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Anidi IU, Kirenga B, Fennelly KP. Pulmonary Rehabilitation for Post-Tuberculosis Lung Disease. Am J Respir Crit Care Med 2023; 208:1246-1247. [PMID: 37797326 PMCID: PMC10868368 DOI: 10.1164/rccm.202309-1571le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/05/2023] [Indexed: 10/07/2023] Open
Affiliation(s)
- Ifeanyichukwu U. Anidi
- Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, and
- T Lymphocyte Biology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland; and
| | - Bruce Kirenga
- Population Studies and Clinical Trials, Makerere Lung Institute, Makerere University College of Health Sciences, Mulago Hospital, Kampala, Uganda
| | - Kevin P. Fennelly
- Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, and
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2
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Acuña-Villaorduña C, Fennelly KP, Jones-López EC. Aerosol Sampling Outperforms Sputum to Predict Mycobacterium tuberculosis Transmission. Clin Infect Dis 2023; 77:1072. [PMID: 37462403 PMCID: PMC10552576 DOI: 10.1093/cid/ciad372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Affiliation(s)
- Carlos Acuña-Villaorduña
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- Department of Public Health, Section of Infectious Diseases, Lemuel Shattuck Hospital, Jamaica Plain, Massachusetts, USA
| | - Kevin P Fennelly
- Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Edward C Jones-López
- Division of Infectious Diseases, Department of Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, CaliforniaUSA
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3
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Cooper R, Williams M, Fennelly KP. Abandon the Acid-Fast Bacilli Smear for Patients With TB on Effective Treatment. Chest 2023; 164:21-23. [PMID: 37423694 DOI: 10.1016/j.chest.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)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/03/2023] [Indexed: 07/11/2023] Open
Affiliation(s)
- Ryan Cooper
- Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, AB, Canada
| | - Margaret Williams
- Intramural Research Training Award Program, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Kevin P Fennelly
- Pulmonary Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD.
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4
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Fennelly KP, Martinez L, Mandalakas AM. Tuberculosis: First in Flight. Am J Respir Crit Care Med 2021; 205:272-274. [PMID: 34905703 PMCID: PMC8886999 DOI: 10.1164/rccm.202111-2513ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Kevin P Fennelly
- National Institutes of Health, Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland, United States;
| | - Leonardo Martinez
- Boston University, 1846, Department of Epidemiology, School of Public Health, Boston, Massachusetts, United States
| | - Anna Maria Mandalakas
- Baylor College of Medicine and Texas Children's Hospital, Global TB Program, Department of Pediatrics, Houston, Texas, United States
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5
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Wilson KC, Schoenberg NC, Cohn DL, Crothers K, Fennelly KP, Metlay JP, Saukkonen JJ, Strange C, Waterer G, Dweik R. Community-acquired Pneumonia Guideline Recommendations-Impact of a Consensus-based Process versus Systematic Reviews. Clin Infect Dis 2021; 73:e1467-e1475. [PMID: 32964218 PMCID: PMC8677595 DOI: 10.1093/cid/ciaa1428] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 05/27/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) Community-acquired Pneumonia (CAP) guidelines were developed using systematic reviews to inform every recommendation, as suggested by the Institute of Medicine Standards for Trustworthy Guidelines. Recent studies suggest that an expert consensus-based approach, called the Convergence of Opinion on Recommendations and Evidence (CORE) process, can produce recommendations that are concordant with recommendations informed by systematic reviews. PURPOSE The goal of the study was to evaluate the efficacy of the CORE process had it been used to develop the ATS/IDSA CAP guidelines. METHODS Experts in CAP who were not on the guideline panel and had no knowledge of the guideline's systematic reviews or recommendations were recruited to participate in the CORE process, addressing the same questions asked by the guideline panel. Recommendations derived from the CORE process were compared to the guideline recommendations. Concordance of the course of action, strength of recommendation, and quality of evidence were determined. RESULTS Using a threshold of 70% of experts selecting the same course of action to make a recommendation, the CORE process yielded a recommendation for 20 of 31 (65%) questions. Among the 20 CORE-derived recommendations, 19 (95%) were concordant with the guideline recommendations (kappa agreement 0.88, 95% CI .64-1.00). There was less agreement among the strength of recommendations (58%) and quality of evidence (42%). CONCLUSIONS If the CORE process had been used, 11 systematic reviews would have been necessary rather than 31, with minimal impact on the recommended courses of action.
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Affiliation(s)
- Kevin C Wilson
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- American Thoracic Society, New York, New York, USA
| | - Noah C Schoenberg
- Department of Medicine, Beth Israel Deaconess Medicine Center, Boston, Massachusetts, USA
| | - David L Cohn
- Denver Public Health, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Kristina Crothers
- Veterans Affairs Puget Sound Healthcare System and Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Kevin P Fennelly
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Joshua P Metlay
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jussi J Saukkonen
- Department of Medicine, Beth Israel Deaconess Medicine Center, Boston, Massachusetts, USA
| | - Charlie Strange
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Grant Waterer
- Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Raed Dweik
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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6
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Campbell-Washburn AE, Malayeri AA, Jones EC, Moss J, Fennelly KP, Olivier KN, Chen MY. T2-weighted Lung Imaging Using a 0.55-T MRI System. Radiol Cardiothorac Imaging 2021; 3:e200611. [PMID: 34250492 DOI: 10.1148/ryct.2021200611] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 04/22/2021] [Accepted: 05/04/2021] [Indexed: 02/03/2023]
Abstract
Purpose To assess a 0.55-T MRI system for imaging lung disease and to compare image quality with clinical CT scans. Materials and Methods In this prospective study conducted between November 2018 and December 2019, respiratory-triggered T2-weighted turbo spin-echo MRI at 0.55 T was compared with clinical CT scans in 24 participants (mean age, 59 years ± 16 [standard deviation]; 18 women) with common lung abnormalities. MR images were reviewed and scored by experienced readers. Abnormal findings identified with MRI and CT were compared using the Cohen κ statistic. Results High-quality structural pulmonary MR images were attained with an average acquisition time of 11 minutes ± 3. MRI generated sufficient image quality to robustly detect bronchiectasis (κ = 0.61), consolidative opacities (κ = 1.00), cavitary lesions (κ = 1.00), effusion (κ = 0.64), mucus plug (κ = 0.68), and solid scattered nodularity (κ = 0.82). Diffuse disease, including ground-glass opacities (κ = 0.57) and tree-in-bud nodules (κ = 0.48), were the findings that were most difficult to discern using MRI, with false readings in four of 18 patients for each feature. Nodule size, which was measured independently at CT and MRI, was strongly correlated (R 2 = 0.99) for nodules with a measurement of 10 mm ± 5 (range, 5-23 mm). Conclusion This initial study indicates that high-performance 0.55-T MRI holds promise in the evaluation of common lung disease.Clinical trials registration no. NCT03331380Supplemental material is available for this article. Keywords: MRI, Pulmonary, Technology Assessment© RSNA, 2021.
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Affiliation(s)
- Adrienne E Campbell-Washburn
- Cardiovascular (A.E.C.W., M.Y.C.) and Pulmonary (J.M., K.P.F., K.N.O.) Branches, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Building 10, Room BID-47, 10 Center Dr, Bethesda, MD 20892; and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Department of Health and Human Services, Bethesda, Md (A.A.M., E.C.J.)
| | - Ashkan A Malayeri
- Cardiovascular (A.E.C.W., M.Y.C.) and Pulmonary (J.M., K.P.F., K.N.O.) Branches, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Building 10, Room BID-47, 10 Center Dr, Bethesda, MD 20892; and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Department of Health and Human Services, Bethesda, Md (A.A.M., E.C.J.)
| | - Elizabeth C Jones
- Cardiovascular (A.E.C.W., M.Y.C.) and Pulmonary (J.M., K.P.F., K.N.O.) Branches, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Building 10, Room BID-47, 10 Center Dr, Bethesda, MD 20892; and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Department of Health and Human Services, Bethesda, Md (A.A.M., E.C.J.)
| | - Joel Moss
- Cardiovascular (A.E.C.W., M.Y.C.) and Pulmonary (J.M., K.P.F., K.N.O.) Branches, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Building 10, Room BID-47, 10 Center Dr, Bethesda, MD 20892; and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Department of Health and Human Services, Bethesda, Md (A.A.M., E.C.J.)
| | - Kevin P Fennelly
- Cardiovascular (A.E.C.W., M.Y.C.) and Pulmonary (J.M., K.P.F., K.N.O.) Branches, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Building 10, Room BID-47, 10 Center Dr, Bethesda, MD 20892; and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Department of Health and Human Services, Bethesda, Md (A.A.M., E.C.J.)
| | - Kenneth N Olivier
- Cardiovascular (A.E.C.W., M.Y.C.) and Pulmonary (J.M., K.P.F., K.N.O.) Branches, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Building 10, Room BID-47, 10 Center Dr, Bethesda, MD 20892; and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Department of Health and Human Services, Bethesda, Md (A.A.M., E.C.J.)
| | - Marcus Y Chen
- Cardiovascular (A.E.C.W., M.Y.C.) and Pulmonary (J.M., K.P.F., K.N.O.) Branches, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Building 10, Room BID-47, 10 Center Dr, Bethesda, MD 20892; and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Department of Health and Human Services, Bethesda, Md (A.A.M., E.C.J.)
