Effects of long-term tobramycin inhalation solution (TIS) once daily on exacerbation rate in patients with non-cystic fibrosis bronchiectasis

Inhaled tobramycin in non-cystic fibrosis bronchiectasis: A meta-analysis of randomized controlled trials

BACKGROUND

Non-cystic fibrosis bronchiectasis (NCFB) is often complicated by chronic Pseudomonas aeruginosa infection. Inhaled antibiotics, such as tobramycin, have been explored for their efficacy in managing these infections, but their efficacy and safety in NCFB remains uncertain.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the efficacy and safety of inhaled tobramycin in NCFB patients. PubMed, EMBASE, Cochrane Library, and ISI Web of Science databases were searched up to June 2024 using predefined keywords. Studies comparing inhaled tobramycin versus placebo were included if they reported outcomes related to P. aeruginosa eradication, sputum density, exacerbations, hospital admissions, and adverse events.

RESULTS

Nine RCTs involving 772 patients met the inclusion criteria. Inhaled tobramycin significantly increased P. aeruginosa eradication rates compared to placebo (I2 = 22.0 %, P = 0.255; RR 2.422, 95 % CI 1.570 to 3.738, P < 0.001). There was a marked reduction in hospital admissions (I2 = 27.9 %, P = 0.250; WMD -0.523, 95 % CI -0.879 to -0.167, P = 0.004) but no significant difference in exacerbation rates (I2 = 31.9 %, P = 0.196; RR 0.837, 95 % CI 0.519 to 1.349, P = 0.464). Adverse events leading to trial discontinuation were higher in the tobramycin group (I2 = 0.0 %, P = 0.634; RR 1.968, 95 % CI 1.197 to 3.236, P = 0.008).

CONCLUSIONS

Inhaled tobramycin therapy demonstrated efficacy in eradicating P. aeruginosa and reducing hospital admissions in patients with NCFB. However, no significant impact on exacerbation rates was observed, and the higher incidence of adverse events necessitates careful consideration in clinical practice.

Inhaled Medications for Maintenance Therapy in Pediatric Noncystic Fibrosis Bronchiectasis

OBJECTIVE

This review focuses on evaluating literature for the use of inhaled mucolytics (hypertonic saline, mannitol, and dornase alfa), inhaled antibiotics (tobramycin, aztreonam, colistin, and amikacin), and inhaled corticosteroids in pediatric noncystic fibrosis bronchiectasis.

DATA SOURCES

A literature search via PubMed was conducted using the search terms "non-cystic fibrosis bronchiectasis," "primary ciliary dyskinesia," and "bronchiectasis" in combination with each inhaled agent of interest.

STUDY SELECTION AND DATA EXTRACTION

Studies were included if they were specific to patients with a clinical diagnosis of noncystic fibrosis bronchiectasis published from 1998 to July 2024.

DATA SYNTHESIS

Several inhaled medications can be considered as maintenance therapies for pediatric patients with noncystic fibrosis bronchiectasis. Hypertonic saline could be considered for its potential airway clearance benefits and low risk of causing harm. Inhaled antipseudomonal antibiotics should be considered in patients who are colonized with Pseudomonas aeruginosa. Inhaled corticosteroid therapy should be reserved for patients with concomitant asthma. Dornase alfa has shown worse outcomes in adults with noncystic fibrosis bronchiectasis and should be used with caution. Risks and benefits should be carefully considered when evaluating these therapies for use in noncystic fibrosis bronchiectasis, and patient-specific treatment regimens should be developed.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Chronic management of pediatric noncystic fibrosis bronchiectasis remains challenging due to paucity of applicable literature. Risks and benefits of different agents are discussed in this article with recommendations for application to clinical practice based on studies performed in both adult and pediatric patients with noncystic fibrosis bronchiectasis.

CONCLUSION

Several inhaled medications could be considered as maintenance therapies for pediatric patients with noncystic fibrosis bronchiectasis, with more robust evidence to support use of inhaled antipseudomonal antibiotics and hypertonic saline compared with other available agents. Further investigation is needed to identify a clear place in therapy for inhaled therapies in pediatric noncystic fibrosis bronchiectasis.

Comparative efficacy and safety of inhaled antibiotics in managing chronic Pseudomonas aeruginosa infection in patients with cystic fibrosis and bronchiectasis: a systematic review and network meta-analysis

Background

An expanding array of inhaled antibiotic therapies can be effective for the treatment of chronic Pseudomonas aeruginosa (P. aeruginosa) infection in patients with cystic fibrosis (CF) and non-CF bronchiectasis (NCFB). Nonetheless, there is a paucity of direct studies comparing the curative effects of these regimens. This network meta-analysis (NMA) aimed to assess the efficacy and safety of different inhaled antibiotic therapies for the relative short-term (4 weeks) and long-term (≥4 months) management of chronic P. aeruginosa infection in patients with CF and NCFB, respectively.

Methods

We searched PubMed, Web of Science, Embase, and Cochrane Library database as at 25th February, 2024. Randomized controlled trials (RCTs) involving inhaled antibiotic therapies for treatment of CF or NCFB were thoroughly screened. We conducted this NMA within a Bayesian framework. The surface under the cumulative ranking curve (SUCRA) was calculated to estimate relative effects of interventions per outcome.

