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Ben-Meir E, Perrem L, Shaw M, Ratjen F, Grasemann H. SPLUNC1 as a biomarker of pulmonary exacerbations in children with cystic fibrosis. J Cyst Fibros 2024:S1569-1993(24)00024-9. [PMID: 38413298 DOI: 10.1016/j.jcf.2024.02.009] [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: 10/19/2023] [Revised: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Short palate, lung, and nasal epithelium clone 1 (SPLUNC1) is an innate defence protein that acts as an anti-microbial agent and regulates airway surface liquid volume through inhibition of the epithelial sodium channel (ENaC). SPLUNC1 levels were found to be reduced in airway secretions of adults with cystic fibrosis (CF). The potential of SPLUNC1 as a biomarker in children with CF is unknown. METHODS We quantified SPLUNC1, interleukin-8 (IL-8) and neutrophil elastase (NE) in sputum of CF children treated with either intravenous antibiotics or oral antibiotics for a pulmonary exacerbation (PEx)s, and in participants of a prospective cohort of CF children with preserved lung function on spirometry, followed over a period of two years. RESULTS Sputum SPLUNC1 levels were significantly lower before compared to after intravenous and oral antibiotic therapy for PEx. In the longitudinal cohort, SPLUNC1 levels were found to be decreased at PEx visits compared to both previous and subsequent stable visits. Higher SPLUNC1 levels at stable visits were associated with longer PEx-free time (hazard ratio 0.85, p = 0.04). SPLUNC1 at PEx visits did not correlate with IL-8 or NE levels in sputum or forced expiratory volume in one second (FEV1) but did correlate with the lung clearance index (LCI) (r=-0.53, p < 0.001). CONCLUSION SPLUNC1 demonstrates promising clinometric properties as a biomarker of PEx in children with CF.
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Affiliation(s)
- E Ben-Meir
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada; Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - L Perrem
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada; Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - M Shaw
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada; Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - F Ratjen
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada; Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - H Grasemann
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada; Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
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2
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Graham BI, Harris JK, Zemanick ET, Wagner BD. Integrating airway microbiome and blood proteomics data to identify multi-omic networks associated with response to pulmonary infection. Microbe 2023; 1:100023. [PMID: 38264413 PMCID: PMC10805068 DOI: 10.1016/j.microb.2023.100023] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Host response to airway infections can vary widely. Cystic fibrosis (CF) pulmonary exacerbations provide an opportunity to better understand the interplay between respiratory microbes and the host. This study aimed to investigate the observed heterogeneity in airway infection recovery by analyzing microbiome and host response (i.e., blood proteome) data collected during the onset of 33 pulmonary infection events. We used sparse multiple canonical correlation network (SmCCNet) analysis to integrate these two types of -omics data along with a clinical measure of recovery. Four microbe-protein SmCCNet subnetworks at infection onset were identified that strongly correlate with recovery. Our findings support existing knowledge regarding CF airway infections. Additionally, we discovered novel microbe-protein subnetworks that are associated with recovery and merit further investigation.
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Affiliation(s)
- Brenton I.M. Graham
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - J. Kirk Harris
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Edith T. Zemanick
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Brandie D. Wagner
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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3
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Murru A, Vadeboncoeur N, Therrien AA, Coderre L, Vaillancourt M, Labrecque MM, Berthiaume Y, Bouvet G, Adam D, Brochiero E, Lesage S, Flamand N, Bilodeau L, Fernandes MJ. Association of low-density neutrophils with lung function and disease progression in adult cystic fibrosis. J Cyst Fibros 2023; 22:1080-1084. [PMID: 36973151 DOI: 10.1016/j.jcf.2023.03.009] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/02/2023] [Accepted: 03/10/2023] [Indexed: 03/28/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) neutrophils fail to eradicate infection despite their massive recruitment into the lung. While studies mostly focus on pathogen clearance by normal density neutrophils in CF, the contribution of low-density neutrophil (LDNs) subpopulations to disease pathogenesis remains unclear. METHODS LDNs were isolated from whole blood donations of clinically stable adult CF patients and from healthy donors. LDN proportion and immunophenotype was assessed by flow cytometry. Associations of LDNs with clinical parameters were determined. RESULTS LDN proportion was increased in CF patients' circulation compared with healthy donors. LDNs are a heterogeneous population of both mature and immature cells in CF and in healthy individuals. Moreover, a higher proportion of mature LDN correlates with a gradual decline in lung function and repeated pulmonary exacerbations in CF patients. CONCLUSIONS Collectively, our observations suggest that low-density neutrophils are linked to CF pathogenesis and underscore the potential clinical relevance of neutrophil subpopulations in CF.
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Affiliation(s)
- Andréa Murru
- Infectious and Immune Diseases Division, CHU de Québec Research Center, Laval University, Québec, QC, Canada; Department of Microbiology-Infectious Diseases and Immunology, Faculty of Medicine, Laval University, Québec, QC, Canada; Quebec Heart and Lung Institute, Québec, QC, Canada
| | | | | | - Lise Coderre
- Maisonneuve-Rosemont Hospital Research Center, Montréal, QC, Canada
| | - Myriam Vaillancourt
- Infectious and Immune Diseases Division, CHU de Québec Research Center, Laval University, Québec, QC, Canada; Department of Microbiology-Infectious Diseases and Immunology, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - Marie-Michèle Labrecque
- Infectious and Immune Diseases Division, CHU de Québec Research Center, Laval University, Québec, QC, Canada; Department of Microbiology-Infectious Diseases and Immunology, Faculty of Medicine, Laval University, Québec, QC, Canada
| | | | | | - Damien Adam
- The University of Montreal Hospital Research Centre (CRCHUM), Montréal, QC, Canada; Department of Medicine, Faculty of Medicine, University of Montréal, Montréal, QC, Canada
| | - Emmanuelle Brochiero
- The University of Montreal Hospital Research Centre (CRCHUM), Montréal, QC, Canada; Department of Medicine, Faculty of Medicine, University of Montréal, Montréal, QC, Canada
| | - Sylvie Lesage
- Maisonneuve-Rosemont Hospital Research Center, Montréal, QC, Canada; Department of Microbiology, Infectiology and Immunology, University of Montréal, Montréal, QC, Canada
| | | | | | - Maria J Fernandes
- Infectious and Immune Diseases Division, CHU de Québec Research Center, Laval University, Québec, QC, Canada; Department of Microbiology-Infectious Diseases and Immunology, Faculty of Medicine, Laval University, Québec, QC, Canada.
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4
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Wagner BD, Zemanick ET, Sagel SD, Robertson CE, Stevens MJ, Mayer-Hamblett N, Retsch-Bogart G, Ramsey BW, Harris JK. Limited effects of azithromycin on the oropharyngeal microbiome in children with CF and early pseudomonas infection. BMC Microbiol 2023; 23:312. [PMID: 37891457 PMCID: PMC10612347 DOI: 10.1186/s12866-023-03073-8] [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: 08/23/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Tobramycin inhalation solution (TIS) and chronic azithromycin (AZ) have known clinical benefits for children with CF, likely due to antimicrobial and anti-inflammatory activity. The effects of chronic AZ in combination with TIS on the airway microbiome have not been extensively investigated. Oropharyngeal swab samples were collected in the OPTIMIZE multicenter, randomized, placebo-controlled trial examining the addition of AZ to TIS in 198 children with CF and early P. aeruginosa infection. Bacterial small subunit rRNA gene community profiles were determined. The effects of TIS and AZ were assessed on oropharyngeal microbial diversity and composition to uncover whether effects on the bacterial community may be a mechanism of action related to the observed changes in clinical outcomes. RESULTS Substantial changes in bacterial communities (total bacterial load, diversity and relative abundance of specific taxa) were observed by week 3 of TIS treatment for both the AZ and placebo groups. On average, these shifts were due to changes in non-traditional CF taxa that were not sustained at the later study visits (weeks 13 and 26). Bacterial community measures did not differ between the AZ and placebo groups. CONCLUSIONS This study provides further evidence that the mechanism for AZ's effect on clinical outcomes is not due solely to action on airway microbial composition.
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Affiliation(s)
- Brandie D Wagner
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, USA.
- Children's Hospital Colorado, Aurora, CO, USA.
| | - Edith T Zemanick
- Children's Hospital Colorado, Aurora, CO, USA
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Scott D Sagel
- Children's Hospital Colorado, Aurora, CO, USA
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | | | - Mark J Stevens
- Children's Hospital Colorado, Aurora, CO, USA
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Seattle Children's Hospital, Seattle, WA, USA
| | | | - Bonnie W Ramsey
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Seattle Children's Hospital, Seattle, WA, USA
| | - J Kirk Harris
- Children's Hospital Colorado, Aurora, CO, USA
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
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5
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Song WH, Wong KS, Goldfarb DM, Bone JN, Rayment JH. Frequent microbiological surveillance during inpatient cystic fibrosis pulmonary exacerbations has limited clinical value. J Cyst Fibros 2023:S1569-1993(23)00930-X. [PMID: 37838488 DOI: 10.1016/j.jcf.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND No evidence exists to guide the frequency of obtaining bacterial respiratory cultures during inpatient treatment of pediatric cystic fibrosis (CF) pulmonary exacerbations (PEx). At our institution, admission and weekly respiratory cultures are routinely collected to guide antimicrobial selection. This study evaluates the extent that this practice informs clinical management and the healthcare-related costs associated with routinely repeating cultures. METHODS All children with CF with at least one hospital admission for IV antibiotics from January 2015 to December 2019 were included. Data collected included patient demographics, culture results, and antibiotic history. Respiratory cultures were numbered from the last clinic culture (`Culture 1'), culture on admission (`Culture 2'), and so on (`Cultures 3-6'). Outcomes assessed were microbiological results, frequency and timing of antibiotic change, and total microbiological laboratory costs. RESULTS Seventy-eight children with 224 admissions and 695 bacterial cultures were analyzed. Repeated microbiology sampling revealed 118 new bacterial species in 82 admissions. Culture 2 was most likely to identify a new bacterial species (91/115, 79.1 %) and most likely to be followed by a change in antibiotic (33/37; 89.2 %). The total cost of all cultures was $18,264.79. Eliminating Cultures 3-6 from routine practice could represent a 51 % cost-savings ($9,362.89), without significant impact on identification of new clinically relevant isolates. CONCLUSION Ongoing bacterial surveillance during a CF PEx beyond admission culture provides minimal information, rarely impacts clinical management, and can increase healthcare costs. An optimized approach would be to routinely obtain admission cultures and to obtain further cultures only if clinically indicated.
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Affiliation(s)
- Wendy Hc Song
- Medical Undergraduate Program, University of British Columbia, Vancouver, Canada; BC Children's Hospital Research Institute, Vancouver, Canada
| | - Kendrew Sk Wong
- Medical Undergraduate Program, University of British Columbia, Vancouver, Canada; BC Children's Hospital Research Institute, Vancouver, Canada
| | - David M Goldfarb
- BC Children's Hospital Research Institute, Vancouver, Canada; Department of Pediatrics, University of British Columbia, Vancouver, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Jeffrey N Bone
- BC Children's Hospital Research Institute, Vancouver, Canada
| | - Jonathan H Rayment
- BC Children's Hospital Research Institute, Vancouver, Canada; Department of Pediatrics, University of British Columbia, Vancouver, Canada.
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6
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Gold LS, Hansen RN, Heltshe SL, Flume PA, Goss CH, West NE, Sanders DB, Kessler L. Characteristics associated with cystic fibrosis-related pulmonary exacerbation treatment location. J Cyst Fibros 2023:S1569-1993(23)00926-8. [PMID: 37805355 PMCID: PMC10995101 DOI: 10.1016/j.jcf.2023.10.004] [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: 03/01/2023] [Revised: 09/01/2023] [Accepted: 10/03/2023] [Indexed: 10/09/2023]
Abstract
Previous studies indicate that hospital rather than home treatment of pulmonary exacerbations (PEx) in people with cystic fibrosis (CF) can improve outcomes. We evaluated characteristics of adult participants from the Standardized Treatment of Pulmonary Exacerbations (STOP2) trial with two separate comparisons: (1) those who were treated initially in hospital (N = 768) to those treated initially at home (N = 214) and (2) those treated only in hospital (N = 328) to those who were treated only at home or both at home and in hospital (N = 654). Participants who had Medicaid insurance, were treated for shorter duration, and traveled longer to reach treatment centers were more likely to have been treated initially in the hospital. Having Medicaid insurance, being treated for a shorter duration, and being male were associated with being treated only in the hospital. This analysis suggests decisions about the location of treatment are based on pragmatic factors rather than on clinical characteristics.