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7
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Winer KK, Schmitt MM, Ferre EMN, Fennelly KP, Olivier KN, Heller T, Lionakis MS. Impact of periprocedural subcutaneous parathyroid hormone on control of hypocalcaemia in APS-1/APECED patients undergoing invasive procedures. Clin Endocrinol (Oxf) 2021; 94:377-383. [PMID: 32955743 DOI: 10.1111/cen.14335] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/09/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022]
Abstract
CONTEXT The monogenic disorder autoimmune polyendocrine syndrome type 1 (APS-1) or autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) manifests frequently with hypoparathyroidism, which requires treatment with oral supplementation with calcium and active vitamin D analogs. The majority of APS-1/APECED patients also suffer from intestinal malabsorption, which complicates the management of hypoparathyroidism and may lead to refractory severe hypocalcaemia. In such situations, reliance on intravenous calcium carries a high risk of nephrocalcinosis and renal damage. METHODS Here, we report our experience of periprocedural subcutaneous administration of recombinant human parathyroid hormone (rhPTH 1-34) in APS-1/APECED patients. Serum calcium was measured up to five times within the 36-hour period starting the evening before the scheduled procedure and ending the morning following the procedure. RESULTS Twenty-seven APS-1/APECED patients with hypoparathyroidism (aged 4-67 years) underwent 31 invasive gastrointestinal and/or pulmonary procedures. The patients received an average rhPTH1-34 dose of 9.6 ± 1.4 µg by subcutaneous injection. 92% of the adults and 54% of children in our cohort had evidence of nephrocalcinosis. Mean calcium levels remained stable and ranged from 2.06 to 2.17 mmol/L with minimal fluctuation. None of our patients experienced periprocedural adverse events connected with hypocalcaemia. CONCLUSION rhPTH 1-34 is an alternative to conventional therapy in patients with APS-1/APECED and hypoparathyroidism undergoing invasive procedures. Subcutaneous PTH1-34 given directly before and after procedures resulted in well-controlled serum calcium levels maintained in the low-normal range and avoided the need for intravenous calcium which may contribute to renal calcifications and tubular damage.
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Affiliation(s)
- Karen K Winer
- Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD), NIH, Bethesda, MD, USA
| | - Monica M Schmitt
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Elise M N Ferre
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Kevin P Fennelly
- Laboratory of Chronic Airway Infection, Pulmonary Branch, National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD, USA
| | - Kenneth N Olivier
- Laboratory of Chronic Airway Infection, Pulmonary Branch, National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD, USA
| | - Theo Heller
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, MD, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
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8
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Fennelly KP. Particle sizes of infectious aerosols: implications for infection control. Lancet Respir Med 2020; 8:914-924. [PMID: 32717211 PMCID: PMC7380927 DOI: 10.1016/s2213-2600(20)30323-4] [Citation(s) in RCA: 320] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 12/13/2022]
Abstract
The global pandemic of COVID-19 has been associated with infections and deaths among health-care workers. This Viewpoint of infectious aerosols is intended to inform appropriate infection control measures to protect health-care workers. Studies of cough aerosols and of exhaled breath from patients with various respiratory infections have shown striking similarities in aerosol size distributions, with a predominance of pathogens in small particles (<5 μm). These are immediately respirable, suggesting the need for personal respiratory protection (respirators) for individuals in close proximity to patients with potentially virulent pathogens. There is no evidence that some pathogens are carried only in large droplets. Surgical masks might offer some respiratory protection from inhalation of infectious aerosols, but not as much as respirators. However, surgical masks worn by patients reduce exposures to infectious aerosols to health-care workers and other individuals. The variability of infectious aerosol production, with some so-called super-emitters producing much higher amounts of infectious aerosol than most, might help to explain the epidemiology of super-spreading. Airborne infection control measures are indicated for potentially lethal respiratory pathogens such as severe acute respiratory syndrome coronavirus 2.
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Affiliation(s)
- Kevin P Fennelly
- Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
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9
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Ferré EMN, Break TJ, Burbelo PD, Allgäuer M, Kleiner DE, Jin D, Xu Z, Folio LR, Mollura DJ, Swamydas M, Gu W, Hunsberger S, Lee CCR, Bondici A, Hoffman KW, Lim JK, Dobbs K, Niemela JE, Fleisher TA, Hsu AP, Snow LN, Darnell DN, Ojaimi S, Cooper MA, Bozzola M, Kleiner GI, Martinez JC, Deterding RR, Kuhns DB, Heller T, Winer KK, Rajan A, Holland SM, Notarangelo LD, Fennelly KP, Olivier KN, Lionakis MS. Lymphocyte-driven regional immunopathology in pneumonitis caused by impaired central immune tolerance. Sci Transl Med 2020; 11:11/495/eaav5597. [PMID: 31167928 DOI: 10.1126/scitranslmed.aav5597] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 04/05/2019] [Indexed: 12/19/2022]
Abstract
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), a monogenic disorder caused by AIRE mutations, presents with several autoimmune diseases. Among these, endocrine organ failure is widely recognized, but the prevalence, immunopathogenesis, and treatment of non-endocrine manifestations such as pneumonitis remain poorly characterized. We enrolled 50 patients with APECED in a prospective observational study and comprehensively examined their clinical and radiographic findings, performed pulmonary function tests, and analyzed immunological characteristics in blood, bronchoalveolar lavage fluid, and endobronchial and lung biopsies. Pneumonitis was found in >40% of our patients, presented early in life, was misdiagnosed despite chronic respiratory symptoms and accompanying radiographic and pulmonary function abnormalities, and caused hypoxemic respiratory failure and death. Autoantibodies against BPIFB1 and KCNRG and the homozygous c.967_979del13 AIRE mutation are associated with pneumonitis development. APECED pneumonitis features compartmentalized immunopathology, with accumulation of activated neutrophils in the airways and lymphocytic infiltration in intraepithelial, submucosal, peribronchiolar, and interstitial areas. Beyond APECED, we extend these observations to lung disease seen in other conditions with secondary AIRE deficiency (thymoma and RAG deficiency). Aire-deficient mice had similar compartmentalized cellular immune responses in the airways and lung tissue, which was ameliorated by deficiency of T and B lymphocytes. Accordingly, T and B lymphocyte-directed immunomodulation controlled symptoms and radiographic abnormalities and improved pulmonary function in patients with APECED pneumonitis. Collectively, our findings unveil lung autoimmunity as a common, early, and unrecognized manifestation of APECED and provide insights into the immunopathogenesis and treatment of pulmonary autoimmunity associated with impaired central immune tolerance.
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Affiliation(s)
- Elise M N Ferré
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Timothy J Break
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Peter D Burbelo
- Dental Clinical Research Core, National Institute of Dental and Craniofacial Research (NIDCR), NIH, Bethesda, MD 20892, USA
| | - Michael Allgäuer
- Laboratory of Pathology, Center for Cancer Research, NCI, NIH, Bethesda, MD 20892, USA.,Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - David E Kleiner
- Laboratory of Pathology, Center for Cancer Research, NCI, NIH, Bethesda, MD 20892, USA
| | - Dakai Jin
- Radiology and Imaging Sciences, NIH Clinical Center (CC), NIH, Bethesda, MD 20892, USA
| | - Ziyue Xu
- Radiology and Imaging Sciences, NIH Clinical Center (CC), NIH, Bethesda, MD 20892, USA
| | - Les R Folio
- Radiology and Imaging Sciences, NIH Clinical Center (CC), NIH, Bethesda, MD 20892, USA
| | - Daniel J Mollura
- Radiology and Imaging Sciences, NIH Clinical Center (CC), NIH, Bethesda, MD 20892, USA
| | - Muthulekha Swamydas
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Wenjuan Gu
- Biostatistics Research Branch, Division of Clinical Research (DCR), NIAID, NIH, Bethesda, MD 20892, USA
| | - Sally Hunsberger
- Biostatistics Research Branch, Division of Clinical Research (DCR), NIAID, NIH, Bethesda, MD 20892, USA
| | - Chyi-Chia R Lee
- Laboratory of Pathology, Center for Cancer Research, NCI, NIH, Bethesda, MD 20892, USA
| | - Anamaria Bondici
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Kevin W Hoffman
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jean K Lim
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Kerry Dobbs
- Immune Deficiency Genetics Section, LCIM, NIAID, NIH, Bethesda, MD 20892, USA
| | - Julie E Niemela
- Immunology Service, Department of Laboratory Medicine (DLM), NIH CC, NIH, Bethesda, MD 20892, USA
| | - Thomas A Fleisher
- Immunology Service, Department of Laboratory Medicine (DLM), NIH CC, NIH, Bethesda, MD 20892, USA
| | - Amy P Hsu
- Immunopathogenesis Section, LCIM, NIAID, NIH, Bethesda, MD 20892, USA
| | - Laquita N Snow
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Dirk N Darnell
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Samar Ojaimi
- Department of Infectious Diseases, Monash Health, Melbourne, VIC 3800, Australia.,Centre for Inflammatory Diseases, Monash University, Melbourne, VIC 3800, Australia
| | - Megan A Cooper
- Department of Pediatrics, Division of Rheumatology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Martin Bozzola
- Department of Pediatrics, British Hospital, Perdriel 74, CABA-Buenos Aires, Argentina
| | - Gary I Kleiner
- University of Miami Department of Pediatrics, Miami, FL 33136, USA
| | - Juan C Martinez
- Cystic Fibrosis, Pulmonary, and Sleep Division, Joe DiMaggio Children's Hospital, Hollywood, FL 33021, USA
| | - Robin R Deterding
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Douglas B Kuhns
- Neutrophil Monitoring Laboratory, Applied/Developmental Research Directorate, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research Inc., Frederick, MD 21701, USA
| | - Theo Heller
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 20892, USA
| | - Karen K Winer
- Pediatric Growth and Nutrition Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD 20892, USA
| | - Arun Rajan
- Thoracic and Gastrointestinal Malignancies Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD 20892, USA
| | - Steven M Holland
- Immunopathogenesis Section, LCIM, NIAID, NIH, Bethesda, MD 20892, USA
| | - Luigi D Notarangelo
- Immune Deficiency Genetics Section, LCIM, NIAID, NIH, Bethesda, MD 20892, USA
| | - Kevin P Fennelly
- Laboratory of Chronic Airway Infection, Pulmonary Branch, National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD 20892, USA
| | - Kenneth N Olivier
- Laboratory of Chronic Airway Infection, Pulmonary Branch, National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD 20892, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA.
