Mayer Hamblett
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Biostatistics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ronald L Gibson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Wayne J Morgan
- Department of Pediatrics, The University of Arizona, Tucson, Arizona, USA
| | - Margaret Rosenfeld
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Seattle Children's Research Institute, Seattle, Washington, USA
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Manos J. Current and Emerging Therapies to Combat Cystic Fibrosis Lung Infections. Microorganisms 2021; 9:1874. [PMID: 34576767 PMCID: PMC8466233 DOI: 10.3390/microorganisms9091874] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/26/2021] [Accepted: 08/30/2021] [Indexed: 11/30/2022] Open
Abstract
The ultimate aim of any antimicrobial treatment is a better infection outcome for the patient. Here, we review the current state of treatment for bacterial infections in cystic fibrosis (CF) lung while also investigating potential new treatments being developed to see how they may change the dynamics of antimicrobial therapy. Treatment with antibiotics coupled with regular physical therapy has been shown to reduce exacerbations and may eradicate some strains. Therapies such as hypertonic saline and inhaled PulmozymeTM (DNase-I) improve mucus clearance, while modifier drugs, singly and more successfully in combination, re-open certain mutant forms of the cystic fibrosis transmembrane conductance regulator (CFTR) to enable ion passage. No current method, however, completely eradicates infection, mainly due to bacterial survival within biofilm aggregates. Lung transplants increase lifespan, but reinfection is a continuing problem. CFTR modifiers normalise ion transport for the affected mutations, but there is conflicting evidence on bacterial clearance. Emerging treatments combine antibiotics with novel compounds including quorum-sensing inhibitors, antioxidants, and enzymes, or with bacteriophages, aiming to disrupt the biofilm matrix and improve antibiotic access. Other treatments involve bacteriophages that target, infect and kill bacteria. These novel therapeutic approaches are showing good promise in vitro, and a few have made the leap to in vivo testing.
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Affiliation(s)
- Jim Manos
- Infection, Immunity and Inflammation, Faculty of Medicine and Health, School of Medical Sciences, The University of Sydney, Sydney 2006, Australia
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28
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Association of Inhaled Antibiotics in Addition to Standard Intravenous Therapy and Outcomes of Pediatric Inpatient Pulmonary Exacerbations. Ann Am Thorac Soc 2021; 17:1590-1598. [PMID: 32726564 DOI: 10.1513/annalsats.202002-179oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Rationale: Considerable morbidity and disease progression in people with cystic fibrosis (CF) result from pulmonary exacerbations (PExs). PEx guidelines note insufficient evidence to recommend for or against the concomitant use of inhaled and intravenous antibiotics.Objectives: We hypothesize that the addition of inhaled antibiotics for PEx therapy is associated with improvements in lung function and a longer time to next PEx compared with standard intravenous antibiotics alone.Methods: We performed a retrospective cohort study using the CF Foundation Patient Registry-Pediatric Health Information System linked dataset. People with CF were included if they were hospitalized for PEx between 2006 and 2016 and 6 to 21 years of age. Lung function outcomes were assessed by linear mixed effect modeling and generalized estimating equations. The time to next PEx was assessed by Cox proportional hazards regression. To estimate independent causal effects while accounting for indication bias and other confounders, inverse probabilities of treatment weights were calculated based on covariates believed to influence the likelihood of inhaled antibiotic use during PEx treatment.Results: A total of 3,253 children and adolescents contributed 9,040 PEx events for analysis. Inhaled antibiotics were used in 23% of PEx events but were not associated with better pre- to post-PEx percent predicted forced expiratory volume in 1 second responses (mean difference, -1.11%; 95% confidence interval [CI], -1.83 to -0.38; P = 0.003), higher odds of returning to lung function baseline (odds ratio, 0.94; 95% CI, 0.82 to 1.07; P = 0.34), or longer time to next PEx (hazard ratio, 1.05; 95% CI, 0.99 to 1.12; P = 0.098).Conclusions: The addition of inhaled antibiotics to standard intravenous antibiotic PEx treatment was not associated with improved lung function outcomes or a longer time to next PEx.
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Effect of Concomitant Azithromycin and Tobramycin Use on Cystic Fibrosis Pulmonary Exacerbation Treatment. Ann Am Thorac Soc 2021; 18:266-272. [PMID: 32810412 DOI: 10.1513/annalsats.202002-176oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Pulmonary exacerbations (PExs) are associated with significant morbidity in people with cystic fibrosis (CF). Severe PExs are treated with intravenous antibiotics, including tobramycin. CF care guidelines recommend continuing chronic maintenance medications during PEx treatment. Azithromycin (AZM) is one of the most widely prescribed chronic medications for CF in the United States. Recent evidence has identified a potential antagonistic relationship between AZM and tobramycin.Objectives: To determine whether, among PEx treated with intravenous tobramycin, concomitant AZM use is associated with worse clinical outcomes.Methods: Retrospective cohort study using the CF Foundation Patient Registry-Pediatric Health Information System (CFFPR-PHIS)-linked dataset. People with CF age 6-21 years were included if they were hospitalized between 2006 and 2016 for a PEx. Inverse probability of treatment weighing was used to minimize the effects of confounders, including indication bias. Associations of concomitant treatment with AZM and lung function outcomes were determined using linear mixed-effect models and generalized estimating equations. Cox proportional hazard regression models were used to evaluate associations with time to next PEx.Results: Among the 10,660 people with CF included in the CFFPR-PHIS-linked dataset, 2,294 children and adolescents with 5,022 PExs that had intravenous tobramycin use were identified. A little less than half (n = 2,247; 45%) of all PExs were treated concomitantly with AZM and intravenous tobramycin. AZM use both at the most recent outpatient clinic encounter and during PEx treatment in combination with intravenous tobramycin was associated with a significantly lower absolute improvement in percentage-predicted forced expiratory volume in 1 second (ppFEV1) (-0.93%; 95% confidence interval [CI], -1.78 to -0.07; P = 0.033), a lesser odds of returning to 90% or more of baseline ppFEV1 (odds ratio, 0.79; 95% CI, 0.68-0.93; P = 0.003), and a shorter time to next PEx requiring intravenous antibiotics (hazard ratio, 1.22; 95% CI, 1.14-1.31; P < 0.001) compared with intravenous tobramycin use without concomitant AZM.Conclusions: Concomitant AZM and intravenous tobramycin use for in-hospital PEx treatment was associated with poorer clinical outcomes than treatment with intravenous tobramycin without AZM. These results support the hypothesis that an antagonistic relationship between these two medications might exist.
