Implementation and outcomes of a quality improvement project to systematically assess the gross motor skills in school-aged children with cystic fibrosis

INTRODUCTION

Limited data exist on the gross motor abilities of children with cystic fibrosis (CF). The objective of this research project was to implement a systematic gross motor assessment in children with CF ages 4-12 years. Secondarily, we aimed to assess demographic characteristics associated with gross motor delays.

METHODS

Physical therapists aimed to evaluate at least 50% of eligible children (4-12 years) at our CF Center over 1 year using the Bruininks-Oseretsky Test of motor Proficiency, second edition (BOT-2). Delays are defined by scores less than 18th percentile. Demographic and clinical data included body mass index, hospitalizations, genotype, and comorbidities. Basic descriptive statistics summarized patient information. Parametric and nonparametric methods compared groups of interest. Linear regression assessed associations between BOT-2 measures and clinical characteristics.

RESULTS

The BOT-2 evaluation was successfully implemented with 69% of eligible patients being evaluated. Forty-five (62.5%) scored below average. Impaired strength (22.2%) was most common, followed by impaired balance (16.7%), running speed and agility (15.3%), and bilateral coordination (8.3%). 15.5% scored below average on their total motor composite score (TMC). Increased age, comorbidities and hospitalizations were associated with a lower TMC.

CONCLUSIONS

The BOT-2 was successfully implemented as part of routine CF care to screen for gross motor delays in children. Results suggest that a high percentage of children with CF, especially older children with comorbid conditions or a history of hospitalization, have impaired gross motor function. These findings support the need for routine gross motor evaluations and physical therapy interventions within pediatric CF clinics.

Remote endpoints for clinical trials in cystic fibrosis: Report from the U.S. CF foundation remote endpoints task force

The COVID-19 pandemic necessitated a rapid shift in clinical research to perform virtual visits and remote endpoint assessments, providing a key opportunity to optimize the use of remote endpoints for clinical trials in cystic fibrosis. The use of remote endpoints could allow more diverse participation in clinical trials while minimizing participant burden but must be robustly evaluated to ensure adequate performance and feasibility. In response, the Cystic Fibrosis Foundation convened the Remote Endpoint Task Force (Supplemental Table 1), a multidisciplinary group of CF researchers with remote endpoint expertise and community members tasked to better understand the current and future use of remote endpoints for clinical research. Here, we describe the current use of remote endpoints in CF clinical research, address key unanswered questions regarding their use and feasibility, and discuss the next steps to determine clinical trial readiness.

A Pilot Randomized Clinical Trial of Pediatric Cystic Fibrosis Pulmonary Exacerbations Treatment Strategies

Rationale: Despite the high prevalence and clear morbidity of cystic fibrosis (CF) pulmonary exacerbations (PEx), there have been no published clinical trials of outpatient exacerbation management. Objectives: To assess the feasibility of a pediatric clinical trial in which treatment of mild PEx is assigned randomly to immediate oral antibiotics or tailored therapy (increased airway clearance alone with oral antibiotics added only for prespecified criteria). The outcome on which sample size was based was the proportion of tailored therapy participants who avoided oral antibiotics during the 28 days after randomization. Methods: In this randomized, open-label, pilot feasibility study at 10 U.S. sites, children 6-18 years of age with CF were enrolled at their well baseline visits and followed through their first randomized PEx. Results: One hundred twenty-one participants were enrolled, of whom 94 (78%) reported symptoms of PEx at least once; of these, 81 (86%) had at least one exacerbation that met randomization criteria, of whom 63 (78%) were randomized. Feasibility goals were met, including enrollment, early detection of symptoms of PEx, and ability to randomize. Among the 33 participants assigned to tailored therapy, 10 (30%) received oral antibiotics, while 29 of 30 (97%) assigned to immediate antibiotics received oral antibiotics. The avoidance of oral antibiotics in 70% (95% confidence interval, 54-85%) was statistically significantly different from our null hypothesis that <10% of participants assigned to the tailored therapy arm would avoid antibiotics. Conclusions: Our pilot study demonstrates that conducting a randomized trial of oral antibiotic treatment strategies for mild PEx in children with CF is feasible and that assignment to a tailored therapy arm may reduce antibiotic exposure. Clinical trial registered with www.clinicaltrials.gov (NCT04608019).

Phase 3 Open-Label Clinical Trial of Elexacaftor/Tezacaftor/Ivacaftor in Children Aged 2-5 Years with Cystic Fibrosis and at Least One F508del Allele

Rationale: Elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) has been shown to be safe and effective in people with cystic fibrosis (CF) aged ⩾6 years with at least one F508del-CFTR allele but has not been studied in younger children. Objectives: To evaluate the safety, pharmacokinetics, pharmacodynamics, and efficacy of ELX/TEZ/IVA in children with CF aged 2-5 years. Methods: In this phase 3, open-label, two-part study (parts A and B), children weighing <14 kg (on Day 1) received ELX 80 mg once daily (qd), TEZ 40 mg qd, and IVA 60 mg each morning and 59.5 mg each evening; children weighing ⩾14 kg received ELX 100 mg qd, TEZ 50 mg qd, and IVA 75 mg every 12 hours. Measurements and Main Results: The primary endpoints for part A (15-d treatment period) were pharmacokinetics and safety and tolerability. For part B (24-wk treatment period), the primary endpoint was safety and tolerability; secondary endpoints included pharmacokinetics and absolute changes from baseline in sweat chloride concentration and lung clearance index2.5 (LCI2.5, defined as the number of lung turnovers required to reduce the end tidal N2 concentration to 2.5% of its starting value) through Week 24. Analysis of pharmacokinetic data from 18 children enrolled in part A confirmed the appropriateness of the part B dosing regimen. In part B, 75 children (F508del/minimal function genotypes, n = 52; F508del/F508del genotype, n = 23) were enrolled and dosed. Seventy-four children (98.7%) had adverse events, which were all mild (62.7%) or moderate (36.0%) in severity. The most common adverse events were cough, fever, and rhinorrhea. Decreases in sweat chloride concentration (-57.9 mmol/L; 95% confidence interval [CI], -61.3 to -54.6; n = 69) and LCI2.5 (-0.83 U; 95% CI, -1.01 to -0.66; n = 50) were observed from baseline through Week 24. Mean body mass index was within the normal range at baseline and remained stable at Week 24. Conclusions: In this open-label study in children 2-5 years of age, ELX/TEZ/IVA treatment was generally safe and well tolerated, with a safety profile consistent with that observed in older age groups, and led to clinically meaningful reductions in sweat chloride concentration and LCI2.5. Clinical trial registered with www.clinicaltrials.gov (NCT04537793).