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10
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Fennelly KP, Acuna-Villaorduna C, Jones-Lopez E, Lindsley WG, Milton DK. Microbial Aerosols: New Diagnostic Specimens for Pulmonary Infections. Chest 2019; 157:540-546. [PMID: 31678308 DOI: 10.1016/j.chest.2019.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 06/15/2019] [Revised: 10/04/2019] [Accepted: 10/09/2019] [Indexed: 01/20/2023] Open
Abstract
Pulmonary infections are important causes of global morbidity and mortality, but diagnostics are often limited by the ability to collect specimens easily, safely, and in a cost-effective manner. We review recent advances in the collection of infectious aerosols from patients with TB and with influenza. Although this research has been focused on assessing the infectious potential of such patients, we propose that these methods have the potential to lead to the use of patient-generated microbial aerosols as noninvasive diagnostic tests of disease and tests of infectiousness.
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Affiliation(s)
- Kevin P Fennelly
- National Institutes of Health, National Heart, Lung and Blood Institute, Bethesda, MD.
| | | | - Edward Jones-Lopez
- Boston Medical Center and Boston University School of Medicine, Boston, MA
| | - William G Lindsley
- National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV
| | - Donald K Milton
- Maryland Institute for Applied Environmental Health, School of Public Health, University of Maryland, College Park, MD
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Acuña-Villaorduña C, Ayakaka I, Schmidt-Castellani LG, Mumbowa F, Marques-Rodrigues P, Gaeddert M, White LF, Palaci M, Ellner JJ, Dietze R, Joloba M, Fennelly KP, Jones-López EC. Host Determinants of Infectiousness in Smear-Positive Patients With Pulmonary Tuberculosis. Open Forum Infect Dis 2019; 6:ofz184. [PMID: 31205972 PMCID: PMC6557197 DOI: 10.1093/ofid/ofz184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/10/2019] [Indexed: 12/12/2022] Open
Abstract
Background Epidemiologic data suggests that only a minority of tuberculosis (TB) patients are infectious. Cough aerosol sampling is a novel quantitative method to measure TB infectiousness. Methods We analyzed data from three studies conducted in Uganda and Brazil over a 13-year period. We included sputum acid fast bacilli (AFB) and culture positive pulmonary TB patients and used a cough aerosol sampling system (CASS) to measure the number of colony-forming units (CFU) of Mycobacterium tuberculosis in cough-generated aerosols as a measure for infectiousness. Aerosol data was categorized as: aerosol negative (CFU = 0) and aerosol positive (CFU > 0). Logistic regression models were built to identify factors associated with aerosol positivity. Results M. tuberculosis was isolated by culture from cough aerosols in 100/233 (43%) TB patients. In an unadjusted analysis, aerosol positivity was associated with fewer days of antituberculous therapy before CASS sampling (p = .0001), higher sputum AFB smear grade (p = .01), shorter days to positivity in liquid culture media (p = .02), and larger sputum volume (p = .03). In an adjusted analysis, only fewer days of TB treatment (OR 1.47 per 1 day of therapy, 95% CI 1.16-1.89; p = .001) was associated with aerosol positivity. Conclusion Cough generated aerosols containing viable M. tuberculosis, the infectious moiety in TB, are detected in a minority of TB patients and rapidly become non-culturable after initiation of antituberculous treatment. Mechanistic studies are needed to further elucidate these findings.
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Affiliation(s)
- Carlos Acuña-Villaorduña
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Massachusetts.,Lemuel Shattuck Hospital, Boston University School of Public Health, Massachusetts
| | - Irene Ayakaka
- Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | | | - Francis Mumbowa
- Department of Microbiology, Makerere University College of Medicine, Kampala, Uganda
| | | | - Mary Gaeddert
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Massachusetts
| | - Laura F White
- Department of Biostatistics, Boston University School of Public Health, Massachusetts
| | - Moises Palaci
- Núcleo de Doenças Infecciosas, Universidade Federal do Espírito Santo, Vitória, Brazil
| | - Jerrold J Ellner
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Massachusetts
| | - Reynaldo Dietze
- Núcleo de Doenças Infecciosas, Universidade Federal do Espírito Santo, Vitória, Brazil.,Global Health & Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Moses Joloba
- Department of Microbiology, Makerere University College of Medicine, Kampala, Uganda
| | - Kevin P Fennelly
- Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Edward C Jones-López
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Massachusetts
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Acuña-Villaorduña C, Schmidt-Castellani LG, Marques-Rodrigues P, White LF, Hadad DJ, Gaeddert M, Ellner JJ, Fennelly KP, Palaci M, Dietze R, Jones-López EC. Cough-aerosol cultures of Mycobacterium tuberculosis in the prediction of outcomes after exposure. A household contact study in Brazil. PLoS One 2018; 13:e0206384. [PMID: 30372480 PMCID: PMC6205616 DOI: 10.1371/journal.pone.0206384] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 10/11/2018] [Indexed: 11/19/2022] Open
Abstract
Background Mycobacterium tuberculosis cultures of cough-generated aerosols from patients with pulmonary tuberculosis (TB) are a quantitative method to measure infectiousness and to predict secondary outcomes in exposed contacts. However, their reproducibility has not been established. Objective To evaluate the predictive value of colony-forming units (CFU) of M. tuberculosis in cough aerosols on secondary infection and disease in household contacts in Brazil. Methods Adult sputum smear+ and culture+ pulmonary TB cases underwent a standard evaluation and were categorized according to aerosol CFU. We evaluated household contacts for infection at baseline and at 8 weeks with TST and IGRA, and secondary disease. Results We enrolled 48 index TB cases; 40% had negative aerosols, 27% low aerosols (<10 CFU) and 33% high aerosols (≥10 CFU). Of their 230 contacts, the proportion with a TST ≥10 mm at 8 weeks was 59%, 65% and 75%, respectively (p = 0.34). Contacts of high aerosol cases had greater IGRA readouts (median 4.6 IU/mL, IQR 0.02–10) when compared to those with low (0.8, 0.2–10) or no aerosol (0.1, 0–3.7; p = 0.08). IGRA readouts in TST converters of high aerosol cases (median 20 IU/mL, IQR 10–24) were larger than those from aerosol-negative (0.13, 0.04–3; p = o.o2). 8/9 (89%) culture+ secondary TB cases occurred in contacts of aerosol+ cases. Conclusion Aerosol CFU predicts quantitatively IGRA readouts among household contacts of smear positive TB cases. Our results strengthen the argument of using cough aerosols to guide targeted preventive treatment strategies, a necessary component of current TB elimination projections.
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Affiliation(s)
- Carlos Acuña-Villaorduña
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
- * E-mail:
| | | | | | - Laura F. White
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - David Jamil Hadad
- Núcleo de Doenças Infecciosas, Universidade Federal do Espírito Santo, Vitória, Brazil
| | - Mary Gaeddert
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
| | - Jerrold J. Ellner
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
| | - Kevin P. Fennelly
- Pulmonary Clinical Medicine Section, Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Moises Palaci
- Mycobacteriology Laboratory, Núcleo de Doenças Infecciosas, Universidade Federal do Espírito Santo, Vitória, Brazil
| | - Reynaldo Dietze
- Núcleo de Doenças Infecciosas, Universidade Federal do Espírito Santo, Vitória, Brazil
- Global Health & Tropical Medicine - Instituto de Higiene e Medicina Tropical - Universidade Nova de Lisboa, Lisbon, Portugal
| | - Edward C. Jones-López
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
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13
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Jones MM, Winthrop KL, Nelson SD, Duvall SL, Patterson OV, Nechodom KE, Findley KE, Radonovich LJ, Samore MH, Fennelly KP. Epidemiology of nontuberculous mycobacterial infections in the U.S. Veterans Health Administration. PLoS One 2018; 13:e0197976. [PMID: 29897938 PMCID: PMC5999224 DOI: 10.1371/journal.pone.0197976] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 05/13/2018] [Indexed: 11/18/2022] Open
Abstract
Objective We identified patients with non-tuberculous mycobacterial (NTM) disease in the US Veterans Health Administration (VHA), examined the distribution of diseases by NTM species, and explored the association between NTM disease and the frequency of clinic visits and mortality. Methods We combined mycobacterial isolate (from natural language processing) with ICD-9-CM diagnoses from VHA data between 2008 and 2012 and then applied modified ATS/IDSA guidelines for NTM diagnosis. We performed validation against a reference standard of chart review. Incidence rates were calculated. Two nested case-control studies (matched by age and location) were used to measure the association between NTM disease and each of 1) the frequency of outpatient clinic visits and 2) mortality, both adjusted by chronic obstructive pulmonary disease (COPD), other structural lung diseases, and immunomodulatory factors. Results NTM cases were identified with a sensitivity of 94%, a specificity of >99%. The incidence of NTM was 12.6/100k patient-years. COPD was present in 68% of pulmonary NTM. NTM incidence was highest in the southeastern US. Extra-pulmonary NTM rates increased during the study period. The incidence rate ratio of clinic visits in the first year after diagnosis was 1.3 [95%CI 1.34–1.35]. NTM patients had a hazard ratio of mortality of 1.4 [95%CI 1.1–1.9] in the 6 months after NTM identification compared to controls and 1.99 [95%CI 1.8–2.3] thereafter. Conclusions In VHA, pulmonary NTM disease is commonly associated with COPD, with the highest rates in the southeastern US. After adjustment, NTM patients had more clinic visits and greater mortality compared to matched patients.