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Therapeutic Approach of Chronic Pseudomonas Infection in Cystic Fibrosis-A Network Meta-Analysis. Antibiotics (Basel) 2021; 10:antibiotics10080936. [PMID: 34438986 PMCID: PMC8388982 DOI: 10.3390/antibiotics10080936] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 12/12/2022] Open
Abstract
Pseudomonas infection is a major determinant of morbidity and mortality in cystic fibrosis (CF). Maintaining optimal lung function in CF patients carrying Pseudomonas remains a challenge. Our study aims to investigate the efficacy of antipseudomonal inhaled antibiotics in CF patients with chronic Pseudomonas infection. A Bayesian network meta-analysis of randomized controlled trials was conducted. The main outcomes were changes in: (a) forced respiratory volume (FEV1), (b) Pseudomonas aeruginosa sputum density, and (c) CF Questionnaire Revised Respiratory Symptom Score (CFQR-RSS) at 4 weeks follow-up. Eighteen trials which reported on treatment with aztreonam lysine, tobramycin, colistin, levofloxacin, fosfomycin/tobramycin, and amikacin in various dosages were eligible for inclusion. In terms of change in FEV1%, aztreonam lysine (t.i.d., 75 mg) with a 28-day run in the tobramycin phase, aztreonam lysine (b.i.d., 75 mg) with a 28-day run in the tobramycin phase had the highest probability of being the most effective treatment (SUCRAs were 77, 76%, respectively). Regarding change in Pseudomonas sputum density, aztreonam lysine (b.i.d., 75 mg) with a 28-day run in the tobramycin phase, aztreonam lysine (t.i.d., 75 mg) with a 28-day run in the tobramycin phase had the highest probability of being the most effective treatment (SUCRAs were 90, 86%, respectively). Regarding change in CFQR-RSS, aztreonam lysine (t.i.d., 75 mg) and aztreonam lysine (b.i.d., 75 mg) with a 28-day run in the tobramycin inhalation solution phase had the highest probability of being the most effective treatments (SUCRA:74% and 72%, respectively). Regarding changes in FEV1% and Pseudomonas sputum density, aztreonam lysine with a run in tobramycin phase may be the best treatment option in treating chronic Pseudomonas in CF. According to CFQR-RSS no significant differences were found. Given the limitations of the studies included, validation trials are called for.
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Bilton D, Fajac I, Pressler T, Clancy JP, Sands D, Minic P, Cipolli M, Galeva I, Solé A, Quittner AL, Jumadilova Z, Ciesielska M, Konstan MW. Long-term amikacin liposome inhalation suspension in cystic fibrosis patients with chronic P. aeruginosa infection. J Cyst Fibros 2021; 20:1010-1017. [PMID: 34144923 DOI: 10.1016/j.jcf.2021.05.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 04/22/2021] [Accepted: 05/14/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND . In CLEAR-108-a phase 3, randomised, open-label study-once-daily amikacin liposome inhalation suspension (ALIS) was noninferior to twice-daily tobramycin inhalation solution (TIS) in improving lung function in patients with cystic fibrosis (CF) and chronic Pseudomonas aeruginosa infection after 3 treatment cycles (28 days on/28 days off). The CLEAR-110 extension study (ClinicalTrials.gov: NCT01316276; EudraCT: 2011-000443-24) assessed long-term safety, tolerability, and efficacy of ALIS in eligible patients who completed CLEAR-108. METHODS . Patients received once-daily ALIS 590 mg for 12 treatment cycles (96 weeks). Patients were grouped by prior treatment: the "prior-ALIS" cohort received ALIS in CLEAR-108, and the "ALIS-naive" cohort received TIS in CLEAR-108. RESULTS . Overall, 206 patients (prior-ALIS, n=92; ALIS-naive, n=114) entered CLEAR-110 and received ≥1 dose of ALIS. Most patients (88.8%) experienced ≥1 treatment-emergent adverse event (TEAE) through day 672 (end of year 2). Most TEAEs (72.3%) were mild or moderate in severity. Severe TEAEs were reported in 31 patients (15.0%). Two life-threatening TEAEs (haemoptysis; intestinal obstruction) and 1 death (cardiac failure) were reported. Twenty-one patients (10.2%) discontinued treatment due to a TEAE (mostly infective pulmonary exacerbation of CF). Mean change from baseline in forced expiratory volume in 1 second percent predicted at day 672 was -3.1% (prior-ALIS, -4.0%; ALIS-naive, -2.3%). Mean change from baseline in sputum density of P. aeruginosa at day 672 was 0.02 (prior-ALIS, -0.16; ALIS-naive, 0.19) log CFU/g. CONCLUSIONS . Long-term treatment with ALIS was well tolerated with a favourable adverse event profile and demonstrated continued antibacterial activity in CF patients with chronic P. aeruginosa infection.