Results

A total of 39 RCTs were included, involving 18 inhaled antibiotic treatment regimens and 7,486 participants. The primary outcomes assessed were microbiological efficacy and tolerability. According to SUCRA results, for patients with CF, tobramycin inhalation powder (TIP) had the best profile regarding microbiological efficacy at both short-term and long-term follow-up (SUCRA, 94.5%; 90.5%). Colistin for inhalation (SUCRA, 84.0%) and tobramycin inhalation solution (TIS; SUCRA, 75.7%) had the best tolerability profile at short-term and long-term follow-up, respectively. For patients with NCFB, TIP (SUCRA, 84.2%) and gentamicin injectable solution (GM) for inhalation (SUCRA, 92.2%) had the best profile regarding microbiological efficacy at short-term and long-term follow-up, respectively. Ciprofloxacin inhalation powder had the best tolerability profile at both short-term and long-term follow-up (SUCRA, 66.4%; 85.6%).

Conclusions

The present study suggests that inhalation of TIS and GM are deemed exhibiting favorable profile across various outcomes for treating chronic P. aeruginosa infection in patients with CF and NCFB, respectively. Further large-scale and higher-quality studies are needed to support the conclusion.

Utilization of Inhaled Antibiotics in Pediatric Non-Cystic Fibrosis Bronchiectasis: A Comprehensive Review

The lack of available treatments in pediatric non-cystic fibrosis (non-CF) bronchiectasis is a major concern, especially in the context of the increasing disease burden due to better detection rates with advanced imaging techniques. Recurrent infections in these patients are the main cause of deterioration, leading to impaired lung function and increasing the risk of morbidity and mortality. Since pediatric non-CF bronchiectasis with early recognition and appropriate treatment can be reversible, optimal management is an issue of growing significance. The use of inhaled antibiotics as a treatment option, although a standard of care for CF patients, has been poorly studied in patients with non-CF bronchiectasis, especially in children. In this review, we present the current data on the potential use of inhaled antibiotics in the treatment of non-CF bronchiectasis and assess their safety and efficacy profile, focusing mainly on children. We conclude that inhaled antibiotics as an adjuvant maintenance treatment option could be tried in a subgroup of patients with frequent exacerbations and recent or chronic Pseudomonas aeruginosa infection as they appear to have beneficial effects on exacerbation rate and bacterial load with minimal safety concerns. However, the level of evidence in children is extremely low; therefore, further research is needed on the validity of this recommendation.

[Management of adult bronchiectasis - Consensus-based Guidelines for the German Respiratory Society (DGP) e. V. (AWMF registration number 020-030)]

Bronchiectasis is an etiologically heterogeneous, chronic, and often progressive respiratory disease characterized by irreversible bronchial dilation. It is frequently associated with significant symptom burden, multiple complications, and reduced quality of life. For several years, there has been a marked global increase in the prevalence of bronchiectasis, which is linked to a substantial economic burden on healthcare systems. This consensus-based guideline is the first German-language guideline addressing the management of bronchiectasis in adults. The guideline emphasizes the importance of thoracic imaging using CT for diagnosis and differentiation of bronchiectasis and highlights the significance of etiology in determining treatment approaches. Both non-drug and drug treatments are comprehensively covered. Non-pharmacological measures include smoking cessation, physiotherapy, physical training, rehabilitation, non-invasive ventilation, thoracic surgery, and lung transplantation. Pharmacological treatments focus on the long-term use of mucolytics, bronchodilators, anti-inflammatory medications, and antibiotics. Additionally, the guideline covers the challenges and strategies for managing upper airway involvement, comorbidities, and exacerbations, as well as socio-medical aspects and disability rights. The importance of patient education and self-management is also emphasized. Finally, the guideline addresses special life stages such as transition, family planning, pregnancy and parenthood, and palliative care. The aim is to ensure comprehensive, consensus-based, and patient-centered care, taking into account individual risks and needs.

Efficacy of combination antibiotic therapy including inhaled tobramycin on Burkholderia cepacia pneumonia in a non-cystic fibrosis patient

Burkholderia cepacia complex (BCC) has been recognized as a serious cause of pneumonia in patients with cystic fibrosis. BCC infection has also been reported in non-cystic fibrosis patients. Notably, the mortality rate of bacterial pneumonia caused by BCC is high. Nonetheless, therapeutic management of BCC infection remains to be established. Recent reports have indicated successful treatment of BCC pneumonia with combination antibiotic therapy. However, no reports have detailed the efficacy of combination antibiotic therapy for both initial and recurrent BCC pneumonia management. We herein describe a rare case of BCC pneumonia in a non-cystic fibrosis patient that was successfully treated with a combination of intravenous, inhalational and oral antibiotics. Furthermore, antibiotic therapy including inhaled tobramycin has been continued after discharge from hospital, and no side effects or recurrence of bacterial pneumonia has been observed, although BCC has been detected in sputum. The findings of the present case suggest that combination antibiotic therapy including inhaled tobramycin may be effective for recurrent bacterial pneumonia caused by BCC. In the management of BCC infection, early diagnosis should be made based on sputum culture results, and combination antibiotic therapy should be initiated promptly.