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Affiliation(s)
- Makoto M Jones
- VA Salt Lake City Health Care System, Salt Lake City, Utah, United States of America.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah, United States of America
| | - Kevin L Winthrop
- Public Health and Preventive Medicine, Division of Infectious Diseases, Oregon Health and Sciences University, Portland, Oregon, United States of America
| | - Scott D Nelson
- VA Salt Lake City Health Care System, Salt Lake City, Utah, United States of America.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Scott L Duvall
- VA Salt Lake City Health Care System, Salt Lake City, Utah, United States of America.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah, United States of America
| | - Olga V Patterson
- VA Salt Lake City Health Care System, Salt Lake City, Utah, United States of America.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah, United States of America
| | - Kevin E Nechodom
- VA Salt Lake City Health Care System, Salt Lake City, Utah, United States of America.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah, United States of America
| | - Kimberly E Findley
- National Center for Occupational Health and Infection Control, Patient Care Services (Public Health), Veterans Health Administration, Gainesville, Florida, United States of America
| | - Lewis J Radonovich
- Formerly with the National Center for Occupational Health and Infection Control, Patient Care Services (Public Health), Veterans Health Administration, Gainesville, Florida, United States of America
| | - Matthew H Samore
- VA Salt Lake City Health Care System, Salt Lake City, Utah, United States of America.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah, United States of America
| | - Kevin P Fennelly
- Formerly with the National Center for Occupational Health and Infection Control, Patient Care Services (Public Health), Veterans Health Administration, Gainesville, Florida, United States of America.,Pulmonary Clinical Medicine Section, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, United States of America
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14
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Acuña-Villaorduña C, White LF, Fennelly KP, Jones-López EC. Tuberculosis transmission: sputum vs aerosols. Lancet Infect Dis 2018; 16:770-771. [PMID: 27352747 DOI: 10.1016/s1473-3099(16)30075-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 04/29/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Carlos Acuña-Villaorduña
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA
| | - Laura F White
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Kevin P Fennelly
- Pulmonary Clinical Medicine Section, Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, MD, USA; National Institutes of Health, Bethesda, MD, USA
| | - Edward C Jones-López
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA.
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15
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Acuña-Villaorduña C, Orikiriza P, Nyehangane D, White LF, Mwanga-Amumpaire J, Kim S, Bonnet M, Fennelly KP, Boum Y, Jones-López EC. Effect of previous treatment and sputum quality on diagnostic accuracy of Xpert ® MTB/RIF. Int J Tuberc Lung Dis 2018; 21:389-397. [PMID: 28284253 DOI: 10.5588/ijtld.16.0785] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING In early studies, Xpert® MTB/RIF accurately detected culture-proven pulmonary tuberculosis (TB). Recent reports have, however, found a lower than expected specificity in previously treated TB patients. OBJECTIVE To investigate the diagnostic accuracy of Xpert in presumptive pulmonary TB patients in Southwestern Uganda. DESIGN We obtained demographic and clinical information and collected three sputum samples from each patient for smear microscopy, Xpert and culture. We estimated Xpert sensitivity and specificity against culture, and stratified the analysis by previous treatment and sputum quality status. RESULTS We analyzed results from 860 presumptive TB patients, including 109 (13%) with a previous history of anti-tuberculosis treatment; 205 (24%) were culture-positive. Xpert specificity was lower (91.8%, 95%CI 84.9-96.2) in previously treated than in new TB patients (97.5%, 95%CI 96.1-98.5; P = 0.01). In an adjusted analysis, patients with culture-, Xpert+ results were more likely to have been previously treated for TB (OR 8.3, 95%CI 2.1-32.0; P = 0.002), and to have mucosalivary sputum (OR 4.1, 95%CI 1.1-14.6; P = 0.03), but were less likely to self-report fever (OR 0.23, 95%CI 0.1-0.7; P = 0.008) than patients with concordant positive results. CONCLUSION Xpert specificity was lower in previously treated patients with suspected TB. The clinical and programmatic impact of culture-, Xpert+ results requires evaluation in future studies.
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Affiliation(s)
- C Acuña-Villaorduña
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - P Orikiriza
- Epicentre, Médecins Sans Frontières, Mbarara, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - L F White
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - J Mwanga-Amumpaire
- Epicentre, Médecins Sans Frontières, Mbarara, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - S Kim
- Department of Biostatistics, Rutgers School of Public Health, Rutgers, The State University of New Jersey, Newark, New Jersey, USA
| | - M Bonnet
- Unité Mixte Internationale 233, Recherches Translationnelles sur le VIH et les Maladies Infectieuses, Unité 1175, Institut pour la Recherche et le Development, Institut National de la Santé et de la Recherche Médicale, Montpellier, France
| | - K P Fennelly
- Pulmonary Clinical Medicine Section, Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, University of Florida, Gainesville, Florida, USA
| | - Y Boum
- Epicentre, Médecins Sans Frontières, Mbarara, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - E C Jones-López
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
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16
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Abadie ME, Strich JR, Kim T, Xie YL, Fennelly KP, Olivier KN, Waldman M, Arora K, Holland SM, Chen RY. Renal Fanconi syndrome with meropenem/amoxicillin-clavulanate during treatment of extensively drug-resistant tuberculosis. Eur Respir J 2017; 50:50/6/1702023. [PMID: 29284688 DOI: 10.1183/13993003.02023-2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 10/12/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Miriam E Abadie
- Dept of Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Jeffrey R Strich
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Tiffany Kim
- Dept of Pharmacy, Clinical Center, National Institutes of Health, Bethesda, MD, USA.,Division of Pharmacovigilance, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Yingda L Xie
- Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Kevin P Fennelly
- Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kenneth N Olivier
- Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Meryl Waldman
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Kriti Arora
- Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Steven M Holland
- Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
| | - Ray Y Chen
- Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
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Abstract
The transmission of tuberculosis is complex. Necessary factors include a source case with respiratory disease that has developed sufficiently for Mycobacterium tuberculosis to be present in the airways. Viable bacilli must then be released as an aerosol via the respiratory tract of the source case. This is presumed to occur predominantly by coughing but may also happen by other means. Airborne bacilli must be capable of surviving in the external environment before inhalation into a new potential host-steps influenced by ambient conditions and crowding and by M. tuberculosis itself. Innate and adaptive host defenses will then influence whether new infection results; a process that is difficult to study owing to a paucity of animal models and an inability to measure infection directly. This review offers an overview of these steps and highlights the many gaps in knowledge that remain.
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Affiliation(s)
| | - Christopher Chiu
- Section of Infectious Diseases & Immunity, Imperial College London, United Kingdom
| | - Gavin J Churchyard
- Aurum Institute and
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Hanif Esmail
- Radcliffe Department of Medicine, University of Oxford, United Kingdom
- Wellcome Center for Infectious Diseases Research in Africa, University of Cape Town, South Africa
| | - David M Lewinsohn
- Department of Molecular Microbiology and Immunology, Oregon Health & Science University, Portland
| | - Neel R Gandhi
- School of Medicine and Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kevin P Fennelly
- Pulmonary Clinical Medicine Section, Cardiovascular Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
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18
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da Silva JL, Nguyen J, Fennelly KP, Zelazny AM, Olivier KN. Survival of pathogenic Mycobacterium abscessus subsp. massiliense in Acanthamoeba castellanii. Res Microbiol 2017; 169:56-60. [PMID: 29056478 DOI: 10.1016/j.resmic.2017.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 10/03/2017] [Indexed: 12/21/2022]
Abstract
We used an amoeba model to study the intracellular growth and cytotoxicity of clinical strains of Mycobacterium abscessus subsp. massiliense (Mabsm) isolated from 2 patients (one with cystic fibrosis, the other one with idiopathic bronchiectasis) during the early (smooth colonies) and late stage (rough colonies) of chronic pulmonary infection. Acanthamoeba castellanii were infected with Mabsm (MOI 100) and samples collected every 24 h for 72 h. Results showed Mabsm is able to survive in trophozoites and persist in cysts for at least 7 days. Late Mabsm demonstrated higher cytotoxicity toward A. castellanii when compared to early strains. A. castellanii is a useful in vitro host model to study infection of Mabsm clinical isolates.
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Affiliation(s)
- Joas L da Silva
- Pulmonary Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jan Nguyen
- Pulmonary Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kevin P Fennelly
- Pulmonary Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Adrian M Zelazny
- Microbiology Service, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Kenneth N Olivier
- Pulmonary Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
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19
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Garinis AC, Cornell A, Allada G, Fennelly KP, Maggiore RJ, Konrad-Martin D. Ototoxicity monitoring through the eyes of the treating physician: Perspectives from pulmonology and medical oncology. Int J Audiol 2017; 57:S19-S24. [PMID: 28978238 DOI: 10.1080/14992027.2017.1381769] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Integrating audiological management into the care pathways of clinical specialties that prescribe ototoxic medications for essential, often life-preserving medical care that is critical for early hearing loss identification and remediation. Research shows that successful implementation of a new health service or intervention requires alignment of goals among provider groups, institutional leadership and patients. Thoughtful consideration of the physician's viewpoints about ototoxicity and its implications for treatment planning is, therefore, important for the implementation and enduring success of an ototoxicity monitoring programme (OMP). DESIGN This discussion paper uses qualitative methods to explore the perspectives of four physicians on OMP provision in their patient populations. STUDY SAMPLE Three pulmonologists and one oncologist completed the written survey or survey-based interview described in this report. RESULTS Each physician indicated that (i) ototoxicity is a potential problem for their patients; (ii) monitoring hearing is important to ensure good quality of life among their patients and (iii) treatment modification would be considered if an alternative treatment option were available. The physicians differed in their approaches to ototoxicity monitoring, from routine referrals to audiology, to relying on patient self-referral. CONCLUSION Physician provider input is needed to optimise monitoring schedules and OMP care coordination with audiology.