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Affiliation(s)
- Diana Bilton
- Royal Brompton Hospital, Sydney Street, London SW3 6NP, United Kingdom
| | - Isabelle Fajac
- AP-HP, Centre-Université de Paris, 27, Rue du Faubourg Saint-Jacques, Paris 75014, France; European Reference Network ERN-LUNG, Cystic Fibrosis Core Network, Germany
| | - Tacjana Pressler
- Cystic Fibrosis Center, Rigshospitalet (Hospital), Blegdamsvej 9, Copenhagen 2100, Denmark
| | - John Paul Clancy
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, USA
| | - Dorota Sands
- Cystic Fibrosis Department, Institute of Mother and Child, 17a Kasprzaka Str. 01-211, Warsaw, Poland
| | - Predrag Minic
- Institute for Mother and Child Health Care, Department of Pulmonology, Medical School University of Belgrade, 6-8, Radoja Dakica Str. New Belgrade 11070, Serbia
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani, 1, Verona 37126, Italy
| | - Ivanka Galeva
- Pediatric Clinic, Infants Department, Alexandrovska University Hospital, 1 Georgi Sofiiski Blvd, Sofia 1431, Bulgaria
| | - Amparo Solé
- Lung Transplant and Cystic Fibrosis Unit, Hospital Universitari i Politecnic La Fe, Valencia 46026, Spain
| | | | - Zhanna Jumadilova
- Insmed Incorporated, 700 US Highway 202/206, Bridgewater, NJ 08807, USA
| | - Monika Ciesielska
- Insmed Incorporated, 700 US Highway 202/206, Bridgewater, NJ 08807, USA
| | - Michael W Konstan
- Case Western Reserve University and Rainbow Babies and Children's Hospital, 10900 Euclid Avenue, Cleveland, OH 44106, USA.
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Thorn CR, Carvalho-Wodarz CDS, Horstmann JC, Lehr CM, Prestidge CA, Thomas N. Tobramycin Liquid Crystal Nanoparticles Eradicate Cystic Fibrosis-Related Pseudomonas aeruginosa Biofilms. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2021; 17:e2100531. [PMID: 33978317 DOI: 10.1002/smll.202100531] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/15/2021] [Indexed: 06/12/2023]
Abstract
Pseudomonas aeruginosa biofilms cause persistent and chronic infections, most known clinically in cystic fibrosis (CF). Tobramycin (TOB) is a standard anti-pseudomonal antibiotic; however, in biofilm infections, its efficacy severely decreases due to limited permeability across the biofilm matrix. Herewith, a biomimetic, nanostructured, lipid liquid crystal nanoparticle-(LCNP)-formulation is discovered to significantly enhance the efficacy of TOB and eradicate P. aeruginosa biofilm infections. Using an advanced, biologically-relevant co-culture model of human CF bronchial epithelial cells infected with P. aeruginosa biofilms at an air-liquid interface, nebulized TOB-LCNPs completely eradicated 1 × 109 CFU mL-1 of P. aeruginosa after two doses, a 100-fold improvement over the unformulated antibiotic. The enhanced activity of TOB is not observed with a liposomal formulation of TOB or with ciprofloxacin, an antibiotic that readily penetrates biofilms. It is demonstrated that the unique nanostructure of the LCNPs drives the enhanced penetration of TOB across the biofilm barrier, but not through the healthy lung epithelium barrier, significantly increasing the available antibiotic concentration at the site of infection. The LCNPs are an innovative strategy to improve the performance of TOB as a directed pulmonary therapy, enabling the administration of lower doses, reducing the toxicity, and amplifying the anti-biofilm activity of the anti-pseudomonal antibiotic.
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Affiliation(s)
- Chelsea R Thorn
- Clinical and Health Science, University of South Australia, North Tce, Adelaide, SA, 5000, Australia
- The Basil Hetzel Institute for Translational Health Research, Woodville, SA, 5011, Australia
- ARC Centre for Excellence in Bio-Nano Science and Technology, Australia
- Adelaide Biofilm Test Facility, Cancer Research Institute, University of South Australia, North Tce, Adelaide, SA, 5000, Australia
| | | | - Justus C Horstmann
- Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), 66123, Saarbrücken, Germany
- Department of Pharmacy, Saarland University, 66123, Saarbrücken, Germany
| | - Claus-Michael Lehr
- Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), 66123, Saarbrücken, Germany
- Department of Pharmacy, Saarland University, 66123, Saarbrücken, Germany
| | - Clive A Prestidge
- Clinical and Health Science, University of South Australia, North Tce, Adelaide, SA, 5000, Australia
- ARC Centre for Excellence in Bio-Nano Science and Technology, Australia
| | - Nicky Thomas
- Clinical and Health Science, University of South Australia, North Tce, Adelaide, SA, 5000, Australia
- The Basil Hetzel Institute for Translational Health Research, Woodville, SA, 5011, Australia
- ARC Centre for Excellence in Bio-Nano Science and Technology, Australia
- Adelaide Biofilm Test Facility, Cancer Research Institute, University of South Australia, North Tce, Adelaide, SA, 5000, Australia
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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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Cystic Fibrosis: Recent Insights into Inhaled Antibiotic Treatment and Future Perspectives. Antibiotics (Basel) 2021; 10:antibiotics10030338. [PMID: 33810116 PMCID: PMC8004710 DOI: 10.3390/antibiotics10030338] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 02/08/2023] Open
Abstract
Although new inhaled antibiotics have profoundly improved respiratory diseases in cystic fibrosis (CF) patients, lung infections are still the leading cause of death. Inhaled antibiotics, i.e., colistin, tobramycin, aztreonam lysine and levofloxacin, are used as maintenance treatment for CF patients after the development of chronic Pseudomonas aeruginosa (P. aeruginosa) infection. Their use offers advantages over systemic therapy since a relatively high concentration of the drug is delivered directly to the lung, thus, enhancing the pharmacokinetic/pharmacodynamic parameters and decreasing toxicity. Notably, alternating treatment with inhaled antibiotics represents an important strategy for improving patient outcomes. The prevalence of CF patients receiving continuous inhaled antibiotic regimens with different combinations of the anti-P. aeruginosa antibiotic class has been increasing over time. Moreover, these antimicrobial agents are also used for preventing acute pulmonary exacerbations in CF. In this review, the efficacy and safety of the currently available inhaled antibiotics for lung infection treatment in CF patients are discussed, with a particular focus on strategies for eradicating P. aeruginosa and other pathogens. Moreover, the effects of long-term inhaled antibiotic therapy for chronic P. aeruginosa infection and for the prevention of pulmonary exacerbations is reviewed. Finally, how the mucus environment and microbial community richness can influence the efficacy of aerosolized antimicrobial agents is discussed.
