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McElvaney OJ, Heltshe SL, Odem-Davis K, West NE, Sanders DB, Fogarty B, VanDevanter DR, Flume PA, Goss CH. Adjunctive Systemic Corticosteroids for Pulmonary Exacerbations of Cystic Fibrosis. Ann Am Thorac Soc 2024; 21:716-726. [PMID: 38096105 DOI: 10.1513/annalsats.202308-673oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
Rationale: Pulmonary exacerbations (PEx) remain the most common cause of morbidity, recurrent hospitalization, and diminished survival in people with cystic fibrosis (PWCF) and are characterized by excess inflammation. Corticosteroids are potent, widely available antiinflammatory drugs. However, corticosteroid efficacy data from randomized controlled trials in PWCF are limited. Objectives: To determine whether adjunctive systemic corticosteroid therapy is associated with improved outcomes in acute CF PEx. Methods: We performed a secondary analysis of Standardized Treatment of Pulmonary Exacerbations 2 (STOP2), a large multicenter randomized controlled trial of antimicrobial treatment durations for adult PWCF presenting with PEx, that included the use of corticosteroids as a stratification criterion in its randomization protocol. Corticosteroid treatment effects were determined after propensity score matching for covariates including age, sex, baseline forced expiratory volume in 1 second (FEV1), genotype, and randomization arm. The primary outcome measure was the change in percentage predicted FEV1 (ppFEV1). Symptoms, time to next PEx, and the incidence of adverse events (AEs) and serious adverse events (SAEs) were assessed as secondary endpoints. Phenotypic factors associated with the clinical decision to prescribe steroids were also investigated. Results: Corticosteroids were prescribed for 168 of 982 PEx events in STOP2 (17%). Steroid prescription was associated with decreased baseline ppFEV1, increased age, and female sex. Cotreatment with corticosteroids was independent of treatment arm allocation and did not result in greater mean ppFEV1 response, longer median time to next PEx, or more substantial symptomatic improvement compared with propensity-matched PWCF receiving antibiotics alone. AEs were not increased in corticosteroid-treated PWCF. The total number of SAEs-but not the number of corticosteroid-related or PEx-related SAEs-was higher among patients receiving corticosteroids. Conclusions: Empiric, physician-directed treatment with systemic corticosteroids, although common, is not associated with improved clinical outcomes in PWCF receiving antibiotics for PEx. Clinical trial registered with www.clinicaltrials.gov (NCT02781610).
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Affiliation(s)
- Oliver J McElvaney
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
- Department of Medicine and
| | - Sonya L Heltshe
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Katherine Odem-Davis
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Natalie E West
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Don B Sanders
- Department of Pediatrics, Indiana University, Indianapolis, Indiana
| | - Barbra Fogarty
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio; and
| | - Patrick A Flume
- Department of Pediatrics and
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Christopher H Goss
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
- Department of Medicine and
- Department of Pediatrics, University of Washington, Seattle, Washington
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Thornton CS, Caverly LJ, Kalikin LM, Carmody LA, McClellan S, LeBar W, Sanders DB, West NE, Goss CH, Flume PA, Heltshe SL, VanDevanter DR, LiPuma JJ. Prevalence and Clinical Impact of Respiratory Viral Infections from the STOP2 Study of Cystic Fibrosis Pulmonary Exacerbations. Ann Am Thorac Soc 2024; 21:595-603. [PMID: 37963297 PMCID: PMC10995546 DOI: 10.1513/annalsats.202306-576oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/14/2023] [Indexed: 11/16/2023] Open
Abstract
Rationale: Rates of viral respiratory infection (VRI) are similar in people with cystic fibrosis (CF) and the general population; however, the associations between VRI and CF pulmonary exacerbations (PEx) require further elucidation.Objectives: To determine VRI prevalence during CF PEx and evaluate associations between VRI, clinical presentation, and treatment response.Methods: The STOP2 (Standardized Treatment of Pulmonary Exacerbations II) study was a multicenter randomized trial to evaluate different durations of intravenous antibiotic therapy for PEx. In this ancillary study, participant sputum samples from up to three study visits were tested for respiratory viruses using multiplex polymerase chain reactions. Baselines and treatment-associated changes in mean lung function (percent predicted forced expiratory volume in 1 s), respiratory symptoms (Chronic Respiratory Infection Symptom Score), weight, and C-reactive protein were compared as a function of virus detection. Odds of PEx retreatment within 30 days and future PEx hazard were modeled by logistic and Cox proportional hazards regression, respectively.Results: A total of 1,254 sputum samples from 621 study participants were analyzed. One or more respiratory viruses were detected in sputum samples from 245 participants (39.5%). Virus-positive participants were more likely to be receiving CF transmembrane conductance regulator modulator therapy (45% vs. 34%) and/or chronic azithromycin therapy (54% vs. 44%) and more likely to have received treatment for nontuberculous Mycobacterium infection in the preceding 2 years (7% vs. 3%). At study visit 1, virus-positive participants were more symptomatic (mean Chronic Respiratory Infection Symptom Score, 53.8 vs. 51.1), had evidence of greater systemic inflammation (log10 C-reactive protein concentration, 1.32 log10 mg/L vs. 1.23 log10 mg/L), and had a greater drop in percent predicted forced expiratory volume in 1 second from the prior 6-month baseline (5.8 vs. 3.6). Virus positivity was associated with reduced risk of future PEx (hazard ratio, 0.82; 95% confidence interval, 0.69-0.99; P = 0.034) and longer median time to next PEx (255 d vs. 172 d; P = 0.021) compared with virus negativity.Conclusions: More than one-third of STOP2 participants treated for a PEx had a positive test result for a respiratory virus with more symptomatic initial presentation compared with virus-negative participants, but favorable long-term outcomes. More refined phenotyping of PEx, taking VRIs into account, may aid in optimizing personalized management of PEx.Clinical trial registered with www.clinicaltrials.gov (NCT02781610).
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Affiliation(s)
| | | | | | | | - Scott McClellan
- Department of Pathology, University of Michigan Medical School, Ann Arbor, Michigan
| | - William LeBar
- Department of Pathology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Don B. Sanders
- Department of Pediatrics, Indiana University, Indianapolis, Indiana
| | - Natalie E. West
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Christopher H. Goss
- Department of Medicine and
- Department of Pediatrics, University of Washington, Seattle, Washington
- CF Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington
| | - Patrick A. Flume
- Department of Medicine and
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina; and
| | - Sonya L. Heltshe
- Department of Pediatrics, University of Washington, Seattle, Washington
- CF Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington
| | - Donald R. VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Zemanick ET, Emerman I, McCreary M, Mayer-Hamblett N, Warden MN, Odem-Davis K, VanDevanter DR, Ren CL, Young J, Konstan MW. Heterogeneity of CFTR modulator-induced sweat chloride concentrations in people with cystic fibrosis. J Cyst Fibros 2024:S1569-1993(24)00015-8. [PMID: 38360461 DOI: 10.1016/j.jcf.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/03/2024] [Accepted: 02/04/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Sweat chloride (SC) concentrations in people with cystic fibrosis (PwCF) reflect relative CF transmembrane conductance regulator (CFTR) protein function, the primary CF defect. Populations with greater SC concentrations tend to have lesser CFTR function and more severe disease courses. CFTR modulator treatment can improve CFTR function within specific CF genotypes and is commonly associated with reduced SC concentration. However, SC concentrations do not necessarily fall to concentrations seen in the unaffected population, suggesting potential for better CFTR treatment outcomes. We characterized post-modulator SC concentration variability among CHEC-SC study participants by genotype and modulator. METHODS PwCF receiving commercially approved modulators for ≥90 days were enrolled for a single SC measurement. Clinical data were obtained from chart review and the CF Foundation Patient Registry (CFFPR). Variability of post-modulator SC concentrations was assessed by cumulative SC concentration frequencies. RESULTS Post-modulator SC concentrations (n = 3787) were collected from 3131 PwCF; most (n = 1769, 47 %) were collected after elexacaftor/tezacaftor/ivacaftor (ETI) treatment. Modulator use was associated with lower SC distributions, with post-ETI concentrations the lowest on average. Most post-ETI SC concentrations were <60 mmol/L (79 %); 26 % were <30 mmol/L. Post-ETI distributions varied by genotype. All genotypes containing at least one F508del allele had individuals with post-ETI SC ≥60 mmol/L, with the largest proportion being F508del/minimal function (31 %). CONCLUSIONS Post-modulator SC concentration heterogeneity was observed among all genotypes and modulators, including ETI. The presence of PwCF with post-modulator SC concentrations within the CF diagnostic range suggests room for additional treatment-associated CFTR restoration in this population.
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Affiliation(s)
- E T Zemanick
- University of Colorado Anschutz Medical Campus, Aurora, CO, United States.
| | - I Emerman
- Seattle Children's Hospital, Seattle, WA, United States
| | - M McCreary
- Seattle Children's Hospital, Seattle, WA, United States
| | - N Mayer-Hamblett
- Seattle Children's Hospital, Seattle, WA, United States; University of Washington, Seattle, WA, United States
| | - M N Warden
- Seattle Children's Hospital, Seattle, WA, United States
| | - K Odem-Davis
- Seattle Children's Hospital, Seattle, WA, United States
| | - D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - C L Ren
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - J Young
- Seattle Children's Hospital, Seattle, WA, United States
| | - M W Konstan
- Case Western Reserve University School of Medicine, Cleveland, OH, United States; Rainbow Babies and Children's Hospital, Cleveland, OH, United States
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VanDevanter DR, LiPuma JJ, Konstan MW. Longitudinal bacterial prevalence in cystic fibrosis airways: Fact and artifact. J Cyst Fibros 2024; 23:58-64. [PMID: 37783605 PMCID: PMC10949087 DOI: 10.1016/j.jcf.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/12/2023] [Accepted: 09/20/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Opportunistic bacterial infection is a hallmark of cystic fibrosis (CF) lung disease and early mortality. Poorly characterized prevalence changes have accompanied two decades of health improvements, with CFTR modulators likely to further affect infection epidemiology. METHODS Bacterial prevalence change trends across birth cohorts were assessed with linear regression using 2001-2019 US CF Foundation Patient Registry data. Informative missingness was assessed, as was age-to-age infection status. RESULTS Bacterial prevalence constantly changed from 2001 to 2019, with changes differing across birth cohorts. Informative censoring affected prevalence change for some organisms. Age-to-age infection status changes were greater than net changes in bacterial prevalence and varied by age. CONCLUSIONS CF infection epidemiology changed over two decades and will continue to do so. Understanding how modulators affect infection epidemiology will require creative designs for longitudinal prevalence change studies emphasizing prevalence changes independent of effects on lung biology.
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Affiliation(s)
- D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland OH USA.
| | - J J LiPuma
- University of Michigan, Ann Arbor, MI USA
| | - M W Konstan
- Case Western Reserve University School of Medicine, Cleveland OH USA; Rainbow Babies and Children's Hospital, Cleveland OH USA
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Heltshe SL, Russell R, VanDevanter DR, Sanders DB. Re-examining baseline lung function recovery following IV-treated pulmonary exacerbations. J Cyst Fibros 2023; 22:864-867. [PMID: 36803635 PMCID: PMC10427727 DOI: 10.1016/j.jcf.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/02/2023] [Accepted: 02/10/2023] [Indexed: 02/18/2023]
Abstract
CF registry pulmonary exacerbation (PEx) analyses have employed "before and after" spirometry recovery, where the best percent predicted forced expiratory volume in 1 s (ppFEV1) prior to PEx ("baseline") is compared to the best ppFEV1 <3 months post-PEx. This methodology lacks comparators and ascribes recovery failure to PEx. Herein, we describe 2014 CF Foundation Patient Registry PEx analyses including a comparator: recovery around nonPEx events, birthdays. 49.6% of 7357 individuals with PEx achieved baseline ppFEV1 recovery while 36.6% of 14,141 achieved baseline recovery after birthdays; individuals with both PEx and birthdays were more likely to recover baseline after PEx than after birthdays (47% versus 34%); mean ppFEV1 declines were 0.3 (SD=9.3) and 3.1 (9.3), respectively. Post-event measure number had more effect on baseline recovery than did real ppFEV1 loss in simulations, suggesting that PEx recovery analyses lacking comparators are prone to artifact and poorly describe PEx contributions to disease progression.