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Affiliation(s)
- Angela C Garinis
- a Department of Otolaryngology - Head and Neck Surgery , Oregon Health & Science University , Portland , OR , USA.,b VA Portland Health Care System , VA RR&D Center of Excellence, National Center for Rehabilitative Auditory Research , Portland , OR , USA
| | - Alexandra Cornell
- c Division of Pulmonary and Critical Care Medicine Adult Cystic Fibrosis Program , Oregon Health & Science University , Portland , OR , USA
| | - Gopal Allada
- d Department of Pediatrics Pulmonary Medicine , Oregon Health & Science University , Portland , OR , USA
| | - Kevin P Fennelly
- e National Heart, Lung and Blood Institute , National Institutes of Health , Bethesda , MD , USA
| | - Ronald J Maggiore
- b VA Portland Health Care System , VA RR&D Center of Excellence, National Center for Rehabilitative Auditory Research , Portland , OR , USA.,f Department of Medicine, Hematology & Oncology , Oregon Health & Science University , Portland , OR , USA , and.,g Department of Medicine, Hematology & Oncology , University of Rochester , Rochester , NY , USA
| | - Dawn Konrad-Martin
- a Department of Otolaryngology - Head and Neck Surgery , Oregon Health & Science University , Portland , OR , USA.,b VA Portland Health Care System , VA RR&D Center of Excellence, National Center for Rehabilitative Auditory Research , Portland , OR , USA
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20
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Dheda K, Gumbo T, Maartens G, Dooley KE, McNerney R, Murray M, Furin J, Nardell EA, London L, Lessem E, Theron G, van Helden P, Niemann S, Merker M, Dowdy D, Van Rie A, Siu GKH, Pasipanodya JG, Rodrigues C, Clark TG, Sirgel FA, Esmail A, Lin HH, Atre SR, Schaaf HS, Chang KC, Lange C, Nahid P, Udwadia ZF, Horsburgh CR, Churchyard GJ, Menzies D, Hesseling AC, Nuermberger E, McIlleron H, Fennelly KP, Goemaere E, Jaramillo E, Low M, Jara CM, Padayatchi N, Warren RM. The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis. Lancet Respir Med 2017; 5:S2213-2600(17)30079-6. [PMID: 28344011 DOI: 10.1016/s2213-2600(17)30079-6] [Citation(s) in RCA: 376] [Impact Index Per Article: 53.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/24/2016] [Accepted: 12/08/2016] [Indexed: 12/25/2022]
Abstract
Global tuberculosis incidence has declined marginally over the past decade, and tuberculosis remains out of control in several parts of the world including Africa and Asia. Although tuberculosis control has been effective in some regions of the world, these gains are threatened by the increasing burden of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis. XDR tuberculosis has evolved in several tuberculosis-endemic countries to drug-incurable or programmatically incurable tuberculosis (totally drug-resistant tuberculosis). This poses several challenges similar to those encountered in the pre-chemotherapy era, including the inability to cure tuberculosis, high mortality, and the need for alternative methods to prevent disease transmission. This phenomenon mirrors the worldwide increase in antimicrobial resistance and the emergence of other MDR pathogens, such as malaria, HIV, and Gram-negative bacteria. MDR and XDR tuberculosis are associated with high morbidity and substantial mortality, are a threat to health-care workers, prohibitively expensive to treat, and are therefore a serious public health problem. In this Commission, we examine several aspects of drug-resistant tuberculosis. The traditional view that acquired resistance to antituberculous drugs is driven by poor compliance and programmatic failure is now being questioned, and several lines of evidence suggest that alternative mechanisms-including pharmacokinetic variability, induction of efflux pumps that transport the drug out of cells, and suboptimal drug penetration into tuberculosis lesions-are likely crucial to the pathogenesis of drug-resistant tuberculosis. These factors have implications for the design of new interventions, drug delivery and dosing mechanisms, and public health policy. We discuss epidemiology and transmission dynamics, including new insights into the fundamental biology of transmission, and we review the utility of newer diagnostic tools, including molecular tests and next-generation whole-genome sequencing, and their potential for clinical effectiveness. Relevant research priorities are highlighted, including optimal medical and surgical management, the role of newer and repurposed drugs (including bedaquiline, delamanid, and linezolid), pharmacokinetic and pharmacodynamic considerations, preventive strategies (such as prophylaxis in MDR and XDR contacts), palliative and patient-orientated care aspects, and medicolegal and ethical issues.
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Affiliation(s)
- Keertan Dheda
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa.
| | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ruth McNerney
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Megan Murray
- Department of Global Health and Social Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Edward A Nardell
- TH Chan School of Public Health, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Leslie London
- School of Public Health and Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Grant Theron
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Paul van Helden
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Stefan Niemann
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Schleswig-Holstein, Germany; German Centre for Infection Research (DZIF), Partner Site Borstel, Borstel, Schleswig-Holstein, Germany
| | - Matthias Merker
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Schleswig-Holstein, Germany
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Annelies Van Rie
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; International Health Unit, Epidemiology and Social Medicine, Faculty of Medicine, University of Antwerp, Antwerp, Belgium
| | - Gilman K H Siu
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR, China
| | - Jotam G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Camilla Rodrigues
- Department of Microbiology, P.D. Hinduja National Hospital & Medical Research Centre, Mumbai, India
| | - Taane G Clark
- Faculty of Infectious and Tropical Diseases and Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Frik A Sirgel
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
| | - Aliasgar Esmail
- Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Hsien-Ho Lin
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Sachin R Atre
- Center for Clinical Global Health Education (CCGHE), Johns Hopkins University, Baltimore, MD, USA; Medical College, Hospital and Research Centre, Pimpri, Pune, India
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kwok Chiu Chang
- Tuberculosis and Chest Service, Centre for Health Protection, Department of Health, Hong Kong SAR, China
| | - Christoph Lange
- Division of Clinical Infectious Diseases, German Center for Infection Research, Research Center Borstel, Borstel, Schleswig-Holstein, Germany; International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany; Department of Medicine, Karolinska Institute, Stockholm, Sweden; Department of Medicine, University of Namibia School of Medicine, Windhoek, Namibia
| | - Payam Nahid
- Division of Pulmonary and Critical Care, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Zarir F Udwadia
- Pulmonary Department, Hinduja Hospital & Research Center, Mumbai, India
| | | | - Gavin J Churchyard
- Aurum Institute, Johannesburg, South Africa; School of Public Health, University of Witwatersrand, Johannesburg, South Africa; Advancing Treatment and Care for TB/HIV, South African Medical Research Council, Johannesburg, South Africa
| | - Dick Menzies
- Montreal Chest Institute, McGill University, Montreal, QC, Canada
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Eric Nuermberger
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kevin P Fennelly
- Pulmonary Clinical Medicine Section, Division of Intramural Research, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Eric Goemaere
- MSF South Africa, Cape Town, South Africa; School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Marcus Low
- Treatment Action Campaign, Johannesburg, South Africa
| | | | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), MRC HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Robin M Warren
- SA MRC Centre for Tuberculosis Research/DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Tygerberg, South Africa
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Luongo JC, Fennelly KP, Keen JA, Zhai ZJ, Jones BW, Miller SL. Role of mechanical ventilation in the airborne transmission of infectious agents in buildings. Indoor Air 2016; 26:666-78. [PMID: 26562748 PMCID: PMC7165552 DOI: 10.1111/ina.12267] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 10/31/2015] [Indexed: 05/04/2023]
Abstract
Infectious disease outbreaks and epidemics such as those due to SARS, influenza, measles, tuberculosis, and Middle East respiratory syndrome coronavirus have raised concern about the airborne transmission of pathogens in indoor environments. Significant gaps in knowledge still exist regarding the role of mechanical ventilation in airborne pathogen transmission. This review, prepared by a multidisciplinary group of researchers, focuses on summarizing the strengths and limitations of epidemiologic studies that specifically addressed the association of at least one heating, ventilating and/or air-conditioning (HVAC) system-related parameter with airborne disease transmission in buildings. The purpose of this literature review was to assess the quality and quantity of available data and to identify research needs. This review suggests that there is a need for well-designed observational and intervention studies in buildings with better HVAC system characterization and measurements of both airborne exposures and disease outcomes. Studies should also be designed so that they may be used in future quantitative meta-analyses.
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Affiliation(s)
- J C Luongo
- Department of Mechanical Engineering, University of Colorado, Boulder, CO, USA
| | - K P Fennelly
- Division of Infectious Diseases and Global Medicine, Emerging Pathogens Institute, College of Medicine, University of Florida, Gainesville, FL, USA
| | - J A Keen
- Department of Architectural Engineering and Construction Science, Kansas State University, Manhattan, KS, USA
| | - Z J Zhai
- Department of Civil, Environmental, and Architectural Engineering, University of Colorado, Boulder, CO, USA
| | - B W Jones
- Department of Mechanical and Nuclear Engineering, Kansas State University, Manhattan, KS, USA
| | - S L Miller
- Department of Mechanical Engineering, University of Colorado, Boulder, CO, USA.