The Efficacy and Safety of Inhaled Antibiotics for the Treatment of Bronchiectasis in Adults: Updated Systematic Review and Meta-Analysis

BACKGROUND

Inhaled antibiotics are recommended conditionally by international bronchiectasis guidelines for the treatment of patients with bronchiectasis, but results of individual studies are inconsistent. A previous meta-analysis demonstrated promising results regarding the efficacy and safety of inhaled antibiotics in bronchiectasis. Subsequent publications have supplemented the existing body of evidence further in this area.

RESEARCH QUESTION

To what extent do inhaled antibiotics demonstrate both efficacy and safety as a treatment option for adults with bronchiectasis?

STUDY DESIGN AND METHODS

Systematic review and meta-analysis of randomized controlled trials of inhaled antibiotics in adult patients with bronchiectasis. We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials.gov for eligible studies. Studies were included if they enrolled adults with bronchiectasis diagnosed by CT imaging and had a treatment duration of at least 4 weeks. The primary end point was exacerbation frequency, with additional key efficacy end points including severe exacerbations, bacterial load, symptoms, quality of life, and FEV1. Data were pooled through random-effects meta-analysis.

RESULTS

Twenty studies involving 3,468 patients were included. Inhaled antibiotics were associated with reduced number of patients with exacerbations (risk ratio, 0.85; 95% CI, 0.75-0.96), a slight reduction in exacerbation frequency (rate ratio [RR], 0.78; 95% CI, 0.68-0.91), a probable reduction in the frequency of severe exacerbations (RR, 0.48; 95% CI, 0.31-0.74), and a likely slight increase in time to first exacerbation (hazard ratio, 0.80; 95% CI, 0.68-0.94). Inhaled antibiotics likely lead to a slight increase in the Quality of Life Questionnaire-Bronchiectasis respiratory symptom score (mean difference, 2.51; 95% CI, 0.44-4.31) and may reduce scores on the St. George Respiratory Questionnaire (mean difference, -3.13; 95% CI, -5.93 to -0.32). Bacterial load consistently was reduced, but FEV1 was not changed with treatment. Evidence suggests little to no difference in adverse effects between groups (OR, 0.99; 95% CI, 0.75-1.30). Antibiotic-resistant organisms likely were increased by treatment.

INTERPRETATION

In this systematic review and meta-analysis, inhaled antibiotics resulted in a slight reduction in exacerbations, a probable reduction in severe exacerbations, and a likely slight improvement in symptoms and quality of life in adults with bronchiectasis.

TRIAL REGISTRY

International Prospective Register of Systematic Reviews; No.: CRD42023384694; URL: https://www.crd.york.ac.uk/prospero/.

Bronchiectasis management in adults: state of the art and future directions

Formerly regarded as a rare disease, bronchiectasis is increasingly recognised. A renewed interest in this disease has led to significant progress in bronchiectasis research. Randomised clinical trials (RCTs) have demonstrated the benefits of airway clearance techniques, inhaled antibiotics and long-term macrolide therapy in bronchiectasis patients. However, the heterogeneity of bronchiectasis remains one of the most challenging aspects of management. Phenotypes and endotypes of bronchiectasis have been identified to help find "treatable traits" and partially overcome disease complexity. The goals of therapy for bronchiectasis are to reduce the symptom burden, improve quality of life, reduce exacerbations and prevent disease progression. We review the pharmacological and non-pharmacological treatments that can improve mucociliary clearance, reduce airway inflammation and tackle airway infection, the key pathophysiological features of bronchiectasis. There are also promising treatments in development for the management of bronchiectasis, including novel anti-inflammatory therapies. This review provides a critical update on the management of bronchiectasis focusing on treatable traits and recent RCTs.

Advances in pharmacotherapy for bronchiectasis in adults

INTRODUCTION

Bronchiectasis has become a growing concern of chronic airway disease because of the enormous socioeconomic burden. Four cardinal interdependent components - impaired airway defense, recurrent airway infections, inflammatory response, and airway damage, in conjunction with the underlying etiology, have collectively played a role in modulating the vicious vortex of the pathogenesis and progression of bronchiectasis. Current pharmacotherapy aims to target at these aspects to break the vicious vortex.

AREAS COVERED

The authors retrieve and review, in MEDLINE, Web of Science and ClinicalTrials.gov registry, the studies about pharmacotherapy for bronchiectasis from these aspects: antibiotics, mucoactive medications, bronchodilators, anti-inflammatory drug, and etiological treatment.

EXPERT OPINION

Future drug development and clinical trials of bronchiectasis need to pay more attention to the different phenotypes or endotypes of bronchiectasis. There is a need for the development of novel inhaled antibiotics that could reduce bacterial loads, improve quality-of-life, and decrease exacerbation risks. More efforts are needed to explore the next-generation neutrophil-targeted therapeutic drugs that are expected to ameliorate respiratory symptom burden, reduce exacerbation risks, and hinder airway destruction in bronchiectasis.