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Affiliation(s)
- Sonya L Heltshe
- University of Washington School of Medicine, 1920 Terry Ave, Suite 400, Seattle, WA 98101, United States; CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States.
| | - Renee Russell
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States
| | - Donald R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Don B Sanders
- Indiana University School of Medicine, Indianapolis, IN, United States
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McElvaney OJ, Heltshe SL, Odem-Davis K, West NE, Sanders DB, Fogarty B, VanDevanter DR, Flume PA, Goss CH. Impact of lumacaftor/ivacaftor and tezacaftor/ivacaftor on treatment response in pulmonary exacerbations of F508del/F508del cystic fibrosis. J Cyst Fibros 2023; 22:875-879. [PMID: 37407341 PMCID: PMC10761587 DOI: 10.1016/j.jcf.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/01/2023] [Accepted: 06/26/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Pulmonary exacerbations (PEx) remain a major cause of morbidity and mortality in people with cystic fibrosis (PWCF). Although the combination cystic fibrosis transmembrane conductance regulator (CFTR) modulators lumacaftor/ivacaftor and tezacaftor/ivacaftor have been shown to reduce PEx frequency, their influence on clinical and biochemical responses to acute PEx treatment is unknown. METHODS We performed a secondary analysis of STOP2, a large multicenter randomized controlled trial of antimicrobial treatment durations for adult PWCF presenting with PEx. Propensity score matching was used to compare outcomes in antibiotic-treated F508del/F508del PWCF receiving lumacaftor/ivacaftor or tezacaftor/ivacaftor with those observed in antibiotic-treated F508del/F508del controls not receiving CFTR modulator therapy. The primary outcome measure was the change in percent predicted FEV1 (ppFEV1) following completion of intravenous (IV) antibiotics, with post-antibiotic changes in symptoms, serum C-reactive protein (CRP) concentrations and weight included as secondary endpoints. RESULTS Among 982 PEx events in randomized PWCF, 480 were homozygous for F508del, of whom 289 were receiving lumacaftor/ivacaftor or tezacaftor/ivacaftor at initiation of antibiotic therapy. Modulator-treated F508del/F508del PWCF did not demonstrate greater improvements in ppFEV1, symptoms, serum CRP or weight following antibiotic treatment compared to modulator-naïve controls matched for age, sex, baseline ppFEV1, genotype, body mass index, initial CRP, initial symptoms, exacerbation history, diabetic status, randomization arm and concomitant medical therapy. CONCLUSION In the acute setting, CFTR modulator therapy with lumacaftor/ivacaftor or tezacaftor/ivacaftor does not convey additional clinical or biochemical advantage above standardized PEx treatment in F508del/F508del PWCF.
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Affiliation(s)
- Oliver J McElvaney
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Department of Medicine, University of Washington, Seattle WA, United States
| | - Sonya L Heltshe
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Department of Medicine, University of Washington, Seattle WA, United States
| | - Katherine Odem-Davis
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States
| | - Natalie E West
- Department of Medicine, Johns Hopkins University, Baltimore MD, United States
| | - Don B Sanders
- Department of Pediatrics, Indiana University, Indianapolis IN, United States
| | - Barbra Fogarty
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland OH, United States
| | - Patrick A Flume
- Department of Pediatrics, Medical University of South Carolina, Charleston SC, United States; Department of Medicine, Medical University of South Carolina, Charleston SC, United States
| | - Christopher H Goss
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Department of Medicine, University of Washington, Seattle WA, United States; Department of Pediatrics, University of Washington, Seattle WA, United States.
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VanDevanter DR, Zemanick ET, Konstan MW, Ren CL, Odem-Davis K, Emerman I, Young J, Mayer-Hamblett N. Willingness of people with cystic fibrosis receiving elexacaftor/tezacaftor/ivacaftor (ETI) to participate in randomized modulator and inhaled antimicrobial clinical trials. J Cyst Fibros 2023; 22:652-655. [PMID: 37100705 PMCID: PMC10523954 DOI: 10.1016/j.jcf.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/31/2023] [Accepted: 04/13/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVE To assess the feasibility of enrolling people with CF (pwCF) taking the CFTR modulator elexacaftor/tezacaftor/ivacaftor (ETI) in clinical trials of a new modulator. METHODS PwCF receiving ETI at CHEC-SC study (NCT03350828) enrollment were surveyed for interest in 2-week to 6-month placebo- (PC) and active-comparator (AC) modulator studies. Those taking inhaled antimicrobials (inhABX) were surveyed for interest in PC inhABX studies. RESULTS Of 1791 respondents, 75% [95% CI 73, 77] would enroll in a 2-week PC modulator study versus 51% [49, 54] for a 6-month study; 82% [81, 84] and 63% [61, 65] would enroll in 2-week and 6 month AC studies; 77% [74, 80] of 551 taking inhABX would enroll in a 2-week PC inhABX study versus 59% [55, 63] for a 6-month study. Previous clinical trial experience increased willingness. CONCLUSIONS Study designs will affect feasibility of future clinical trials of new modulators and inhABX in people receiving ETI.
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Affiliation(s)
- D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH United States.
| | - E T Zemanick
- University of Colorado, Anschutz Medical Campus, Aurora CO United States
| | - M W Konstan
- Case Western Reserve University School of Medicine, Cleveland, OH United States; Rainbow Babies and Children's Hospital, Cleveland, OH United States
| | - C L Ren
- Children's Hospital of Philadelphia, Philadelphia, PA United States
| | - K Odem-Davis
- Seattle Children's Hospital, Seattle, WA United States
| | - I Emerman
- Seattle Children's Hospital, Seattle, WA United States
| | - J Young
- Seattle Children's Hospital, Seattle, WA United States
| | - N Mayer-Hamblett
- Seattle Children's Hospital, Seattle, WA United States; University of Washington, Seattle, WA United States
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Caverly LJ, VanDevanter DR. The Elusive Role of Airway Infection in Cystic Fibrosis Exacerbation. J Pediatric Infect Dis Soc 2022; 11:S40-S45. [PMID: 36069900 DOI: 10.1093/jpids/piac062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/22/2022] [Indexed: 11/14/2022]
Abstract
Cystic fibrosis (CF) pulmonary exacerbations (PEx) are clinical events that commonly result in increased treatment burden, decreased quality of life, and accelerated lung disease progression. CF PEx have historically been approached as though dealing with acute infections, and antibiotic treatments have been associated with improved outcomes. In this review, we discuss data supporting a causal role of CF airway infection in PEx as well studies that highlight our knowledge gaps in regard to PEx definitions, pathophysiology, and optimal treatment approaches. In the era of highly effective cystic fibrosis transmembrane conductance regulator modulator therapy, and the continually increasing health and longevity of persons with CF, a better understanding of PEx and further optimization of PEx antibiotic treatment approaches are needed.
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Affiliation(s)
- Lindsay J Caverly
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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VanDevanter DR, West NE, Sanders DB, Skalland M, Goss CH, Flume PA, Heltshe SL. Antipseudomonal treatment decisions during CF exacerbation management. J Cyst Fibros 2022; 21:753-758. [PMID: 35466039 PMCID: PMC9509480 DOI: 10.1016/j.jcf.2022.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/01/2022] [Accepted: 04/04/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) pulmonary exacerbation (PEx) treatment guidelines suggest that Pseudomonas aeruginosa (Pa) airway infection be treated with two antipseudomonal agents. METHODS We retrospectively studied treatment responses for STOP2 PEx treatment trial (NCT02781610) participants with a history of Pa infection. Mean lung function and symptom changes from intravenous (IV) antimicrobial treatment start to Visit 2 (7 to 10 days later) were compared between those receiving one, two, and three+ antipseudomonal classes before Visit 2 by ANCOVA. Odds of PEx retreatment with IV antimicrobials within 30 days and future IV-treated PEx hazard were modeled by logistic and Cox proportional hazards regression, respectively. Sensitivity analyses limited to the most common one-, two-, and three-class regimens, to only IV/oral antipseudomonal treatments, and with more stringent Pa infection definitions were conducted. RESULTS Among 751 participants, 50 (6.7%) were treated with one antipseudomonal class before Visit 2, while 552 (73.5%) and 149 (19.8%) were treated with two and with three+ classes, respectively. Females and participants with a negative Pa culture in the prior month were more likely to be treated with a single class. The most common single, double, and triple class regimens were beta-lactam (BL; n = 42), BL/aminoglycoside (AG; n = 459), and BL/AG/fluoroquinolone (FQ; n = 73). No lung function or symptom response, odds of retreatment, or future PEx hazard differences were observed by number of antipseudomonal classes administered in primary or sensitivity analyses. CONCLUSIONS We were unable to identify additional benefit when multiple antipseudomonal classes are used to treat PEx in people with CF and Pa.
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Affiliation(s)
- D R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, United States.
| | - N E West
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - D B Sanders
- Department of Pediatrics, Indiana University, Indianapolis, IN, United States
| | - M Skalland
- CF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States
| | - C H Goss
- CF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States; Department of Medicine, University of Washington, Seattle, WA, United States; Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - P A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - S L Heltshe
- CF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States; Department of Pediatrics, University of Washington, Seattle, WA, United States
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Carmody LA, Kalikin LM, VanDevanter DR, Li G, Opron K, Simon RH, Caverly LJ, LiPuma JJ. Changes in airway bacterial communities occur soon after initiation of antibiotic treatment of pulmonary exacerbations in cystic fibrosis. J Cyst Fibros 2022; 21:766-768. [PMID: 35667975 PMCID: PMC10440828 DOI: 10.1016/j.jcf.2022.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/02/2022] [Accepted: 05/29/2022] [Indexed: 01/04/2023]
Abstract
Chronic polymicrobial airway infections are a hallmark of cystic fibrosis (CF) lung disease. Antibiotic therapy is a primary treatment of CF pulmonary exacerbations (PEx); however, the impact of episodic antibiotic treatment on airway bacterial communities has not been well described. We analyzed sputum samples from adults with CF obtained immediately before and during antibiotic treatment of PEx. Sequencing of the V4 region of the bacterial 16S ribosomal RNA gene was used to assess changes in bacterial community structure during antibiotic treatment. The peak impact of antibiotic treatment was observed by day four or five of treatment. These findings advance our understanding of bacterial community dynamics during antibiotic treatment of PEx and complement recent and ongoing studies evaluating the optimal duration of antibiotic therapy for PEx.
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Affiliation(s)
- Lisa A Carmody
- Department of Pediatrics, University of Michigan Medical School, 1150 West Medical Center Drive, Ann Arbor, MI 48109, United States
| | - Linda M Kalikin
- Department of Pediatrics, University of Michigan Medical School, 1150 West Medical Center Drive, Ann Arbor, MI 48109, United States
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Gen Li
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, United States
| | - Kristopher Opron
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Richard H Simon
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Lindsay J Caverly
- Department of Pediatrics, University of Michigan Medical School, 1150 West Medical Center Drive, Ann Arbor, MI 48109, United States
| | - John J LiPuma
- Department of Pediatrics, University of Michigan Medical School, 1150 West Medical Center Drive, Ann Arbor, MI 48109, United States.
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Gold LS, Hansen RN, Patrick DL, Tabah A, Heltshe SL, Flume PA, Goss CH, West NE, Sanders DB, VanDevanter DR, Kessler L. Health care costs in a randomized trial of antimicrobial duration among cystic fibrosis patients with pulmonary exacerbations. J Cyst Fibros 2022; 21:594-599. [PMID: 35300932 DOI: 10.1016/j.jcf.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 03/01/2022] [Accepted: 03/06/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of these analyses was to determine whether overall costs were reduced in cystic fibrosis (CF) patients experiencing pulmonary exacerbation (PEx) who received shorter versus longer durations of treatment. METHODS Among people with CF experiencing PEx, we calculated 30-day inpatient, outpatient, emergency room, and medication costs and summed these to derive total costs in 2020 USD. Using the Kaplan-Meier sample average (KMSA) method, we calculated adjusted costs and differences in costs within two pairs of randomized groups: early robust responders (ERR) randomized to receive treatment for 10 days (ERR-10 days) or 14 days (ERR-14 days), and non-early robust responders (NERR) randomized to receive treatment for 14 days (NERR-14 days) or 21 days (NERR-21 days). RESULTS Patients in the shorter treatment duration groups had shorter lengths of stay per hospitalization (mean ± standard deviation (SD) for ERR-10 days: 7.9 ± 3.0 days per hospitalization compared to 10.1 ± 4.2 days in ERR-14 days; for NERR-14 days: 8.7 ± 4.9 days per hospitalization compared to 9.6 ± 6.5 days in NERR-21 days). We found statistically significantly lower adjusted mean costs (95% confidence interval) among those who were randomized to receive shorter treatment durations (ERR-10 days: $60,800 ($59,150 - $62,430) vs $74,420 ($72,610 - $76,450) in ERR-14 days; NERR-14 days: $66,690 ($65,960-$67,400) versus $74,830 ($73,980-$75,650) in NERR-21 days). CONCLUSIONS Tied with earlier evidence that shorter treatment duration was not associated with worse clinical outcomes, our analyses indicate that treating with shorter antimicrobial durations can reduce costs without diminishing clinical outcomes.