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Fennelly KP, Ojano-Dirain C, Yang Q, Liu L, Lu L, Progulske-Fox A, Wang GP, Antonelli P, Schultz G. Biofilm Formation by Mycobacterium abscessus in a Lung Cavity. Am J Respir Crit Care Med 2016; 193:692-3. [PMID: 26731090 DOI: 10.1164/rccm.201508-1586im] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | | | - Li Lu
- 5 Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, and
| | - Ann Progulske-Fox
- 6 Center for Molecular Microbiology, Department of Oral Biology, College of Dentistry, University of Florida, Gainesville, Florida; and
| | - Gary P Wang
- 1 Department of Medicine.,7 Medical Service, North Florida/South Georgia Veterans Health System, Gainesville, Florida
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Jones-López EC, Acuña-Villaorduña C, Ssebidandi M, Gaeddert M, Kubiak RW, Ayakaka I, White LF, Joloba M, Okwera A, Fennelly KP. Cough Aerosols of Mycobacterium tuberculosis in the Prediction of Incident Tuberculosis Disease in Household Contacts. Clin Infect Dis 2016; 63:10-20. [PMID: 27025837 DOI: 10.1093/cid/ciw199] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 03/18/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Tuberculosis disease develops in only 5%-10% of humans infected with Mycobacterium tuberculosis The mechanisms underlying this variability remain poorly understood. We recently demonstrated that colony-forming units of M. tuberculosis in cough-generated aerosols are a better predictor of infection than the standard sputum acid-fast bacilli smear. We hypothesized that cough aerosol cultures may also predict progression to tuberculosis disease in contacts. METHODS We conducted a retrospective cohort study of 85 patients with smear-positive tuberculosis and their 369 household contacts in Kampala, Uganda. Index case patients underwent a standard evaluation, and we cultured M. tuberculosis from cough aerosols. Contacts underwent a standard evaluation at enrollment, and they were later traced to determine their tuberculosis status. RESULTS During a median follow-up of 3.9 years, 8 (2%) of the contacts developed tuberculosis disease. In unadjusted and adjusted analyses, incident tuberculosis disease in contacts was associated with sputum Mycobacterial Growth Indicator Tube culture (odds ratio, 8.2; 95% confidence interval, 1.1-59.2; P = .04), exposure to a high-aerosol tuberculosis case patient (6.0, 1.4-25.2; P = .01), and marginally, human immunodeficiency virus in the contact (6.11; 0.89-41.7; P = .07). We present data demonstrating that sputum and aerosol specimens measure 2 related but different phenomena. CONCLUSIONS We found an increased risk of tuberculosis progression among contacts of high-aerosol case patients. The hypothesis that a larger infectious inoculum, represented by high aerosol production, determines the risk of disease progression deserves evaluation in future prospective studies.
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Affiliation(s)
- Edward C Jones-López
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine Makerere University-Boston Medical Center Research Collaboration
| | - Carlos Acuña-Villaorduña
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine
| | | | - Mary Gaeddert
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine
| | - Rachel W Kubiak
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine
| | - Irene Ayakaka
- Makerere University-Boston Medical Center Research Collaboration
| | - Laura F White
- Department of Biostatistics, Boston University School of Public Health, Massachusetts
| | - Moses Joloba
- Department of Microbiology, Makerere University College of Health Sciences
| | - Alphonse Okwera
- Makerere University-Boston Medical Center Research Collaboration Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Kevin P Fennelly
- Pulmonary Clinical Medicine Section, Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
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Fennelly KP, Jones-López EC. Corrigendum: Quantity and Quality of Inhaled Dose Predicts Immunopathology in Tuberculosis. Front Immunol 2015; 6:511. [PMID: 26483797 PMCID: PMC4589614 DOI: 10.3389/fimmu.2015.00511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 09/18/2015] [Indexed: 11/26/2022] Open
Affiliation(s)
- Kevin P. Fennelly
- Department of Medicine, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
- *Correspondence: Kevin P. Fennelly,
| | - Edward C. Jones-López
- Section of Infectious Diseases, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
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Jones-López EC, White LF, Kirenga B, Mumbowa F, Ssebidandi M, Moine S, Mbabazi O, Mboowa G, Ayakaka I, Kim S, Thornton CS, Okwera A, Joloba M, Fennelly KP. Cough Aerosol Cultures of Mycobacterium tuberculosis: Insights on TST / IGRA Discordance and Transmission Dynamics. PLoS One 2015; 10:e0138358. [PMID: 26394149 PMCID: PMC4578948 DOI: 10.1371/journal.pone.0138358] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 08/28/2015] [Indexed: 01/17/2023] Open
Abstract
Rationale The diagnosis of latent tuberculosis (TB) infection (LTBI) is complicated by the absence of a gold standard. Discordance between tuberculin skin tests (TST) and interferon gamma release assays (IGRA) occurs in 10–20% of individuals, but the underlying mechanisms are poorly understood. Methods We analyzed data from a prospective household contact study that included cough aerosol culture results from index cases, environmental and contact factors. We assessed contacts for LTBI using TST and IGRA at baseline and six weeks. We examined TST/IGRA discordance in qualitative and quantitative analyses, and used multivariable logistic regression analysis with generalized estimating equations to analyze predictors of discordance. Measurements and Results We included 96 TB patients and 384 contacts. Discordance decreased from 15% at baseline to 8% by six weeks. In adjusted analyses, discordance was related to less crowding (p = 0.004), non-cavitary disease (OR 1.41, 95% CI: 1.02–1.96; p = 0.03), and marginally with BCG vaccination in contacts (OR 1.40, 95% CI: 0.99–1.98, p = 0.06). Conclusions We observed significant individual variability and temporal dynamism in TST and IGRA results in household contacts of pulmonary TB cases. Discordance was associated with a less intense infectious exposure, and marginally associated with a BCG-mediated delay in IGRA conversion. Cough aerosols provide an additional dimension to the assessment of infectiousness and risk of infection in contacts.
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Affiliation(s)
- Edward C. Jones-López
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, United States of America
- Makerere University–Boston Medical Center Research Collaboration, Kampala, Uganda
- * E-mail:
| | - Laura F. White
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Bruce Kirenga
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Francis Mumbowa
- Department of Microbiology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Martin Ssebidandi
- Makerere University–Boston Medical Center Research Collaboration, Kampala, Uganda
| | - Stephanie Moine
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Olive Mbabazi
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Gerald Mboowa
- Department of Microbiology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Irene Ayakaka
- Makerere University–Boston Medical Center Research Collaboration, Kampala, Uganda
| | - Soyeon Kim
- Department of Preventive Medicine and Community Health, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey, United States of America
| | - Christina S. Thornton
- Department of Microbiology & Infectious Diseases, University of Calgary, Calgary, Canada
| | - Alphonse Okwera
- Department of Microbiology, Makerere University College of Health Sciences, Kampala, Uganda
- Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Moses Joloba
- Department of Microbiology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Kevin P. Fennelly
- Division of Infectious Diseases and Global Medicine, Department of Medicine and Emerging Pathogens Institute, University of Florida, Gainesville, Florida, United States of America
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Abstract
Experimental animal models of tuberculosis (TB) have convincingly demonstrated that inhaled dose predicts immunopathology and survival. In contrast, the importance of inhaled dose has generally not been appreciated in TB epidemiology, clinical science, or the practice of TB control. Infectiousness of TB patients has traditionally been assessed using microscopy for acid-fast bacilli in the sputum, which should be considered only a risk factor. We have recently demonstrated that cough aerosol cultures from index cases with pulmonary TB are the best predictors of new infection among household contacts. We suggest that cough aerosols of M. tuberculosis are the best surrogates of inhaled dose, and we hypothesize that the quantity of cough aerosols is associated with TB infection versus disease. Although several factors affect the quality of infectious aerosols, we propose that the particle size distribution of cough aerosols is an important predictor of primary upper airway disease and cervical lymphadenitis and of immune responses in exposed hosts. We hypothesize that large droplet aerosols (>5 μ) containing M. tuberculosis deposit in the upper airway and can induce immune responses without establishing infection. We suggest that this may partially explain the large proportion of humans who never develop TB disease in spite of having immunological evidence of M. tuberculosis infection (e.g., positive tuberculin skin test or interferon gamma release assay). If these hypotheses are proven true, they would alter the current paradigm of latent TB infection and reactivation, further demonstrating the need for better biomarkers or methods of assessing TB infection and the risk of developing disease.
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Affiliation(s)
- Kevin P Fennelly
- Department of Medicine, Emerging Pathogens Institute, University of Florida , Gainesville, FL , USA
| | - Edward C Jones-López
- Section of Infectious Diseases, Boston Medical Center, Boston University School of Medicine , Boston, MA , USA
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Acuña-Villaorduña C, Ayakaka I, Dryden-Peterson S, Nakubulwa S, Worodria W, Reilly N, Hosford J, Fennelly KP, Okwera A, Jones-López EC. High mortality associated with retreatment of tuberculosis in a clinic in Kampala, Uganda: a retrospective study. Am J Trop Med Hyg 2015; 93:73-5. [PMID: 25940196 DOI: 10.4269/ajtmh.14-0810] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 03/19/2015] [Indexed: 11/07/2022] Open
Abstract
The World Health Organization recommends for tuberculosis retreatment a regimen of isoniazid (H), rifampicin (R), ethambutol (E), pyrazinamide (Z), and streptomycin (S) for 2 months, followed by H, R, E, and Z for 1 month and H, R, and E for 5 months. Using data from the National Tuberculosis and Leprosy Program registry, this study determined the long-term outcome under programmatic conditions of patients who were prescribed the retreatment regimen in Kampala, Uganda, between 1997 and 2003. Patients were traced to determine their vital status; 62% (234/377) patients were found dead. Having ≤ 2 treatment courses and not completing retreatment were associated with mortality in adjusted analyses.