Managing cystic fibrosis in children aged 6-11yrs: a critical review of elexacaftor/tezacaftor/ivacaftor combination therapy

INTRODUCTION

Cystic fibrosis is a life-limiting, autosomal recessive genetic disorder resulting in multi-organ disease due to CF transmembrane conductance regulator (CFTR) protein dysfunction. CF treatment previously focused on mitigation of disease signs and symptoms. The recent introduction of highly effective CFTR modulators, for which ~90% of people with CF are CFTR variant-eligible, has resulted in substantial health improvements.

AREAS COVERED

In this review, we will describe the clinical trials leading to approval of the highly effective CFTR modulator, elexacaftor-tezacaftor-ivacaftor (ETI), with a focus on the safety and efficacy of this treatment in children aged 6-11 years.

EXPERT OPINION

The use of ETI in variant-eligible children aged 6-11 is associated with marked clinical improvements with a favorable safety profile. We anticipate that introduction of ETI in early childhood may result in the prevention of pulmonary, gastrointestinal, and endocrine complications from CF, consequently leading to previously unimaginable gains in the quality and quantity of life. However, there is an urgent need to develop effective treatments for the remaining 10% of people with CF who are not eligible or unable to tolerate ETI treatment, and to increase access of ETI to more pwCF across the world.

Airway Inflammation in Children with Primary Ciliary Dyskinesia

Rationale: The role of airway inflammation in disease pathogenesis in children with primary ciliary dyskinesia (PCD) is poorly understood. Objectives: We investigated relationships between sputum inflammation measurements, age, lung function, bronchiectasis, airway infection, and ultrastructural defects in children with PCD. Methods: Spontaneously expectorated sputum was collected from clinically stable children and adolescents with PCD ages 6 years and older participating in a multicenter, observational study. Sputum protease and inflammatory cytokine concentrations were correlated with age, lung function, and chest computed tomography measures of structural lung disease, whereas differences in concentrations were compared between ultrastructural defect categories and between those with and without detectable bacterial infection. Results: Sputum from 77 children with PCD (39 females [51%]; mean [standard deviation] age, 13.9 [4.9] yr; mean [standard deviation] forced expiratory volume in 1 second [FEV1]% predicted, 80.8 [20.5]) was analyzed. Sputum inflammatory marker measurements, including neutrophil elastase activity, IL-1β (interleukin-1β), IL-8, and TNF-α (tumor necrosis factor α) concentrations, correlated positively with age, percentage of bronchiectasis, and percentage of total structural lung disease on computed tomography, and negatively with lung function. Correlations between neutrophil elastase concentrations and FEV1% predicted and percentage of bronchiectasis were -0.32 (95% confidence interval, -0.51 to -0.10) and 0.46 (0.14 to 0.69), respectively. Sputum neutrophil elastase, IL-1β, and TNF-α concentrations were higher in those with detectable bacterial pathogens. Participants with absent inner dynein arm and microtubular disorganization had similar inflammatory profiles compared with participants with outer dynein arm defects. Conclusions: In this multicenter pediatric PCD cohort, elevated concentrations of sputum proteases and cytokines were associated with impaired lung function and structural damage as determined by chest computed tomography, suggesting that sputum inflammatory measurements could serve as biomarkers in PCD.

Effects of ivacaftor on systemic inflammation and the plasma proteome in people with CF and G551D

BACKGROUND

Ivacaftor is a cystic fibrosis transmembrane conductance regulator (CFTR) potentiator for people with CF and the G551D mutation. We aimed to investigate the biology of CFTR modulation and systemic effects of CFTR restoration by examining changes in circulating measurements of inflammation and growth and novel proteins with ivacaftor treatment.

METHODS

Blood samples from 64 CF subjects with G551D-CFTR were analyzed for inflammatory and growth-related proteins at baseline, 1 and 6 months after ivacaftor initiation. In 30 subjects, plasma was assayed for 1,322 proteins using the SomaScan proteomic platform at baseline and 6 months post-ivacaftor. Correlations with clinical outcomes were assessed.

MEASUREMENTS AND MAIN RESULTS

Significant reductions in high mobility group box-1 protein (HMGB-1), calprotectin, serum amyloid A, and granulocyte colony-stimulating factor (G-CSF), and an increase in insulin-like growth factor (IGF-1) occurred 1 month after ivacaftor. This treatment effect was sustained at 6 months for HMGB-1 and calprotectin. Correcting for multiple comparisons in the proteomic analysis, 9 proteins (albumin, afamin, leptin, trypsin, pancreatic stone protein [PSP], pituitary adenylate cyclase-activating polypeptide-38, repulsive guidance molecule A [RGMA], calreticulin, GTPase KRas) changed significantly with ivacaftor. Proteins changing with treatment are involved in lipid digestion and transport and extracellular matrix organization biological processes. Reductions in calprotectin and G-CSF and increases in calreticulin, and RGMA correlated with improved lung function, while increasing IGF-1, leptin and afamin and decreasing PSP correlated with increased weight.