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Kwong K, Benedetti A, Yau Y, Waters V, Nguyen D. Failed eradication therapy of new onset Pseudomonas aeruginosa infections in cystic fibrosis children is associated with bacterial resistance to neutrophil functions. J Infect Dis 2021; 225:1886-1895. [PMID: 33606875 PMCID: PMC9159338 DOI: 10.1093/infdis/jiab102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/12/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Antibiotics, such as inhaled tobramycin are used to eradicate new onset Pseudomonas aeruginosa (PA) infections in cystic fibrosis (CF) patients but frequently fail due to reasons poorly understood. We hypothesized that PA isolates' resistance to neutrophil antibacterial functions was associated with failed eradication in patients harboring those strains. METHODS We analyzed all PA isolates from a cohort of 39 CF children with new onset PA infections undergoing tobramycin eradication therapy, where N=30 patients had eradicated and N=9 patients had persistent infection. We characterized several bacterial phenotypes and measured the isolates' susceptibility to neutrophil antibacterial functions using in vitro assays of phagocytosis and intracellular bacterial killing. RESULTS PA isolates from persistent infections were more resistant to neutrophil functions, with lower phagocytosis and intracellular bacterial killing compared to those from eradicated infections. In multivariable analyses, in vitro neutrophil responses were positively associated with twitching motility, and negatively with mucoidy. In vitro neutrophil phagocytosis was a predictor of persistent infection following tobramycin even after adjustment for clinical risk factors. CONCLUSIONS PA isolates from new onset CF infection show strain-specific susceptibility to neutrophil antibacterial functions, and infection with PA isolates resistant to neutrophil phagocytosis is an independent risk factor for failed tobramycin eradication.
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Affiliation(s)
- K Kwong
- Department of Microbiology and Immunology, McGill University, Montreal, CA.,Meakins Christie Laboratories, Research Institute of the McGill University Health Centre, Montreal, CA
| | - A Benedetti
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, CA.,Centre for Health Outcome Research, Research Institute of the McGill University Health Centre, Montreal, CA
| | - Y Yau
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, CA.,Division of Microbiology, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, CA
| | - V Waters
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, CA.,Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, CA
| | - D Nguyen
- Department of Microbiology and Immunology, McGill University, Montreal, CA.,Meakins Christie Laboratories, Research Institute of the McGill University Health Centre, Montreal, CA.,Department of Medicine, McGill University, Montreal, CA
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Vaitekenas A, Tai AS, Ramsay JP, Stick SM, Kicic A. Pseudomonas aeruginosa Resistance to Bacteriophages and Its Prevention by Strategic Therapeutic Cocktail Formulation. Antibiotics (Basel) 2021; 10:145. [PMID: 33540528 PMCID: PMC7912912 DOI: 10.3390/antibiotics10020145] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/23/2021] [Accepted: 01/27/2021] [Indexed: 12/12/2022] Open
Abstract
Antimicrobial resistance poses a significant threat to modern healthcare as it limits treatment options for bacterial infections, particularly impacting those with chronic conditions such as cystic fibrosis (CF). Viscous mucus accumulation in the lungs of individuals genetically predisposed to CF leads to recurrent bacterial infections, necessitating prolonged antimicrobial chemotherapy. Pseudomonas aeruginosa infections are the predominant driver of CF lung disease, and airway isolates are frequently resistant to multiple antimicrobials. Bacteriophages, or phages, are viruses that specifically infect bacteria and are a promising alternative to antimicrobials for CF P. aeruginosa infections. However, the narrow host range of P. aeruginosa-targeting phages and the rapid evolution of phage resistance could limit the clinical efficacy of phage therapy. A promising approach to overcome these issues is the strategic development of mixtures of phages (cocktails). The aim is to combine phages with broad host ranges and target multiple distinct bacterial receptors to prevent the evolution of phage resistance. However, further research is required to identify and characterize phage resistance mechanisms in CF-derived P. aeruginosa, which differ from their non-CF counterparts. In this review, we consider the mechanisms of P. aeruginosa phage resistance and how these could be overcome by an effective future phage therapy formulation.
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Affiliation(s)
- Andrew Vaitekenas
- Occupation and the Environment, School of Public Health, Curtin University, Perth, WA 6102, Australia
- Wal-Yan Respiratory Research Centre, Telethon Kids Institute, The University of Western Australia, Crawley, WA 6009, Australia; (A.V.); (S.M.S.)
| | - Anna S. Tai
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA 6009, Australia;
- Institute for Respiratory Health, Perth, WA 6009, Australia
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, WA 6009, Australia
| | - Joshua P. Ramsay
- Curtin Medical School and Curtin Health Innovation Research Institute, Curtin University, Perth, WA 6102, Australia;
| | - Stephen M. Stick
- Wal-Yan Respiratory Research Centre, Telethon Kids Institute, The University of Western Australia, Crawley, WA 6009, Australia; (A.V.); (S.M.S.)
- Division of Paediatrics, School of Medicine, The University of Western Australia, Perth, WA 6009, Australia
- Department of Respiratory and Sleep Medicine, Perth Children’s Hospital, Perth, WA 6009, Australia
- Center for Cell Therapy and Regenerative Medicine, School of Medicine and Pharmacology, The University of Western Australia and Harry Perkins Institute of Medical Research, Perth, WA 6009, Australia
| | - Anthony Kicic
- Occupation and the Environment, School of Public Health, Curtin University, Perth, WA 6102, Australia
- Wal-Yan Respiratory Research Centre, Telethon Kids Institute, The University of Western Australia, Crawley, WA 6009, Australia; (A.V.); (S.M.S.)