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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
| | - 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
| | - Larry Kessler
- Department of Health Services, University of Washington, Seattle, WA, United States
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7
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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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8
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Sutharsan S, Dillenhoefer S, Welsner M, Stehling F, Brinkmann F, Burkhart M, Ellemunter H, Dittrich AM, Smaczny C, Eickmeier O, Kappler M, Schwarz C, Sieber S, Naehrig S, Naehrlich L. Impact of elexacaftor/tezacaftor/ivacaftor on lung function, nutritional status, pulmonary exacerbation frequency and sweat chloride in people with cystic fibrosis: real-world evidence from the German CF Registry. Lancet Reg Health Eur 2023; 32:100690. [PMID: 37554663 PMCID: PMC10405057 DOI: 10.1016/j.lanepe.2023.100690] [Citation(s) in RCA: 2] [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] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/26/2023] [Accepted: 06/30/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Treatment with elexacaftor/tezacaftor/ivacaftor (ETI) improves multiple clinical outcomes in people with cystic fibrosis (pwCF) with at least one F508del allele. This study evaluated the real-world impact of ETI on lung function, nutritional status, pulmonary exacerbation frequency, and sweat chloride concentrations in a large group of pwCF. METHODS This observational cohort study used data from the German CF Registry for pwCF who received ETI therapy and were followed up for a period of 12 months. FINDINGS The study included 2645 pwCF from 67 centres in Germany (mean age 28.0 ± 11.5 years). Over the first year after ETI was initiated, percent predicted forced expiratory volume in 1 s (ppFEV1) increased by 11.3% (95% confidence interval [CI] 10.8-11.8, p < 0.0001), body mass index (BMI) z-score increased by 0.3 (95% CI 0.3-0.4, p < 0.0001) in individuals aged 12 to <18 years and BMI in adults increased by 1.4 kg/m2 (95% CI 1.3-1.4, p < 0.0001), pulmonary exacerbations decreased by 75.9% (p < 0.0001) and mean sweat chloride concentration decreased by 50.9 mmol/L (95% CI -52.6, -49.3, p < 0.0001). Improvements in ppFEV1 over the first year of therapy were greater in pwCF who had not previously received cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy (12.6% [95% CI 11.9-13.4] vs. 9.7% [95% CI 9.0-10.5] in those with prior CFTR modulator treatment. INTERPRETATION These real-world data are consistent with the findings of randomised clinical trials, and support the use of ETI as a highly effective treatment option for pwCF who have at least one F508del allele. FUNDING None.
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Affiliation(s)
- Sivagurunathan Sutharsan
- Department of Pulmonary Medicine, University Hospital Essen-Ruhrlandklinik, Adult Cystic Fibrosis Center, University of Duisburg-Essen, Essen, Germany
| | - Stefanie Dillenhoefer
- Department of Pediatric Pulmonology, Cystic Fibrosis Center, University Children's Hospital of Ruhr University Bochum at St. Josef-Hospital, Bochum, Germany
| | - Matthias Welsner
- Department of Pulmonary Medicine, University Hospital Essen-Ruhrlandklinik, Adult Cystic Fibrosis Center, University of Duisburg-Essen, Essen, Germany
| | - Florian Stehling
- Pediatric Pulmonology and Sleep Medicine, Children's University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Folke Brinkmann
- Department of Pediatric Pneumology & Allergology, The University of Lübeck, University Medical Center Schleswig-Holstein, Campus Centrum Lübeck, Member of Airway Research Center North (ARCN) of the German Center of Lung Research (DZL), Lübeck, Germany
| | | | - Helmut Ellemunter
- Medical University of Innsbruck, Cystic Fibrosis Centre Innsbruck, Innsbruck, Austria
| | - Anna-Maria Dittrich
- Department of Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Germany
| | - Christina Smaczny
- University Hospital Frankfurt/Main, Goethe University, Pneumology and Allergology, Christiane Herzog CF Center Frankfurt/Main, Frankfurt/Main, Germany
| | - Olaf Eickmeier
- Pediatric Allergology, Pulmonology & Cystic Fibrosis, Christiane Herzog CF Center- Frankfurt a.M., University Hospital Frankfurt a.M., Germany
| | - Matthias Kappler
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Germany
| | - Carsten Schwarz
- Division Cystic Fibrosis, HMU-Health and Medical University Potsdam, Clinic Westbrandenburg, Potsdam, Germany
| | - Sarah Sieber
- STAT-UP Statistical Consulting & Data Science GmbH, Munich, Germany
| | - Susanne Naehrig
- Department of Internal Medicine V, Cystic Fibrosis Center for Adults, University Hospital, Ludwig Maximilian University (LMU) Munich, Germany
| | - Lutz Naehrlich
- Department of Pediatrics, Justus-Liebig-University Giessen, Giessen, Germany
- Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
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9
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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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10
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Blanchard AC, Shaw M, Ratjen F, Tullis E, Daneman N, Waters V. Factors associated with lung function response with oral antibiotic treatment of pulmonary exacerbations in cystic fibrosis. J Cyst Fibros 2023; 22:880-883. [PMID: 37474423 DOI: 10.1016/j.jcf.2023.06.015] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 06/28/2023] [Accepted: 06/28/2023] [Indexed: 07/22/2023]
Abstract
Pulmonary exacerbations treated with oral antibiotics (oPEx) have a significant effect on lung function decline in people with cystic fibrosis (CF). However, factors associated with lung function response with oPExs are not well defined. We performed a retrospective cohort study of pediatric and adult patients with CF followed in the Toronto CF Database. Lung function response was measured both as the change in forced expiratory volume in 1 second (FEV1) from Day 0 of antibiotic therapy to end of treatment as well as from baseline to end of treatment. Drop from baseline to Day 0 FEV1 was strongly associated with lung function response (p<0.001). Greater FEV1 improvements were associated with longer antibiotic treatment durations. Older, female patients had less improvements in FEV1 at end of treatment compared to younger, male patients.
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Affiliation(s)
- Ana C Blanchard
- Division of Infectious Diseases, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, 3175 Chemin de la Côte Sainte-Catherine, Montreal, Quebec H3T 1C5, Canada
| | - Michelle Shaw
- Translational Medicine Research Program, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto M5G 1 × 8, Canada
| | - Felix Ratjen
- Translational Medicine Research Program, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto M5G 1 × 8, Canada; Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto M5G 1 × 8, Canada
| | - Elizabeth Tullis
- Division of Respiratory Medicine, Department of Medicine, St Michael's Hospital, University of Toronto, 30 Bond St, Toronto, M5B 1W8, Canada
| | - Nick Daneman
- Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto M4N 3M5, Canada
| | - Valerie Waters
- Translational Medicine Research Program, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto M5G 1 × 8, Canada; Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto M5G 1 × 8, Canada.
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11
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Albon D, Zhang L, Patrie J, Jones M, Li ZG, Noonan E, Borish L. Association between Cystic Fibrosis exacerbations, lung function, T2 inflammation and microbiological colonization. Allergy Asthma Clin Immunol 2023; 19:15. [PMID: 36849900 PMCID: PMC9969710 DOI: 10.1186/s13223-023-00760-z] [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] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 01/04/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND The Cystic Fibrosis Foundation Patient Registry (CFFPR) reports a high prevalence of asthma (34.6%) in people with Cystic Fibrosis (PwCF). While our current understanding of this relationship is limited, a type 2 inflammatory (T2) phenotype has often been identified in CF patients. RESEARCH QUESTION This study aimed to evaluate the relationship between the eosinophilic CF T2 inflammatory phenotype and CF-related pulmonary outcomes and microbiological data. STUDY DESIGN AND METHODS We conducted a retrospective chart review of adult patients with CF (18 and older; n = 93) receiving their care at University of Virginia Medical Center adult program from January, 2013 through December, 2018. Data collected included demographic data, CFTR (CF transmembrane conductance regulator) mutation, CF comorbidities, medications, Absolute Eosinophil Counts (AEC) in cells/µL and Immunoglobulin E (IgE) levels in IU/mL. RESULTS Of 93 patients screened for study eligibility, 74 were included in the final analysis; 19 patients were excluded due to lack of longitudinal data across the study timeline. Lung function decline correlated with increased AEC (p < 0.001) and IgE (p < 0.001) even when adjusting for covariates: age, gender, presence of Pseudomonas spp., MRSA, other bacterial spp., Aspergillus spp., and other fungi (p < 0.001). Univariate analysis demonstrated that people with CF who experienced more than 2 exacerbations requiring hospitalizations and/or intravenous antibiotics a year were more likely to have high AEC (p = 0.018). Logistic regression showed that as AEC increases, the probability that the measurement was taken during a CF exacerbation increases (p = 0.0039). A linear mixed model showed that each additional annual exacerbation event increased on average the log IgE by 0.04. (p = 0.015). This finding remained stable in a multivariate model (p = 0.0145). When adjusted for atopy, log IgE increases as the number of exacerbation events increases (p = 0.022). There was no association between AEC and IgE and microbiological colonization. INTERPRETATION This study has shown that in CF patients, T2 inflammation based on serum AEC and IgE correlated with pulmonary exacerbations requiring hospitalizations and/or intravenous antibiotics, independent of bacterial airway colonization. In addition, lung function decline correlated with increased IgE and AEC. Further studies are needed to explore these correlations and potential impact on treatment.
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Affiliation(s)
- Dana Albon
- Departments of Medicine, University of Virginia School of Medicine, 800546, Charlottesville, VA, 22908, USA.
| | - Lijia Zhang
- grid.224260.00000 0004 0458 8737Department of Psychiatry, Virginia Commonwealth University, Richmond, VA USA
| | - James Patrie
- grid.27755.320000 0000 9136 933XPublic Health Sciences, University of Virginia, Charlottesville, VA USA
| | - Marieke Jones
- grid.27755.320000 0000 9136 933XPublic Health Sciences, University of Virginia, Charlottesville, VA USA
| | - Z. Galvin Li
- grid.27755.320000 0000 9136 933XDepartment of Statistics, University of Virginia, Charlottesville, VA USA
| | - Emily Noonan
- grid.27755.320000 0000 9136 933XDepartments of Medicine, University of Virginia School of Medicine, 800546, Charlottesville, VA 22908 USA
| | - Larry Borish
- grid.27755.320000 0000 9136 933XDepartments of Medicine, University of Virginia School of Medicine, 800546, Charlottesville, VA 22908 USA ,grid.27755.320000 0000 9136 933XDepartment of Microbiology, University of Virginia, 800546, Charlottesville, VA 22908 USA
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12
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Khan MS, Douglas P, Hansell AL, Simmonds NJ, Piel FB. Assessing the health risk of living near composting facilities on lung health, fungal and bacterial disease in cystic fibrosis: a UK CF Registry study. Environ Health 2022; 21:130. [PMID: 36517903 PMCID: PMC9753251 DOI: 10.1186/s12940-022-00932-1] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/27/2022] [Indexed: 06/17/2023]
Abstract
AIM To explore the health risk of living near permitted composting sites (PCSs) on disease severity in children and adults with cystic fibrosis (CF) across the UK. METHODS: A semi-individual cross-sectional study was used to examine the risk of disease severity in people with CF (pwCF) within and beyond 4 km of PCSs in the UK in 2016. All pwCF registered in the UK CF Registry were eligible for this study. Linear and Poisson regressions, adjusted for age, gender, genotype, BMI, Pseudomonas aeruginosa and deprivation, were used to quantify associations between distance to a PCS and percent predicted forced expiratory volume in one second (ppFEV1), pulmonary exacerbations (#IVdays), and fungal and bacterial infections. RESULTS The mean age of the 9,361 pwCF (3,931 children and 5,430 adults) studied was 20.1 (SD = 14.1) years; 53.3% were male; and 49.2% were homozygous F508del. Over 10% of pwCF (n = 1,015) lived within 4 km of a PCS. We found no statistically significant difference in ppFEV1 and #IVdays/year in children. However, in adults, ppFEV1 was -1.07% lower (95% confidence interval (CI): -2.29%, 0.16%) and #IVdays/year were 1.02 day higher (95%CI: 1.01, 1.04) within 4 km of a PCS. Furthermore, there were statistically significant differences in mean ppFEV1 in CF adults with Aspergillus fumigatus (58.2.% vs 62.0%, p = 0.005) and Candida spp. (56.9% vs 59.9%, p = 0.029) residing within 4 km of a PCS. No associations were identified for allergic bronchopulmonary aspergillosis, P. aeruginosa or Staphylococcus aureus. CONCLUSIONS This novel national study provides evidence that adults with CF living near a PCS may experience small reductions in lung function, an increased risk of pulmonary exacerbations, and more frequent fungal infections. If confirmed by studies using refined exposure assessment methods accounting for bioaerosol dispersion, these results could have important implications for the living environment of pwCF.