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Affiliation(s)
- Laura S Gold
- Department of Radiology, University of Washington, O1-140-6 UW Tower, 4333 Brooklyn Ave NE, Box 359558, Seattle, WA 98195-9558, United States.
| | - Ryan N Hansen
- School of Pharmacy, University of Washington, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States
| | - Donald L Patrick
- Department of Health Services, University of Washington, Seattle, WA, United States
| | - Ashley Tabah
- School of Pharmacy, University of Washington, Seattle, WA, United States
| | - Sonya L Heltshe
- Department of Pediatrics, University of Washington, Seattle, WA, United States; Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States
| | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Christopher H Goss
- Department of Pediatrics, University of Washington, Seattle, WA, United States; Department of Medicine, University of Washington, Seattle, WA, United States
| | - Natalie E West
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Don B Sanders
- Department of Pediatrics, Indiana University, Indianapolis, IN, United States
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Larry Kessler
- Department of Health Services, University of Washington, Seattle, WA, United States
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12
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VanDevanter DR, Heltshe SL, Skalland M, West NE, Sanders DB, Goss CH, Flume PA. C-reactive protein (CRP) as a biomarker of pulmonary exacerbation presentation and treatment response. J Cyst Fibros 2021; 21:588-593. [PMID: 34933824 DOI: 10.1016/j.jcf.2021.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/09/2021] [Accepted: 12/05/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND C-reactive protein (CRP) has been proposed as a biomarker for pulmonary exacerbation (PEx) diagnosis and treatment response. CRP >75mg/L has been associated with increased risk of PEx treatment failure. We have analyzed CRP measures as biomarkers for clinical response during the STOP2 PEx study (NCT02781610). METHODS CRP measures were collected at antimicrobial treatment start (V1), seven to 10 days later (V2), and two weeks after treatment end (V3). V1 log10CRP concentrations and log10CRP change from V1 to V3 correlations with clinical responses (changes in lung function and symptom score) were assessed by least squares regression. Odds of intravenous (IV) antimicrobial retreatment within 30 days and future PEx hazard associated with V1 and V3 CRP concentrations and V1 CRP >75 mg/L were studied by adjusted logistic regression and proportional hazards modeling, respectively. RESULTS In all, 951 of 982 STOP2 subjects (92.7%) had CRP measures at V1. V1 log10CRP varied significantly by V1 lung function subgroup, symptom score quartile, and sex, but not by age subgroup. V1 log10CRP correlated moderately with log10CRP change at V3 (r2=0.255) but less so with lung function (r2=0.016) or symptom (r2=0.031) changes at V3. Higher V1 CRP was associated with greater response. CRP changes from V1 to V3 only weakly correlated with lung function (r2=0.061) and symptom (r2=0.066) changes. However, V3 log10CRP was associated with increased odds of retreatment (P = .0081) and future PEx hazard (P = .0114). DISCUSSION Despite consistent trends, log10CRP change was highly variable with only limited utility as a biomarker of PEx treatment response.
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Affiliation(s)
- D R VanDevanter
- Case Western Reserve Univ. School of Medicine, Cleveland OH, USA.
| | - S L Heltshe
- Univ. of Washington, Seattle WA, USA; CFF TDNCC, Seattle Children's Hospital, Seattle WA, USA
| | - M Skalland
- CFF TDNCC, Seattle Children's Hospital, Seattle WA, USA
| | - N E West
- Johns Hopkins University, Baltimore MD, USA
| | - D B Sanders
- Indiana Univ. School of Medicine, Indianapolis IN, USA
| | - C H Goss
- Univ. of Washington, Seattle WA, USA
| | - P A Flume
- Medical Univ. of South Carolina, Charleston SC, USA
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13
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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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14
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Goss CH, Heltshe SL, West NE, Skalland M, Sanders DB, Jain R, Barto TL, Fogarty B, Marshall BC, VanDevanter DR, Flume PA. A Randomized Trial of Antimicrobial Duration for Cystic Fibrosis Pulmonary Exacerbation Treatment. Am J Respir Crit Care Med 2021; 204:1295-1305. [PMID: 34469706 DOI: 10.1164/rccm.202102-0461oc] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE People with cystic fibrosis (CF) experience acute worsening of respiratory symptoms and lung function known as pulmonary exacerbations. Treatment with intravenous antimicrobials is common; however, there is scant evidence to support a standard treatment duration. OBJECTIVE Test differing durations of intravenous antimicrobials for CF exacerbations. METHODS STOP2 was a multi-center, randomized, controlled, clinical trial in exacerbation among adults with CF. After 7-10-days of treatment, participants exhibiting pre-defined lung function and symptom improvements were randomized to 10- or 14-days total antimicrobial duration; all others were randomized to 14- or 21-days. MEASUREMENTS The primary outcome was percent predicted forced expiratory volume in 1 second (ppFEV1) change from treatment initiation to two weeks after cessation. Among early responders non-inferiority of 10-days to 14-days was tested; superiority of 21-days compared to 14-days was compared for the others. Symptoms, weight, and adverse events were secondary. RESULTS Among 982 randomized, 277 met improvement criteria and were randomized to 10- or 14-days treatment; the remaining 705 received 21- or 14-days. Mean ppFEV1 change was 12.8 and 13.4 for 10- and 14-days, respectively, a ‒0.65 difference [95%CI ‒3.3, 2.0], excluding the pre-defined noninferiority margin. The 21- and 14-day arms experienced 3.3 and 3.4 mean ppFEV1 changes, a difference of ‒0.10 [‒1.3, 1.1]. Secondary endpoints and sensitivity analyses were supportive. CONCLUSIONS Among CF adults with early treatment improvement during exacerbation, ppFEV1 after 10-days of intravenous antimicrobials is not inferior to 14-days. For those with less improvement after one week, 21-days is not superior to 14-days. Clinical trial registration available at www.clinicaltrials.gov, ID: NCT02781610.
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Affiliation(s)
- Christopher H Goss
- University of Washington, 7284, Medicine, Seattle, Washington, United States.,University of Washington, 7284, Pediatrics, Seattle, Washington, United States.,Seattle Children's Research Institute, 145793, CF Therapeutics Development Network Coordinating Center, Seattle, Washington, United States;
| | - Sonya L Heltshe
- University of Washington, 7284, Pediatrics, Seattle, Washington, United States.,Seattle Children's Research Institute, 145793, CF Therapeutics Development Network Coordinating Center, Seattle, Washington, United States
| | - Natalie E West
- Johns Hopkins Medicine School of Medicine, 1500, Medicine, Baltimore, Maryland, United States
| | - Michelle Skalland
- Seattle Children's Research Institute, 145793, Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle, Washington, United States
| | - Don B Sanders
- Indiana University School of Medicine, 12250, Pediatrics, Indianapolis, Indiana, United States
| | - Raksha Jain
- UT Southwestern, 12334, Medicine, Dallas, Texas, United States
| | - Tara L Barto
- Baylor College of Medicine, 3989, Medicine, Houston, Texas, United States
| | - Barbra Fogarty
- Seattle Children's Research Institute, 145793, Seattle, Washington, United States
| | - Bruce C Marshall
- Cystic Fibrosis Foundation, Medical, Bethesda, Maryland, United States
| | - Donald R VanDevanter
- Case Western Reserve University School of Medicine, 12304, Pediatrics, Cleveland, Ohio, United States
| | - Patrick A Flume
- Medical University of South Carolina, 2345, Medicine, Charleston, South Carolina, United States.,Medical University of South Carolina, 2345, Pediatrics, Charleston, South Carolina, United States
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15
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Konstan MW, Pasta DJ, VanDevanter DR, Wagener JS, Morgan WJ. Epidemiologic Study of Cystic Fibrosis: 25 years of observational research. Pediatr Pulmonol 2021; 56:823-836. [PMID: 33434406 PMCID: PMC9123916 DOI: 10.1002/ppul.25248] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/19/2020] [Accepted: 12/25/2020] [Indexed: 11/09/2022]
Abstract
The Epidemiologic Study of Cystic Fibrosis (ESCF) was a prospective observational study of over 32,000 people with cystic fibrosis (CF) from 250 clinical care sites in North America from 1994 to 2005. Begun as a pharmacovigilance study in connection with the approval of dornase alfa in 1993, ESCF was open to all people with CF treated at any participating site in the United States or Canada. In addition to obtaining safety and effectiveness data on dornase alfa, ESCF collected encounter-based data to characterize the natural history and management of CF with a special focus on lung disease. During the study, 32,178 patients reported at least one encounter, contributing 869,136 encounters, 622,592 pulmonary function tests, 432,896 cultures, and 118,563 pulmonary exacerbations treated with intravenous antibiotics. Although ESCF data collection concluded in 2005, through a collaboration with the U.S. Cystic Fibrosis Foundation Patient Registry, additional follow-up data through 2017 was available for two-thirds of patients. This allowed for updating of CF genotype and survival information. Fifty-six peer-reviewed publications (cited over 3600 times) resulted from this study. In this manuscript we summarize the published ESCF manuscripts in thematic groups with key study findings and brief comments, and speculate on how ESCF findings will inform future data registries and patient care practices.
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Affiliation(s)
- Michael W Konstan
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | | | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Jeffrey S Wagener
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Wayne J Morgan
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA
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16
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Zemanick ET, Konstan MW, VanDevanter DR, Rowe SM, Clancy JP, Odem-Davis K, Skalland M, Mayer-Hamblett N. Measuring the impact of CFTR modulation on sweat chloride in cystic fibrosis: Rationale and design of the CHEC-SC study. J Cyst Fibros 2021; 20:965-971. [PMID: 33573995 DOI: 10.1016/j.jcf.2021.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/23/2021] [Accepted: 01/26/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Characterizing CFTR Modulated Changes in Sweat Chloride and their Association with Clinical Outcomes (CHEC-SC) study is a large epidemiologic study designed to determine the relationship between sweat chloride response and clinical outcomes in people with cystic fibrosis (CF) on commercially approved CFTR modulators. A challenge to study feasibility was capturing sweat chloride measurements before modulator initiation. We tested the hypothesis that historic sweat chloride approximated contemporary pre-modulator values to estimate CFTR modulator-induced changes, allowing a single-visit study design. METHODS GOAL and PROSPECT were multi-center prospective studies of individuals initiating ivacaftor or lumacaftor-ivacaftor. At enrollment, pre-modulator sweat chloride was measured and historic results recorded. Post-modulator sweat chloride was measured at 1, 3 and 6 months. For this analysis, differences between historic and pre-modulator sweat chloride were estimated. CFTR modulator-induced sweat chloride mean changes were compared using historic and pre-modulator sweat chloride. RESULTS Paired historic and pre-modulator sweat chloride (n=406 participants) revealed a non-significant mean change of -1.0 mmol/L (95% CI: -2.71, 0.66) over an average of 17.2 years. Calculating sweat response to ivacaftor or lumacaftor-ivacaftor using historic or pre-modulator values resulted in similar estimates of modulator response. Based on these results, the CHEC-SC study was designed with a single, post-modulator sweat chloride measurement. CONCLUSIONS Historic sweat chloride values provide a reliable estimate of pre-modulator sweat chloride for people starting on modulator therapy. The CHEC-SC study anticipates capturing approximately 5,000 sweat chloride values, providing an unprecedented understanding of sweat chloride across the CF population in the era of CFTR modulators.
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Affiliation(s)
- Edith T Zemanick
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
| | - Michael W Konstan
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland OH USA; Rainbow Babies and Children's Hospital, Cleveland OH USA
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland OH USA
| | - Steven M Rowe
- Department of Medicine and the Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL USA
| | - J P Clancy
- Cystic Fibrosis Foundation, Bethesda, MD USA
| | | | | | - Nicole Mayer-Hamblett
- Seattle Children's Research Institute, Seattle, WA 98145, USA; Department of Biostatistics and Pediatrics, University of Washington, Seattle, WA 98195, USA
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17
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Affiliation(s)
- Donald R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, United States.