- Division of Paediatrics, School of Medicine, The University of Western Australia, Perth, WA 6009, Australia
- Department of Respiratory and Sleep Medicine, Perth Children’s Hospital, Perth, WA 6009, Australia
- Center for Cell Therapy and Regenerative Medicine, School of Medicine and Pharmacology, The University of Western Australia and Harry Perkins Institute of Medical Research, Perth, WA 6009, Australia
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Pust MM, Wiehlmann L, Davenport C, Rudolf I, Dittrich AM, Tümmler B. The human respiratory tract microbial community structures in healthy and cystic fibrosis infants. NPJ Biofilms Microbiomes 2020; 6:61. [PMID: 33319812 PMCID: PMC7738502 DOI: 10.1038/s41522-020-00171-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 11/13/2020] [Indexed: 02/06/2023] Open
Abstract
The metagenome development of the human respiratory tract was investigated by shotgun metagenome metagenomic sequencing of cough swabs from healthy children and children with cystic fibrosis (CF) between 3 weeks and 6 years of age. A healthy microbial community signature was associated with increased absolute abundances in terms of bacterial–human cell ratios of core and rare species across all age groups, with a higher diversity of rare species and a tightly interconnected species co-occurrence network, in which individual members were found in close proximity to each other and negative correlations were absent. Even without typical CF pathogens, the CF infant co-occurrence network was found to be less stable and prone to fragmentation due to fewer connections between species, a higher number of bridging species and the presence of negative species correlations. Detection of low-abundant DNA of the CF hallmark pathogen Pseudomonas aeruginosa was neither disease- nor age-associated in our cohort. Healthy and CF children come into contact with P. aeruginosa on a regular basis and from early on.
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Affiliation(s)
- Marie-Madlen Pust
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research, Hannover Medical School, Hannover, Germany
| | - Lutz Wiehlmann
- Research Core Unit Genomics, Hannover Medical School, Hannover, Germany
| | - Colin Davenport
- Research Core Unit Genomics, Hannover Medical School, Hannover, Germany
| | - Isa Rudolf
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research, Hannover Medical School, Hannover, Germany
| | - Anna-Maria Dittrich
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research, Hannover Medical School, Hannover, Germany
| | - Burkhard Tümmler
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany. .,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research, Hannover Medical School, Hannover, Germany.
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Garcia-Clemente M, de la Rosa D, Máiz L, Girón R, Blanco M, Olveira C, Canton R, Martinez-García MA. Impact of Pseudomonas aeruginosa Infection on Patients with Chronic Inflammatory Airway Diseases. J Clin Med 2020; 9:jcm9123800. [PMID: 33255354 PMCID: PMC7760986 DOI: 10.3390/jcm9123800] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/20/2020] [Accepted: 11/22/2020] [Indexed: 12/12/2022] Open
Abstract
Pseudomonas aeruginosa (P. aeruginosa) is a ubiquitous and opportunistic microorganism and is considered one of the most significant pathogens that produce chronic colonization and infection of the lower respiratory tract, especially in people with chronic inflammatory airway diseases such as asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), and bronchiectasis. From a microbiological viewpoint, the presence and persistence of P. aeruginosa over time are characterized by adaptation within the host that precludes any rapid, devastating injury to the host. Moreover, this microorganism usually develops antibiotic resistance, which is accelerated in chronic infections especially in those situations where the frequent use of antimicrobials facilitates the selection of “hypermutator P. aeruginosa strain”. This phenomenon has been observed in people with bronchiectasis, CF, and the “exacerbator” COPD phenotype. From a clinical point of view, a chronic bronchial infection of P. aeruginosa has been related to more severity and poor prognosis in people with CF, bronchiectasis, and probably in COPD, but little is known on the effect of this microorganism infection in people with asthma. The relationship between the impact and treatment of P. aeruginosa infection in people with airway diseases emerges as an important future challenge and it is the most important objective of this review.
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Affiliation(s)
- Marta Garcia-Clemente
- Pneumology Department, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain;
| | - David de la Rosa
- Pneumology Department, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain;
| | - Luis Máiz
- Servicio de Neumología, Unidad de Fibrosis Quística, Bronquiectasias e Infección Bronquial Crónica, Hospital Ramón y Cajal, 28034 Madrid, Spain;
| | - Rosa Girón
- Pneumology Department, Hospital Univesitario la Princesa, 28006 Madrid, Spain;
| | - Marina Blanco
- Servicio de Neumología, Hospital Universitario A Coruña, 15006 A Coruña, Spain;
| | - Casilda Olveira
- Servicio de Neumología, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga, 29010 Málaga, Spain;
| | - Rafael Canton
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain;
| | - Miguel Angel Martinez-García
- Pneumology Department, Universitary and Polytechnic La Fe Hospital, 46012 Valencia, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28034 Madrid, Spain
- Correspondence: ; Tel.: +34-609865934
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Choi J, Novak K, Thompson R. Evaluation of Inhaled Tobramycin in Early Eradication of Pseudomonas aeruginosa in Infants With Cystic Fibrosis. J Pediatr Pharmacol Ther 2020; 25:709-716. [PMID: 33214782 DOI: 10.5863/1551-6776-25.8.709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Early antibiotic therapy has the potential to eradicate initial Pseudomonas aeruginosa infection and postpone chronic infection. There are limited data evaluating the efficacy and safety of inhaled tobramycin in patients with cystic fibrosis (CF) who are younger than 1 year. The objective of this study was to evaluate the effectiveness of inhaled tobramycin in early eradication of P aeruginosa in infants with CF. METHODS This retrospective study evaluated patients with CF younger than 1 year with first time infection with P aeruginosa. The primary outcome was the frequency of P aeruginosa eradication. Secondary outcomes were sustained culture negativity at 12 and 18 months and safety assessments. RESULTS Of 18 patients included in the study, 9 received inhaled tobramycin and an enteral fluoroquinolone and 9 received inhaled tobramycin alone. Microbiologic clearance of respiratory cultures was observed in 83% patients at end of therapy and 78% of patients at 1 month posttherapy. Eradication of P aeruginosa was observed in 56% of patients at 6 months posttreatment with sustained culture negativity observed in 39% of patients up to 18 months. CONCLUSIONS Inhaled-tobramycin therapy is effective in early eradication of P aeruginosa infection and is well tolerated in infants younger than 1 year.