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Affiliation(s)
- Muhammad Saleem Khan
- UK Small Area Health Statistics Unit, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
- National Institute for Health Research Health Protection Research Units in Environmental Exposures and Health, Imperial College London, London, UK
| | - Philippa Douglas
- National Institute for Health Research Health Protection Research Units in Environmental Exposures and Health, Imperial College London, London, UK
- Centre for Radiation, Chemical and Environmental Hazards, UK Health Security Agency (UKHSA), Harwell Science Campus, Didcot, UK
- Centre for Environmental Health and Sustainability, University of Leicester, Leicester, UK
- National Institute for Health Research Health Protection Research Units in Environmental Exposures and Health, University of Leicester, Leicester, UK
| | - Anna L. Hansell
- Centre for Environmental Health and Sustainability, University of Leicester, Leicester, UK
- National Institute for Health Research Health Protection Research Units in Environmental Exposures and Health, University of Leicester, Leicester, UK
| | - Nicholas J. Simmonds
- Adult Cystic Fibrosis Centre, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Frédéric B. Piel
- UK Small Area Health Statistics Unit, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
- National Institute for Health Research Health Protection Research Units in Environmental Exposures and Health, Imperial College London, London, UK
- MRC Centre for Environment and Health, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
- Protection Research Unit in Chemical and Radiation Threats and Hazards, Imperial College London, London, UK
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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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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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15
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Woodley FW, Gecili E, Szczesniak RD, Shrestha CL, Nemastil CJ, Kopp BT, Hayes D. Sweat metabolomics before and after intravenous antibiotics for pulmonary exacerbation in people with cystic fibrosis. Respir Med 2022; 191:106687. [PMID: 34864373 PMCID: PMC8810598 DOI: 10.1016/j.rmed.2021.106687] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 06/29/2021] [Revised: 11/06/2021] [Accepted: 11/20/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND People with cystic fibrosis (PWCF) suffer from acute unpredictable reductions in pulmonary function associated with a pulmonary exacerbation (PEx) that may require hospitalization. PEx symptoms vary between PWCF without universal diagnostic criteria for diagnosis and response to treatment. RESEARCH QUESTION We characterized sweat metabolomes before and after intravenous (IV) antibiotics in PWCF hospitalized for PEx to determine feasibility and define biological alterations by IV antibiotics for PEx. STUDY DESIGN AND METHODS PWCF with PEx requiring hospitalization for IV antibiotics were recruited from clinic. Sweat samples were collected using the Macroduct® Sweat Collection System at admission prior to initiation of IV antibiotics and after completion prior to discharge. Samples were analyzed for metabolite changes using ultra-high-performance liquid chromatography/tandem accurate mass spectrometry. RESULTS Twenty-six of 29 hospitalized PWCF completed the entire study. A total of 326 compounds of known identity were detected in sweat samples. Of detected metabolites, 147 were significantly different between pre-initiation and post-completion of IV antibiotics for PEx (average treatment 14 days). Global sweat metabolomes changed from before and after IV antibiotic treatment. We discovered specific metabolite profiles predictive of PEx status as well as enriched biologic pathways associated with PEx. However, metabolomic changes were similar in PWCF who failed to return to baseline pulmonary function and those who did not. INTERPRETATION Our findings demonstrate the feasibility of non-invasive sweat metabolomic profiling in PWCF and the potential for sweat metabolomics as a prospective diagnostic and research tool to further advance our understanding of PEx in PWCF.
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Affiliation(s)
- Frederick W. Woodley
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Emrah Gecili
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rhonda D. Szczesniak
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA,Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Chandra L. Shrestha
- Center for Microbial Pathogenesis, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Christopher J. Nemastil
- Division of Pulmonary Medicine, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Benjamin T. Kopp
- Division of Pulmonary Medicine, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH, USA,Center for Microbial Pathogenesis, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Don Hayes
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
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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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Hassanzad M, Kiani A, Abedini A, Ghaffaripour H, Emami H, Alizadeh N, Zoghi G, Hashemi S, Velayati AA. Lung ultrasound for the diagnosis of cystic fibrosis pulmonary exacerbation. BMC Pulm Med 2021; 21:353. [PMID: 34743707 PMCID: PMC8572653 DOI: 10.1186/s12890-021-01728-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/03/2021] [Indexed: 01/03/2023] Open
Abstract
Background High-resolution computed tomography (HRCT) is the gold standard for the evaluation of cystic fibrosis (CF) lung disease; however, lung ultrasound (LUS) is being increasingly used for the assessment of lung in these patients due to its lower cost, availability, and lack of irradiation. We aimed to determine the diagnostic performance of LUS for the evaluation of CF pulmonary exacerbation. Methods This cross-sectional study included patients with CF pulmonary exacerbation admitted to Masih Daneshvari Hospital, Tehran, Iran, from March 21, 2020 to March 20, 2021. Age, gender, and body mass index (BMI) of the patients were recorded. All patients underwent chest X-ray (CXR), HRCT, and LUS on admission. Pleural thickening, atelectasis, air bronchogram, B-line, and consolidation were noted in LUS and then compared with the corresponding findings in CXR and HRCT. Taking HRCT findings as reference, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy (DA) of LUS and CXR for the detection of each pulmonary abnormality were determined. Results Of the 30 patients included in this study, with a mean age of 19.62 ± 5.53 years, 14 (46.7%) were male. Of the 15 patients aged 2–20 years, BMI was below the 5th percentile in 10 (66.7%), within the 5–10 percentiles in 1 (6.7%), 10–25 percentiles in 3 (20%), and 25-50 percentiles in 1 (6.7%). The mean BMI for 15 patients > 20 years was 18.03 ± 2.53 kg/m2. LUS had better diagnostic performance compared to CXR for the detection of air bronchogram, consolidation, and pleural thickening (area under the receiver operating characteristic curve [AUROC]: 0.966 vs. 0.483, 0.900 vs. 0.575, and 0.656 vs. 0.531, respectively). Also, LUS was 100% and 96.7% specific for the diagnosis of pleural effusion and atelectasis, respectively. Conclusions LUS appears to be superior to CXR and comparable with HRCT for the evaluation of CF pulmonary exacerbation, especially in terms of air bronchogram and consolidation detection. LUS can be used to lengthen the HRCT evaluation intervals in this regard or utilized along with HRCT for better evaluation of CF pulmonary exacerbation.
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Affiliation(s)
- Maryam Hassanzad
- Pediatric Respiratory Diseases Research Center (PRDRC), National Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arda Kiani
- Chronic Respiratory Diseases Research Center, National Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Atefeh Abedini
- Chronic Respiratory Diseases Research Center, National Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hoseinali Ghaffaripour
- Pediatric Respiratory Diseases Research Center (PRDRC), National Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Habib Emami
- Tobacco Prevention and Control Research Center, National Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Niloufar Alizadeh
- Department of Biostatistics, National Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ghazal Zoghi
- Endocrinology and Metabolism Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Saeed Hashemi
- Pediatric Respiratory Diseases Research Center (PRDRC), National Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Ali Akbar Velayati
- Mycobacteriology Research Center (MRC), National Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Olcese C, Casciaro R, Pirlo D, Debbia C, Castagnola E, Cresta F, Castellani C. SARS-CoV-2 and Burkholderia cenocepacia infection in a patient with Cystic Fibrosis: An unfavourable conjunction? J Cyst Fibros 2021; 20:e29-e31. [PMID: 33883098 PMCID: PMC8030994 DOI: 10.1016/j.jcf.2021.03.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 12/28/2022]
Abstract
The effects of the concomitant infection by COVID-19 and Burkholderia cepacia (Bc) in CF are not known. We describe the case of a 34 years woman with CF, colonized by Bc and found SARS-CoV2 positive. In the first hospital week she suffered acute respiratory failure and chest imaging showed interstitial involvement and multiple thickenings. She was treated with antibiotics, dexamethasone, remdesivir and heparin, with gradual improvement and discharge at day 20th. The reciprocal role of SARS-CoV-2 and Bc, their potential interactions and the contribution of the individual therapies to the favourable outcome are unclear. It is debatable whether it was SARS-CoV2 that triggered a Bc pulmonary exacerbation or if the chronic Bc infection facilitated the development of a COVID-19 more aggressive than usually seen in CF. If the latter hypothesis were confirmed by similar cases, Bc colonization should be regarded as a risk factor for severe COVID-19 expression in CF.
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Affiliation(s)
- C Olcese
- Cystic Fibrosis Center, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa.
| | - R Casciaro
- Cystic Fibrosis Center, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - D Pirlo
- Department of Emergency, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - C Debbia
- Department of Emergency, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - E Castagnola
- Unit of Infectious Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - F Cresta
- Cystic Fibrosis Center, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - C Castellani
- Cystic Fibrosis Center, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Pallin M, Kumar S, Daley C, Dawadi S, Leong P, Carr E, Soldatos G. Continuous glucose monitoring indices predict poor FEV 1 recovery following cystic fibrosis pulmonary exacerbations. J Cyst Fibros 2021; 20:785-791. [PMID: 33781701 DOI: 10.1016/j.jcf.2021.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 07/06/2020] [Revised: 03/03/2021] [Accepted: 03/08/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Little is known about the effect of dysglycemia during cystic fibrosis pulmonary exacerbation (PEx) on recovery of FEV1 percentage predicted (ppFEV1) METHODS: Continuous glucose monitoring (CGM) was commenced at the time of admission to hospital for PEx and continued for 6 weeks. The CGM indices, percentage of time glucose greater than 7.8 mmol/L (%T>7.8) and mean glucose were evaluated as predictors of absolute ppFEV1 change following treatment of PEx. RESULTS Of the 20 participants who completed the study 13 (65%) had cystic fibrosis related diabetes (CFRD). The mean of both CGM indices were highest during the first week of pulmonary exacerbation and continued to decline over the first 4 weeks at which point they plateaued. Using multivariate regression models, factors which were predictive of maximum attained ppFEV1 change over 6 weeks were %T>7.8, mean glucose, HbA1c and preadmission ppFEV1 change from baseline. These relationships were independent of a diagnosis of CFRD, which was not associated with ppFEV1 recovery. In a longitudinal model of ppFEV1 change at weeks 1, 2 and 6, the CGM index %T>7.8 approached significance as a predictive variable. CONCLUSIONS Hyperglycemia during PEx in adult CF patients is associated with poorer ppFEV1 recovery. Conversely, there was no association observed between CFRD diagnosis and ppFEV1 improvement, suggesting that optimization of glycemic control in CFRD patients may positively influence recovery of lung function. Further clinical trials are required to evaluate the merits of intensive glycemic control in CFRD during PEx.
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Affiliation(s)
- Michael Pallin
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton VIC 3168, Victoria, Australia.
| | - Shanal Kumar
- Monash Centre for Health Research and Implementation, Monash University, Melbourne, Victoria, Australia
| | - Chris Daley
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton VIC 3168, Victoria, Australia
| | - Shrinkhala Dawadi
- Monash Centre for Health Research and Implementation, Monash University, Melbourne, Victoria, Australia
| | - Paul Leong
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton VIC 3168, Victoria, Australia
| | - Erin Carr
- Monash Children's Allied Health, Monash Medical Centre, 246 Clayton Road, Clayton VIC 3168, Victoria, Australia
| | - Georgia Soldatos
- Monash Centre for Health Research and Implementation, Monash University, Melbourne, Victoria, Australia
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Wang C, Johnson R, Horani S, Brown C, Mitchell R, Shah G. Chronic rhinosinusitis and endoscopic sinus surgery in children admitted for pulmonary exacerbations of cystic fibrosis. Int J Pediatr Otorhinolaryngol 2021; 140:110548. [PMID: 33302019 DOI: 10.1016/j.ijporl.2020.110548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 09/17/2020] [Revised: 11/24/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Non-surgical management of chronic rhinosinusitis (CRS) in children with cystic fibrosis (CF) has been increasing over the last decade. This study examines inpatient children with pulmonary exacerbation of CF who were also diagnosed with CRS and underwent endoscopic sinus surgery (ESS). STUDY DESIGN We used the 2003 to 2016 Kids Inpatient Database to perform a cross-sectional analysis of inpatients (ages 0-21 years) diagnosed with CF and CRS in the United States from 2003 to 2016. Demographics and CF-associated comorbidities were recorded and rates of CRS and ESS in children with CF were examined. RESULTS 49,110 children were included in the study. A total of 9334 (19%) were diagnosed with CRS. The average age was 13 (SD 5.9) years; the majority were female (56%), and White (67%). The prevalence of CRS increased from 2003 to 2016 (14%-23%, p < 0.001) while the rate of ESS decreased (20%-11%, p < .001). Patients with CRS that underwent ESS more commonly had CF-associated comorbidities including GI manifestations (15%-25%, p < .001) and liver disease (15%-30%, p < .001). CONCLUSION The diagnosis of CRS in children with CF hospitalized for pulmonary exacerbation has increased while ESS has decreased in the last decade. Patients with CRS that underwent ESS more commonly had CF-associated comorbidities. Studies to determine whether children with CF-associated comorbidities are more likely to benefit from ESS are needed.