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Affiliation(s)
- Carlos Acuña-Villaorduña
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Irene Ayakaka
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Scott Dryden-Peterson
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Susan Nakubulwa
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - William Worodria
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Nancy Reilly
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Jennifer Hosford
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Kevin P Fennelly
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Alphonse Okwera
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Edward C Jones-López
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
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Hosford JD, von Fricken ME, Lauzardo M, Chang M, Dai Y, Lyon JA, Shuster J, Fennelly KP. Hepatotoxicity from antituberculous therapy in the elderly: a systematic review. Tuberculosis (Edinb) 2014; 95:112-22. [PMID: 25595441 DOI: 10.1016/j.tube.2014.10.006] [Citation(s) in RCA: 41] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 10/14/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND Elderly persons have the highest rates of tuberculosis (TB) in the United States compared to all other age groups. A systematic literature review was conducted to determine if older age was a risk factor for hepatotoxicity resulting from treatment with first-line drugs used to treat active (TB) and latent tuberculosis (LTBI). METHODS A systematic review of MEDLINE, Cochrane Controlled Trial Registry, CINAHL(®), and Science Citation Index Expanded (from 1970 to 2011) was performed to determine the risk of hepatotoxicity, comparing those over 60 with those under 60. A meta-analysis was performed using a random effects model along with log odds ratios and the chi-square test. FINDINGS Thirty-eight studies (40,034 participants; 1208 cases of hepatotoxicity) met the selection criteria. For active TB, an overall mean effect of 0.277 (p = 0.024, 95% CI: 0.037-0.517) was observed, which is equivalent to an odds ratio of 1.32 (95% CI: 1.04-1.68). For LTBI, an overall mean effect of 1.42 (p < 0.001, 95% CI: 0.794-2.05) was observed, which translates to an odds ratio of 4.14 (95% CI: 2.21-7.74). INTERPRETATION Our analysis revealed that patients older than 60 had significantly more risk of hepatotoxicity. These studies suggest that a gentler regimen of treatment for older individuals could benefit health outcomes in this population of TB patients and minimize risks to the public's health.
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Affiliation(s)
- Jennifer D Hosford
- Southeastern National Tuberculosis Center, Department of Medicine, University of Florida, Gainesville, FL, USA; Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Michael E von Fricken
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA; Department of Environmental and Global Health, University of Florida, Gainesville, FL, USA
| | - Michael Lauzardo
- Southeastern National Tuberculosis Center, Department of Medicine, University of Florida, Gainesville, FL, USA; Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Myron Chang
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Yunfeng Dai
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Jennifer A Lyon
- Biomedical and Health Information Services, University of Florida, Gainesville, FL, USA
| | - John Shuster
- Department of Health Outcomes and Policy, University of Florida, Gainesville, FL, USA
| | - Kevin P Fennelly
- Southeastern National Tuberculosis Center, Department of Medicine, University of Florida, Gainesville, FL, USA; Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA.
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Egelund EF, Mohamed MF, Fennelly KP, Peloquin CA. Concomitant Use of Carbamazepine and Rifampin in a Patient With Mycobacterium avium Complex and Seizure Disorder. J Pharm Technol 2014; 30:93-96. [PMID: 34860865 DOI: 10.1177/8755122514523934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Objectives. To report a probable interaction between rifampin and carbamazepine, likely leading to a seizure, and to review conflicting reports regarding this interaction. Case Summary. A 55-year-old female was treated with carbamazepine 200 mg 3 times daily for grand mal seizures, with excellent control. A 6-hour postdose carbamazepine concentration was 10.7 µg/mL (therapeutic range = 4-10 µg/mL). After she was diagnosed with pulmonary Mycobacterium avium complex, she received rifampin 300 mg twice daily, ethambutol 800 mg daily, and clarithromycin 500 mg twice daily. At first clinic visit, rifampin was changed to 600 mg daily, and clarithromycin was replaced with azithromycin 250 mg daily. A 4-hour postdose carbamazepine concentration was 7.1 µg/mL. Two weeks later, the patient experienced a seizure (no carbamazepine concentration reported at that time), but admitted to missing doses of carbamazepine. After experiencing 2 more seizures, the patient stopped taking rifampin. Subsequently, the carbamazepine dose was increased to 400 mg twice daily and rifampin was restarted at 600 mg daily. Two follow-up peak carbamazepine concentrations were 4.7 µg/mL and 4.4 µg/mL, with no reported seizures. No additional factors were identified as potential causes of the seizures or the lower carbamazepine concentrations. A Drug Interaction Probability Scale score of 6 indicates a probable interaction. Discussion. Conflicting reports exist regarding the effect of rifampin on carbamazepine concentrations, likely reflecting rifampin's ability to display time-dependent, mixed effects on transporters and cytochrome P450 enzymes. Conclusions. Our case report describes a patient who experienced seizures after the addition of rifampin to her regimen, followed by lower peak concentrations of carbamazepine. Therapeutic drug monitoring in patients receiving both rifampin and carbamazepine is recommended to help clinicians optimize drug therapy.
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Ghesani N, Patrawalla A, Lardizabal A, Salgame P, Fennelly KP. Increased cellular activity in thoracic lymph nodes in early human latent tuberculosis infection. Am J Respir Crit Care Med 2014; 189:748-50. [PMID: 24628316 DOI: 10.1164/rccm.201311-1976le] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Jones-López EC, Namugga O, Mumbowa F, Ssebidandi M, Mbabazi O, Moine S, Mboowa G, Fox MP, Reilly N, Ayakaka I, Kim S, Okwera A, Joloba M, Fennelly KP. Cough aerosols of Mycobacterium tuberculosis predict new infection: a household contact study. Am J Respir Crit Care Med 2013; 187:1007-15. [PMID: 23306539 DOI: 10.1164/rccm.201208-1422oc] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Airborne transmission of Mycobacterium tuberculosis results from incompletely characterized host, bacterial, and environmental factors. Sputum smear microscopy is associated with considerable variability in transmission. OBJECTIVES To evaluate the use of cough-generated aerosols of M. tuberculosis to predict recent transmission. METHODS Patients with pulmonary tuberculosis (TB) underwent a standard evaluation and collection of cough aerosol cultures of M. tuberculosis. We assessed household contacts for new M. tuberculosis infection. We used multivariable logistic regression analysis with cluster adjustment to analyze predictors of new infection. MEASUREMENTS AND MAIN RESULTS From May 2009 to January 2011, we enrolled 96 sputum culture-positive index TB cases and their 442 contacts. Only 43 (45%) patients with TB yielded M. tuberculosis in aerosols. Contacts of patients with TB who produced high aerosols (≥10 CFU) were more likely to have a new infection compared with contacts from low-aerosol (1-9 CFU) and aerosol-negative cases (69%, 25%, and 30%, respectively; P = 0.009). A high-aerosol patient with TB was the only predictor of new M. tuberculosis infection in unadjusted (odds ratio, 5.18; 95% confidence interval, 1.52-17.61) and adjusted analyses (odds ratio, 4.81; 95% confidence interval, 1.20-19.23). Contacts of patients with TB with no aerosols versus low and high aerosols had differential tuberculin skin test and interferon-γ release assay responses. CONCLUSIONS Cough aerosols of M. tuberculosis are produced by a minority of patients with TB but predict transmission better than sputum smear microscopy or culture. Cough aerosols may help identify the most infectious patients with TB and thus improve the cost-effectiveness of TB control programs.
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Affiliation(s)
- Edward C Jones-López
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA 02118, USA.
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Subhash SS, Baracco G, Fennelly KP, Hodgson M, Radonovich LJ. Isolation anterooms: important components of airborne infection control. Am J Infect Control 2013; 41:452-5. [PMID: 23036479 PMCID: PMC7135637 DOI: 10.1016/j.ajic.2012.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 06/01/2012] [Accepted: 06/04/2012] [Indexed: 11/25/2022]
Affiliation(s)
- Shobha S Subhash
- National Center for Occupational Health and Infection Control, North Florida/South Georgia Veterans Health System, Gainesville, FL 32608, USA.
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Zitter JN, Maldjian P, Brimacombe M, Fennelly KP. Inhaled Dornase alfa (Pulmozyme) as a noninvasive treatment of atelectasis in mechanically ventilated patients. J Crit Care 2012; 28:218.e1-7. [PMID: 23266402 DOI: 10.1016/j.jcrc.2012.09.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 09/24/2012] [Accepted: 09/26/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Lobar or segmental collapse of the lung in mechanically ventilated patients is a common occurrence in the intensive care unit. Management is labor and time intensive and not highly effective. METHODS We conducted a randomized, placebo-controlled, double-blind pilot study to determine whether nebulized Dornase alfa improves radiologic and clinical outcomes in ventilated patients with lobar atelectasis. Drug or placebo was administered twice daily until extubation, death, or transfer. The primary outcome was the total chest x-ray score: secondary outcomes of interest were oxygenation, lung compliance, and rate of extubation over the first 5 days. The groups consisted of 14 intervention patients and 16 control patients. RESULTS There were no significant differences in "Total Chest X-Ray Score" or compliance over the 5 days of study. There was an improvement in oxygenation for the intervention group at day 5 (P = .03). In addition, this group was less likely to remain intubated over the first 24 hours of the study, a difference that did not persist over the course of the study. CONCLUSIONS Dornase alfa does not improve the appearance of atelectasis on chest radiographs, or the "Total Chest X-Ray Score" over the first 5 days of treatment in mechanically ventilated patients. The intervention group's higher rate of extubation during the first 24 hours as well as its improved oxygenation on day 5 were likely chance findings given the multiple potential confounders for extubation and low study power.