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Affiliation(s)
- Jane Choi
- Department of Pharmacy (JC, KN), Nationwide Children's Hospital, Columbus OH
| | - Kimberly Novak
- Department of Pharmacy (JC, KN), Nationwide Children's Hospital, Columbus OH.,Section of Pulmonary Medicine (KN, RT), Nationwide Children's Hospital, Columbus OH
| | - Rohan Thompson
- Section of Pulmonary Medicine (KN, RT), Nationwide Children's Hospital, Columbus OH
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Hewer SCL, Smyth AR, Brown M, Jones AP, Hickey H, Kenna D, Ashby D, Thompson A, Williamson PR. Intravenous versus oral antibiotics for eradication of Pseudomonas aeruginosa in cystic fibrosis (TORPEDO-CF): a randomised controlled trial. THE LANCET RESPIRATORY MEDICINE 2020; 8:975-986. [PMID: 33007285 PMCID: PMC7606906 DOI: 10.1016/s2213-2600(20)30331-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 05/05/2020] [Accepted: 06/08/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Chronic pulmonary infection with Pseudomonas aeruginosa is one of the most important causes of mortality and morbidity in cystic fibrosis. If antibiotics are commenced promptly, infection can be eradicated. The aim of the trial was to compare the effectiveness and safety of intravenous ceftazidime and tobramycin versus oral ciprofloxacin in the eradication of P aeruginosa. METHODS We did a multicentre, parallel group, open-label, randomised controlled trial in 72 cystic fibrosis centres (70 in the UK and two in Italy). Eligible participants were older than 28 days with an isolate of P aeruginosa (either the first ever isolate or a new isolate after at least 1 year free of infection). Participants were excluded if the P aeruginosa was resistant to, or they had a contraindication to, one or more of the trial antibiotics; if they were already receiving P aeruginosa suppressive therapy; if they had received any P aeruginosa eradication therapy within the previous 9 months; or if they were pregnant or breastfeeding. We used web-based randomisation to assign patients to 14 days intravenous ceftazidime and tobramycin or 12 weeks oral ciprofloxacin. Both were combined with 12 weeks inhaled colistimethate sodium. Randomisation lists were generated by a statistician, who had no involvement in the trial, using a computer-generated list. Randomisation was stratified by centre and because of the nature of the interventions, blinding was not possible. Our primary outcome was eradication of P aeruginosa at 3 months and remaining free of infection to 15 months. Primary analysis used intention to treat (powered for superiority). Safety analysis included patients who received at least one dose of study drug. TORPEDO-CF was registered on the ISRCTN register, ISRCTN02734162, and EudraCT, 2009-012575-10. FINDINGS Between Oct 5, 2010, and Jan 27, 2017, 286 patients were randomly assigned to treatment: 137 to intravenous antibiotics and 149 to oral antibiotics. 55 (44%) of 125 participants in the intravenous group and 68 (52%) of 130 participants in the oral group achieved the primary outcome. Participants randomly assigned to the intravenous group were less likely to achieve the primary outcome, although the difference between groups was not statistically significant (relative risk 0·84, 95% CI 0·65-1·09; p=0·18). 11 serious adverse events occurred in ten (8%) of 126 participants in the intravenous antibiotics group and 17 serious adverse events in 12 (8%) of 146 participants in the oral antibiotics group. INTERPRETATION Compared with oral therapy, intravenous antibiotics did not achieve sustained eradication of P aeruginosa in a greater proportion of patients with cystic fibrosis and was more expensive. Although there were fewer hospitalisations in the intravenous group than the oral group during follow-up, this confers no advantage over oral treatment because intravenous eradication frequently requires hospitalisation. These results do not support the use of intravenous antibiotics to eradicate P aeruginosa in cystic fibrosis. FUNDING National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Simon C Langton Hewer
- Department of Paediatric Respiratory Medicine, Bristol Royal Hospital for Children, University of Bristol, Bristol, UK.
| | - Alan R Smyth
- Division of Child Health, Obstetrics & Gynaecology, University of Nottingham, Nottingham, UK
| | - Michaela Brown
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - Ashley P Jones
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - Helen Hickey
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - Dervla Kenna
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, London, UK
| | - Deborah Ashby
- School of Public Health, Imperial College London, London, UK
| | - Alexander Thompson
- The University of Manchester, Manchester Centre for Health Economics, Manchester, UK
| | - Paula R Williamson
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool Health Partners, Liverpool, UK
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Jablonski L, Lee CKK, Rosenstein BJ, Mogayzel PJ, Paranjape S, Pan A. Real World Experience of Pseudomonas aeruginosa Eradication at an Urban Pediatric Cystic Fibrosis Center. J Pediatr Pharmacol Ther 2020; 25:623-628. [PMID: 33041717 DOI: 10.5863/1551-6776-25.7.623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Clinical practice guidelines for eradication of Pseudomonas aeruginosa (PA) in patients with cystic fibrosis (CF) have been established, but current studies have not assessed how these guidelines translate into clinical practice. This study aimed to characterize the real-world eradication strategies, eradication rates, and microbiologic outcomes of patients with first acquisition of PA at an urban pediatric CF center. METHODS The Cystic Fibrosis Foundation Patient Registry was used to identify patients with CF who received care between January 2014 and September 2018 and had PA isolated from an airway culture. Patients were included if they had a first positive PA culture or the first positive culture in 2 years. Data regarding patient demographics, timing and results of airway cultures, and treatment regimens were collected. RESULTS Over a 3.75-year period, 75 patients had an initial positive culture for PA. Of those patients, 74 (98.7%) received eradication treatment. Tobramycin inhalation solution (TIS) monotherapy was the most common regimen prescribed (52.7%) followed by TIS plus an oral fluoroquinolone (28.4%) (TIS + FQ). Of those treated, 62 (83.8%) patients had eradication of PA at first follow-up culture (median, 58 days; IQR, 49-77 days). Eradication rates (84.6% vs 76.2%, p = 0.421) and times to recurrence (6.37 months vs 5.1 months, p = 0.726) were comparable between TIS and TIS + FQ cohorts. CONCLUSIONS The eradication rate for PA in clinical practice is similar to that published in the literature. Consistent with published guidelines, these microbiologic outcomes do not support the addition of an oral FQ to TIS for initial PA eradication.
