The risk of respiratory tract infections and antibiotic use in a general population and among people with asthma

Is There a Role for Immunostimulant Bacterial Lysates in the Management of Respiratory Tract Infection?

Bacterial Lysates are immunostimulants clinically prescribed for the prevention of respiratory tract infections (RTIs). It has been shown that Bacterial Lysates upregulate the immune system, acting both on innate and adaptive reactions. In fact, there are demonstrations of their efficacy in restoring the integrity and immune function of epithelial barriers, activating ILC3 and dendritic cells with an enhanced Th1 response, and producing serum IgG and serum and salivary IgA specific to the administered bacterial antigens. The activated immune system also protects against other bacteria and viruses due to a trained immunity effect. Most studies show that the number of RTIs and their severity decrease in Bacterial Lysates-pretreated patients, without relevant side effects. The Bacterial Lysates treatment, in addition to reducing the number of RTIs, also prevents the deterioration of the underlying disease (i.e., COPD) induced by repeated infections. Despite these positive data, the most recent meta-analyses evidence the weakness of the studies performed, which are of low quality and have an inadequate number of patients, some of which were non-randomized while others were without a control group or were performed contemporarily in different clinical conditions or with different ages. The high heterogeneity of the studies does not allow us to state Bacterial Lysates' effectiveness in preventing RTIs with sufficient certainty. To completely define their indications, double-blind, placebo-controlled, multicenter, randomized clinical trials should be performed for each product and for each indication. The study population should be adequate for each indication. For this purpose, an adequate run-in phase will be necessary.

Biologics for asthma and risk of pneumonia

OBJECTIVE

Modification of the immune system with biologics raises theoretical concerns about the risk of infections but it is still unclear whether currently routinely used biologics in severe asthma may facilitate the development of pneumonia. Therefore, we aimed to determine whether omalizumab, mepolizumab, benralizumab, and dupilumab are associated with pneumonia in a real-world setting.

METHODS

A retrospective disproportionality analysis was performed using adverse event (AE) reports submitted to FAERS from January 2020 to September 30, 2023. MedDRA was used to identify infections and infestations and then pneumonia cases. ROR and PRR were used to measure disproportionality.

RESULTS

The percentage of reported cases of pneumonia compared to infections and infestations was highest for mepolizumab (36.8%), followed by omalizumab (32.6%), benralizumab (19.2%) and dupilumab (5.7%). We found a moderate or strong signal for increased risk of pneumonia with mepolizumab (ROR = 3.74, 95%CI 3.50-4.00), omalizumab (ROR = 3.26, 95%CI 3.06-3.49) and benralizumab (ROR = 2.65, 95%CI 2.49-2.83).

CONCLUSIONS

Mepolizumab, omalizumab and benralizumab, but not dupilumab, were associated with high odds of reporting pneumonia. Our results represent only potential associations between these biologics and pneumonia but not causality. The nature of the FAERS database is such that the cause of the reported events is uncertain. Therefore, we can only roughly estimate the incidence of AEs by the signal strength (ROR value). Nevertheless, although causality could not be assessed, the signal from our study is interesting. We believe it deserves to be further substantiated by real-world studies with robust designs.

Adverse respiratory outcomes among patients with resolved asthma: matched retrospective cohort study

BACKGROUND

Patients with asthma may have symptom remission leading to a primary care code of resolved asthma. Little is known about subsequent rates of exacerbations and respiratory tract infections (RTIs).

AIM

To assess the risk of adverse respiratory outcomes for people with resolved asthma compared with those with active asthma and without asthma.

DESIGN AND SETTING

This was a retrospective cohort study of patients aged >5 years, registered with a general practice in England contributing data to the Clinical Practice Research Datalink between January 2010 and December 2019.

METHOD

Patients with resolved asthma were matched to non-asthma controls and active asthma controls for age, sex, and practice. Negative binomial regression was used to estimate incidence rate ratios (IRRs) with 95% confidence intervals (CIs) for asthma exacerbations, RTIs, flu/pneumonia, and antibiotic prescriptions.

RESULTS

Cohorts included 16 023 patients (8720 (54.4%) females, mean age 37 years). Compared with the active asthma cohort, the resolved cohort had fewer hospital admissions (adjusted IRR 0.29, 95% CI = 0.27 to 0.32) and general practice consultations (adjusted IRR 0.05, 95% CI = 0.04 to 0.07) for asthma exacerbations. The resolved and non-asthma cohorts had similar rates of hospital admissions for RTIs or flu/pneumonia. However, the resolved cohort had significantly greater incidence of general practice consultations for lower RTIs (adjusted IRR 2.34, 95% CI = 2.08 to 2.64) and antibiotic prescriptions (adjusted IRR 1.37, 95% CI = 1.30 to 1.44).

CONCLUSION

Patients with resolved asthma had greater risk of general practice RTI and antibiotic prescription than the general population and may benefit from defined strategies for reassessing symptoms and reinitiating asthma therapy.