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Affiliation(s)
- Cynthia Wang
- Department of Otolaryngology Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Romaine Johnson
- Department of Otolaryngology Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sami Horani
- Department of Otolaryngology Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Clarice Brown
- Department of Otolaryngology Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ron Mitchell
- Department of Otolaryngology Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Gopi Shah
- Department of Otolaryngology Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Magaret AS, Salerno J, Deen JF, Kloster M, Mayer-Hamblett N, Ramsey BW, Nichols DP. Long-term azithromycin use is not associated with QT prolongation in children with cystic fibrosis. J Cyst Fibros 2020; 20:e16-e18. [PMID: 33246911 DOI: 10.1016/j.jcf.2020.11.005] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/03/2020] [Accepted: 11/07/2020] [Indexed: 11/29/2022]
Abstract
Chronic Azithromycin (AZM) is a common treatment for lung infection. Among adults at risk of cardiac events, AZM use has been associated with cardiovascular harm. We assessed cardiovascular safety of AZM among children with CF, as a secondary analysis of a placebo-controlled, clinical trial, in which study drug was taken thrice-weekly for a planned 18 months. Safety assessments using electrocardiogram (ECG) occurred at study enrollment, and then after 3 weeks and 18 months of participation. Among 221 study participants with a median of 18 months follow-up, increased corrected QT interval (QTc) of ≥30 msec was rare, at 3.4 occurrences per 100 person-years; and incidence of QTc prolongation was no higher in the AZM arm than the placebo arm (1.8 versus 5.4 per 100 person-years). No persons experienced QTc intervals above 500 msec. Long-term chronic AZM use was not associated with increased QT prolongation.
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Affiliation(s)
- Amalia S Magaret
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA, United States; Department of Biostatistics, University of Washington, Seattle, WA, United States; Seattle Children's Hospital, Seattle, WA, United States.
| | - Jack Salerno
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA, United States; Seattle Children's Hospital, Seattle, WA, United States
| | - Jason F Deen
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, United States; Seattle Children's Hospital, Seattle, WA, United States
| | | | - Nicole Mayer-Hamblett
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA, United States; Department of Biostatistics, University of Washington, Seattle, WA, United States; Seattle Children's Hospital, Seattle, WA, United States
| | - Bonnie W Ramsey
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA, United States; Seattle Children's Hospital, Seattle, WA, United States
| | - Dave P Nichols
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA, United States; Seattle Children's Hospital, Seattle, WA, United States
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McLeod C, Wood J, Schultz A, Norman R, Smith S, Blyth CC, Webb S, Smyth AR, Snelling TL. Outcomes and endpoints reported in studies of pulmonary exacerbations in people with cystic fibrosis: A systematic review. J Cyst Fibros 2020; 19:858-867. [PMID: 33191129 DOI: 10.1016/j.jcf.2020.08.015] [Citation(s) in RCA: 4] [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: 05/27/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There is no consensus about which outcomes should be evaluated in studies of pulmonary exacerbations in people with cystic fibrosis (CF). Outcomes used for evaluation should be meaningful; that is, they should capture how people feel, function or survive and be acknowledged as important to people with CF, or should be reliable surrogates of those outcomes. We aimed to summarise the outcomes and corresponding endpoints which have been reported in studies of pulmonary exacerbations, and to identify those which are most likely to be meaningful. METHODS A PROSPERO registered systematic review (CRD42020151785) was conducted in Medline, Embase and Cochrane from inception until July 2020. Registered trials were also included. RESULTS 144 studies met the inclusion criteria. A wide range of outcomes and corresponding endpoints were reported. Death, QoL and many patient-reported outcomes are likely to be meaningful as they directly capture how people feel, function or survive. Forced expiratory volume in 1-second [FEV1] is a validated surrogate of risk of death and reduced QoL. The extent of structural lung disease has also been correlated with lung function, pulmonary exacerbations and risk of death. Since no evidence of a correlation between airway microbiology or biomarkers with clinically meaningful outcomes was found, the value of these as surrogates was unclear. CONCLUSIONS Death, QoL, patient-reported outcomes, FEV1, and structural lung changes were identified as outcomes that are most likely to be meaningful. Development of a core outcome set in collaboration with stakeholders including people with CF is recommended.
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Affiliation(s)
- Charlie McLeod
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, 15 Hospital Ave, Nedlands WA 6009, Australia; Infectious Diseases Department, Perth Children's Hospital, 15 Hospital Ave, Nedlands 6009, Australia; Division of Paediatrics, Faculty of Medicine, University of Western Australia, 35 Stirling Hwy, Nedlands 6009, Australia.
| | - Jamie Wood
- Physiotherapy Department, Sir Charles Gairdner Hospital, Hospital Ave, Nedlands 6009, Australia; Abilities Research Center, Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, United States of America.
| | - André Schultz
- Centre for Respiratory Health, Telethon Kids Institute, University of Western Australia, 35 Stirling Hwy, Nedlands 6009, Australia; Respiratory Department, Perth Children's Hospital, 15 Hospital Ave, Nedlands 6009, Australia.
| | - Richard Norman
- School of Public health, 400 Curtin University, Kent St, Bentley 6102, Australia.
| | - Sherie Smith
- Evidence Based Child Health Group, University of Nottingham, Queens Medical Centre, Nottingham NG7 2UH, United Kingdom.
| | - Christopher C Blyth
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, 15 Hospital Ave, Nedlands WA 6009, Australia; Infectious Diseases Department, Perth Children's Hospital, 15 Hospital Ave, Nedlands 6009, Australia; Pathwest Laboratory Medicine WA, QEII Medical Centre, Nedlands 6009, Australia.
| | - Steve Webb
- St John of God Hospital, 12 Salvado Road, Subiaco 6008, Australia; School of Population Health and Preventive Medicine, 553 St Kilda Rd, Monash University, Melbourne 3004, Australia.
| | - Alan R Smyth
- Evidence Based Child Health Group, University of Nottingham, Queens Medical Centre, Nottingham NG7 2UH, United Kingdom.
| | - Thomas L Snelling
- Menzies School of Health Research, PO Box 41096 Casuarina NT 0811, Australia; Sydney School of Public Health, Faculty of Medicine and Health, Edward Ford Building, University of Sydney NSW 2006, Australia.
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Bhimavarapu A, Deng Q, Bean M, Lee N, Ziegler TR, Alvarez J, Tangpricha V. Factors Contributing to Vitamin D Status at Hospital Admission for Pulmonary Exacerbation in Adults With Cystic Fibrosis. Am J Med Sci 2021; 361:75-82. [PMID: 32988598 DOI: 10.1016/j.amjms.2020.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 07/15/2020] [Accepted: 08/17/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Individuals with cystic fibrosis (CF) have difficulty maintaining optimal vitamin D status due to pancreatic insufficiency-induced malabsorption, inadequate sunlight exposure, and poor intake of vitamin D containing foods. Vitamin D deficiency may increase the risk of pulmonary exacerbations of CF. The objective of this study was to assess factors impacting vitamin D status in patients with CF recently hospitalized for a pulmonary exacerbation of CF. METHODS This was a pre-planned analysis of vitamin D intake in patients enrolled in a multi-center, double-blind, randomized controlled study examining vitamin D therapy for pulmonary exacerbation of CF. Demographic information, responses from a habitual sun exposure questionnaire and food frequency questionnaire, and vitamin D supplement usage were queried and compared to serum 25-hydroxyvitamin D (25(OH)D) concentrations. RESULTS A total of 48 subjects were included in this analysis. Subjects were taking approximately 1,200 IU of vitamin D daily. Reported vitamin D intake, age, race, employment, and education were not significantly associated with vitamin D status in this population. However, smoking status, sunlight exposure in the last 3 years, and skin type (in the bivariate model) were all significantly associated with vitamin D status (all p<0.05). CONCLUSIONS Sunlight exposure was the most predictive determinant of vitamin D status in patients with CF prior to pulmonary exacerbation. Subjects reported vitamin D intake below the recommended amounts. The role and mode of optimizing vitamin D status prior to a pulmonary exacerbation needs further investigation.
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VanDevanter DR, Heltshe SL, Hilliard JB, Konstan MW. Pseudomonas aeruginosa antimicrobial susceptibility test (AST) results and pulmonary exacerbation treatment responses in cystic fibrosis. J Cyst Fibros 2021; 20:257-63. [PMID: 32505525 DOI: 10.1016/j.jcf.2020.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 05/12/2020] [Accepted: 05/25/2020] [Indexed: 11/24/2022]
Abstract
Background Antimicrobial susceptibility testing (AST) of bacterial isolates is a time- and resource-intensive procedure recommended by cystic fibrosis (CF) treatment guidelines for antimicrobial selection for pulmonary exacerbation (PEx) treatment. Methods We studied relationships between Pseudomonas aeruginosa (Pa) isolate AST results, antipseudomonal PEx treatments, and treatment responses as change in weight and percent predicted forced expiratory volume in 1 s (ppFEV1) as well as future antimicrobial treatment hazard for PEx occurring at a CF care center from 1999 through 2018. Treatments were categorized by "Pa coverage" as complete (all Pa isolates susceptible by AST to at least one administered agent), none (no isolates susceptible), incomplete (some, but not all isolates susceptible), and indeterminant (administered antipseudomonals not evaluated by AST). Weight and ppFEV1 responses were compared across Pa coverage categories using unadjusted and adjusted general estimating equations; hazard of future treatment was assessed by Cox and logistic regression. Results Among 3820 antimicrobial PEx treatment events in 413 patients with Pa, 62.6% (2390) had complete Pa coverage; 8.9% (340), 2.4% (99), and 26.2% (1000), had no, incomplete, and indeterminant Pa coverage, respectively. Mean baseline to follow-up weight change was +0.74 kg [95% CI 0.63, 0.86]; ppFEV1 change was +1.60 [1.29, 1.90]. Pa coverage category was not associated with significant differences in weight or ppFEV1 change or with future antimicrobial treatment hazard. Conclusions We did not observe superior responses for AST-defined complete Pa coverage treatments versus lesser coverage treatments, suggesting that AST may be of little utility in choosing antimicrobials for CF PEx treatment.
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Bene Z, Fejes Z, Macek M, Amaral MD, Balogh I, Nagy B. Laboratory biomarkers for lung disease severity and progression in cystic fibrosis. Clin Chim Acta 2020; 508:277-286. [PMID: 32428503 DOI: 10.1016/j.cca.2020.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 08/20/2019] [Revised: 04/20/2020] [Accepted: 05/07/2020] [Indexed: 12/22/2022]
Abstract
Although the clinical outcomes of cystic fibrosis (CF) have been markedly improved through the recent implementation of novel CF transmembrane conductance regulator (CFTR) modulator drugs, robust and reliable biomarkers are still demanded for the early detection of CF lung disease progression, monitoring treatment efficacy and predicting life-threatening clinical complications. Thus, there is an unmet need to identify and validate novel, ideally blood based biomarkers with strong correlations to the severity of CF lung disease, which represents a major contribution to overall CF morbidity and mortality. In this review, we aim to summarize the utility of thus far studied blood-, sputum- and bronchoalveolar lavage (BAL)-based biomarkers to evaluate inflammatory conditions in the lung and to follow treatment efficacy in CF. Measurements of sweat chloride concentrations and the spirometric parameter FEV1 are currently utilized to monitor CFTR function and the effect of various CF therapies. Nonetheless, both have inherent pitfalls and limitations, thus routinely analyzed biomarkers in blood, sputum or BAL samples are required as surrogates for lung disorders. Recent discovery of new protein (e.g. HE4) and RNA-based biomarkers, such as microRNAs may offer a higher efficacy, which in aggregate may be valuable to evaluate disease prognosis and to substantiate CF drug efficacy.
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Affiliation(s)
- Zsolt Bene
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; Department of Pediatrics, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zsolt Fejes
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Milan Macek
- Department of Biology and Medical Genetics, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Margarida D Amaral
- University of Lisboa, Faculty of Sciences, BioISI-Biosystems & Integrative Sciences Institute, Lisboa, Portugal
| | - István Balogh
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; Division of Clinical Genetics, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Béla Nagy
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
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Hoo ZH, Bramley NR, Curley R, Edenborough FP, Walters SJ, Campbell MJ, Wildman MJ. Intravenous antibiotic use and exacerbation events in an adult cystic fibrosis centre: A prospective observational study. Respir Med 2019; 154:109-115. [PMID: 31234038 DOI: 10.1016/j.rmed.2019.06.017] [Citation(s) in RCA: 4] [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: 03/02/2019] [Revised: 05/29/2019] [Accepted: 06/17/2019] [Indexed: 11/16/2022]
Abstract
INTRODUCTION In CF, people with higher FEV1 are less aggressively treated with intravenous (IV) antibiotics, with resultant negative impact on their health outcomes. This could be entirely clinician-driven, but patient choice may also influence IV use. In this prospective observational study, we explored IV recommendations by clinicians and IV acceptance by adults with CF to understand how clinical presentations consistent with exacerbations resulted in IV use. METHODS Clinical presentations consistent with exacerbations, IV recommendation by clinicians and IV acceptance by patients were prospectively identified for every adult with CF in Sheffield throughout 2016, excluding those who had lung transplantation (n = 7) or on ivacaftor (n = 13). Relevant demographic data, e.g. %FEV1, were extracted from medical records. Multi-level mixed-effects logistic regression models were used to compare IV recommendations vs non-recommendations for all clinical encounters, and IV acceptance vs non-acceptance for all IV recommendations. RESULTS Among 186 adults (median age 27 years, median FEV1 78.5%), there were 434 exacerbation events and 318 IV use episodes following 1010 clinical encounters. Only 254 (58.5%) of exacerbations were IV treated. A diagnosis of exacerbation, higher number of symptoms and lower %FEV1 were independent predictors for IV recommendation by clinicians. Higher number of symptoms and lower %FEV1 were also independent predictors for IV acceptance by adults with CF. CONCLUSIONS Lower IV use among adults with higher %FEV1 was influenced by both clinicians' and patients' decisions. Using IV antibiotics as an exacerbation surrogate could under-estimate exacerbation rates and conceal differential treatment decisions according to varying clinical characteristics.