CONCLUSIONS

Ivacaftor led to changes in inflammatory, lipid digestion, and extracellular matrix proteins, lending insights into the extrapulmonary effects of CFTR modulation.

Case report: Cystic fibrosis with kwashiorkor: A rare presentation in the era of universal newborn screening

BACKGROUND

Universal newborn screening changed the way medical providers think about the presentation of cystic fibrosis (CF). Before implementation of universal screening, it was common for children with CF to present with failure to thrive, nutritional deficiencies, and recurrent infections. Now, nearly all cases of CF are diagnosed by newborn screening shortly after birth before significant symptoms develop. Therefore, providers often do not consider this illness in the setting of a normal newborn screen. Newborn screening significantly decreases the risk of complications in early childhood, yet definitive testing should be pursued if a patient with negative newborn screening presents with symptoms consistent with CF, including severe failure to thrive, metabolic alkalosis due to significant salt losses, or recurrent respiratory infections.

CASE PRESENTATION

We present a case of a 6-month-old infant male with kwashiorkor, severe edema, multiple vitamin deficiencies, hematemesis secondary to coagulopathy, and diffuse erythematous rash, all secondary to severe pancreatic insufficiency. His first newborn screen had an immunoreactive trypsinogen (IRT) value below the state cut-off value, so additional testing was not performed, and his growth trajectory appeared reassuring. He was ultimately diagnosed with CF by genetic testing and confirmatory sweat chloride testing, in the setting of his parents being known CF carriers and his severe presentation being clinically consistent with CF. Acutely, management with supplemental albumin, furosemide, potassium, and vitamin K was initiated to correct the presenting hypoalbuminemia, edema, and coagulopathy. Later, pancreatic enzyme supplementation and additional vitamins and minerals were added to manage ongoing deficiencies from pancreatic insufficiency. With appropriate treatment, his vitamin deficiencies and edema resolved, and his growth improved.

CONCLUSION

Due to universal newborn screening, symptomatic presentation of CF is rare and presentation with kwashiorkor is extremely rare in resource-rich communities. The diagnosis of CF was delayed in our patient because of a normal newborn screen and falsely reassuring growth, which after diagnosis was determined to be secondary to severe edematous malnutrition. This case highlights that newborn screening is a useful but imperfect tool. Clinicians should continue to have suspicion for CF in the right clinical context, even in the setting of normal newborn screen results.

Detection of bacterial pathogens using home oropharyngeal swab collection in children with cystic fibrosis

BACKGROUND

Collection of respiratory cultures for airway microbiology surveillance is an essential component of routine clinical care in cystic fibrosis (CF). The COVID-19 global pandemic has necessitated increased use of telehealth, but one limitation of telehealth is the inability to collect respiratory specimens. We initiated a protocol for at-home collection of oropharyngeal (OP) swabs from children with CF.

METHODS

Home respiratory specimen collection was offered during telehealth encounters. Home OP swab kits were sent to participating families via mail with instructions for collection and return. Specimens were returned by overnight shipping or dropped off at a hospital lab for processing and culture. We evaluated demographic data and compared culture results from the home-collected specimen to the most recent specimen collected in clinic. We also tracked the frequency of newly identified Pseudomonas aeruginosa.

RESULTS

Home OP swab kits were sent to families of 33 children with CF (range 1.5-19 years). OP swab kits were successfully returned from 19 children (range 1.5-19 years). One or more CF pathogens grew from 79% of the specimens. For four individuals, the home collected specimen demonstrated the new growth of P. aeruginosa.

CONCLUSIONS

Home collection of OP swabs for bacterial culture is feasible in children with CF across a range of ages. Most home-collected specimens demonstrated growth of one or more CF pathogens and results were similar to recent in-clinic specimens, suggesting acceptable sample collection technique. Anti-pseudomonal therapy was initiated for four children based on the growth of P. aeruginosa from the home respiratory specimen.

Long-term safety of lumacaftor-ivacaftor in children aged 2-5 years with cystic fibrosis homozygous for the F508del-CFTR mutation: a multicentre, phase 3, open-label, extension study

BACKGROUND

A previous phase 3 study showed that lumacaftor-ivacaftor was generally safe and well tolerated over 24 weeks of treatment in children aged 2-5 years with cystic fibrosis homozygous for the F508del-CFTR mutation. In this study, we aimed to assess the long-term safety of lumacaftor-ivacaftor in a rollover study of children who participated in this previous phase 3 study.

METHODS

In this multicentre, phase 3, open-label, extension study (study 116; VX16-809-116), we assessed safety of lumacaftor-ivacaftor in children included in a previous multicentre, phase 3, open-label study (study 115; VX15-809-115). The study was done at 20 cystic fibrosis care centres in the USA and Canada. Children aged 2-5 years with cystic fibrosis homozygous for the F508del-CFTR mutation who completed 24 weeks of lumacaftor-ivacaftor treatment in study 115 received weight-based and age-based doses of oral lumacaftor-ivacaftor: children weighing less than 14 kg and aged younger than 6 years at study 116 screening received lumacaftor 100 mg-ivacaftor 125 mg every 12 h; children weighing 14 kg or more and aged younger than 6 years at screening received lumacaftor 150 mg-ivacaftor 188 mg every 12 h; and children aged 6 years or older received lumacaftor 200 mg-ivacaftor 250 mg every 12 h. Children received treatment for up to 96 weeks, equivalent to up to 120 weeks of treatment in total from the start of study 115 to completion of study 116. The primary endpoint was the safety and tolerability of the study drug in all participants who had received lumacaftor-ivacaftor for 24 weeks in study 115 and had received at least one dose in study 116. Secondary endpoints included change from baseline in study 115 at week 96 of study 116 in sweat chloride concentration, growth parameters, markers of pancreatic function, and lung clearance index (LCI) parameters in all children who received at least one dose of lumacaftor-ivacaftor in study 116. This study is registered with ClinicalTrials.gov, NCT03125395.