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Riquena B, Silva Filho LVRFD, Nakaie CMA, Almeida MBD, Rodrigues JC, Adde FV. Effectiveness of a multistep Pseudomonas aeruginosa eradication treatment protocol in children with cystic fibrosis in Brazil. J Bras Pneumol 2020; 46:e20180294. [PMID: 32696837 PMCID: PMC7567631 DOI: 10.36416/1806-3756/e20180294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 06/21/2019] [Indexed: 11/24/2022] Open
Abstract
Objective: Although various strategies have been proposed for eradicating Pseudomonas aeruginosa in patients with cystic fibrosis (CF), only a few employ multistep treatment in children colonized by that pathogen for the first time. The aim of this study was to describe the effectiveness of a three-phase eradication protocol, initiated after the first isolation of P. aeruginosa, in children with CF in Brazil. Methods: This was a retrospective real-life study in which we reviewed the medical records of pediatric CF patients in whom the eradication protocol was applied between June of 2004 and December of 2012. The three-phase protocol was guided by positive cultures for P. aeruginosa in airway secretions, and the treatment consisted of inhaled colistimethate and oral ciprofloxacin. Success rates were assessed after each phase, as well as cumulatively. Results: During the study period, 47 episodes of P. aeruginosa colonization, in 29 patients, were eligible for eradication. Among the 29 patients, the median age was 2.7 years, 17 (59%) were male, and 19 (65%) had at least one F508del allele. All 29 patients completed the first phase of the protocol, whereas only 12 and 6 completed the second and third phases, respectively. Success rates for eradication in the three treatment phases were 58.6% (95% CI: 40.7-74.5), 50.0% (95% CI: 25.4-74.6), and 66.7% (95% CI: 30.0-90.3), respectively. The cumulative success rate was 93.1% (95% CI: 78.0-98.1). Treatment failure in all three phases occurred in only 2 patients. Conclusions: In this sample of patients, the multistep eradication protocol was effective and had a high success rate.
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Affiliation(s)
- Barbara Riquena
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | | | | | - Fabíola Villac Adde
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Prevention of chronic infection with Pseudomonas aeruginosa infection in cystic fibrosis. Curr Opin Pulm Med 2020; 25:636-645. [PMID: 31397692 DOI: 10.1097/mcp.0000000000000616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW This review provides an update on definitions of chronicity of infection, approaches to airway sampling to detect infection, strategies for Pseudomonas aeruginosa eradication, impact of cystic fibrosis transmembrane regulator protein (CFTR) modulators and future challenges for clinical trials. RECENT FINDINGS Rates of P. aeruginosa have decreased over the past two decades with establishment of effective eradication protocols. Definitions of chronic P. aeruginosa infection have required adaptation for healthier populations. Although molecular (PCR) approaches to early P. aeruginosa detection are sensitive, to date, earlier diagnosis has not impacted on clinical outcomes. Despite eradication regimens, some people with early P. aeruginosa fail to clear their infection. Most people also experience a recurrence and eventual transition to chronic infection. Several recent studies sought to address this gap. CFTR modulators (predominantly ivacaftor) demonstrated reduced P. aeruginosa density, although infection may persist or recur demonstrating the need for continued antiinfective therapies in the modulator era. SUMMARY Future studies of approaches to P. aeruginosa eradication will be complex due to expanded availability and ongoing competitive clinical trials of CFTR modulators. Studies to address optimal eradication therapy, particularly in adults, will be required, though adequate recruitment to power these studies may prove challenging.
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Blanco-Aparicio M, Saleta Canosa JL, Valiño López P, Martín Egaña MT, Vidal García I, Montero Martínez C. Eradication of Pseudomonas aeruginosa with inhaled colistin in adults with non-cystic fibrosis bronchiectasis. Chron Respir Dis 2020; 16:1479973119872513. [PMID: 31480862 PMCID: PMC6724485 DOI: 10.1177/1479973119872513] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The persistent isolation of Pseudomonas aeruginosa in the airways of non-cystic fibrosis bronchiectasis (NCFB) patients is associated with a worsening of the symptoms, increase of exacerbations, poor quality of life and functional impairment. The objective of this study was the analysis of the eradication rate of P. aeruginosa in the sputum of patients with NCFB treated with inhaled colistin and the effects of the treatment in the exacerbations. This was a prospective, cohort, study of 67 NCFB patients treated with inhaled colistin at the Hospital of A Coruña (Spain). We recorded dyspnoea, exacerbations, lung function and sputum cultures of P. aeruginosa in the patients. The mean age of the patients was 67.25 ± 14.6 years (59.7% male). The percentages of eradication of P. aeruginosa in sputum at 3, 6, 9 and 12 months were 61.2%, 50.7%, 43.3% and 40.3%, respectively. We observed a significant decrease in exacerbations after 1 year of colistin treatment (1.98 ± 3.62) versus the previous year (3.40 ± 4.21, p < 0.001). We conclude that treatment with inhaled colistin in patients with NCFB and P. aeruginosa in sputum can achieve high rates of eradication even in patients with several previous positive cultures, as well as a significant decrease of exacerbations and hospital admissions.
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Affiliation(s)
| | | | - Paz Valiño López
- 1 Department of Pneumology, Hospital Universitario A Coruña, A Coruña, Spain
| | | | - Iria Vidal García
- 1 Department of Pneumology, Hospital Universitario A Coruña, A Coruña, Spain
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Prados C, Zamarrón E, Girón R, Quintana E, Máiz L, Nieto R, Asensio Ó, Álvarez-Sala R, Quirós S, Martínez-Redondo M, Mangas A, Martínez-Martínez T. ¿Qué supuso el consenso español para el tratamiento de la infección por Pseudomonas aeruginosa en pacientes con fibrosis quística en la infección pulmonar inicial? Med Clin (Barc) 2020; 154:232-235. [DOI: 10.1016/j.medcli.2019.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 08/06/2019] [Accepted: 08/26/2019] [Indexed: 11/25/2022]
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Cogen JD, Kahl BC, Maples H, McColley SA, Roberts JA, Winthrop KL, Morris AM, Holmes A, Flume PA, VanDevanter DR, Waters V, Muhlebach MS, Elborn JS, Saiman L, Bell SC. Finding the relevance of antimicrobial stewardship for cystic fibrosis. J Cyst Fibros 2020; 19:511-520. [PMID: 32122785 DOI: 10.1016/j.jcf.2020.02.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 01/29/2020] [Accepted: 02/12/2020] [Indexed: 12/15/2022]
Abstract
Antimicrobials have undoubtedly improved the lives of people with CF, but important antimicrobial-related toxicities and the emergence of antimicrobial-resistant bacteria associated with their use must be considered. Antimicrobial stewardship (AMS) is advocated across the spectrum of healthcare to promote the appropriate use of antimicrobials to preserve their current effectiveness and to optimise treatment, and it is clear that AMS strategies are applicable to and can benefit both non-CF and CF populations. This perspective explores the definition and components of an AMS program, the current evidence for AMS, and the reasons why AMS is a challenging concept in the provision of CF care. We also discuss the elements of CF care which align with AMS programs and principles and propose research priorities for AMS in CF.