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Affiliation(s)
- Zhe Hui Hoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK; Sheffield Adult CF Centre, Northern General Hospital, Sheffield, UK.
| | - Nicole R Bramley
- Sheffield Adult CF Centre, Northern General Hospital, Sheffield, UK; School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Rachael Curley
- Sheffield Adult CF Centre, Northern General Hospital, Sheffield, UK; School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Stephen J Walters
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Michael J Campbell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Martin J Wildman
- Sheffield Adult CF Centre, Northern General Hospital, Sheffield, UK; School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Diab-Cáceres L, Girón-Moreno RM, Pastor-Sanz MT, Quintana-Gallego E, Delgado-Pecellín I, Blanco-Aparicio M, Maiz L, García-Clemente MM, Luna-Paredes C, Mondéjar-López P, Ruiz-de-Valbuena M, Fernández O, Barrio M, González M, López-Neyra A, Cols-I-Roig M, Palou-Rotger A, Gómez-de-Terreros-Caro FJ. Compassionate Use of Lumacaftor/Ivacaftor in Cystic Fibrosis: Spanish Experience. Arch Bronconeumol 2018; 54:614-618. [PMID: 30518496 DOI: 10.1016/j.arbres.2018.05.004] [Citation(s) in RCA: 6] [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: 10/27/2017] [Revised: 04/09/2018] [Accepted: 05/01/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The most common cystic fibrosis (CF)-causing mutation is deltaF508 (F508del), which is present in 28% of CF Spanish patients. While the literature based on real-life studies on CF patients homozygous F508del treated with lumacaftor/ivacaftor is limited, it demonstrates the need for better strategies to prevent related adverse events (AEs) as well as the development of newer drugs. METHODS We conducted a multicenter, retrospective, observational study to describe the effects of lumacaftor/ivacaftor treatment in real-life in Spain. 20 CF patients were included, all aged 6 and upwards and presented with ppFEV1<40%, chosen from CF units country-wide. For the purposes of the study, they were treated with lumacaftor/ivacaftor 200/125mg two tablets twice a day on a compassionate use programme throughout 2016. The primary endpoint was measured in all of the sample patients. Data were analysed from ppFEV1 at baseline and was measured every 6 months. RESULTS The mean age was 26.65 (range of 10-45), while the mean ppFEV1 before the treatment was 32.4% and mean BMI was 19.9kg/m2. We analysed the changes in ppFEV1 and BMI from baseline during the treatment with lumacaftor/ivacaftor, but no differences were found. However, a moderate association between days of intravenous antibiotic needed and the use of lumacaftor/ivacaftor (p=0.001) was established. Indeed, under the lumacaftor/ivacaftor, patients required 5.8 days of intravenous antibiotic treatment compared to 14.9 days prior to study. Also, severe pulmonary exacerbations requiring hospitalisation were statistically fewer under lumacaftor/ivacaftor treatment (p=0.003). Finally, 75% of the sample presented with AEs, which led 35% of the subjects to discontinue the treatment. CONCLUSIONS While treatment with lumacaftor/ivacaftor resulted in an improvement in the number of pulmonary severe exacerbations, no improvement in ppFEV1 or BMI was found.
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Affiliation(s)
| | | | | | - Esther Quintana-Gallego
- Hospital Universitario Virgen del Rocío, Sevilla, Spain. Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Isabel Delgado-Pecellín
- Hospital Universitario Virgen del Rocío, Sevilla, Spain. Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Luis Maiz
- Hospital Ramón y Cajal, Respirology, Madrid, Spain
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Hoppe JE, Wagner BD, Accurso FJ, Zemanick ET, Sagel SD. Characteristics and outcomes of oral antibiotic treated pulmonary exacerbations in children with cystic fibrosis. J Cyst Fibros 2018; 17:760-8. [PMID: 29921503 DOI: 10.1016/j.jcf.2018.05.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/25/2018] [Accepted: 05/29/2018] [Indexed: 11/24/2022]
Abstract
Background Pulmonary exacerbations (PEx) in children with cystic fibrosis (CF) are frequently treated in the outpatient setting with oral antibiotics. However, little is known about the characteristics of PEx managed on an outpatient basis and the effectiveness of oral antibiotic therapy. We sought to prospectively evaluate clinical and laboratory changes associated with oral antibiotic treatment for PEx. Methods Children with CF between 8 and 18 years of age prescribed two weeks of oral antibiotics for a PEx were eligible to enroll. The study consisted of a visit within 48 h of starting antibiotics and a second visit within one week of antibiotic completion. Twenty-eight participants were evaluated by exacerbation score, quality of life measurements, lung function, sputum microbiology and inflammation. Results Oral antibiotic treatment was associated with a significant improvement in exacerbation score and quality of life measured by the CF Questionnaire-Revised (CFQ-R) respiratory domain. Following treatment, forced expiratory volume in 1 s (FEV1) % predicted increased [median (range)] 9% (−8%, 31%), and 22 (81%) subjects returned to 90% or higher of baseline FEV1. Bacterial density of the primary organism identified on sputum culture decreased significantly with a median (range) decrease of 0.8 log10 cfu/mL (−8 log10, 2 log10, p = 0.03). Sputum neutrophil elastase [−37 μg/mL (−464, 272), p = 0.02] and IL-1β [−2.8 × 103μg/mL (−6.9 × 104, 3.3 × 104), p = 0.03] decreased significantly following treatment in this cohort. Conclusions Treatment of PEx with oral antibiotics was associated with measurable improvements in patient reported outcomes, lung function, bacterial density and sputum inflammatory markers.
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Spoletini G, Kennedy M, Flint L, Graham T, Etherington C, Shaw N, Whitaker P, Denton M, Clifton I, Peckham D. Intravenous fosfomycin for pulmonary exacerbation of cystic fibrosis: Real life experience of a large adult CF centre. Pulm Pharmacol Ther 2018; 50:82-87. [PMID: 29660401 DOI: 10.1016/j.pupt.2018.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 03/15/2018] [Accepted: 04/10/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND The increased prevalence of multi-drug resistant strains of P.aeruginosa and allergic reactions among adult patients with cystic fibrosis (CF) limits the number of antibiotics available to treat pulmonary exacerbations. Fosfomycin, a unique broad spectrum bactericidal antibiotic, might offer an alternative therapeutic option in such cases. AIM To describe the clinical efficacy, safety and tolerability of intravenous fosfomycin in combination with a second anti-pseudomonal antibiotic to treat pulmonary exacerbations in adult patients with CF. METHOD A retrospective analysis of data captured prospectively, over a 2-years period, on the Unit electronic medical records for patients who received IV fosfomycin was performed. Baseline characteristics in the 12 months prior treatment, lung function, CRP, renal and liver function and electrolytes at start and end of treatment were retrieved. RESULTS 54 patients received 128 courses of IV fosfomycin in combination with a second antibiotic, resulting in improved FEV1 (0.94 L vs 1.24 L, p < 0.01) and reduced CRP (65 mg/L vs 19.3 mg/L, p < 0.01). Renal function pre- and post-treatment remained stable. 4% (n = 5) of courses were complicated with AKI at mid treatment, which resolved at the end of the course. Electrolyte supplementation was required in 18% of cases for potassium and magnesium and 7% for phosphate. Nausea was the most common side effect (48%), but was well controlled with anti-emetics. CONCLUSION Antibiotic regimens including fosfomycin appear to be clinically effective and safe. Fosfomycin should, therefore, be considered as an add-on therapy in patients who failed to respond to initial treatment and with multiple drug allergies.
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Affiliation(s)
- G Spoletini
- The Leeds Regional Adult Cystic Fibrosis Centre, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK; Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK.
| | - M Kennedy
- Department of Respiratory Medicine, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - L Flint
- Department of Respiratory Medicine, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - T Graham
- The Leeds Regional Adult Cystic Fibrosis Centre, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - C Etherington
- The Leeds Regional Adult Cystic Fibrosis Centre, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - N Shaw
- The Leeds Regional Adult Cystic Fibrosis Centre, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - P Whitaker
- The Leeds Regional Adult Cystic Fibrosis Centre, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - M Denton
- The Leeds Regional Adult Cystic Fibrosis Centre, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK; Department of Microbiology, Leeds General Infirmary, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - I Clifton
- The Leeds Regional Adult Cystic Fibrosis Centre, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - D Peckham
- The Leeds Regional Adult Cystic Fibrosis Centre, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK; Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
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Kuti JL, Pettit RS, Neu N, Cies JJ, Lapin C, Muhlebach MS, Novak KJ, Nguyen ST, Saiman L, Nicolau DP. Meropenem time above the MIC exposure is predictive of response in cystic fibrosis children with acute pulmonary exacerbations. Diagn Microbiol Infect Dis 2018; 91:294-297. [PMID: 29661528 DOI: 10.1016/j.diagmicrobio.2018.01.020] [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: 05/08/2017] [Revised: 01/04/2018] [Accepted: 01/24/2018] [Indexed: 11/28/2022]
Abstract
Meropenem exposures from 15 children (8-17 years old) with cystic fibrosis (CF) acute pulmonary exacerbation were analyzed to define the pharmacodynamic threshold required for a positive response. The primary endpoint was the relative increase in forced expiratory volume in 1 s (↑FEV1) between pre- and posttreatment. Meropenem pharmacodynamic indices (fT > MIC, fAUC/MIC, fCmin/MIC) over the first 24 h were estimated for each participant based on their individual parameter estimates and the isolated pathogen with the highest meropenem MIC. Pseudomonas aeruginosa was the most common pathogen (n = 11/15). The mean ± SD ↑FEV1 was 18.8% ± 11.3% posttreatment. The mean (range) fT > MIC exposure was 63% (0-100%). An Emax model determined a significant relationship between fT > MIC and ↑FEV1 (r2 = 0.8, P < 0.0004). 65% fT > MIC was a significant predictor of response; the median (25th, 75th %) ↑FEV1 was 28.5% (22.2%, 31.7%) in those patients who achieved above 65% fT > MIC and 7.8% (1.1%, 12.6%) in those at or below 65% fT > MIC (P = 0.001). This is the first study in CF children to link meropenem exposure with a positive response as measured by ↑FEV1. Larger studies are required to confirm this exposure threshold.
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Affiliation(s)
- Joseph L Kuti
- Center for Anti-Infective Research & Development, Hartford Hospital, Hartford, CT, USA.
| | - Rebecca S Pettit
- Department of Pharmacy, Riley Hospital for Children, Indianapolis, IN, USA
| | - Natalie Neu
- Department of Pediatrics, Division of Infectious Diseases, Columbia University Medical Center and New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Jeffrey J Cies
- Department of Pharmacy, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Craig Lapin
- Pediatric Pulmonology, Connecticut Children's Medical Center, Hartford, CT, USA
| | | | - Kimberly J Novak
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, OH, USA
| | - Sean T Nguyen
- Department of Pharmacy, Children's Medical Center, Dallas, TX, USA
| | - Lisa Saiman
- Department of Pediatrics, Division of Infectious Diseases, Columbia University Medical Center and New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - David P Nicolau
- Center for Anti-Infective Research & Development, Hartford Hospital, Hartford, CT, USA
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Krivchenia K, Tumin D, Nemastil CJ, Tobias JD, Hayes D Jr. Timing of Spirometry May Impact Hospital Length of Stay for Cystic Fibrosis Pulmonary Exacerbation. Lung 2018; 196:207-11. [PMID: 29349537 DOI: 10.1007/s00408-018-0082-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 01/04/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE The optimal timing of spirometry during hospitalization for acute pulmonary exacerbation (PEx) in patients with cystic fibrosis (CF) is unclear. We retrospectively evaluated whether measuring spirometry earlier during hospitalization was associated with a shorter length of stay (LOS). METHODS In this retrospective study, we analyzed data from the electronic medical record of CF patients 6 years of age and older admitted to a single center for acute PEx requiring IV antibiotic therapy between 2009 and 2016. After excluding patient encounters with missing data on covariates, random-effects linear regression was used to predict LOS as a function of days to first pulmonary function testing (PFT), which was spirometry for our study. RESULTS One thousand thirty-five hospitalizations of 242 patients met inclusion criteria, with 801 including complete data on covariates. Mean LOS was 10 ± 7 days, with mean time to first PFT of 4 ± 3 days after admission. In multivariable analysis, each additional day to first PFT was associated with 0.97 days longer LOS (95% CI 0.29, 1.64; p = 0.005). CONCLUSIONS As CF researchers and clinicians work to improve management of PEx, the timing of spirometry during hospitalization remains an important question. Obtaining objective lung function data earlier during the course of therapy may provide information which can lead to reduced hospital LOS for PEx.