Can Therapeutic Targeting of the Human Microbiome Influence Asthma Management? A Pro/Con Debate

Asthma is a clinically heterogeneous disease, and despite substantial improvements in therapies, there remains an unmet need for well-tolerated, effective treatments. Observational studies have demonstrated that alterations in the respiratory and gut microbiome are associated with the development of asthma and its severity. These findings are supported by preclinical models demonstrating that respiratory and gut microbes can alter airway inflammation. Therapeutic approaches to target the human microbiome have been increasingly applied to a wide range of acute and chronic diseases, but there are currently no microbiome-based therapeutics approved for the treatment of asthma. This clinical commentary addresses the future role of microbiome-based therapeutics in asthma management from both a pro and con perspective. We examine (1) the prospects for clinical studies demonstrating a causal relationship between the human microbiome and the severity of asthma; (2) the challenges and potential solutions for designing, testing, and implementing a microbiome-based therapeutic; and (3) the possibility of microbiome-based therapeutics for conditions comorbid to asthma. We conclude by identifying research priorities that will help determine the future of microbiome-based therapeutics for the management of asthma.

Acute respiratory infections hamper training and competition in cross-country skiers, especially in those with asthma

Acute respiratory infections (ARinf) are one of the leading causes that prevent athletes from training and competing. The aim of this study was to investigate the burden of ARinfs during one season among cross-country skiers. All Finnish cross-country skiers enrolled in the largest national competitions in winter 2019 (n = 1282) were sent a postal questionnaire. A higher proportion of skiers with than without asthma had to refrain from competitions because of ARinf (76.9% vs. 62.2%, p = 0.011) but there was no significant difference in refraining from training (91.2% vs. 83.8%, p = 0.084). In skiers with asthma, the median duration of a single ARinf episode was longer (5.0 days, IQR 3.8-6.8 vs. 4.0 days, IQR 3.0-6.7, p  = 0.017), and they had more days of absence because of ARinf throughout the season (median 15 days (IQR 8-28) vs. 10 days (IQR 6-18), p  = 0.006) in comparison to non-asthmatics. However, many of the skiers either trained (54.4%) or competed (22.5%) during an ARinf.

Characteristics of patients initiating treatment with baricitinib and outcomes at follow-up: analysis of BSRBR-RA Registry data

OBJECTIVES

To describe selected baseline characteristics, continuation with baricitinib and disease activity over time in patients initiating treatment with baricitinib in a UK real-world rheumatology setting.

METHODS

Baseline and follow-up data were analysed from baricitinib-treated patients newly recruited to the British Society for Rheumatology Biologics Registry-RA (BSRBR-RA) baricitinib cohort between 1 January 2018 and 31 March 2020. The primary objective was to evaluate continuation of baricitinib treatment in patients with at least one follow-up. Analyses were performed using the full baricitinib cohort, overall and by patient subgroup: biologic DMARD (bDMARD)/targeted synthetic (ts)DMARD-naive vs -experienced, baricitinib 4 vs 2 mg, age ≥65 vs <65 years, monotherapy vs combination therapy and male vs female.

RESULTS

At baseline, the study cohort (n = 561) was 76.5% female, mean age 60.0 years, had longstanding (mean 13.1 years) and severe RA, and 54.0% had previously received a bDMARD/tsDMARD. Of 265 and 110 patients completing the 6- and 12-month follow-ups with available data, 77.7 and 69.1% remained on baricitinib at each time, respectively. In all Kaplan-Meier analyses, >60% of patients remained on baricitinib at 540 days. Continuation of baricitinib therapy differed between some subgroup pairs (bDMARD/tsDMARD naive/experienced, baricitinib 2 mg/4 mg). Disease activity was lower at both follow-ups than at baseline, overall and in all subgroups.

CONCLUSION

In the early years of real-world baricitinib use in the UK, a high proportion of patients continued with treatment at both 6 and 12 months, at which times disease activity was lower than at baseline.

Inflammatory bowel disease and asthma. Results from the RHINE study

BACKGROUND

Asthma and inflammatory bowel disease (IBD) are common inflammatory diseases. The aim of this study was to investigate the associations of IBD with asthma and respiratory symptoms.

METHODS

This study is based on 13,499 participants from seven northern European countries that filled in a postal questionnaire on asthma, respiratory symptoms, IBD including ulcerative colitis and Crohn's disease and various lifestyle variables.

RESULTS

There were 195 participants with IBD. The prevalence of asthma (14.5 vs 8.1%, p = 0.001), different respiratory symptoms (range 11.9-36.8% vs range 6.0-18.6%, p < 0.005), non-infectious rhinitis (52.1 vs. 41.6%, p = 0.004) and chronic rhinosinusitis (11.6 vs 6.0%, p = 0.001) were higher in subjects with IBD than in those without IBD. In multivariable regression analysis, the association between IBD and asthma was statistically significant (OR 1.95 (95% CI 1.28-2.96)) after adjusting for confounders such as sex, BMI, smoking history, educational level and physical activity. There was a significant association between asthma and ulcerative colitis (adjusted OR 2.02 (95% CI 1.27-2.19)), and asthma but not Crohn's disease (adjusted OR 1.66 (95% CI 0.69-3.95)). A significant gender interaction was found with a significant association between IBD and asthma in women but not in men ((OR 2.72 (95% CI 1.67-4.46) vs OR 0.87 (95% CI 0.35-2.19), p = 0.038).

CONCLUSIONS

Patients with IBD, particularly those with ulcerative colitis and female, have a higher prevalence of asthma and respiratory symptoms. Our findings indicate that it is important to consider respiratory symptoms and disorders when examining patients with manifest or suspected IBD.