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18
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VanDevanter DR, Hamblett NM, Simon N, McIntosh J, Konstan MW. Evaluating assumptions of definition-based pulmonary exacerbation endpoints in cystic fibrosis clinical trials. J Cyst Fibros 2021; 20:39-45. [PMID: 32682670 PMCID: PMC7362840 DOI: 10.1016/j.jcf.2020.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/09/2020] [Accepted: 07/09/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) pulmonary exacerbations can be serious respiratory events and reduction in exacerbation rate or risk are important efficacy endpoints for CF therapeutic trials. Variability in exacerbation diagnoses and treatment have led drug developers to employ "objective" exacerbation definitions combining antimicrobial treatment (AT) and the presence of ≥4 of 12 respiratory criteria (first published by Fuchs et al. [NEJM 1994;331(10):637-42]). Assumptions underlying this approach have yet to be formally evaluated. METHODS Respiratory events (RE) observed during a 48-week trial of ataluren (NCT02139306), a read-through agent for premature nonsense codons, were compared across six exacerbation definitions: any AT, intravenous AT (IVAT), ≥4 Fuchs criteria present, AT plus ≥4 Fuchs criteria, IVAT plus ≥4 Fuchs criteria, and investigator assessment. Fuchs definitions were evaluated by assessing missingness of individual criteria and associations between criteria presence and clinician exacerbation assessment. RESULTS Among 751 RE, more than one third had ≥4 Fuchs criteria present but were not assessed as exacerbations by investigators. Data for ≥1 and for 4 Fuchs criteria, respectively, were missing for ~ 90% and >30% of RE. Only 6/12 Fuchs criteria were present more often when investigators assessed RE as exacerbations than when they did not. CONCLUSIONS "Objective" definitions have shortcomings inconsistent with their purpose of optimizing exacerbation capture in clinical trials : 1) they capture events clinicians do not consider exacerbations, 2) are prone to data missingness which can bias the likelihood of meeting the definition, and 3) employ criteria that are not associated with investigator assessment of exacerbation.
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Affiliation(s)
- Donald R. VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, USA,Corresponding author at: 12520 33rd Street CT E, Edgewood, WA, 98372, USA
| | | | - Noah Simon
- University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | | | - Michael W. Konstan
- Case Western Reserve University School of Medicine, Cleveland, OH, USA,Rainbow Babies and Children's Hospital, Cleveland, OH, USA
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19
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Waters VJ, Kidd TJ, Canton R, Ekkelenkamp MB, Johansen HK, LiPuma JJ, Bell SC, Elborn JS, Flume PA, VanDevanter DR, Gilligan P. Reconciling Antimicrobial Susceptibility Testing and Clinical Response in Antimicrobial Treatment of Chronic Cystic Fibrosis Lung Infections. Clin Infect Dis 2020; 69:1812-1816. [PMID: 31056660 DOI: 10.1093/cid/ciz364] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 04/29/2019] [Indexed: 01/28/2023] Open
Abstract
Median cystic fibrosis (CF) survival has increased dramatically over time due to several factors, including greater availability and use of antimicrobial therapies. During the progression of CF lung disease, however, the emergence of multidrug antimicrobial resistance can limit treatment effectiveness, threatening patient longevity. Current planktonic-based antimicrobial susceptibility testing lacks the ability to predict clinical response to antimicrobial treatment of chronic CF lung infections. There are numerous reasons for these limitations including bacterial phenotypic and genotypic diversity, polymicrobial interactions, and impaired antibiotic efficacy within the CF lung environment. The parallels to other chronic diseases such as non-CF bronchiectasis are discussed as well as research priorities for moving forward.
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Affiliation(s)
- Valerie J Waters
- Division of Infectious Diseases, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Canada
| | - Timothy J Kidd
- School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Australia
| | - Rafael Canton
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Miquel B Ekkelenkamp
- Department of Medical Microbiology, University Medical Center Utrecht, The Netherlands
| | - Helle Krogh Johansen
- Department of Clinical Microbiology, Rigshospitalet, Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - John J LiPuma
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor
| | - Scott C Bell
- Department of Thoracic Medicine, Prince Charles Hospital and QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - J Stuart Elborn
- Imperial College Hospital, Queen's University Belfast, Northern Ireland
| | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Peter Gilligan
- Department of Pathology-Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill
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20
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Konstan MW, VanDevanter DR, Rowe SM, Wilschanski M, Kerem E, Sermet-Gaudelus I, DiMango E, Melotti P, McIntosh J, De Boeck K. Efficacy and safety of ataluren in patients with nonsense-mutation cystic fibrosis not receiving chronic inhaled aminoglycosides: The international, randomized, double-blind, placebo-controlled Ataluren Confirmatory Trial in Cystic Fibrosis (ACT CF). J Cyst Fibros 2020; 19:595-601. [PMID: 31983658 PMCID: PMC9167581 DOI: 10.1016/j.jcf.2020.01.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 01/17/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Ataluren was developed for potential treatment of nonsense-mutation cystic fibrosis (CF). A previous phase 3 ataluren study failed to meet its primary efficacy endpoint, but post-hoc analyses suggested that aminoglycosides may have interfered with ataluren's action. Thus, this subsequent trial (NCT02139306) was designed to assess the efficacy and safety of ataluren in patients with nonsense-mutation CF not receiving aminoglycosides. METHODS Eligible subjects with nonsense-mutation CF (aged ≥6 years; percent predicted (pp) FEV1 ≥40 and ≤90) from 75 sites in 16 countries were randomly assigned in double-blinded fashion to receive oral ataluren or matching placebo thrice daily for 48 weeks. The primary endpoint was absolute change in average ppFEV1 from baseline to the average of Weeks 40 and 48. FINDINGS 279 subjects were enrolled; 138 subjects in the ataluren arm and 136 in the placebo arm were evaluable for efficacy. Absolute ppFEV1 change from baseline did not differ significantly between the ataluren and placebo groups at Week 40 (-0.8 vs -1.8) or Week 48 (-1.7 vs -2.4). Average ppFEV1 treatment difference from baseline to Weeks 40 and 48 was 0.6 (95% CI -1.3, 2.5; p = 0.54). Pulmonary exacerbation rate per 48 weeks was not significantly different (ataluren 0.95 vs placebo 1.13; rate ratio p = 0.40). Safety was similar between groups. No life-threatening adverse events or deaths were reported. INTERPRETATION Neither ppFEV1 change nor pulmonary exacerbation rate over 48 weeks were statistically different between ataluren and placebo groups. Development of a nonsense-mutation CF therapy remains elusive.
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Affiliation(s)
- M W Konstan
- Rainbow Babies and Children's Hospital, Cleveland, OH 44106 USA; Case Western Reserve University School of Medicine, Cleveland, OH 44106 USA.
| | - D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH 44106 USA
| | - S M Rowe
- Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL 35249 USA
| | - M Wilschanski
- Center for Cystic Fibrosis, Hadassah Hebrew University Medical Center, Jerusalem, 91240, Israel
| | - E Kerem
- Center for Cystic Fibrosis, Hadassah Hebrew University Medical Center, Jerusalem, 91240, Israel
| | - I Sermet-Gaudelus
- Centre de Ressource et de Competence de la Mucoviscidose, Service de Pediatrie Generale, Service de Pneumologie Pediatrique, Service de Radiologie Pediatrique, Centre d'Investigation Clinique Hôpital Necker - Enfants Malades, 75015 Paris, France
| | - E DiMango
- Pulmonary, Allergy, and Critical Care Medicine, Columbia University, Department of Medicine, New York, NY 10032 USA
| | - P Melotti
- Centro Fibrosi Cistica, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - J McIntosh
- PTC Therapeutics, South Plainfield, NJ 07080 USA
| | - K De Boeck
- Pediatric Pulmonology and Infectious Diseases, University Hospital of Leuven, University of Leuven, Belgium
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21
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Bullington W, Hempstead S, Smyth AR, Drevinek P, Saiman L, Waters VJ, Bell SC, VanDevanter DR, Flume PA, Elborn S, Muhlebach MS. Antimicrobial resistance: Concerns of healthcare providers and people with CF. J Cyst Fibros 2020; 20:407-412. [PMID: 32563724 DOI: 10.1016/j.jcf.2020.05.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/25/2020] [Accepted: 05/27/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chronic lung infections and their treatment pose risks for the development of antimicrobial resistance (AMR) in people with cystic fibrosis (PWCF). In this study, we evaluated the attitudes of healthcare providers' (HCP) and PWCF or their parents' toward AMR within the international CF community. METHODS HCP and PWCF identified through listservs and CF-related organizations were asked to complete an AMR centered survey, with additional questions on antimicrobial stewardship (AMS) for HCP. Descriptive analyses are reported. RESULTS The responding 443 HCP and 464 PWCF/Parents were from 30 and 25 countries, respectively. Sixty-two percent of HCP and 56% of PWCF stated they were "very concerned" about AMR, with Pseudomonas spp. and Burkholderia spp. considered the most concerning organisms for both HCP and PWCF/Parents. Non-tuberculous mycobacteria were of greater concern to HCP compared to PWCF/Parents. There was a discrepancy regarding AMR education to PWCF, with 80% of HCP stating having discussed this with PWCF/Parents, but only 50% of PWCF recalling such discussions. CONCLUSION These results highlight that AMR is relevant to CF HCP and PWCF internationally, indicating that educational tools and research are warranted.
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Affiliation(s)
- Wendy Bullington
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA.
| | | | - Alan R Smyth
- Division of Child Health, Obstetrics & Gynaecology, University of Nottingham, Nottingham, United Kingdom.
| | - Pavel Drevinek
- Departments of Medical Microbiology Motol University Hospital and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Lisa Saiman
- Department of Pediatrics, Columbia University, New York, New York, USA.
| | - Valerie J Waters
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital and QIMR Berghofer Medical Research Institute, Brisbane, Australia.
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC, USA.
| | - Stuart Elborn
- Imperial College and Royal Brompton Hospital, London and Queen's University Belfast, United Kingdom.
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22
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Mayer-Hamblett N, van Koningsbruggen-Rietschel S, Nichols DP, VanDevanter DR, Davies JC, Lee T, Durmowicz AG, Ratjen F, Konstan MW, Pearson K, Bell SC, Clancy JP, Taylor-Cousar JL, De Boeck K, Donaldson SH, Downey DG, Flume PA, Drevinek P, Goss CH, Fajac I, Magaret AS, Quon BS, Singleton SM, VanDalfsen JM, Retsch-Bogart GZ. Building global development strategies for cf therapeutics during a transitional cftr modulator era. J Cyst Fibros 2020; 19:677-687. [PMID: 32522463 DOI: 10.1016/j.jcf.2020.05.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/18/2020] [Accepted: 05/27/2020] [Indexed: 12/30/2022]
Abstract
As CFTR modulator therapy transforms the landscape of cystic fibrosis (CF) care, its lack of uniform access across the globe combined with the shift towards a new standard of care creates unique challenges for the development of future CF therapies. The advancement of a full and promising CF therapeutics pipeline remains a necessary priority to ensure maximal clinical benefits for all people with CF. It is through collaboration across the global CF community that we can optimize the evaluation and approval process of new therapies. To this end, we must identify areas for which harmonization is lacking and for which efficiencies can be gained to promote ethical, feasible, and credible study designs amidst the changing CF care landscape. This article summarizes the counsel from core advisors across multiple international regions and clinical trial networks, developed during a one-day workshop in October 2019. The goal of the workshop was to identify, in consideration of the highly transitional era of CFTR modulator availability, the drug development areas for which global alignment is currently uncertain, and paths forward that will enable advancement of CF therapeutic development.