FINDINGS

This extension study ran from May 12, 2017, to July 17, 2019. Of 60 participants enrolled and who received lumacaftor-ivacaftor in study 115, 57 (95%) were included in study 116 and continued to receive the study drug. A total of 47 (82%) of 57 participants completed 96 weeks of treatment. Most participants (56 [98%] of 57) had at least one adverse event during study 116, most of which were mild (19 [33%] participants) or moderate (29 [51%] participants) in severity. The most common adverse events were cough (47 [82%] participants), nasal congestion (25 [44%] participants), pyrexia (23 [40%] participants), rhinorrhoea (18 [32%] participants), and vomiting (17 [30%] participants). A total of 15 (26%) participants had at least one serious adverse event; most were consistent with underlying cystic fibrosis or common childhood illnesses. Respiratory adverse events occurred in five (9%) participants, none of which were serious or led to treatment discontinuation. Elevated aminotransferase concentrations, most of which were mild or moderate in severity, occurred in ten (18%) participants. Three (5%) participants discontinued treatment due to adverse events (two due to increased aminotransferase concentrations [one of whom had concurrent pancreatitis], considered as possibly related to study drug; and one due to gastritis and metabolic acidosis, considered unlikely to be related to study drug). No clinically significant abnormalities or changes were seen in electrocardiograms, vital signs, pulse oximetry, ophthalmological examinations, or spirometry assessments. Improvements in secondary endpoints observed in study 115 were generally maintained up to week 96 of study 116, including improvements in sweat chloride concentration (mean absolute change from study 115 baseline at week 96 of study 116 -29·6 mmol/L [95% CI -33·7 to -25·5]), an increase in growth parameters and pancreatic function, and stable lung function relative to baseline, as measured by the LCI.

INTERPRETATION

Lumacaftor-ivacaftor was generally safe and well tolerated, and treatment effects were generally maintained for the duration of the extension study. These findings support the use of lumacaftor-ivacaftor for up to 120 weeks in young children with cystic fibrosis aged 2 years and older homozygous for the F508del-CFTR mutation.

FUNDING

Vertex Pharmaceuticals Incorporated.

Oral antibiotic prescribing patterns for treatment of pulmonary exacerbations in two large pediatric CF centers

INTRODUCTION

Oral antibiotics are frequently prescribed for outpatient pulmonary exacerbations (PEx) in children with cystic fibrosis (CF). This study aimed to characterize oral antibiotic use for PEx and treatment outcomes at two large US CF centers.

METHODS

Retrospective, descriptive study of oral antibiotic prescribing practices among children with CF ages 6-17 years over 1 year. The care setting for antibiotic initiation (clinic or phone encounter) was determined and outcomes were compared.

RESULTS

A total of 763 oral antibiotic courses were prescribed to 312 patients aged 6-17 years (77% of 403 eligible patients) with a median of two courses per year (range: 1-10). Fifty-eight percent of prescriptions were provided over the phone. Penicillin was the most commonly prescribed antibiotic class (36% of prescriptions) but differences in antibiotic class prescriptions were noted between the two centers. Hospitalizations occurred within 3 months following 19% of oral antibiotic courses. Forced expiratory volume in 1 s (FEV₁ ) recovered to within 90% of prior baseline within 6 months in 87% of encounters; the mean (SD) % recovery was 99.6% (12.1%) of baseline. Outcomes did not differ between phone and clinic prescriptions.

CONCLUSIONS

Phone prescriptions, commonly excluded in studies of PEx, made up more than half of all oral antibiotic courses. Heterogeneity in prescribing patterns was observed between the two centers. Most patients had improvement in FEV₁ returning to near their prior baseline, but hospitalizations occurred in one-fifth following oral antibiotic treatment. Efforts to optimize PEx treatment must consider care that occurs over the phone; this is particularly important as the use of telemedicine increases.

Highlights from the 2019 North American Cystic Fibrosis Conference

This review briefly summarizes presentations in several major topic areas at the conference: pathophysiology and basic science of cystic fibrosis lung disease, clinical trials, clinical quality improvement, microbiology and treatment of infection, and transition, advanced lung disease and transplant, mental health and psychosocial concerns. The review is intended to highlight several areas and is not a comprehensive summary of the conference. Citations from the conference are by the first author and abstract number or symposium number, as designated in the supplement.

Pulmonary exacerbations and clinical outcomes in a longitudinal cohort of infants and preschool children with cystic fibrosis

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.

Sputum induction improves detection of pathogens in children with cystic fibrosis

BACKGROUND

Sputum induction is a safe, well tolerated means of obtaining lower airway secretions from children with cystic fibrosis (CF), particularly for assessment of airway inflammation but the clinical value in diagnosing outpatient infections has not been extensively studied.

OBJECTIVES

Investigate the success rate and microbiologic yield of induced sputum (IS) compared to oropharyngeal swabs (OP) and expectorated sputum (ES) samples in children with CF, and determine if IS culture results impact treatment.

METHODS

Two cohorts were included in this prospective, longitudinal comparative study. In one cohort, simultaneously collected OP, ES, and IS specimens were obtained from 17 CF children at three visits over 1 year. In the second group, sputum induction was performed in 35 CF subjects at four annual visits, and culture results were compared to their nearest respiratory culture within 4 months. Antimicrobial treatment regimens were captured retrospectively.

RESULTS

Sputum induction was successful in 149 of 158 (94%) visit encounters. Polymicrobial infection (combined P = 0.005) and gram negative organisms (combined P = 0.003) were detected more frequently in IS samples compared to OP, as were the individual pathogens Pseudomonas aeruginosa (combined P = 0.04) and Stenotrophomonas maltophilia (combined P = 0.05). The microbiologic yield of serial IS samples collected over 1 year was stable. IS culture results led to antibiotic changes in 6% of visit encounters. However, based on current practice 13% of visits could have resulted in treatment changes.