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Krause K, Kopp BT, Tazi MF, Caution K, Hamilton K, Badr A, Shrestha C, Tumin D, Hayes D, Robledo-Avila F, Hall-Stoodley L, Klamer BG, Zhang X, Partida-Sanchez S, Parinandi NL, Kirkby SE, Dakhlallah D, McCoy KS, Cormet-Boyaka E, Amer AO. The expression of Mirc1/Mir17-92 cluster in sputum samples correlates with pulmonary exacerbations in cystic fibrosis patients. J Cyst Fibros 2017; 17:454-461. [PMID: 29241629 DOI: 10.1016/j.jcf.2017.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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: 08/01/2017] [Revised: 10/27/2017] [Accepted: 11/16/2017] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Cystic fibrosis (CF) is a multi-organ disorder characterized by chronic sino-pulmonary infections and inflammation. Many patients with CF suffer from repeated pulmonary exacerbations that are predictors of worsened long-term morbidity and mortality. There are no reliable markers that associate with the onset or progression of an exacerbation or pulmonary deterioration. Previously, we found that the Mirc1/Mir17-92a cluster which is comprised of 6 microRNAs (Mirs) is highly expressed in CF mice and negatively regulates autophagy which in turn improves CF transmembrane conductance regulator (CFTR) function. Therefore, here we sought to examine the expression of individual Mirs within the Mirc1/Mir17-92 cluster in human cells and biological fluids and determine their role as biomarkers of pulmonary exacerbations and response to treatment. METHODS Mirc1/Mir17-92 cluster expression was measured in human CF and non-CF plasma, blood-derived neutrophils, and sputum samples. Values were correlated with pulmonary function, exacerbations and use of CFTR modulators. RESULTS Mirc1/Mir17-92 cluster expression was not significantly elevated in CF neutrophils nor plasma when compared to the non-CF cohort. Cluster expression in CF sputum was significantly higher than its expression in plasma. Elevated CF sputum Mirc1/Mir17-92 cluster expression positively correlated with pulmonary exacerbations and negatively correlated with lung function. Patients with CF undergoing treatment with the CFTR modulator Ivacaftor/Lumacaftor did not demonstrate significant change in the expression Mirc1/Mir17-92 cluster after six months of treatment. CONCLUSIONS Mirc1/Mir17-92 cluster expression is a promising biomarker of respiratory status in patients with CF including pulmonary exacerbation.
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Affiliation(s)
- Kathrin Krause
- Department of Microbial Infection and Immunity, Columbus, OH, USA; Dorothy M. Davis Heart and Lung Research Institute, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Benjamin T Kopp
- Department of Pediatrics, Columbus, OH, USA; Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Mia F Tazi
- Department of Microbial Infection and Immunity, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kyle Caution
- Department of Microbial Infection and Immunity, Columbus, OH, USA; Dorothy M. Davis Heart and Lung Research Institute, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kaitlin Hamilton
- Department of Microbial Infection and Immunity, Columbus, OH, USA; Dorothy M. Davis Heart and Lung Research Institute, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Asmaa Badr
- Department of Microbial Infection and Immunity, Columbus, OH, USA; Dorothy M. Davis Heart and Lung Research Institute, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Chandra Shrestha
- Department of Pediatrics, Columbus, OH, USA; Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Anesthesiology & Pain Medicine, Columbus, OH, USA; Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Don Hayes
- Department of Pediatrics, Columbus, OH, USA; Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Frank Robledo-Avila
- Department of Pediatrics, Columbus, OH, USA; Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Luanne Hall-Stoodley
- Department of Microbial Infection and Immunity, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Brett G Klamer
- Center for Biostatistics, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Xiaoli Zhang
- Center for Biostatistics, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Santiago Partida-Sanchez
- Department of Pediatrics, Columbus, OH, USA; Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Narasimham L Parinandi
- Dorothy M. Davis Heart and Lung Research Institute, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Stephen E Kirkby
- Department of Pediatrics, Columbus, OH, USA; Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Duaa Dakhlallah
- Microbiology, Immunology and Cell Biology Department, West Virginia University, Morgantown, WV, USA
| | - Karen S McCoy
- Department of Pediatrics, Columbus, OH, USA; Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Estelle Cormet-Boyaka
- Department of Veterinary Biosciences, Columbus, OH, USA; Dorothy M. Davis Heart and Lung Research Institute, Columbus, OH, USA
| | - Amal O Amer
- Department of Microbial Infection and Immunity, Columbus, OH, USA; Dorothy M. Davis Heart and Lung Research Institute, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA.
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Hoppe JE, Wagner BD, Sagel SD, Accurso FJ, Zemanick ET. Pulmonary exacerbations and clinical outcomes in a longitudinal cohort of infants and preschool children with cystic fibrosis. BMC Pulm Med 2017; 17:188. [PMID: 29228933 PMCID: PMC5725640 DOI: 10.1186/s12890-017-0546-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 11/30/2017] [Indexed: 12/05/2022] Open
Abstract
Background Pulmonary exacerbations (PEx) in school aged children and adults with cystic fibrosis (CF) lead to increased morbidity and lung function decline. However, the effect of exacerbations in young children with CF is not fully understood. We sought to characterize the frequency and clinical impact of PEx in a pilot study of infants and pre-school aged children with CF. Methods Thirty young children with CF [median (range) 1.5 years (0.2–4.9)] were prospectively followed for 2 years. Exacerbation frequency (hospitalizations and outpatient antibiotic use) was determined. Chest radiographs were performed at enrollment and study completion and assigned a Brasfield score. Lung function at age 7 years was assessed in a subset of children. The association between PEx frequency, chest radiograph score, and lung function was determined using Spearman correlation coefficients and corresponding 95% confidence intervals. Correlations with an absolute magnitude of 0.3 or greater were considered clinically significant. Results Over 2 years, participants experienced a median of two PEx (range 0–13). Chest radiograph scores at enrollment and study completion were inversely associated with PEx frequency (R = −0.48 and R = −0.44, respectively). The association between frequency of PEx and lung function [forced expiratory volume in 1 s (FEV1)] at age 7 years was small (R = 0.20). Higher forced vital capacity (FVC) at 7 years was associated with more frequent PEx during the study (R = 0.44). Conclusions Children with worse chest radiograph scores had more frequent PEx over the subsequent 2 years, suggesting a group of patients at higher risk for PEx. Frequent PEx in infants and young children with CF were not associated with lower FEV1 and FVC at 7 years, although spirometry in this age group may not be a sensitive marker of mild lung disease and disease progression. Electronic supplementary material The online version of this article (10.1186/s12890-017-0546-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jordana E Hoppe
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, 13123 E 16th Avenue, B-395, Aurora, CO, 80045, USA.
| | - Brandie D Wagner
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, 13123 E 16th Avenue, B-395, Aurora, CO, 80045, USA.,Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, CO, USA
| | - Scott D Sagel
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, 13123 E 16th Avenue, B-395, Aurora, CO, 80045, USA
| | - Frank J Accurso
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, 13123 E 16th Avenue, B-395, Aurora, CO, 80045, USA
| | - Edith T Zemanick
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, 13123 E 16th Avenue, B-395, Aurora, CO, 80045, USA
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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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Hoo ZH, Campbell MJ, Curley R, Walters SJ, Wildman MJ. Do cystic fibrosis centres with the lowest FEV 1 still use the least amount of intravenous antibiotics? A registry-based comparison of intravenous antibiotic use among adult CF centres in the UK. J Cyst Fibros 2017; 17:360-367. [PMID: 29074367 DOI: 10.1016/j.jcf.2017.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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: 07/05/2017] [Revised: 10/02/2017] [Accepted: 10/04/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Epidemiologic Study of Cystic Fibrosis using 1995-1996 and 2003-2005 data found that CF centres with lowest FEV1 tended to use fewer intravenous antibiotics. We repeated the analyses using 2013-2014 UK CF registry data to determine if this was still the case. METHODS Analysing data for 2013 and 2014 separately, 28 adult CF centres were ranked according to median % age-adjusted FEV1. The top 7 centres were placed in the 'upper quarter' (best FEV1), the bottom 7 centres in 'lower quarter' (lowest FEV1), and the rest in 'middle half'. IV use was stratified according to %FEV1, then compared between the three groups. RESULTS Centres in the 'upper quarter' and 'middle half' used significantly more IV antibiotics compared to centres in the 'lower quarter' (van Elteren test P-value<0.001). Regression analyses showed that people with CF attending centres in the 'upper quarter' or 'middle half' are 30-50% more likely to receive at least one IV course per year compared to people attending centres in the 'lower quarter'. CONCLUSIONS CF centres with lowest FEV1 are still distinguished by lower use of intravenous antibiotics.
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Affiliation(s)
- Zhe Hui Hoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK; Sheffield Adult CF Centre, Northern General Hospital, Sheffield, UK.
| | - Michael J Campbell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
| | - Rachael Curley
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK; Sheffield Adult CF Centre, Northern General Hospital, Sheffield, UK.
| | - Stephen J Walters
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
| | - Martin J Wildman
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK; Sheffield Adult CF Centre, Northern General Hospital, Sheffield, UK.
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Skolnik K, Nguyen A, Thornton CS, Waddell B, Williamson T, Rabin HR, Parkins MD. Group B streptococcus (GBS) is an important pathogen in human disease- but what about in cystic fibrosis? BMC Infect Dis 2017; 17:660. [PMID: 28969684 PMCID: PMC5625721 DOI: 10.1186/s12879-017-2729-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 09/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Group B Streptococcus (GBS) is a common commensal capable of causing severe invasive infections. Most GBS infections occur in neonates (often as pneumonia). GBS can also cause infection in adults with diabetes and other immunological impairments but rarely leads to pneumonia in adults. GBS has occasionally been found in the sputum of Cystic Fibrosis (CF) patients, an inherited condition known for progressive lung disease. However, the epidemiology and clinical significance of GBS in CF are not understood. METHODS We retrospectively reviewed a large single-centre adult CF population with an associated comprehensive, prospectively collected bacterial biobank beginning in 1978. We identified all individuals with GBS isolated from their sputum on at least one occasion. The primary outcome was risk of pulmonary exacerbation (PEx) at the time of the first GBS isolate compared to the preceding visit. Secondary outcomes included determining: prevalence of GBS infection in a CF population, whether GBS infections where transient or persistent, whether GBS strains were shared among patients, change in % predicted FEV1 at the time of GBS isolate compared to the preceding visit, PEx frequency after the first GBS isolate, change in % predicted FEV1 after the first GBS isolate, and complications of GBS infection. RESULTS GBS was uncommon, infecting 3.5% (11/318) adults within our cohort. Only three individuals developed persistent GBS infection, all lasting > 12 months. There were no shared GBS strains among patients. PEx risk was not increased at initial GBS isolation (RR 5.0, CI 0.69-36.1, p=0.10). In the two years preceding initial GBS isolation compared to the two following years, there was no difference in PEx frequency (median 2, range 0-4 vs 1, range 0 to 5, respectively, p=0.42) or lung function decline, as measured by % predicted FEV1, (median -1.0%, range -19 to 7% vs median -6.0%, range -18 to 22%, p=0.86). There were no invasive GBS infections. CONCLUSION In adults with CF, GBS is uncommon and is generally a transient colonizer of the lower airways. Despite the presence of structural lung disease and impaired innate immunity in CF, incident GBS infection did not increase PEx risk, PEx frequency, rate of lung function decline, or other adverse clinical outcomes.
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Affiliation(s)
- Kate Skolnik
- Department of Medicine, University of Calgary, 7007 14th Street SW, Calgary, AB, T2V 1P9, Canada. .,Department of Community Health Sciences, University of Calgary, Third Floor TRW Building, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
| | - Austin Nguyen
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Christina S Thornton
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Barbara Waddell
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Tyler Williamson
- Department of Community Health Sciences, University of Calgary, Third Floor TRW Building, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Harvey R Rabin
- Department of Medicine, University of Calgary, 7007 14th Street SW, Calgary, AB, T2V 1P9, Canada.,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Michael D Parkins
- Department of Medicine, University of Calgary, 7007 14th Street SW, Calgary, AB, T2V 1P9, Canada.,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
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Svedberg M, Gustafsson PM, Robinson PD, Rosberg M, Lindblad A. Variability of lung clearance index in clinically stable cystic fibrosis lung disease in school age children. J Cyst Fibros 2017; 17:236-241. [PMID: 28822728 DOI: 10.1016/j.jcf.2017.08.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [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: 03/16/2017] [Revised: 07/28/2017] [Accepted: 08/07/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Data on long term variability of Lung Clearance Index (LCI) in Cystic Fibrosis (CF) is urgently needed to guide test result interpretation. Our aim was to evaluate LCI variability in clinically stable CF lung disease in school age children. METHODS Paediatric patients, aged 6 to 17years, attending the outpatient CF clinic performed Multiple Breath Nitrogen Washout (Exhalyzer® D) and spirometry every third month over a period of one year. Clinical stability was assessed by the Cystic Fibrosis Clinical Score (CFCS) at each visit. RESULTS Twentyfive children were recruited: baseline median (range) FEV1% pred. 91 (55-122)%, LCI 9.1 (6.4-18.6), CFCS 15 (12-23). A total of 107 visits were included in the study, of which 93% were defined as clinically stable. In clinically stable visits, within-subject variability of LCI and FEV1% pred. were 10% and 16%, respectively. The upper limit of normal (ULN, 95% percentile) of LCI variability during clinical stability was 17%. CONCLUSIONS LCI within-subject variability was low and comparable to FEV1% pred. which strengthen the use of LCI to monitor lung disease progression in CF patients. An increase in LCI >17% compared to previous LCI-measurement in clinically stable CF patients may therefore indicate early lung disease progression.