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Affiliation(s)
- N Mayer-Hamblett
- University of Washington, Seattle, WA; Seattle Children's Hospital, Seattle, WA.
| | - S van Koningsbruggen-Rietschel
- Cystic Fibrosis Center, Children's Hospital, University of Cologne; Faculty of Medicine and University Hospital Cologne, Cologne Germany
| | - D P Nichols
- University of Washington, Seattle, WA; Seattle Children's Hospital, Seattle, WA
| | - D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - J C Davies
- National Heart & Lung Institute, Imperial College London, London, UK; Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - T Lee
- Leeds Regional Paediatric Cystic Fibrosis Centre, Leeds, UK
| | | | - F Ratjen
- University of Toronto, Toronto, Canada
| | - M W Konstan
- Case Western Reserve University School of Medicine, Cleveland, OH; Rainbow Babies and Children's Hospital, Cleveland, OH
| | - K Pearson
- Seattle Children's Hospital, Seattle, WA
| | - S C Bell
- Children's Health Research Centre, The University of Queensland, Brisbane, Australia
| | - J P Clancy
- Cystic Fibrosis Foundation, Bethesda, MD
| | | | | | - S H Donaldson
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - D G Downey
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
| | - P A Flume
- Medical University of South Carolina, Charleston, SC
| | - P Drevinek
- Charles University, Prague, Czechia, Motol University Hospital, Prague, Czechia
| | - C H Goss
- University of Washington, Seattle, WA; Seattle Children's Hospital, Seattle, WA
| | - I Fajac
- Université de Paris, Paris, France
| | - A S Magaret
- University of Washington, Seattle, WA; Seattle Children's Hospital, Seattle, WA
| | - B S Quon
- University of British Columbia, Vancouver, British Columbia
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23
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Flume PA, VanDevanter DR. Leveraging early markers of cystic fibrosis structural lung disease to improve outcomes. Eur Respir J 2020; 55:55/4/2000105. [DOI: 10.1183/13993003.00105-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/28/2020] [Indexed: 12/17/2022]
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24
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Wagener JS, VanDevanter DR, Konstan MW, Pasta DJ, Millar SJ, Morgan WJ. Lung function changes before and after pulmonary exacerbation antimicrobial treatment in cystic fibrosis. Pediatr Pulmonol 2020; 55:828-834. [PMID: 31746561 DOI: 10.1002/ppul.24577] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/09/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND In cystic fibrosis, observation of a lung function drop (as percent predicted forced expiratory volume in 1 s [FEV1 ]; ppFEV1 ) frequently precedes pulmonary exacerbation (PEx) diagnosis. Recovery of ppFEV1 to a previous "baseline" is commonly used to assess antimicrobial treatment response. However, not all diagnosed PEx are associated with a ppFEV1 drop, and it is unclear whether these are a different type of PEx from those associated with a ppFEV1 drop. METHODS We analyzed pre- and posttreatment ppFEV1 for PEx recorded in the Epidemiologic Study of Cystic Fibrosis from 2003 through 2005. Baseline, pretreatment, and follow-up ppFEV1 were the best recorded within 12-months pre-PEx, the lowest recorded -30 to +3 days of treatment, and the best recorded during 6-month follow-up, respectively. Logistic regression models for return of ppFEV1 to baseline during follow-up were developed separately for PEx with ≥10%, <10%, and no ppFEV1 drop before treatment. RESULTS Of 15 147 PEx, 10 166 (67.1%), 3479 (23.0%), and 1502 (9.9%) presented with a ≥10%, <10%, or no ppFEV1 drop at diagnosis, respectively. 19.5%, 35.2%, and 65.6% of PEx, respectively, had follow-up ppFEV1 equal to or exceeding baseline; overall 27.7% of all PEx treatments resulted in complete recovery of baseline ppFEV1 . Significant predictors of ppFEV1 recovery at follow-up were younger patient age, absence of Aspergillus, lower baseline ppFEV1 , fewer visits during the baseline, lower frequency of prior-year PEx, shorter elapsed time from baseline measure to treatment, smaller relative ppFEV1 drop before treatment, and non intravenous (ie, oral or inhaled antibiotic) treatment. PEx with ≥10%, <10%, and no ppFEV1 drop before treatment had only modest differences in covariate odds ratios associated with complete ppFEV1 recovery. CONCLUSIONS Among the 10% of PEx presenting with no apparent ppFEV1 drop, more than one-third resulted in a decreased ppFEV1 during follow-up. Risk factors for this outcome were the same as those associated with lack of ppFEV1 recovery among PEx with pretreatment ppFEV1 drops. These results suggest that inherent FEV1 variability, baseline and follow-up sampling methodologies, ppFEV1 regression to the mean, and underlying lung disease progression complicate this approach for assessing effects of PEx and treatment response.
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Affiliation(s)
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Michael W Konstan
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - David J Pasta
- Department of Outcomes, ICON Clinical Research, San Francisco, California
| | - Stefanie J Millar
- Department of Outcomes, ICON Clinical Research, San Francisco, California
| | - Wayne J Morgan
- Department of Pediatrics, University of Arizona, Tucson, Arizona
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25
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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26
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Caverly LJ, Lu J, Carmody LA, Kalikin LM, Shedden K, Opron K, Azar M, Cahalan S, Foster B, VanDevanter DR, Simon RH, LiPuma JJ. Measures of Cystic Fibrosis Airway Microbiota during Periods of Clinical Stability. Ann Am Thorac Soc 2019; 16:1534-1542. [PMID: 31415187 PMCID: PMC6956830 DOI: 10.1513/annalsats.201903-270oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 08/15/2019] [Indexed: 12/18/2022] Open
Abstract
Rationale: Differences in cystic fibrosis (CF) airway microbiota between periods of clinical stability and exacerbation of respiratory symptoms have been investigated in efforts to better understand microbial triggers of CF exacerbations. Prior studies have often relied on a single sample or a limited number of samples to represent airway microbiota. However, the variability in airway microbiota during periods of clinical stability is not well known.Objectives: To determine the temporal variability of measures of airway microbiota during periods of clinical stability, and to identify factors associated with this variability.Methods: Sputum samples (N = 527), obtained daily from six adults with CF during 10 periods of clinical stability, underwent sequencing of the V4 region of the bacterial 16S ribosomal RNA gene. The variability in airway microbiota among samples within each period of clinical stability was calculated as the average of the Bray-Curtis similarity measures of each sample to every other sample within the same period. Outlier samples were defined as samples outside 1.5 times the interquartile range within a baseline period with respect to the average Bray-Curtis similarity. Total bacterial load was measured with droplet digital polymerase chain reaction.Results: The variation in Bray-Curtis similarity and total bacterial load among samples within the same baseline period was greater than the variation observed in technical replicate control samples. Overall, 6% of samples were identified as outliers. Within baseline periods, changes in bacterial community structure occurred coincident with changes in maintenance antibiotics (P < 0.05, analysis of molecular variance). Within subjects, bacterial community structure changed between baseline periods (P < 0.01, analysis of molecular variance). Sample-to-sample similarity within baseline periods was greater with fewer interval days between sampling.Conclusions: During periods of clinical stability, airway bacterial community structure and bacterial load vary among daily sputum samples from adults with CF. This day-to-day variation has bearing on study design and interpretation of results, particularly in analyses that rely on single samples to represent periods of interest (e.g., clinical stability vs. pulmonary exacerbation). These data also emphasize the importance of accounting for maintenance antibiotic use and granularity of sample collection in studies designed to assess the dynamics of CF airway microbiota relative to changes in clinical state.
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Affiliation(s)
| | | | | | | | - Kerby Shedden
- Department of Statistics and Biostatistics, University of Michigan, Ann Arbor, Michigan; and
| | - Kristopher Opron
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | | | | | | | - Donald R. VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Richard H. Simon
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
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27
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Zemanick E, Burgel PR, Taccetti G, Holmes A, Ratjen F, Byrnes CA, Waters VJ, Bell SC, VanDevanter DR, Stuart Elborn J, Flume PA. Antimicrobial resistance in cystic fibrosis: A Delphi approach to defining best practices. J Cyst Fibros 2019; 19:370-375. [PMID: 31680041 DOI: 10.1016/j.jcf.2019.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 08/10/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Antimicrobial susceptibility testing (AST) is a cornerstone of infection management in cystic fibrosis. However, there is little evidence that AST predicts the clinical outcome of CF antimicrobial treatment. It has been suggested there is a need for careful consideration of current AST use by the CF community. METHODS We engaged a group of experts consisting of pulmonary (adult and pediatric) and infectious disease clinicians, microbiologists, and pharmacists representing a broad international experience. We conducted an iterative systematic survey (Delphi) to determine and quantify consensus regarding key questions facing CF clinicians in the use of respiratory culture results including what tests to order, when to obtain them, and how to act upon the results of the testing. RESULTS Consensus was reached for many questions but there was not universal agreement to the questions that were addressed. There were some differences with respect to cultures obtained for surveillance compared to when there is clinical worsening. Areas of general consensus include when and how respiratory cultures should be performed, what information should be reported, and when AST should be performed. A key finding is that clinical response to treatment is used to guide treatment decisions rather than AST results. CONCLUSIONS Recommendations are presented regarding questions related to microbiology testing for patients with CF. We have also offered recommendations for priority research questions.
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Affiliation(s)
- Edith Zemanick
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, CO, United States.
| | - Pierre-Régis Burgel
- Division of Respiratory Medicine and Adult Cystic Fibrosis Center, Assistance Publique Hôpitaux de Paris and University Paris Descartes, Paris, France; ERN-Lung cystic fibrosis network.
| | - Giovanni Taccetti
- Cystic Fibrosis Center, Department of Pediatrics, University of Florence, Italy.
| | - Alison Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London. United Kingdom.
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics, Translational Medicine,Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Catherine A Byrnes
- Department of Paediatrics, University of Auckland & Respiratory Department, Starship Children's Health, Auckland, New Zealand
| | - Valerie J Waters
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital and QIMR Berghofer Medical Research Institute, Brisbane, Australia.
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, United States.
| | - J Stuart Elborn
- Imperial College and Royal Brompton Hospital, London and Queen's University Belfast, United Kingdom.
| | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC, United States.
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VanDevanter DR, Mayer-Hamblett N. Important steps in the journey to highly effective CFTR modulator access for people with CF. J Cyst Fibros 2019; 18:577-578. [PMID: 31500809 DOI: 10.1016/j.jcf.2019.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - N Mayer-Hamblett
- University of Washington and Seattle Children's Hospital, Seattle, WA, USA
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29
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VanDevanter DR, Gonda I, Dahms J, Cipolla D, Davis AM, Chalmers JD, Froehlich J. Microbiological changes observed over 48 weeks of treatment with inhaled liposomal ciprofloxacin in individuals with non-cystic fibrosis bronchiectasis and chronic Pseudomonas aeruginosa lung infection. Clin Microbiol Infect 2019; 25:1532-1538. [PMID: 31035017 DOI: 10.1016/j.cmi.2019.04.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 04/09/2019] [Accepted: 04/18/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Non-cystic fibrosis bronchiectasis (NCFBE) with Pseudomonas aeruginosa has been associated with increased pulmonary exacerbation (PEx) and mortality risk. European Respiratory Society guidelines conditionally recommend inhaled antimicrobials for persons with NCFBE, P aeruginosa and three or more PEx/year. We report microbiological results of two randomized, 48-week placebo-controlled trials of ARD-3150 (inhaled liposomal ciprofloxacin) in individuals with NCFBE with P aeruginosa and PEx history [Lancet Respir Med 2019;7:213-26]. METHODS Respiratory secretions from 582 participants receiving up to six 28-day on/off treatment cycles were analysed for sputum P. aeruginosa, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus and Escherichia coli densities, P. aeruginosa susceptibilities to ciprofloxacin and nine other antimicrobials, and prevalence of other bacterial opportunists. Associations between PEx risk and sputum density, antimicrobial susceptibility and opportunist prevalence changes were studied. RESULTS Sputum P. aeruginosa density reductions from baseline after ARD-3150 treatments ranged from 1.77 (95% CI 2.13-1.40) versus 0.54 (95% CI 0.89-0.19) log10 CFU/g for placebo (second period) to 2.07 (95% CI 2.45-1.69) versus 0.70 (95% CI 1.11-0.29) log10 CFU/g for placebo (fourth period) with only modest correlation between density reduction magnitude and PEx benefit. ARD-3150 (but not placebo) treatment was associated with increased P. aeruginosa ciprofloxacin MIC but not emergence of other bacterial opportunists across the study; ciprofloxacin MIC50 increased from 0.5 to 1 mg/L, MIC90 increased from 4 to 16 mg/L. Other antimicrobial MIC were mostly unaffected. CONCLUSION Microbiological changes over 48 weeks of ARD-3150 treatment appear modest. Ciprofloxacin susceptibility (but not other antimicrobial susceptibility) decreases were observed that did not appear to preclude PEx risk reduction benefit.