CONCLUSIONS

Sputum induction is feasible in the outpatient setting and appears to improve pathogen detection in children with CF.

Advances in the diagnosis and treatment of cystic fibrosis

CF is a genetic, life-shortening, multisystem disease that is most commonly diagnosed through newborn screen performed in all 50 states in the United States. In the past, therapies for CF lung disease have primarily targeted the downstream effects of a dysfunctional CFTR protein. Newer CFTR modulator therapies, targeting the basic defect in CF, are available for a limited group of people with CF, and offer the hope of improved treatment options for many more people with CF in the near future. Best practice is directed by consensus clinical care guidelines from the CFF and is provided with a multidisciplinary approach by the team at the CF care center and the primary care office.

Compliance of German pediatric patients with oral antibiotic therapy: results of a nationwide survey

BACKGROUND

Noncompliance with a prescribed therapy is a common problem in ambulatory pediatrics.

OBJECTIVE

To establish a nationwide status quo of compliance of German ambulatory pediatric patients with oral antibiotics prescribed for various bacterial infections.

PATIENTS AND METHODS

In this study, organized and financed by the German Society for Pediatric Infectious Diseases, 42 pediatricians in private practice who were selected to represent the 3 main regions of Germany and residence in large cities or small towns, respectively, enrolled consecutive patients who had bacterial infections that required therapy with oral antibiotics. Choice of agent and duration of treatment were left to the study physicians. Compliance was measured by a standardized telephone interview on the penultimate day and a urine bioassay for antibacterial activity on the last day of the planned treatment period. Parents did not know the true purpose of the study.

RESULTS

Five hundred eight-four patients were fully evaluable. The most frequent diagnoses included tonsillopharyngitis (n = 231), otitis media (n = 170) and lower respiratory tract infections (n = 114). Most frequently prescribed antibiotics included amoxicillin (n = 102), potassium penicillin V (n = 81) and clarithromycin (n = 67). Overall compliance (positive urine test) on the last day of therapy was 69.5% (406 of 584 patients). Compliance was not significantly influenced by the region of residence or the underlying bacterial infection. It was significantly associated with the antibiotic used (macrolides, 89.0%; penicillins, 62.2%; cephalosporins, 66.4%; P = 0.0001 for macrolides vs. the others). Best compliance was found with clarithromycin (94.0%) and erythromycin estolate (89.8%). Compliance was also significantly better in patients > or =6 years old (77.7%; P = 0.016); with a treatment duration of < or =7 days (77.6%; P = 0.014); when the drug package contained a dose-taking reminder (79.7%; P = 0.003); and when the pediatrician's behavior toward the patient was assessed by the parents as "very sympathetic" or "sympathetic" (72.6%; P = 0.017). Subjecting all variables to logistic regression analysis, we found 3 variables to be significant predictors of treatment compliance: choice of antibiotic (P = 0.0001); patient age (P = 0.0008); and residence in town or city (P = 0.03).

CONCLUSIONS

A noncompliance rate of >30% is unsatisfactory. Whereas some variables significantly associated with compliance cannot be influenced (patient age; place of residence in town or city), others are amenable to modifications. These include the physician-patient interaction and the choice of antibiotic. Agents should be preferred that are well-accepted by patients, that enable short-term therapy with few daily doses and with a package that contains a dose-taking reminder.

Compliance of pediatric patients with treatment involving antibiotic suspensions: a pilot study

In collaboration with 11 German pediatricians in private practice, this pilot study assessed the treatment compliance of 289 pediatric patients (56.1% male: mean age, 53.9+/-35.6 months) who were given antibiotic suspensions (selection and duration determined by the pediatrician) to treat the following bacterial infections: acute otitis media, 34.6%; group A streptococcal tonsillopharyngitis/scarlet fever, 28.7%; lower respiratory tract infection, 18.3%; sinusitis/sinobronchitis, 9.3%; and other infections, 9.0%. The most frequently used antibiotics were amoxicillin (26.3%), erythromycin estolate (19.0%), penicillin V benzathine (14.2%), and cefaclor (13.5%). Compliance was assessed by means of a standardized telephone interview and a urine test that detects antibacterial activity using a Bacillus subtilis spore suspension. Overall compliance (positive urine test result at the end of the planned treatment period) was 79.6% (230 of 289 patients). Compliance was highest with erythromycin estolate (94.5%), followed by penicillin V benzathine (85.4%), cefaclor (76.9%), and amoxicillin (71.1%). Good compliance was also significantly associated with a patient age of > or =3 years and a treatment duration of > or =7 days. Compliance was not significantly influenced by the underlying bacterial infection. In summary, 20.4% of patients were noncompliant when treated with antibiotic suspensions.

Evaluation of six commercial tests and the germ-tube test for presumptive identification of Candida albicans

Six commercial tests (Albicans ID, bioMérieux, France; CandiSelect, Sanofi Diagnostics Pasteur, France; CHROMagar Candida, Becton Dickinson, USA; Fluoroplate Candida, Merck, Germany; Fongiscreen 4H, Sanofi Diagnostics Pasteur; and Murex Candida albicans, Murex Diagnostics, USA) and the germ-tube test for presumptive identification of Candida albicans were evaluated using clinical isolates of Candida albicans (n = 350) and of non-albicans yeasts (n = 135). Sensitivities and specificities of all tests regarding the identification of Candida albicans were greater than 97%. The two tests that also allow presumptive identification of some non-albicans yeasts (CHROMagar Candida and Fongiscreen 4H) did not identify all isolates of Candida glabrata and Candida tropicalis. In addition, CHROMagar Candida identified as Candida glabrata some isolates belonging to different species of non-albicans yeasts.

[Detection of antibacterial activity in the urine of children: a comparison of three tests]

BACKGROUND

Detection of antibacterial activity in urine is important for the diagnosis of urinary tract infections and for assessment of patient compliance with antibiotic therapy.