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Affiliation(s)
- Jonathan D Cogen
- Division of Pulmonary & Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Barbara C Kahl
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
| | - Holly Maples
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Susanna A McColley
- Division of Pulmonary and Sleep Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, and Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research and School of Pharmacy, The University of Queensland, Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Division of Anaesthesiology, Critical Care, Emergency and Pain Medicine, Nîmes University Hospital, University of Montpelier, Nîmes France
| | - Kevin L Winthrop
- Oregon Health and Science University School of Medicine and Public Health, Portland, Oregon, USA
| | - Andrew M Morris
- Division of Infectious Diseases, Department of Medicine, Sinai Health, University Health Network, and University of Toronto, Toronto, Canada
| | - Alison Holmes
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK
| | | | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland OH, USA
| | - Valerie Waters
- Division of Infectious Diseases, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Marianne S Muhlebach
- Department of Pediatrics, Division Pulmonology, University of North Carolina at Chapel Hill, NC, USA
| | - J Stuart Elborn
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Lisa Saiman
- Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, NY, USA
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital, and QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
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Meerburg JJ, Andrinopoulou ER, Bos AC, Shin H, van Straten M, Hamed K, Mastoridis P, Tiddens HAWM. Effect of Inspiratory Maneuvers on Lung Deposition of Tobramycin Inhalation Powder: A Modeling Study. J Aerosol Med Pulm Drug Deliv 2020; 33:61-72. [PMID: 32073919 DOI: 10.1089/jamp.2019.1529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Tobramycin inhalation powder (TIP) and tobramycin inhalation solution (TIS) are considered equally effective for the treatment of chronic pulmonary Pseudomonas aeruginosa infection in cystic fibrosis (CF) patients. The impact of TIP inhalation maneuvers on distribution of tobramycin is unknown. We hypothesized that (1) fast TIP inhalations result in greater extrathoracic and reduced small airway concentrations compared with slow or uninstructed TIP inhalations; (2) slow TIP inhalations result in greater small airway concentrations than TIS inhalations. The aim of the study was to assess TIP and TIS deposition with computational fluid dynamics (CFD). Methods: Uninstructed, instructed fast, and instructed slow TIP inhalations of CF patients on maintenance TIP therapy, and inhalations during nebulization of saline with PARI LC Plus® were recorded at home. Drug deposition was determined using TIP and TIS aerosol characteristics together with CFD simulations based on airway geometries from chest computed tomography scans. The drug concentration was assessed in extrathoracic, central, large, and small airways. Results: Twelve patients aged 12-45 years were included, and 144 CFD simulations were performed. In all individual analyses, the tobramycin concentrations were well above the threshold for effective dose of 10 times minimal inhibitory concentration throughout the bronchial tree. Extrathoracic concentrations were comparable between fast and uninstructed TIP inhalations, while slow inhalations resulted in reduced extrathoracic concentrations compared with uninstructed TIP inhalations (p = 0.024). Small airway concentrations were comparable between fast and uninstructed TIP inhalations, while slow TIP inhalations resulted in greater small airway concentrations than uninstructed TIP inhalations (p < 0.001). Small airway concentrations of TIS were comparable with those of slow TIP inhalations (p = 0.065), but greater than those of fast and uninstructed TIP inhalations (p < 0.001). Conclusion: All TIS and TIP inhalation maneuvers resulted in high enough concentrations, however, inhaling TIS or inhaling TIP slowly results in the greatest small airway deposition.
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Affiliation(s)
- Jennifer J Meerburg
- Department of Pediatric Pulmonology and Allergology, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine and Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Aukje C Bos
- Department of Pediatric Pulmonology and Allergology, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine and Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Marcel van Straten
- Department of Radiology and Nuclear Medicine and Erasmus Medical Center, Rotterdam, the Netherlands
| | - Kamal Hamed
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Paul Mastoridis
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Harm A W M Tiddens
- Department of Pediatric Pulmonology and Allergology, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine and Erasmus Medical Center, Rotterdam, the Netherlands
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Addy C, Caskey S, Downey D. Gram negative infections in cystic fibrosis: a review of preventative and treatment options. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1713748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Charlotte Addy
- Centre for Medical Education, Queen’s University Belfast, Belfast, UK
- Northern Ireland Regional Adult CF Centre, Belfast Health and Social Care Trust, Belfast, UK
| | - Steven Caskey
- Northern Ireland Regional Adult CF Centre, Belfast Health and Social Care Trust, Belfast, UK
| | - Damian Downey
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
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Taccetti G, Denton M, Hayes K, Drevinek P, Sermet-Gaudelus I, Bilton D, Campana S, Dolce D, Ferroni A, Héry-Arnaud G, Martin-Gomez MT, Nash E, Pereira L, Pressler T, Tümmler B. A critical review of definitions used to describe Pseudomonas aeruginosa microbiological status in patients with cystic fibrosis for application in clinical trials. J Cyst Fibros 2020; 19:52-67. [DOI: 10.1016/j.jcf.2019.08.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/23/2019] [Accepted: 08/15/2019] [Indexed: 01/23/2023]
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