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Affiliation(s)
- D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - I Gonda
- Respidex LLC, San Francisco, CA, USA
| | - J Dahms
- Aradigm Corporation, Hayward, CA, USA
| | | | - A M Davis
- Grifols, Research Triangle Park, NC, USA
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30
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Somayaji R, Parkins MD, Shah A, Martiniano SL, Tunney MM, Kahle JS, Waters VJ, Elborn JS, Bell SC, Flume PA, VanDevanter DR. Antimicrobial susceptibility testing (AST) and associated clinical outcomes in individuals with cystic fibrosis: A systematic review. J Cyst Fibros 2019; 18:236-243. [PMID: 30709744 DOI: 10.1016/j.jcf.2019.01.008] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/14/2019] [Accepted: 01/21/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Antimicrobial susceptibility testing (AST) is a cornerstone of infection management. Cystic fibrosis (CF) treatment guidelines recommend AST to select antimicrobial treatments for CF airway infection but its utility in this setting has never been objectively demonstrated. METHODS We conducted a systematic review of primary published articles designed to address two PICO (patient, intervention, comparator, outcome) questions: 1) "For individuals with CF, is clinical response to antimicrobial treatment of bacterial airways infection predictable from AST results available at treatment initiation?" and 2) "For individuals with CF, is clinical response to antimicrobial treatment of bacterial airways infection affected by the method used to guide antimicrobial selection?" Relationships between AST results and clinical response (changes in pulmonary function, weight, signs and symptoms of respiratory tract infection, and time to next event) were assessed for each article and results were compared across articles when possible. RESULTS Twenty-five articles describing the results of 20 separate studies, most of which described Pseudomonas aeruginosa treatment, were identified. Thirteen studies described pulmonary exacerbation (PEx) treatment and seven described 'maintenance' of chronic bacterial airways infection. In only three of 16 studies addressing PICO question #1 was there a suggestion that baseline bacterial isolate antimicrobial susceptibility was associated with clinical response to treatment. None of the four studies addressing PICO question #2 suggested that antimicrobial selection methods influenced clinical outcomes. CONCLUSIONS There is little evidence that AST predicts the clinical outcome of CF antimicrobial treatment, suggesting a need for careful consideration of current AST use by the CF community.
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Affiliation(s)
| | | | - Anand Shah
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom; Imperial College London, United Kingdom
| | | | | | | | | | | | - Scott C Bell
- The Prince Charles Hospital and QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
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31
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Kidd TJ, Canton R, Ekkelenkamp M, Johansen HK, Gilligan P, LiPuma JJ, Bell SC, Elborn JS, Flume PA, VanDevanter DR, Waters VJ. Defining antimicrobial resistance in cystic fibrosis. J Cyst Fibros 2018; 17:696-704. [PMID: 30266518 DOI: 10.1016/j.jcf.2018.08.014] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/21/2018] [Accepted: 08/31/2018] [Indexed: 12/31/2022]
Abstract
Antimicrobial resistance (AMR) can present significant challenges in the treatment of cystic fibrosis (CF) lung infections. In CF and other chronic diseases, AMR has a different profile and clinical consequences compared to acute infections and this requires different diagnostic and treatment approaches. This review defines AMR, explains how it occurs, describes the methods used to measure AMR as well as their limitations, and concludes with future directions for research and development in the area of AMR in CF.
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Affiliation(s)
- Timothy J Kidd
- School of Chemistry and Molecular Biosciences, The University of Queensland, Lung Bacteria Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia.
| | - Rafael Canton
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain.
| | - Miquel Ekkelenkamp
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Helle Krogh Johansen
- Department of Clinical Microbiology, Rigshospitalet, Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Peter Gilligan
- Clinical Microbiology-Immunology Laboratories, UNC HealthCare, Chapel Hill, NC, USA.
| | - John J LiPuma
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital and QIMR Berghofer Medical Researhc Institute, Brisbane, Australia.
| | - J Stuart Elborn
- Imperial College and Royal Brompton Hospital, London, Queen's University Belfast, United Kingdom.
| | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC, USA.
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Valerie J Waters
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, USA.
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Clancy JP, Cotton CU, Donaldson SH, Solomon GM, VanDevanter DR, Boyle MP, Gentzsch M, Nick JA, Illek B, Wallenburg JC, Sorscher EJ, Amaral MD, Beekman JM, Naren AP, Bridges RJ, Thomas PJ, Cutting G, Rowe S, Durmowicz AG, Mense M, Boeck KD, Skach W, Penland C, Joseloff E, Bihler H, Mahoney J, Borowitz D, Tuggle KL. CFTR modulator theratyping: Current status, gaps and future directions. J Cyst Fibros 2018; 18:22-34. [PMID: 29934203 DOI: 10.1016/j.jcf.2018.05.004] [Citation(s) in RCA: 165] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND New drugs that improve the function of the cystic fibrosis transmembrane conductance regulator (CFTR) protein with discreet disease-causing variants have been successfully developed for cystic fibrosis (CF) patients. Preclinical model systems have played a critical role in this process, and have the potential to inform researchers and CF healthcare providers regarding the nature of defects in rare CFTR variants, and to potentially support use of modulator therapies in new populations. METHODS The Cystic Fibrosis Foundation (CFF) assembled a workshop of international experts to discuss the use of preclinical model systems to examine the nature of CF-causing variants in CFTR and the role of in vitro CFTR modulator testing to inform in vivo modulator use. The theme of the workshop was centered on CFTR theratyping, a term that encompasses the use of CFTR modulators to define defects in CFTR in vitro, with application to both common and rare CFTR variants. RESULTS Several preclinical model systems were identified in various stages of maturity, ranging from the expression of CFTR variant cDNA in stable cell lines to examination of cells derived from CF patients, including the gastrointestinal tract, the respiratory tree, and the blood. Common themes included the ongoing need for standardization, validation, and defining the predictive capacity of data derived from model systems to estimate clinical outcomes from modulator-treated CF patients. CONCLUSIONS CFTR modulator theratyping is a novel and rapidly evolving field that has the potential to identify rare CFTR variants that are responsive to approved drugs or drugs in development.
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Affiliation(s)
- John Paul Clancy
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | | | - Scott H Donaldson
- University of North Carolina at Chapel Hill - Marsico Lung Institute, United States
| | - George M Solomon
- University of Alabama at Birmingham, University of Alabama at Birmingham
| | - Donald R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Michael P Boyle
- Cystic Fibrosis Foundation, Johns Hopkins University, United States
| | - Martina Gentzsch
- Marsico Lung Institute/Cystic Fibrosis Research Center, University of North Carolina, Chapel Hill, United States; Department of Cell Biology and Physiology, University of North Carolina, Chapel Hill, United States
| | - Jerry A Nick
- National Jewish Health, Denver, CO, United States
| | - Beate Illek
- UCSF Benioff Children's Hospital Oakland, United States
| | - John C Wallenburg
- Cystic Firbosis Canada, Directeur en chef des activites scientifiques, fibrose kystique, Canada
| | | | | | | | | | | | | | - Garry Cutting
- Johns Hopkins University School of Medicine, United States
| | - Steven Rowe
- University of Alabama at Birmingham, University of Alabama at Birmingham
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Carmody LA, Caverly LJ, Foster BK, Rogers MAM, Kalikin LM, Simon RH, VanDevanter DR, LiPuma JJ. Fluctuations in airway bacterial communities associated with clinical states and disease stages in cystic fibrosis. PLoS One 2018. [PMID: 29522532 PMCID: PMC5844593 DOI: 10.1371/journal.pone.0194060] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Bacteria that infect the airways of persons with cystic fibrosis (CF) include a group of well-described opportunistic pathogens as well as numerous, mainly obligate or facultative anaerobic species typically not reported by standard sputum culture. We sequenced the V3-V5 hypervariable region of the bacterial 16S rRNA gene in DNA derived from 631 sputum specimens collected from 111 CF patients over 10 years. We describe fluctuations in the relative abundances of typical CF pathogens, as well as anaerobic species, in relation to changes in patients’ clinical state and lung disease stage. Both bacterial community diversity and the relative abundance of anaerobes increased during exacerbation of symptoms (prior to antibiotic treatment), although this trend was not observed uniformly across disease stages. Community diversity and the relative abundance of anaerobic species decreased during antibiotic treatment. These results support current hypotheses regarding the role of anaerobes in CF pulmonary exacerbations and lung disease progression.
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Affiliation(s)
- Lisa A. Carmody
- Department of Pediatrics and Communicable Disease, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - Lindsay J. Caverly
- Department of Pediatrics and Communicable Disease, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - Bridget K. Foster
- Department of Pediatrics and Communicable Disease, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - Mary A. M. Rogers
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Linda M. Kalikin
- Department of Pediatrics and Communicable Disease, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - Richard H. Simon
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Donald R. VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - John J. LiPuma
- Department of Pediatrics and Communicable Disease, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
- * E-mail:
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Konstan MW, Pasta DJ, Wagener JS, VanDevanter DR, Morgan WJ. BMI fails to identify poor nutritional status in stunted children with CF. J Cyst Fibros 2018; 16:158-160. [PMID: 27916550 DOI: 10.1016/j.jcf.2016.11.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 11/16/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Body mass index (BMI) is currently emphasized for evaluating nutritional status in children with cystic fibrosis (CF). Weight for age (WFA) and height for age (HFA) may get less attention. METHODS Data from the Epidemiologic Study of Cystic Fibrosis were used to compare patient WFA, HFA, and BMI percentiles for children age 2 to 18years. RESULTS For children with BMI between the 25th and 50th percentiles, 16.8% had WFA <10th percentile and 26.6% had HFA <10th percentile. CONCLUSIONS BMI fails to identify a substantial proportion of children with CF who have stunting or potentially poor nutritional status as measured by WFA and/or HFA.
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Affiliation(s)
- Michael W Konstan
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | | | - Jeffrey S Wagener
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Wayne J Morgan
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA.
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VanDevanter DR, Craib ML, Pasta DJ, Millar SJ, Morgan WJ, Konstan MW. Cystic fibrosis clinical characteristics associated with dornase alfa treatment regimen change. Pediatr Pulmonol 2018; 53:43-49. [PMID: 29064184 DOI: 10.1002/ppul.23897] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/23/2017] [Indexed: 11/05/2022]
Abstract
BACKGROUND When the chronic respiratory therapy dornase alfa was made commercially available for cystic fibrosis (CF) more than 20 years ago, two regimens were approved: 2.5 mg inhaled once daily (QD) or twice daily (BID). In the intervening years, there has been little guidance as to when to use each regimen. We have studied clinical practice patterns captured in the Epidemiologic Study of CF (ESCF) during the decade following dornase alfa approval (1994-2005) to better understand clinical characteristics associated with QD versus BID dornase alfa use. Methods We studied the characteristics of ESCF patients who received either dornase alfa regimen for at least 12 months and who were then switched to the alternate regimen for at least 6 months and who had adequate data available around the time of the switch. Average lung function and weight-for-age (WFA) z-scores, numbers of intravenous (IV) antibiotic-treated pulmonary exacerbations, and prevalence of signs and symptoms were determined for 6-month periods capturing the beginning (FIRST) and the end (LAST) of the initial regimen, the 6 months preceding the final 6 months of the initial regimen (PRIOR), and the beginning of the second regimen (POST). Changes in values from FIRST to LAST, PRIOR to LAST, and LAST to POST were studied to better understand clinical scenarios associated with decisions to change regimens. RESULTS A total of 1342 QD and 574 BID regimens were studied with median durations of 3.19 and 2.09 years, respectively. On average, patients beginning BID regimens had worse lung function and a greater number of pulmonary exacerbations treated with IV antibiotics than those beginning QD regimens. However, by the time of regimen switch, patients switching from QD to BID dornase alfa had experienced substantial deterioration with respect to pulmonary exacerbations and signs and symptoms, whereas patients switching from BID to QD had not. Interestingly, incidence of IV-treated pulmonary exacerbations and signs and symptom prevalence decreased for both populations after regimen switch. CONCLUSIONS We have studied populations of patients with CF receiving dornase alfa who were switched between regimens to characterize clinical course. Our results suggest that the most common clinical attribute associated with switching from QD to BID dornase alfa was a marked deterioration in stability characterized by increased incidence and frequency of pulmonary exacerbation. For this population, deterioration in lung function did not appear to be a driver for this switch. In contrast, patients receiving BID dornase alfa who were ultimately switched to QD appeared to be clinically stable, on average, suggesting that treatment burden and cost may have been drivers of the decision to switch regimens.