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Affiliation(s)
- Marcus Svedberg
- Department of Pediatrics, Queen Silvia's Children Hospital, Gothenburg, Sweden.
| | | | - Paul D Robinson
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, NSW, Australia; Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead Clinical School, University of Sydney, Sydney, Australia
| | - Monica Rosberg
- Department of Clinical Physiology, Queen Silvia's Children Hospital, Gothenburg, Sweden
| | - Anders Lindblad
- Department of Pediatrics, Queen Silvia's Children Hospital, Gothenburg, Sweden
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Sanders DB, Li Z, Zhao Q, Farrell PM. Poor recovery from a pulmonary exacerbation does not lead to accelerated FEV 1 decline. J Cyst Fibros 2017; 17:S1569-1993(17)30818-4. [PMID: 28765072 PMCID: PMC5788732 DOI: 10.1016/j.jcf.2017.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 11/23/2016] [Revised: 06/30/2017] [Accepted: 07/04/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Patients with CF treated for pulmonary exacerbations (PEx) may experience faster subsequent declines in FEV1. Additionally, incomplete recovery to baseline FEV1 occurs frequently following PEx treatment. Whether accelerated declines in FEV1 are preceded by poor PEx recovery has not been studied. METHODS Using 2004 to 2011 CF Foundation Patient Registry data, we randomly selected one PEx among patients ≥6years of age with no organ transplantations, ≥12months of data before and after the PEx, and ≥1 FEV1 recorded within the 6months before and 3months after the PEx. We defined poor PEx recovery as the best FEV1 in the 3months after the PEx <90% of the best FEV1 in the 6months before the PEx. We calculated mean (95% CI) hazard ratios (HR) of having >5% predicted/year FEV1 decline and poor PEx recovery using multi-state Markov models. RESULTS From 13,954 PEx, FEV1 declines of >5% predicted/year were more likely to precede poor spirometric recovery, HR 1.17 (1.08, 1.26), in Markov models adjusted for age and sex. Non-Responders were less likely to have a subsequent fast FEV1 decline, HR 0.41 (0.37, 0.46), than patients who recovered to >90% of baseline FEV1 following PEx treatment. CONCLUSIONS Accelerated declines in FEV1 are more likely to precede a PEx with poor recovery than to occur in the following year. Preventing or halting declines in FEV1 may also have the benefit of preventing PEx episodes.
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Affiliation(s)
- Don B Sanders
- Department of Pediatrics, Riley Hospital for Children, School of Medicine, Indiana University, Indiana, IN, USA.
| | - Zhanhai Li
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA; Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Qianqian Zhao
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA; Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Philip M Farrell
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
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May TL, Gifford AH, Lahiri T, Black A, Trang J, Cornell AG, Gonzalez K, Morin S, Napier M, Duarte CW, Zuckerman JB. Complications of long and intermediate term venous catheters in cystic fibrosis patients: A multicenter study. J Cyst Fibros 2018; 17:96-104. [PMID: 28579360 DOI: 10.1016/j.jcf.2017.04.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 04/27/2017] [Accepted: 04/28/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Totally implantable venous access devices (TIVADs) or peripherally inserted central venous catheters (PICCs) are commonly used in the care of patients with cystic fibrosis (CF), but they are associated with various complications, including thrombosis, infection, and insertion site symptoms. METHODS We conducted a retrospective review of PICC and TIVAD use in adults and children with CF over an 8-year period at 3 accredited care centers. Patient attributes included CFTR genotype, comorbidities, lung function, body mass index, use of anticoagulation, and respiratory tract microbiology. Catheter data included line type, caliber, and lumen number. We assessed practice variation by surveying physicians. RESULTS In a population of 592 CF patients, 851 PICC and 61 TIVADs were placed between January 1, 2003 and July 1, 2011. Larger catheter caliber and increased lumen number were risk factors for PICC complications in adults. Patient-related risk factors for PICC complications included poor nutritional status, infection with Burkholderia cepacia spp., and having ≥5 lines inserted during the study period. The probability of a PICC complication varied across centers (2.6% to 14.1%, p=0.001) and remained significant after adjustment for patient-and line-related risk factors. The median complication-free survival of TIVADs, however, did not vary significantly by center (p=0.85). CONCLUSIONS This is the first longitudinal, multicenter assessment of complication rates for PICCs and TIVADs in a large cohort of adults and children with CF. Specific patient- and catheter-related characteristics were associated with increased risk of complications. Center effects on complication rates were observed for PICCs.
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Alvarez JA, Chong EY, Walker DI, Chandler JD, Michalski ES, Grossmann RE, Uppal K, Li S, Frediani JK, Tirouvanziam R, Tran VT, Tangpricha V, Jones DP, Ziegler TR. Plasma metabolomics in adults with cystic fibrosis during a pulmonary exacerbation: A pilot randomized study of high-dose vitamin D 3 administration. Metabolism 2017; 70:31-41. [PMID: 28403943 PMCID: PMC5407388 DOI: 10.1016/j.metabol.2017.02.006] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/07/2017] [Accepted: 02/05/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) is a chronic catabolic disease often requiring hospitalization for acute episodes of worsening pulmonary exacerbations. Limited data suggest that vitamin D may have beneficial clinical effects, but the impact of vitamin D on systemic metabolism in this setting is unknown. OBJECTIVE We used high-resolution metabolomics (HRM) to assess the impact of baseline vitamin D status and high-dose vitamin D3 administration on systemic metabolism in adults with CF with an acute pulmonary exacerbation. DESIGN Twenty-five hospitalized adults with CF were enrolled in a randomized trial of high-dose vitamin D3 (250,000IU vitamin D3 bolus) versus placebo. Age-matched healthy subjects served as a reference group for baseline comparisons. Plasma was analyzed with liquid chromatography/ultra-high resolution mass spectrometry. Using recent HRM bioinformatics and metabolic pathway enrichment methods, we examined associations with baseline vitamin D status (sufficient vs. deficient per serum 25-hydroxyvitamin D concentrations) and the 7-day response to vitamin D3 supplementation. RESULTS Several amino acids and lipid metabolites differed between CF and healthy control subjects, indicative of an overall catabolic state. In CF subjects, 343 metabolites differed (P<0.05) by baseline vitamin D status and were enriched within 7 metabolic pathways including fatty acid, amino acid, and carbohydrate metabolism. A total of 316 metabolites, which showed enrichment for 15 metabolic pathways-predominantly representing amino acid pathways-differed between the vitamin D3- and placebo-treated CF subjects over time (P<0.05). In the placebo group, several tricarboxylic acid cycle intermediates increased while several amino acid-related metabolites decreased; in contrast, little change in these metabolites occurred with vitamin D3 treatment. CONCLUSIONS Numerous metabolic pathways detected by HRM varied in association with vitamin D status and high-dose vitamin D3 supplementation in adults with CF experiencing a pulmonary exacerbation. Overall, these pilot data suggest an anti-catabolic effect of high-dose vitamin D3 in this clinical setting.
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Affiliation(s)
- Jessica A Alvarez
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | - Elizabeth Y Chong
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Douglas I Walker
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Joshua D Chandler
- Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, GA, USA; Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Ellen S Michalski
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Nutrition and Health Sciences Graduate Program, Laney Graduate School, Emory University, Atlanta, GA, USA
| | | | - Karan Uppal
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Shuzhao Li
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jennifer K Frediani
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Nutrition and Health Sciences Graduate Program, Laney Graduate School, Emory University, Atlanta, GA, USA
| | - Rabindra Tirouvanziam
- Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, GA, USA; Division of Pulmonary, Allergy & Immunology, Cystic Fibrosis and Sleep, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - ViLinh T Tran
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, GA, USA; Section of Endocrinology, Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA
| | - Dean P Jones
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Thomas R Ziegler
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, GA, USA; Section of Endocrinology, Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA
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Ananthan A, Balasubramanian H, Rao S, Patole S. Probiotic supplementation in children with cystic fibrosis-a systematic review. Eur J Pediatr 2016; 175:1255-66. [PMID: 27576473 DOI: 10.1007/s00431-016-2769-8] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 08/09/2016] [Accepted: 08/19/2016] [Indexed: 12/17/2022]
Abstract
UNLABELLED Probiotics may benefit in cystic fibrosis (CF) as gut dysbiosis is associated with gastrointestinal symptoms and exacerbation of respiratory symptoms in CF. We conducted a systematic review of randomized controlled trials (RCTs) and non-RCTs of probiotic supplementation in children with CF, using the Cochrane methodology, preferred reporting items for systematic reviews (PRISMA) statement, and meta-analysis of observational studies in epidemiology (MOOSE) guidelines. Primary outcomes were pulmonary exacerbations, duration of hospitalization and antibiotics, and all-cause mortality. Secondary outcomes included gastrointestinal symptoms, markers of gut inflammation, and intestinal microbial balance. A total of nine studies (RCTs, 6, non-RCTs, 3; N = 275) with some methodological weaknesses were included in the review. The pooled estimate showed significant reduction in the rate of pulmonary exacerbation (fixed effects model, two parallel group RCTs and one cross-over trial: relative risk (RR) 0.25, (95 % confidence interval (95 % CI) 0.15,0.41); p < 0.00001; level of evidence: low) and decrease in fecal calprotectin (FCLP) levels (fixed effect model, three RCTs: mean difference (MD) -16.71, 95 % CI -27.30,-6.13); p = 0.002; level of evidence: low) after probiotic supplementation. Probiotic supplementation significantly improved gastrointestinal symptoms (one RCT, one non-RCT) and gut microbial balance (decreased Proteobacteria, increased Firmicutes, and Bacteroides in one RCT, one non-RCT). CONCLUSION Limited low-quality evidence exists on the effects of probiotics in children with CF. Well-designed adequately powered RCTs assessing clinically meaningful outcomes are required to study this important issue. WHAT IS KNOWN • Gut dysbiosis is frequent in children with cystic fibrosis due to frequent exposure to pathogens and antibiotics. • Probiotics decrease gut dysbiosis and improve gut maturity and function. What is New: • This comprehensive systematic review shows that current evidence on the safety and efficacy of probiotics in children with cystic fibrosis is limited and of low quality. • Well-designed and adequately powered trials assessing clinically important outcomes are required considering the health burden of cystic fibrosis and the potential benefits of probiotics.
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Affiliation(s)
- Anitha Ananthan
- Department of Neonatal Paediatrics, King Edward Memorial Hospital for Women, 378 Bagot Road, Subiaco, Perth, WA, 6008, Australia.
| | - Haribalakrishna Balasubramanian
- Department of Neonatal Paediatrics, King Edward Memorial Hospital for Women, 378 Bagot Road, Subiaco, Perth, WA, 6008, Australia
| | - Shripada Rao
- Department of Neonatal Paediatrics, Princess Margaret Hospital for Children, Perth, WA, Australia.,Centre for Neonatal Research and Education, University of Western Australia, Crawley, Australia
| | - Sanjay Patole
- Department of Neonatal Paediatrics, King Edward Memorial Hospital for Women, 378 Bagot Road, Subiaco, Perth, WA, 6008, Australia.,Centre for Neonatal Research and Education, University of Western Australia, Crawley, Australia
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Abstract
There is a high prevalence of Pseudomonas aeruginosa in patients with cystic fibrosis and clear epidemiologic links between chronic infection and morbidity and mortality exist. Prevention and early identification of infection are critical, and stand to improve with the advent of new vaccines and laboratory methods. Once the organism is identified, a variety of treatment options are available. Aggressive use of antipseudomonal antibiotics is the standard of care for acute pulmonary exacerbations in cystic fibrosis, and providers must take into account specific patient characteristics when making treatment decisions related to antibiotic selection, route and duration of administration, and site of care.