METHOD

Urines of paediatric inpatients were examined by the Bacillus subtilis agar diffusion test and two commercial test strips (Micur BT and Urotest AB).

RESULTS

566 urines of 431 patients were examined. The B. subtilis agar diffusion test was the most reliable method (accuracy 98.8%). Micur BT showed a comparatively low specificity (87.6%) and Urotest AB had a comparatively low sensitivity (86.0%).

CONCLUSION

The B. subtilis agar diffusion test is the most reliable method for detection of antibacterial activity in the urine of children.

Evaluation of three methods for culturing alginate throat swabs from cystic fibrosis patients

Deep throat swabs are usually cultured for potential respiratory pathogens in patients with cystic fibrosis (CF) who do not produce sputum. Using alginate swabs, three methods were examined in the present study: (i) semiquantitative processing (direct plating); (ii) mere elution of swabs in Ringer's lactate followed by plating of the eluate; and (iii) complete quantitative processing (elution plus two-step dilution series). Throat swabs from 56 CF patients yielded 122 isolates of potential respiratory pathogens. Semiquantitative processing (n = 101 isolates) was not significantly inferior to elution (n = 104) and quantitative processing (n = 113; p > 0.05). Since semiquantitative processing is the simplest method, it is to be preferred, provided that alginate swabs are used.

Comparison of three media for agar dilution susceptibility testing of Bordetella pertussis using six antibiotics

Since antimicrobial susceptibility testing of the fastidious species Bordetella pertussis is not standardized, the most suitable medium for agar dilution testing of this species has not yet been determined. In the present study, Mueller-Hinton, Bordet-Gengou, and Oxoid charcoal agars (each supplemented with 5% horse blood) were evaluated for agar dilution susceptibility testing of Bordetella pertussis against ampicillin, chloramphenicol, ciprofloxacin, doxycycline, erythromycin, and trimethoprim-sulfamethoxazole. Mueller-Hinton agar was the most suitable medium.

In vitro susceptibilities of Bordetella pertussis and Bordetella parapertussis to two ketolides (HMR 3004 and HMR 3647), four macrolides (azithromycin, clarithromycin, erythromycin A, and roxithromycin), and two ansamycins (rifampin and rifapentine)

When tested by agar dilution on Mueller-Hinton agar supplemented with 5% horse blood, the ketolides HMR 3004 and HMR 3647 were slightly more active (MIC at which 90% of the isolates were inhibited [MIC90], 0.03 microg/ml) against Bordetella pertussis than azithromycin, clarithromycin, erythromycin A, and roxithromycin. Azithromycin (MIC90, 0.06 microg/ml) was the most active compound against B. parapertussis. Rifampin and rifapentine were considerably less active.

[Acute hematogenous osteomyelitis in childhood--correlation of clinical aspects, diagnostic parameters, therapy and prognosis]

BACKGROUND

Acute hematogenous osteomyelitis is a common disease in childhood. If treated early, conservative management is possible in most cases. During recent decades, clinical picture, diagnostic techniques and treatment have changed due to various reasons, e.g. previous antibiotic treatment. New laboratory tests and improved imaging techniques such as magnetic resonance imaging enable an earlier diagnosis and thus an earlier onset of treatment and improve the prognosis of hematogenous osteomyelitis. Outcome has also been improved by new antibiotics with enhanced activity against staphylococci.

METHOD

The records of 34 children aged 3 weeks to 172 months with acute hematogenous osteomyelitis were evaluated retrospectively. In some cases, the data were completed by phone calls with parents and family physicians. The results were compared with the current literature.

RESULTS AND CONCLUSIONS

If diagnosed and treated early, acute hematogenous osteomyelitis in childhood has a good prognosis. For primary diagnosis, the clinical picture, parameters of inflammation and magnetic resonance imaging or scintigraphy are useful. The course of the disease can be assessed by clinical signs and the erythrocyte sedimentation rate. Complications can be recognized by conventional radiography and sonography. Initial antibiotic treatment should be carried out parenterally for at least 3 weeks. An exclusively oral treatment is not recommended.

[Pertussis: current aspects of diagnosis, therapy and prevention]

Pertussis (whooping cough) may occur at any age. Beside the typical course of the disease in three stages, atypical courses are observed not infrequently, particularly in adults. In early pertussis, isolation of Bordetella pertussis from nasopharyngeal secretions is the diagnostic method of choice. The polymerase chain reaction is a promising, albeit still investigational diagnostic method. In longstanding cough, serology is the method of choice. Pertussis is treated with erythromycin in high doses for 2 weeks. For prevention of the disease, the new acellular vaccines are to be preferred.

Postal transport of sputa from cystic fibrosis patients does not decrease the microbiological yield

Ambulatory cystic fibrosis patients often submit sputum specimens by post. This study addressed the question if and how postal transport affects the microbiological results of sputum cultures from these patients. Thirty-two fresh sputa and 32 next-day sputa posted from home were cultured qualitatively and quantitatively. The numbers of isolates of potentially pathogenic species and the mean numbers of colony-forming units of these isolates grown from parallel specimens were statistically not different. It is concluded that-under the conditions of this study-postal transport of sputa from cystic fibrosis patients does not decrease the microbiological yield.

Efficacy of a two-component acellular pertussis vaccine in infants

OBJECTIVE

This case-control study investigated the protective efficacy against pertussis of three doses of a two-component acellular pertussis vaccine (manufactured by Biken in Japan) combined with diphtheria and tetanus toxoids (manufactured by Connaught Laboratories in the US) in infants.