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Heltshe SL, West NE, VanDevanter DR, Sanders DB, Beckett VV, Flume PA, Goss CH. Study design considerations for the Standardized Treatment of Pulmonary Exacerbations 2 (STOP2): A trial to compare intravenous antibiotic treatment durations in CF. Contemp Clin Trials 2017; 64:35-40. [PMID: 29170074 DOI: 10.1016/j.cct.2017.11.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/14/2017] [Accepted: 11/18/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pulmonary exacerbations (PEx) in cystic fibrosis (CF) are common and contribute to morbidity and mortality. Duration of IV antibiotic therapy to treat PEx varies widely in the US, and there are few data to guide treatment decisions. METHODS We combined a survey of CF stakeholders with retrospective analyses of a recent observational study of CF PEx to design a multicenter, randomized, prospective study comparing the efficacy and safety of different durations of IV antibiotics for PEx to meet the needs of people with CF and their caregivers. RESULTS IV antibiotic duration was cited as the most important PEx research question by responding CF physicians and top concern among surveyed CF patients/caregivers. During PEx, forced expiratory volume in 1s (FEV1% predicted) and symptom responses at 7-10days of IV antibiotics identified two distinct groups: early robust responders (ERR) who subsequently experienced greater FEV1 improvements compared to non-ERR (NERR). In addition to greater FEV1 and symptom responses, only 14% of ERR patients were treated with IV antibiotics for >15days, compared with 45% of NERR patients. CONCLUSIONS A divergent trial design that evaluates subjects' interim improvement in FEV1 and symptoms to tailor randomization to IV treatment duration (10 vs. 14days for ERR, 14 vs. 21days for NERR) may alleviate physician and patient concerns about excess or inadequate treatment. Such a study has the potential to provide evidence necessary to standardize IV antibiotic duration in CF PEx care -a first step to conducting PEx research of other treatment features.
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Affiliation(s)
- Sonya L Heltshe
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98121, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA.
| | - Natalie E West
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | | | - D B Sanders
- Department of Pediatrics, Riley Hospital for Children, School of Medicine, Indiana University, Indiana, IN 46202, USA
| | - Valeria V Beckett
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98121, USA
| | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Christopher H Goss
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98121, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA; Division of Pulmonary Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98121, USA
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Konstan MW, Wagener JS, VanDevanter DR, Pasta DJ, Millar SJ, Morgan WJ. Comparison of FEV 1 reference equations for evaluating a cystic fibrosis therapeutic intervention. Pediatr Pulmonol 2017; 52:1013-1019. [PMID: 28672067 DOI: 10.1002/ppul.23751] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 06/01/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVES The Global Lung Function Initiative (GLI, 2012) developed reference equations for forced expiratory volume in 1 s (FEV1 ). Previous equations were developed by groups led by Knudson (1983), Wang (1993), Hankinson (1999), and Stanojevic (2008).1,2,4,6 We assessed how different prediction equations affect the conclusions from a therapeutic intervention study that evaluated the rate of percent predicted FEV1 (ppFEV1 ) decline. METHODOLOGY Using data from the Epidemiologic Study of cystic fibrosis (CF), we re-analyzed our previous study evaluating the relationship of dornase alfa (DA) use with ppFEV1 using the Knudson, Wang & Hankinson, Stanojevic, and GLI equations. The change in intercept and change in slope of ppFEV1 from a 2-year pre-index period and 2-year post-index period were compared between the treated (N = 2483) and comparator groups (N = 6992, from 4110 unique patients). RESULTS Change in intercept for the comparator group was similar across equations except that Wang & Hankinson values were more negative. The difference in change in intercept between the DA and comparator groups ranged from 3.38 to 4.02% predicted. The change in slope for the comparator group ranged from -0.58 to +0.30 ppFEV1 /year, but the difference in change in slope between the DA and comparator groups was in a narrower range from +0.53 to +0.89 ppFEV1 /year. CONCLUSIONS Although individual patient results are impacted by the choice of reference equations, the study conclusions from this evaluation of a therapeutic intervention were minimally affected. GLI equations are recommended for future studies, but prior results based on other equations should be accepted as reliable.
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VanDevanter DR, Mayer-Hamblett N, Boyle M. Feasibility of placebo-controlled trial designs for new CFTR modulator evaluation. J Cyst Fibros 2017; 16:496-498. [DOI: 10.1016/j.jcf.2017.02.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 02/22/2017] [Accepted: 02/24/2017] [Indexed: 12/01/2022]
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Sanders DB, Solomon GM, Beckett VV, West NE, Daines CL, Heltshe SL, VanDevanter DR, Spahr JE, Gibson RL, Nick JA, Marshall BC, Flume PA, Goss CH. Standardized Treatment of Pulmonary Exacerbations (STOP) study: Observations at the initiation of intravenous antibiotics for cystic fibrosis pulmonary exacerbations. J Cyst Fibros 2017; 16:592-599. [PMID: 28460885 DOI: 10.1016/j.jcf.2017.04.005] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 03/07/2017] [Accepted: 04/04/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND The Standardized Treatment of Pulmonary Exacerbations (STOP) program has the intent of defining best practices in the treatment of pulmonary exacerbations (PEx) in patients with cystic fibrosis (CF). The objective of this analysis was to describe the clinical presentations of patients admitted for intravenous (IV) antibiotics and enrolled in a prospective observational PEx study as well as to understand physician treatment goals at the start of the intervention. METHODS We enrolled adolescents and adults admitted to the hospital for a PEx treated with IV antibiotics. We recorded patient and PEx characteristics at the time of enrollment. We surveyed treating physicians on treatment goals as well as their willingness to enroll patients in various study designs. Additional demographic and clinical data were obtained from the CF Foundation Patient Registry. RESULTS Of 220 patients enrolled, 56% were female, 19% were adolescents, and 71% were infected with P. aeruginosa. The mean (SD) FEV1 at enrollment was 51.1 (21.6)% predicted. Most patients (85%) experienced symptoms for ≥7days before admission, 43% had received IV antibiotics within the previous 6months, and 48% received oral and/or inhaled antibiotics prior to IV antibiotic initiation. Forty percent had ≥10% FEV1 decrease from their best value recorded in the previous 6months, but for 20% of patients, their enrollment FEV1 was their best FEV1 recorded within the previous 6months. Physicians reported that their primary treatment objectives were lung function recovery (53%) and improvement of symptoms (47%) of PEx. Most physicians stated they would enroll patients in studies involving 10-day (72%) or 14-day (87%), but not 7-day (29%), treatment regimens. CONCLUSIONS Based on the results of this study, prospective studies are feasible and physician willingness for interventional studies of PEx exists. Results of this observational study will help design future PEx trials.
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Affiliation(s)
- Don B Sanders
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, USA.
| | - George M Solomon
- Department of Medicine, Gregory Fleming James Cystic Fibrosis Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Valeria V Beckett
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA
| | - Natalie E West
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Cori L Daines
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
| | - Sonya L Heltshe
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jonathan E Spahr
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ronald L Gibson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Jerry A Nick
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | | | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Christopher H Goss
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
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VanDevanter DR, Heltshe SL, Spahr J, Beckett VV, Daines CL, Dasenbrook EC, Gibson RL, Raksha J, Sanders DB, Goss CH, Flume PA. Rationalizing endpoints for prospective studies of pulmonary exacerbation treatment response in cystic fibrosis. J Cyst Fibros 2017; 16:607-615. [PMID: 28438499 DOI: 10.1016/j.jcf.2017.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 03/08/2017] [Accepted: 04/04/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Given the variability in pulmonary exacerbation (PEx) management within and between Cystic Fibrosis (CF) Care Centers, it is possible that some approaches may be superior to others. A challenge with comparing different PEx management approaches is lack of a community consensus with respect to treatment-response metrics. In this analysis, we assess the feasibility of using different response metrics in prospective randomized studies comparing PEx treatment protocols. METHODS Response parameters were compiled from the recent STOP (Standardized Treatment of PEx) feasibility study. Pulmonary function responses (recovery of best prior 6-month and 12-month FEV1% predicted and absolute and relative FEV1% predicted improvement from treatment initiation) and sign and symptom recovery from treatment initiation (measured by the Chronic Respiratory Infection Symptom Score [CRISS]) were studied as categorical and continuous variables. The proportion of patients retreated within 30days after the end of initial treatment was studied as a categorical variable. Sample sizes required to adequately power prospective 1:1 randomized superiority and non-inferiority studies employing candidate endpoints were explored. RESULTS The most sensitive endpoint was mean change in CRISS from treatment initiation, followed by mean absolute FEV1% predicted change from initiation, with the two responses only modestly correlated (R2=.157; P<0.0001). Recovery of previous best FEV1 was a problematic endpoint due to missing data and a substantial proportion of patients beginning PEx treatment with FEV1 exceeding their previous best measures (12.1% >12-month best, 19.6% >6-month best). Although mean outcome measures deteriorated approximately 2-weeks post-treatment follow-up, the effect was non-uniform: 62.7% of patients experienced an FEV1 worsening versus 49.0% who experienced a CRISS worsening. CONCLUSIONS Results from randomized prospective superiority and non-inferiority studies employing mean CRISS and FEV1 change from treatment initiation should prove compelling to the community. They will need to be large, but appear feasible.
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Affiliation(s)
- D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA.
| | - S L Heltshe
- University of Washington, Seattle, WA 98121, USA; CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - J Spahr
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA
| | - V V Beckett
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - C L Daines
- University of Arizona, Tucson, AZ 85724, USA
| | - E C Dasenbrook
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - R L Gibson
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - Jain Raksha
- University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - D B Sanders
- University of Wisconsin, Madison, WI 53792, USA
| | - C H Goss
- University of Washington, Seattle, WA 98121, USA; CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - P A Flume
- Medical University of South Carolina, Charleston, SC 29425, USA
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Affiliation(s)
- Patrick A Flume
- From Medical University of South Carolina, Charleston, South Carolina, and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Donald R VanDevanter
- From Medical University of South Carolina, Charleston, South Carolina, and Case Western Reserve University School of Medicine, Cleveland, Ohio
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Flume PA, VanDevanter DR, Morgan EE, Dudley MN, Loutit JS, Bell SC, Kerem E, Fischer R, Smyth AR, Aaron SD, Conrad D, Geller DE, Elborn JS. A phase 3, multi-center, multinational, randomized, double-blind, placebo-controlled study to evaluate the efficacy and safety of levofloxacin inhalation solution (APT-1026) in stable cystic fibrosis patients. J Cyst Fibros 2016; 15:495-502. [DOI: 10.1016/j.jcf.2015.12.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 11/01/2015] [Accepted: 12/02/2015] [Indexed: 10/22/2022]
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VanDevanter DR, Flume PA, Morris N, Konstan MW. Probability of IV antibiotic retreatment within thirty days is associated with duration and location of IV antibiotic treatment for pulmonary exacerbation in cystic fibrosis. J Cyst Fibros 2016; 15:783-790. [PMID: 27139161 DOI: 10.1016/j.jcf.2016.04.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 03/26/2016] [Accepted: 04/15/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND There are few objective data to guide management of cystic fibrosis (CF) pulmonary exacerbations. We studied intravenous (IV) antibiotic treatment failure as defined by a need to retreat patients with IV antibiotics within 30days of completion of a prior IV antibiotic treatment for pulmonary exacerbation. METHODS The first IV-treated exacerbation on or after Jan. 1, 2010 among US CF Foundation Patient Registry patients was studied, combining treatments separated by <7days into single treatments. IV treatment duration categories were: 1-4, 5-8, 9-12, 13-16, 17-22, and ≥23days (inclusive). Logistic regressions for IV retreatment in ≤30days were adjusted with 12 categorical covariates, including age, sex, lung function, prior-year exacerbations, CF complications, CF Care Program, and ever/never treated in hospital. RESULTS 777 of 13,579 patients (5.7%) were retreated within 30days, with incidence varying by treatment duration: 1-4days, 8.7%; 5-8days; 6.6%; 9-12days, 3.2%; 13-16days, 4.5%; 17-22days, 6.2%; ≥23days, 10.3% and hospitalization: ever, 5.0%; never 8.5%. Adjusted odds ratios (OR) for retreatment (compared to 13-16days treatment) were: 1-4days, 1.94 [95%CI 1.49, 2.54] P<.001; 5-8days, 1.55 [1.18, 2.04] P=.002; 9-12days, 0.78 [0.58, 1.04] P=.09; 17-22days, 1.12 [0.88, 1.42] P=.37; ≥23days, 1.46 [1.12, 1.91] P=.005. Adjusted retreatment OR for never/ever hospitalized was 1.57 [1.29, 1.90] P<.001. Prior-year exacerbation number, oxygen therapy, non-invasive ventilation, and female sex were significantly associated with retreatment. Modeling hazard rate time-dependence showed that treatment duration and location-associated hazard rates attenuated within a few months after treatment. CONCLUSION After adjustment for covariates known to be associated with increased risk of IV treatment for exacerbation, IV antibiotic treatments of <9 and ≥23days and those without hospitalization were significant risk factors for IV retreatment within 30days of completion of an exacerbation treatment.