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Affiliation(s)
- Jaideep S Talwalkar
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208086, New Haven, CT 06520-8086, USA; Department of Pediatrics, Yale School of Medicine, 333 Cedar Street, PO Box 208084, New Haven, CT 06520-8084, USA.
| | - Thomas S Murray
- Department of Medical Sciences, Frank H Netter MD School of Medicine, Quinnipiac University, 275 Mount Carmel Avenue, Hamden, CT 06518, USA; Division of Infectious Diseases and Immunology, Connecticut Children's Medical Center, 282 Washington Street, Suite 2L, Hartford, CT 06106, USA
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Abstract
OBJECTIVE Ivacaftor was approved in 2012 to treat patients with cystic fibrosis (CF) with specific CFTR gene mutations. The objective of this analysis was to analyze the impact of ivacaftor on health resource utilization through analysis of claims data. METHODS Patients diagnosed with CF aged ≥6 years prescribed ivacaftor between January 1, 2012 and July 31, 2014 with ≥12 months of continuous insurance coverage prior to and following the prescription were identified. All-cause and CF-specific healthcare resource utilization during the pre- and post-prescription periods and ivacaftor adherence levels were studied. RESULTS The 79 identified patients had a mean age of 20.8 years, and 54% were female. The proportion of patients with inpatient admissions (all-cause and CF-related) was significantly higher in the pre index compared to post index period (p ≤ 0.05). Mean ivacaftor medication possession ratio was 0.8 (SD = 0.3), and 73% of patients had a medication possession ratio >0.80. LIMITATIONS Only a small number of patients met the inclusion criteria. Additionally, claims data may contain errors or inconsistencies and cannot be used to determine if medications were taken as prescribed. CONCLUSIONS Ivacaftor therapy was associated with significant reductions in hospitalizations along with high rates of adherence to treatment over 12 months.
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Affiliation(s)
| | - Mac Bonafede
- b Truven Health Analytics , Cambridge , MA , USA
| | | | | | - Gregory S Sawicki
- c Division of Respiratory Diseases , Boston Children's Hospital , Boston , MA , USA
| | - Jeffrey S Wagener
- d Department of Pediatrics , University of Colorado Medical School , Aurora , CO , USA
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Abstract
Respiratory system involvement in cystic fibrosis is the leading cause of morbidity and mortality. Defects in the cystic fibrosis transmembrane regulator (CFTR) gene throughout the sinopulmonary tract result in recurrent infections with a variety of organisms including Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and nontuberculous mycobacteria. Lung disease occurs earlier in life than once thought and ideal methods of monitoring lung function, decline, or improvement with therapy are debated. Treatment of sinopulmonary disease may include physiotherapy, mucus-modifying and antiinflammatory agents, antimicrobials, and surgery. In the new era of personalized medicine, CFTR correctors and potentiators may change the course of disease.
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Affiliation(s)
- Danielle M Goetz
- Pediatric Pulmonology, Jacobs School of Medicine, Women & Children's Hospital of Buffalo, State University of New York, 219 Bryant Street, Buffalo, NY 14222, USA.
| | - Shipra Singh
- Pediatric Pulmonology, Jacobs School of Medicine, Women & Children's Hospital of Buffalo, State University of New York, 219 Bryant Street, Buffalo, NY 14222, USA
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Wettlaufer J, Klingel M, Yau Y, Stanojevic S, Tullis E, Ratjen F, Waters V. Longitudinal study of Stenotrophomonas maltophilia antibody levels and outcomes in cystic fibrosis patients. J Cyst Fibros 2017; 16:58-63. [PMID: 27346471 DOI: 10.1016/j.jcf.2016.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 06/13/2016] [Accepted: 06/14/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Previous studies have shown an association between higher Stenotrophomonas maltophilia antibody levels and decreased lung function in patients with cystic fibrosis (CF). The purpose of this study was to assess the serologic response to S. maltophilia over time and to determine whether changes in antibody levels could predict clinical outcomes. METHODS Changes in S. maltophilia antibody levels in adult and pediatric patients with CF from 2008 to 2014 were assessed between groups of infection patterns. Regression models accounting for repeated measures were used to assess whether antibody levels could predict subsequent S. maltophilia microbiological status, and whether they are associated with lung function and subsequent pulmonary exacerbation. RESULTS A total of 409 S. maltophilia antibody samples from 135 CF patients showed that antibody levels did not change significantly between study visits, regardless of infection group. Higher antibody levels were independently associated with future culture positivity (OR 1.62; 95% CI 1.09, 2.41; p=0.02). While higher antibody levels were not independently associated with decreases in FEV1% predicted, they were associated with an increased hazard ratio for subsequent pulmonary exacerbation (HR 1.3; 95% CI 1.1, 1.6; p<0.001). CONCLUSIONS S. maltophilia antibody levels may be helpful to identify individuals at risk of exacerbation who may benefit from earlier antimicrobial treatment.
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Green HD, Bright-Thomas RJ, Mutton KJ, Guiver M, Jones AM. Increased prevalence of Pneumocystis jirovecii colonisation in acute pulmonary exacerbations of cystic fibrosis. J Infect 2016; 73:1-7. [PMID: 27189843 DOI: 10.1016/j.jinf.2016.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 01/07/2016] [Revised: 04/06/2016] [Accepted: 05/08/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This study examined the prevalence of Pneumocystis jirovecii in the sputum of adults with cystic fibrosis during clinical stability and acute pulmonary exacerbation. METHODS This was a prospective, longitudinal observational study of patients attending the Manchester Adult Cystic Fibrosis Centre. Sputum samples were analysed for P. jirovecii DNA using PCR at enrolment and up to 5 follow-up visits. Patients were classified as stable or exacerbating using a modified Fuch's pulmonary exacerbation score. RESULTS 226 samples were tested from 111 patients. P. jirovecii was more likely to be detected in samples at acute pulmonary exacerbation (7/76 (9.2%)) compared with stable visits (3/150 (2%)), p = 0.03. P. jirovecii was detected less frequently if patients had received co-trimoxazole within 3 months of sample collection (0% versus 29.7%, p = 0.03). CONCLUSIONS Prevalence of P. jirovecii in stable patients is low, but P. jirovecii is detected in approximately 1 in 10 patients experiencing an acute pulmonary exacerbation.
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Affiliation(s)
- Heather D Green
- Manchester Adult Cystic Fibrosis Centre, University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK; University of Manchester, Institute of Inflammation and Repair, UK.
| | - Rowland J Bright-Thomas
- Manchester Adult Cystic Fibrosis Centre, University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK; University of Manchester, Institute of Inflammation and Repair, UK
| | - Ken J Mutton
- University of Manchester, Institute of Inflammation and Repair, UK; Central Manchester University Hospitals NHS Trust, Clinical Virology Department and PHE Public Health Laboratory, Clinical Sciences Building, Manchester Royal Infirmary, Manchester, M13 9WL, UK
| | - Malcolm Guiver
- Central Manchester University Hospitals NHS Trust, Clinical Virology Department and PHE Public Health Laboratory, Clinical Sciences Building, Manchester Royal Infirmary, Manchester, M13 9WL, UK
| | - Andrew M Jones
- Manchester Adult Cystic Fibrosis Centre, University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK; University of Manchester, Institute of Inflammation and Repair, UK
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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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Solem CT, Vera-Llonch M, Liu S, Botteman M, Castiglione B. Impact of pulmonary exacerbations and lung function on generic health-related quality of life in patients with cystic fibrosis. Health Qual Life Outcomes 2016; 14:63. [PMID: 27097977 PMCID: PMC4839094 DOI: 10.1186/s12955-016-0465-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 04/07/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The analysis aimed to examine the impact of pulmonary exacerbations (PEs) and lung function on generic measures of HRQL in patients with cystic fibrosis (CF) using trial-based data. METHODS In a 48-week randomized, placebo-controlled study of ivacaftor in patients ≥12 years with CF and a G551D-CFTR mutation the relationship between PEs, PE-related hospitalizations and percent predicted forced expiratory volume in one second (ppFEV1) with EQ-5D measures (index and visual analog scale [VAS]) was examined in post-hoc analyses. Multivariate mixed-effects models were employed to describe the association of PEs, PE-related hospitalizations, and ppFEV1 on EQ-5D measures. RESULTS One hundred sixty one patients (age: mean 25.5 [SD 9.5] years; baseline ppFEV1: 63.6 [16.4]) contributed 1,214 observations (ppFEV1: no lung dysfunction [n = 157], mild [n = 419], moderate [n = 572], severe [n = 66]). Problems were most frequently reported on pain/discomfort, anxiety/depression, and usual activities EQ-5D items. The mean (SE) EQ-5D index nominally decreased (worsened) with worsening severity of lung dysfunction (P = 0.070): 0.931 (0.023); mild: 0.923 (0.021); moderate: 0.904 (0.018); severe: 0.870 (0.020). 146 PEs were experienced by 72 patients, including 52 PEs (35.6 %) that required hospitalization. Mean EQ-5D index and VAS scores were lowest (worst) within 1 week (before or after PE start) for PEs requiring hospitalization. Pulmonary exacerbations, PE-related hospitalizations, and ppFEV1 were significant predictors of EQ-5D index and VAS. CONCLUSIONS In a clinical study of patients with CF (≥12 years of age and a G551D-CFTR mutation), PEs, primarily those requiring hospitalization, were associated with low EQ-5D index and VAS scores. The impact of ppFEV1 was relatively smaller. Reducing PEs, in particular those requiring hospitalization, would likely improve HRQL among these patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT00909532 ; URL: clinicaltrials.gov, May 26, 2009.
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Affiliation(s)
- Caitlyn T. Solem
- />Pharmerit International, 4350 East West Hwy, Suite 430, Bethesda, MD 20814 USA
| | | | - Sizhu Liu
- />Pharmerit International, 4350 East West Hwy, Suite 430, Bethesda, MD 20814 USA
| | - Marc Botteman
- />Pharmerit International, 4350 East West Hwy, Suite 430, Bethesda, MD 20814 USA
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VanDevanter DR, Morris NJ, Konstan MW. IV-treated pulmonary exacerbations in the prior year: An important independent risk factor for future pulmonary exacerbation in cystic fibrosis. J Cyst Fibros 2016; 15:372-9. [PMID: 26603642 DOI: 10.1016/j.jcf.2015.10.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/25/2015] [Accepted: 10/12/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Single-center analyses have suggested that the number of CF pulmonary exacerbations (PEx) treated with intravenous antibiotics an individual has experienced in the prior year is significantly associated with their future PEx hazard. METHODS We studied Prior-year PEx association with future PEx hazard by Cox proportional hazards regression among CF Foundation Patient Registry patients who experienced PEx after Jan 1, 2010. RESULTS Among 13,579 patients, those with 1, 2, 3, or ≥4 Prior-year PEx treated with intravenous antibiotics were at 1.8, 2.9, 4.8, and 8.7 higher PEx hazard vs those without (P<.0001). Adjustment with significant demographic and clinical covariates (univariate P≤.0001) reduced Prior-year PEx hazard ratios to 1.6, 2.4, 3.6, and 6.0 (P<.0001). No other covariates had adjusted hazard ratios of >1.7. CONCLUSIONS Prior-year PEx strongly associate with future PEx hazard and should be accounted for in prospective trials where treatment-associated change in PEx hazard is an efficacy outcome.
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Haworth CS, Bilton D, Elborn JS. Long-term macrolide maintenance therapy in non-CF bronchiectasis: evidence and questions. Respir Med 2014; 108:1397-408. [PMID: 25301290 DOI: 10.1016/j.rmed.2014.09.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [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: 02/14/2014] [Revised: 08/19/2014] [Accepted: 09/07/2014] [Indexed: 12/14/2022]
Abstract
Macrolide antibiotics have anti-inflammatory and immunomodulatory properties in addition to antibacterial activity. Until recently, only a small number of studies evaluating macrolides in patients with non-cystic fibrosis (CF) bronchiectasis had been published. These were open-label, uncontrolled, short-duration studies that included small numbers of patients. However, these studies suggested that macrolides can reduce exacerbation frequency, reduce sputum volume, and improve lung function in patients with non-CF bronchiectasis. Three recently published randomised, double-blind, placebo-controlled studies showed that macrolides (azithromycin or erythromycin) taken for between 6 and 12 months led to significant reductions in exacerbation rate and reduced the decline in lung function. In all studies, macrolides were generally well tolerated. The advantages of macrolide maintenance therapy need to be balanced against the risks, which include emergence of bacterial resistance, cardiotoxicity and ototoxicity. In addition, a key need is the consistent definition of endpoints for studies in non-CF bronchiectasis, particularly the definition of exacerbation, to allow systematic data analysis. Existing studies on the use of low-dose macrolides in non-CF bronchiectasis are encouraging, but further studies are needed to define the optimal agent, dose, duration for treatment, and the patients likely to benefit and long-term safety.
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Affiliation(s)
- Charles S Haworth
- Cambridge Centre for Lung Infection, Papworth Hospital, Cambridge, CB23 3RE, UK.
| | - Diana Bilton
- Department of Respiratory Medicine, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
| | - J Stuart Elborn
- Centre for Infection and Immunity, Queen's University of Belfast, 97 Lisburn Road, Belfast, BT9 7BC, Northern Ireland, UK
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