METHODS

A case-control study was performed in 63 pediatric practices in Germany. Prospective recruitment of 16,780 infants ages 6 to 17 weeks took place between February, 1993, and July, 1994. According to parental choice infants received either Biken acellular pertussis vaccine combined with diphtheria and tetanus toxoids (DTacP) (74.6%) at approximately 2, 4 and 6 months of age, or a licensed German diphtheria-tetanus toxoids-whole cell pertussis vaccine (10.9%), diphtheria-tetanus toxoids vaccine (12.5%) or no vaccine (2.0%). Prospective surveillance of pertussis cases between February, 1993, and May, 1995, was accomplished by culturing all infants < or =2 years of age presenting with cough > or = 7 days. A pertussis case was defined as any cough of 21 days or longer plus a positive Bordetella pertussis culture or household contact exposure.

RESULTS

We identified 241 pertussis cases prospectively by 11,017 B. pertussis cultures and 949 controls matched for age were selected from the same pediatric practices. Medical history and demographic and vaccine status data were collected from each case and for four controls. Data were analyzed through conditional logistic regression taking into account individual matching and adjusting for potential confounding variables. DTacP combined with diphtheria and tetanus toxoids vaccine was 82% protective (95% confidence interval, 68 to 90), diphtheria-tetanus toxoids-whole cell pertussis vaccine was 96% protective (95% confidence interval, 78 to 99). Protection against typical B. pertussis infection characterized by paroxysmal cough lasting > or =21 days was 96% (95% confidence interval, 87 to 99) for DTacP and was 97% (95% confidence interval, 79 to 100) for diphtheria-tetanus toxoids-whole cell pertussis vaccine. Adjustment for potentially confounding variables did not change the results significantly.

CONCLUSIONS

Three doses of the two-component acellular pertussis vaccine protected infants against pertussis disease during the period before the recommended booster vaccination. For typical pertussis disease as defined by the WHO efficacy was high and similar to that of a licensed German diphtheria-tetanus toxoids-whole cell pertussis vaccine.

Comparison of Etest and agar dilution for testing the activity of three macrolides against Bordetella parapertussis

Agar dilution and Etest using Mueller-Hinton II agar supplemented with 5% whole defibrinated horse blood were compared for testing the activities of azithromycin, clarithromycin, and erythromycin against 34 clinical isolates of the fastidious species Bordetella parapertussis. There was good overall agreement (100.0% within +/- 1 log2 dilution step) between both methods. The Etest offers an excellent and convenient alternative to agar dilution for testing the activities of macrolides against B. parapertussis.

Treatment of oropharyngeal candidiasis in immunocompetent infants: a randomized multicenter study of miconazole gel vs. nystatin suspension. The Antifungals Study Group

BACKGROUND

Miconazole gel has previously been shown to be an effective treatment for oropharyngeal candidiasis (thrush) in immunocompetent infants. This study compares miconazole gel with the standard therapeutic agent, nystatin suspension, with regard to efficacy, optimal duration of therapy and safety.

DESIGN

Prospective multicenter, randomized, office-based open trial.

PATIENTS

Twenty-six pediatricians enrolled 227 immunocompetent infants with signs of oropharyngeal thrush. Subjects were randomly assigned to receive 25 mg of miconazole as oral gel four times daily or 100,000 IU of nystatin as suspension four times daily after meals. All subjects were evaluated for safety. Fifteen patients whose thrush was not confirmed by culture were excluded from further analysis. The remaining 212 subjects were entered into an intention-to-treat analysis. Another 29 patients violated the study protocol; the remaining 183 subjects were evaluated for efficacy (per protocol analysis).

RESULTS

Clinical cure by Day 5 of treatment was demonstrated in 84.7% of the 98 subjects in the miconazole group and 21.2% of the 85 subjects in the nystatin group (P < 0.0001). By Day 8, the cumulative clinical cure rates were 96.9% (miconazole) and 37.6% (nystatin), respectively (P < 0.0001). By Day 12.99.0% of subjects in the miconazole group and 54.1% of subjects in the nystatin group were clinically cured (P < 0.0001). Premature cessation of treatment at parents' request because of lack of clinical efficacy occurred in none of the infants treated with miconazole and in 6 infants treated with nystatin (P = 0.029). The oral yeast eradication rate on Day 5 was 54.1% with miconazole and 8.2% with nystatin (P < 0.0001). Clinical relapses of oropharyngeal thrush and side effects of the study drugs were observed with similar frequency in both study arms.

CONCLUSIONS

Miconazole gel was significantly superior to nystatin suspension with regard to efficacy, rapidity of achieving cure and oropharyngeal yeast eradication. Relapses and side effects did not occur more frequently with miconazole than with nystatin. The results of this study indicate that miconazole gel is superior to nystatin suspension as the treatment for oropharyngeal candidiasis in immunocompetent infants.

Retrospective analysis of yeast colonization and infections in paediatric bone marrow transplant recipients

Sixty-four paediatric patients who underwent allogeneic (n = 35), autologous (n = 28) or syngeneic (n = 1) bone marrow transplantation (BMT) between 1992 and 1994 were evaluated retrospectively. As antifungal prophylaxis, all patients received amphotericin B tablets and 62 of 64 (96.9%) received oral fluconazole. Weekly surveillance cultures revealed fungal colonization in 35 patients (54.7%). Six patients (9.4%) were colonized before BMT only, 17 (26.6%) after BMT only and 12 (18.8%) both before and after BMT. Candida albicans was the most frequently isolated fungus [21 of 46 fungal isolates (45.7%)], followed by C. glabrata [14 isolates (30.4%)]. Non-albicans species of Candida were most frequently isolated after BMT from the faeces, often in high numbers. Autologous marrow recipients had a higher fungal colonization rate both before and after BMT than allogeneic marrow recipients. One patient suffered from invasive pulmonary aspergillosis after BMT. No fungaemias or deep-seated yeast infections were observed. Six of the seven patients who had to be treated with intravenous amphotericin B because of antibiotic-refractory fever had undergone autologous BMT. Multivariate analysis of various parameters showed only pre-BMT yeast colonization to be independently associated with post-BMT colonization. Thus, systemic mycoses occurred only rarely in this study population; however yeast colonization after BMT (especially with non-albicans species) was a frequent event in spite of double prophylaxis with oral amphotericin B and fluconazole.