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Affiliation(s)
- D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - P A Flume
- Medical University of South Carolina, Charleston, SC, USA
| | - N Morris
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - M W Konstan
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Rainbow Babies and Children's Hospital, Cleveland, OH, USA
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VanDevanter DR, Kahle JS, O’Sullivan AK, Sikirica S, Hodgkins PS. Cystic fibrosis in young children: A review of disease manifestation, progression, and response to early treatment. J Cyst Fibros 2016; 15:147-57. [DOI: 10.1016/j.jcf.2015.09.008] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 09/18/2015] [Accepted: 09/21/2015] [Indexed: 12/31/2022]
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Elborn JS, Flume PA, Cohen F, Loutit J, VanDevanter DR. Safety and efficacy of prolonged levofloxacin inhalation solution (APT-1026) treatment for cystic fibrosis and chronic Pseudomonas aeruginosa airway infection. J Cyst Fibros 2016; 15:634-40. [PMID: 26935334 DOI: 10.1016/j.jcf.2016.01.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 01/11/2016] [Accepted: 01/30/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Levofloxacin inhalation solution (LIS) is the first aerosolized fluoroquinolone licensed for treatment of patients with cystic fibrosis (CF) and chronic Pseudomonas aeruginosa lung infection. This study evaluated the safety and efficacy of extended LIS treatment. METHODS Patients completing a multinational, randomized study comparing LIS and tobramycin inhalation solution (TIS) were enrolled in an open-label extension in which all patients received three additional cycles of 28days of LIS 240mg twice daily followed by 28days off drug. Endpoints included mean relative change in percent predicted forced expiratory volume in 1s (FEV1), time to pulmonary exacerbation, and patient-reported quality of life. RESULTS Extended treatment with LIS in 88 patients was well tolerated with no new safety signals and evidence of positive effects on FEV1 and quality of life. CONCLUSION Patients receiving extended LIS treatment continued to show favorable efficacy with no additional safety concerns.
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Affiliation(s)
- J Stuart Elborn
- Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, University Belfast, 97 Lisburn Road, Belfast BT9 7AE, UK.
| | - Patrick A Flume
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA; Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA.
| | - Fredric Cohen
- Future Therapies, LLC, Washington Crossing, PA, USA.
| | | | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
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Morgan WJ, VanDevanter DR, Pasta DJ, Foreman AJ, Wagener JS, Konstan MW, Liou T, McColley S, McMullen A, Quittner A, Regelmann W, Ren C, Rosenfeld M, Sawicki G, Schechter M, VanDevanter D, Wagener J, Woo M, Brasfield D, Lyrene R, Sindel L, Roberts D, Carroll J, Warren R, Nassri L, Anderson P, Brown M, Silverthorn A, Radford P, Gong G, Legris G, Greene G, Sudhakar R, Platzker A, Nickerson B, Hardy K, Harwood I, Shay G, Quick B, Lieberthal A, Moss R, Landon C, Fanous Y, Lieberman J, Spiritus E, Chipps B, McDonald R, Pian M, Cropp G, Lewis N, Nielson D, Shapiro B, Wagener J, Accurso F, Saavedra M, Daigle K, Hen J, Palazzo R, Dodds K, Pad-man R, Goodill J, Winnie G, Davies L, Kriseman T, Sallent J, Chiaro J, Kubiet M, Goldfinger S, Schwartzman M, Diaz C, Maupin K, Riff E, Geller D, Livingston F, Mavunda K, Birriel J, Faverio L, Rosenberg D, Schaeffer D, Sherman J, Wagner M, Light M, Schnapf B, Montgomery G, Kirchner K, Weatherly M, Caplan D, Guill M, Hudson V, Akhter J, Davison D, Boas S, McColley S, Chung Y, Latner R, Aljadeff G, Chan Y, Kraut J, Stone A, Still JL, Sharma G, Eagleton L, Hopkins P, Chatrath U, Lester L, Kim YJ, Anthony V, Eigan H, Howenstine M, James P, Gergesha E, Harris J, Plant R, Zivkovich V, Collins A, Nassif E, Ahrens R, Doornbos D, Kanarek J, Leff R, Shaw P, Demoss E, Riva M, Sullivan L, Anstead M, Kanga J, Eid N, Morton R, Hilman B, Jones K, Davis S, Harder R, Lever T, Cairns AM, Caldwell E, Zuckerman J, Mogayzel P, Rosenstein B, McQuestion J, Perry D, Rosenberg S, Gerstle R, Colin A, Wohl ME, Lapey A, Yee W, O'Sullivan B, Zwerdling R, Abdulhamid I, O'Hagan A, Schuen J, Kurlandsky L, Honicky R, Homnick D, Marks J, Pichurko B, Maxvold N, Nasr S, Simon R, Tsai W, Kissner D, McNamara J, Henry N, Marker S, Pryor M, Regelmann W, Walker L, Woodward J, Mizell L, Miller S, Rosenbluth D, Black P, McCubbin M, Cohen A, Ferkol T, Mallory G, Rejent A, Rubin B, Graff G, Konig P, Colombo J, Murphy P, Boyle W, Parker W, Patton C, Zanni R, Atlas A, Turcios N, Laraya-Cuasay L, Bisberg D, Aguila H, Allen S, James D, Perkett E, Thompson M, Budhecha S, Diaz R, Rosen J, Kaslovsky R, Percciacante R, Borowitz D, Cronin J, McMahon C, Quittell L, Giusti R, Cohen R, DeCelie-Germana J, Gorvoy J, Patel K, Kattan M, Dozor A, DiMango E, Berdella M, Anbar R, Ianuzzi D, Sexton J, Tayag-Kier C, McBride J, Ren C, Voter K, Dimaio M, Georgitis J, Majure JM, Martinez M, McIntosh C, Leigh M, Schechter M, Black H, Hughes J, Kantak A, Wilmott R, Omlor G, Stone R, McCoy K, Acton J, Doershuk C, Konstan M, Fink R, Steffan M, Vauthy P, Joseph P, Reyes S, Kramer J, Royall J, Eisenberg J, Wall M, Fiel S, Scanlin T, Phadke S, Winnie G, Weinberg J, Sexauer W, Wolf S, Holsclaw D, Klein D, Warren S, Kinsey R, Perez C, Ganeshanathan M, Shinnick J, Panitch H, Varlotta L, Robinson C, Santana JR, Passero MA, Gwinn J, Baker R, Bowman M, Flume P, Brown D, Marville R, Wallace J, Parry R, Ellenburg D, Rogers J, Mohon R, Ledbetter J, Hanissian A, Schoumacher R, Campbell P, Harris C, Slovis B, Stokes D, Hale K, Katz M, Seilheimer D, Sockrider M, Frank A, Daniel J, Cunningham J, Browning I, Bray J, Dove A, Mandujano F, Tremper L, Morse M, Willey-Courand D, Copenhaver S, Pohl J, McWilliams B, Martine-Logvinoff M, Wallace M, Klein R, Amaro R, Couch L, Brown M, Prestidge C, Inscore S, Lipton A, Chatfield B, Liou T, Marshall B, Lahiri T, Swartz D, Whittaker L, Karlson K, Ropoll I, Rubio T, Schmidt J, Thomas D, Osborn J, Froh D, Gaston B, Elliott G, Gibson R, Ramsey B, McCarthy M, Larson L, Ricker D, Robbins M, Aitken M, Emerson J, Aronoff S, Moffett K, Biller J, Splaingard M, Sullivan B, Pritchard P, Adair S, Holzwarth P, Dopico G, Meyer K, Green C, Rock M. Forced Expiratory Volume in 1 Second Variability Helps Identify Patients with Cystic Fibrosis at Risk of Greater Loss of Lung Function. J Pediatr 2016; 169:116-21.e2. [PMID: 26388208 DOI: 10.1016/j.jpeds.2015.08.042] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 07/15/2015] [Accepted: 08/20/2015] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate several alternative measures of forced expiratory volume in 1 second percent predicted (FEV1 %pred) variability as potential predictors of future FEV1 %pred decline in patients with cystic fibrosis. STUDY DESIGN We included 13,827 patients age ≥6 years from the Epidemiologic Study of Cystic Fibrosis 1994-2002 with ≥4 FEV1 %pred measurements spanning ≥366 days in both a 2-year baseline period and a 2-year follow-up period. We predicted change from best baseline FEV1 %pred to best follow-up FEV1 %pred and change from baseline to best in the second follow-up year by using multivariable regression stratified by 4 lung-disease stages. We assessed 5 measures of variability (some as deviations from the best and some as deviations from the trend line) both alone and after controlling for demographic and clinical factors and for the slope and level of FEV1 %pred. RESULTS All 5 measures of FEV1 %pred variability were predictive, but the strongest predictor was median deviation from the best FEV1 %pred in the baseline period. The contribution to explanatory power (R(2)) was substantial and exceeded the total contribution of all other factors excluding the FEV1 %pred rate of decline. Adding the other variability measures provided minimal additional value. CONCLUSIONS Median deviation from the best FEV1 %pred is a simple metric that markedly improves prediction of FEV1 %pred decline even after the inclusion of demographic and clinical characteristics and the FEV1 %pred rate of decline. The routine calculation of this variability measure could allow clinicians to better identify patients at risk and therefore in need of increased intervention.
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Affiliation(s)
- Wayne J Morgan
- Department of Pediatrics, University of Arizona, Tucson, AZ.
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH
| | | | | | - Jeffrey S Wagener
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Michael W Konstan
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH
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Rosenfeld M, VanDevanter DR, Ren CL, Elkin EP, Pasta DJ, Konstan MW, Morgan WJ. Decline in lung function does not predict future decline in lung function in cystic fibrosis patients. Pediatr Pulmonol 2015; 50:856-62. [PMID: 26086901 DOI: 10.1002/ppul.23227] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 03/04/2015] [Accepted: 03/30/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Despite the attention paid to minimizing lung function decline among cystic fibrosis (CF) patients, the effect of rate of decline on subsequent disease progression is poorly understood. We aimed to describe the rate of decline of FVC, FEV1 , and FEF25-75 and to test the hypothesis that rate of decline of each spirometric variable predicts subsequent rate of decline in that variable and each other variable. METHODS Data were from the Epidemiologic Study of CF, an observational study of North American CF patients from 1994 to 2005. For each year of age, patients' best percent predicted FEV1 and associated FVC and FEF25-75, were used to calculate 2-year slopes for each spirometric variable. Pearson correlations were calculated between reference slopes and follow-up slopes up to 8 years later and, for FEV1 , between reference slopes and level (not slope) of lung function up to 5 years later. RESULTS Twenty six thousand, three hundred and ninety-three patients contributed 427,063 spirometries. Median 2-year slopes of all variables were negative for all ages >6 years and the magnitude varied with age, being greatest among 13-17 year olds, especially for FEF25-75 . There was no correlation (r < 0.10) between reference slopes and subsequent slopes 3-8 years later, either within or across variables. The correlation between 2-year FEV1 slopes and FEV1 level even 5 years later was moderate (0.37-0.49) across disease stage categories. CONCLUSIONS Contrary to our hypothesis, rate of lung function decline did not predict future rate of decline either within or across spirometric variables. In contrast, FEV1 slope did have moderate predictive ability for subsequent FEV1 level. These findings are relevant for clinical care and for clinical trial design.
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Affiliation(s)
- Margaret Rosenfeld
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | | | | | - Eric P Elkin
- ICON Clinical Research, San Francisco, California
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Stuart Elborn J, Geller DE, Conrad D, Aaron SD, Smyth AR, Fischer R, Kerem E, Bell SC, Loutit JS, Dudley MN, Morgan EE, VanDevanter DR, Flume PA. A phase 3, open-label, randomized trial to evaluate the safety and efficacy of levofloxacin inhalation solution (APT-1026) versus tobramycin inhalation solution in stable cystic fibrosis patients. J Cyst Fibros 2015; 14:507-14. [PMID: 25592656 DOI: 10.1016/j.jcf.2014.12.013] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 11/22/2014] [Accepted: 12/22/2014] [Indexed: 11/21/2022]
Affiliation(s)
- J Stuart Elborn
- Centre for Infection and Immunity, Queen's University Belfast, BT9, UK
| | - David E Geller
- Florida State University College of Medicine, Orlando, FL, United States
| | - Douglas Conrad
- Department of Medicine, University of California, San Diego, United States
| | - Shawn D Aaron
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Alan R Smyth
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, UK
| | | | - Eitan Kerem
- Department of Pediatrics, Hadassah Medical Center, Jerusalem, Israel
| | - Scott C Bell
- The Prince Charles Hospital, Queensland, Australia; Queensland Children's Medical Research Institute, Queensland, Australia
| | | | | | | | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Patrick A Flume
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States; Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States.
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