Rational prescribing of antibacterials in hospitalised children

The subject of this review is the rational prescribing of antimicrobial agents for the therapy of serious community-acquired infections in hospitalised infants and children. First, cost-containment strategies such as streamlining of antibacterial therapy, outpatient parenteral antibacterial therapy and sequential ('stepdown') therapy with parenteral followed by oral therapy are reviewed. In most of these areas, paediatric studies are scant or lacking. Then specific paediatric aspects of the choice of parenteral antibacterials such as penicillins, cephalosporins, aminoglycosides, macrolides and other agents are discussed. With particular reference to cost containment, rational treatment strategies for some serious bacterial infections such as meningitis, occult bacteraemia, endocarditis, osteomyelitis, arthritis, pyelonephritis, Lyme borreliosis (advanced stages) and pneumonia are proposed. In most of these disease, there is potential for cutting treatment costs and studies that compare these newer strategies with traditional treatment regimens are urgently needed.

Rational prescribing of antibacterials in ambulatory children

The rational prescribing of oral antimicrobial agents for bacterial infections in children who can be treated in an ambulatory setting is the subject of this review. First, restrictive use of antibacterials is advocated to avoid widespread development of bacterial resistance. The use of simple methods, suitable for office use, to discern viral from bacterial infections is recommended. Second, in selecting an antimicrobial agent, the physician should consider a number of distinctive features of each agent. Besides aspects of pharmacokinetics, antibacterial spectrum and tolerability, the number of daily doses and, of particular importance for children, the palatability of suspensions plays an important role in achieving patient compliance. Agents that can be administered once or twice daily and possess an agreeable taste in addition to proven efficacy, established tolerability and a reasonable price are to be preferred. Specific paediatric aspects in choosing among penicillins, cephalosporins, macrolides and other oral antibacterials are discussed. For pharmacoeconomic reasons, the optimal duration of antibacterial treatment and the role of short course therapy for various bacterial infections should be studied in more detail. Finally, rational antimicrobial treatment of common paediatric bacterial infections, such as streptococcal tonsillopharyngitis, acute otitis media, acute sinusitis, bacterial pneumonia, pertussis, Lyme borreliosis (early stage) and lower urinary tract infection is reviewed.

[Whooping cough in pregnant patients and newborn infants]

Pertussis affects not only children but also adults. The disease often takes an atypical course in adults and it is frequently misdiagnosed. Pregnant women with pertussis do not suffer from serious obstetrical complications. If, however, they are contagious at the time of delivery, they may infect the neonate immediately post partum. Neonates are susceptible to pertussis and may become seriously ill with potentially fatal consequences. Neonatal pertussis is frequently misdiagnosed, too. The disease can be prevented by prophylactical administration of erythromycin to the neonate.

In vitro susceptibilities of Bordetella pertussis and Bordetella parapertussis to four fluoroquinolones (levofloxacin, d-ofloxacin, ofloxacin, and ciprofloxacin), cefpirome, and meropenem

The in vitro activities of levofloxacin, ofloxacin, d-ofloxacin, ciprofloxacin, cefpirome, and meropenem against 34 clinical isolates each of Bordetella pertussis and Bordetella parapertussis were determined by agar dilution on Mueller-Hinton agar supplemented with 5% horse blood. Levofloxacin was as active as ciprofloxacin against both species (MIC, 0.06 microgram/ml) and more active than ofloxacin and d-ofloxacin. Cefpirome was more active against B. pertussis (MIC, 1.0 microgram/ml) than against B. parapertussis (MIC, > 2 micrograms/ml), while the reverse was true for meropenem (MIC, 2.0 micrograms/ml against B. pertussis and 1.0 microgram/ml against B. parapertussis).

Randomized comparison of two nystatin oral gels with miconazole oral gel for treatment of oral thrush in infants. Antimycotics Study Group

Recently, two commercial oral nystatin gels have been marketed in Germany (Candio-Hermal, Hermal; Lederlind, Lederle). In a prospective open randomized multicentre study involving 12 paediatricians in private practice, Candio-Hermal and Lederlind were compared with miconazole oral gel (Daktar, Janssen) in 95 infants with oral thrush (candidosis). Oral and rectal swabs were taken on days 0 and 14. Treatment duration varied according to the amount of drug contained in one tube (Candio-Hermal 10 days; Lederlind 14 days; Daktar 8 days). On day 14, clinical cure was observed in 23 of 27 infants treated with Daktar (85.1%), in 15 of 35 infants treated with Candio-Hermal (42.8%; p < 0.0007); and in 16 of 33 infants treated with Lederlind (48.5%; p < 0.004). Clinical relapses were observed in 15 patients (Candio-Hermal: n = 9; Lederlind: n = 6). The overall oral mycologic cure rate was significantly higher with Daktar (29.6%) and Candio-Hermal (20.0%) than with Lederlind (3.0%; p < 0.005 and < 0.03, respectively). It can be concluded that Daktar oral gel is significantly more effective than Candio-Hermal and Lederlind in curing oral thrush in infants.

Comparison of media for agar dilution susceptibility testing of Bordetella pertussis and Bordetella parapertussis

Antimicrobial susceptibility testing of the fastidious species Bordetella pertussis and Bordetella parapertussis is not standardized. In an attempt to find the optimal medium for agar dilution testing, the activity of erythromycin against Bordetella pertussis and Bordetella parapertussis (34 isolates each) was assessed using homologous broth/agar combinations of Bordet-Gengou, charcoal, Iso-Sensitest (Oxoid) and Mueller-Hinton media. Each medium was supplemented with 5% and 20% whole defibrinated horse blood. Mueller-Hinton medium supplemented with 5% horse blood performed best overall.