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Affiliation(s)
- Jessica Nutik Zitter
- Department of Medicine, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA.
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Fennelly KP, Jones-López EC, Ayakaka I, Kim S, Menyha H, Kirenga B, Muchwa C, Joloba M, Dryden-Peterson S, Reilly N, Okwera A, Elliott AM, Smith PG, Mugerwa RD, Eisenach KD, Ellner JJ. Variability of infectious aerosols produced during coughing by patients with pulmonary tuberculosis. Am J Respir Crit Care Med 2012; 186:450-7. [PMID: 22798319 PMCID: PMC3443801 DOI: 10.1164/rccm.201203-0444oc] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [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: 03/10/2012] [Accepted: 06/21/2012] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Mycobacterium tuberculosis is transmitted by infectious aerosols, but assessing infectiousness currently relies on sputum microscopy that does not accurately predict the variability in transmission. OBJECTIVES To evaluate the feasibility of collecting cough aerosols and the risk factors for infectious aerosol production from patients with pulmonary tuberculosis (TB) in a resource-limited setting. METHODS We enrolled subjects with suspected TB in Kampala, Uganda and collected clinical, radiographic, and microbiological data in addition to cough aerosol cultures. A subset of 38 subjects was studied on 2 or 3 consecutive days to assess reproducibility. MEASUREMENTS AND MAIN RESULTS M. tuberculosis was cultured from cough aerosols of 28 of 101 (27.7%; 95% confidence interval [CI], 19.9-37.1%) subjects with culture-confirmed TB, with a median 16 aerosol cfu (range, 1-701) in 10 minutes of coughing. Nearly all (96.4%) cultivable particles were 0.65 to 4.7 μm in size. Positive aerosol cultures were associated with higher Karnofsky performance scores (P = 0.016), higher sputum acid-fast bacilli smear microscopy grades (P = 0.007), lower days to positive in liquid culture (P = 0.004), stronger cough (P = 0.016), and fewer days on TB treatment (P = 0.047). In multivariable analyses, cough aerosol cultures were associated with a salivary/mucosalivary (compared with purulent/mucopurulent) appearance of sputum (odds ratio, 4.42; 95% CI, 1.23-21.43) and low days to positive (per 1-d decrease; odds ratio, 1.17; 95% CI, 1.07-1.33). The within-test (kappa, 0.81; 95% CI, 0.68-0.94) and interday test (kappa, 0.62; 95% CI, 0.43-0.82) reproducibility were high. CONCLUSIONS A minority of patients with TB (28%) produced culturable cough aerosols. Collection of cough aerosol cultures is feasible and reproducible in a resource-limited setting.
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Affiliation(s)
- Kevin P Fennelly
- Southeastern National Tuberculosis Center, Emerging Pathogens Institute, Room 257, University of Florida, Gainesville, FL 32610, USA.
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Fennelly KP, Hosford JL. Behind the Mask: Overdue Evidence. Am J Respir Crit Care Med 2012; 185:1041-3. [DOI: 10.1164/rccm.201203-0548ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Kevin P. Fennelly
- Emerging Pathogens InstituteUniversity of FloridaGainesville, FloridaandVA National Center for Occupational Health and Infection ControlGainesville, Florida
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Wainwright CE, France MW, O'Rourke P, Anuj S, Kidd TJ, Nissen MD, Sloots TP, Coulter C, Ristovski Z, Hargreaves M, Rose BR, Harbour C, Bell SC, Fennelly KP. Cough-generated aerosols of Pseudomonas aeruginosa and other Gram-negative bacteria from patients with cystic fibrosis. Thorax 2009; 64:926-31. [PMID: 19574243 PMCID: PMC2764123 DOI: 10.1136/thx.2008.112466] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pseudomonas aeruginosa is the most common bacterial pathogen in patients with cystic fibrosis (CF). Current infection control guidelines aim to prevent transmission via contact and respiratory droplet routes and do not consider the possibility of airborne transmission. It was hypothesised that subjects with CF produce viable respirable bacterial aerosols with coughing. METHODS A cross-sectional study was undertaken of 15 children and 13 adults with CF, 26 chronically infected with P aeruginosa. A cough aerosol sampling system enabled fractioning of respiratory particles of different sizes and culture of viable Gram-negative non-fermentative bacteria. Cough aerosols were collected during 5 min of voluntary coughing and during a sputum induction procedure when tolerated. Standardised quantitative culture and genotyping techniques were used. RESULTS P aeruginosa was isolated in cough aerosols of 25 subjects (89%), 22 of whom produced sputum samples. P aeruginosa from sputum and paired cough aerosols were indistinguishable by molecular typing. In four cases the same genotype was isolated from ambient room air. Approximately 70% of viable aerosols collected during voluntary coughing were of particles <or=3.3 microm aerodynamic diameter. P aeruginosa, Burkholderia cenocepacia, Stenotrophomonas maltophilia and Achromobacter xylosoxidans were cultivated from respiratory particles in this size range. Positive room air samples were associated with high total counts in cough aerosols (p = 0.003). The magnitude of cough aerosols was associated with higher forced expiratory volume in 1 s (r = 0.45, p = 0.02) and higher quantitative sputum culture results (r = 0.58, p = 0.008). CONCLUSION During coughing, patients with CF produce viable aerosols of P aeruginosa and other Gram-negative bacteria of respirable size range, suggesting the potential for airborne transmission.
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Affiliation(s)
- C E Wainwright
- Department of Respiratory Medicine, Royal Children's Hospital and Health Service District, Brisbane, Australia.
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Fennelly KP. Variability of airborne transmission of Mycobacterium tuberculosis: implications for control of tuberculosis in the HIV era. Clin Infect Dis 2007; 44:1358-60. [PMID: 17443475 DOI: 10.1086/516617] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2007] [Accepted: 02/16/2007] [Indexed: 11/03/2022] Open
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Fennelly KP. Personal respiratory protection and prevention of occupational tuberculosis. Int J Tuberc Lung Dis 2005; 9:476. [PMID: 15875916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
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Abstract
The lack of identified exposures in 2 of the 11 cases of bioterrorism-related inhalation anthrax in 2001 raised uncertainty about the infectious dose and transmission of Bacillus anthracis. We used the Wells-Riley mathematical model of airborne infection to estimate 1) the exposure concentrations in postal facilities where cases of inhalation anthrax occurred and 2) the risk for infection in various hypothetical scenarios of exposure to B. anthracis aerosolized from contaminated mail in residential settings. These models suggest that a small number of cases of inhalation anthrax can be expected when large numbers of persons are exposed to low concentrations of B. anthracis. The risk for inhalation anthrax is determined not only by bacillary virulence factors but also by infectious aerosol production and removal rates and by host factors.
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Affiliation(s)
- Kevin P Fennelly
- Department of Medicine, New Jersey Medical School-UMDNJ, Newark, 07107-3000, USA.
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Fennelly KP, Martyny JW, Fulton KE, Orme IM, Cave DM, Heifets LB. Cough-generated aerosols of Mycobacterium tuberculosis: a new method to study infectiousness. Am J Respir Crit Care Med 2003; 169:604-9. [PMID: 14656754 DOI: 10.1164/rccm.200308-1101oc] [Citation(s) in RCA: 198] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The concentration and size distribution of infectious aerosols produced by patients with pulmonary tuberculosis (TB) has never been directly measured. We aimed to assess the feasibility of a method that we developed to collect and quantify culturable cough-generated aerosols of Mycobacterium tuberculosis. Subjects were recruited from a referral hospital and most had multidrug-resistant TB. They coughed into a chamber containing microbial air samplers while cough frequency was measured during two 5-minute sessions. Cough-generated aerosol cultures were positive in 4 of 16 subjects (25%) with smear-positive pulmonary TB. There was a rapid decrease in the cough-generated aerosol cultures within the first 3 weeks of effective treatment. Culture-positive cough aerosols were associated with lack of treatment during the previous week (p = 0.007), and there was a trend in the association with cough frequency (p = 0.08). The size distributions of these aerosols were variable, but most particle sizes were in the respirable range. Quantification of viable cough-generated aerosols is feasible and offers a new approach to study infectiousness and transmission of M. tuberculosis and other airborne pathogens.
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MESH Headings
- Aerosols
- Air Microbiology
- Cough/microbiology
- DNA Fingerprinting
- DNA, Bacterial/analysis
- DNA, Bacterial/genetics
- Environmental Monitoring/methods
- Environmental Monitoring/standards
- Epidemiological Monitoring
- Feasibility Studies
- Female
- Humans
- Male
- Molecular Epidemiology
- Mycobacterium tuberculosis/genetics
- Mycobacterium tuberculosis/isolation & purification
- Mycobacterium tuberculosis/pathogenicity
- Particle Size
- Reproducibility of Results
- Selection Bias
- Sensitivity and Specificity
- Sputum/microbiology
- Tuberculosis, Multidrug-Resistant/complications
- Tuberculosis, Multidrug-Resistant/drug therapy
- Tuberculosis, Multidrug-Resistant/epidemiology
- Tuberculosis, Multidrug-Resistant/microbiology
- Tuberculosis, Multidrug-Resistant/transmission
- Tuberculosis, Pulmonary/complications
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/epidemiology
- Tuberculosis, Pulmonary/microbiology
- Tuberculosis, Pulmonary/transmission
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Affiliation(s)
- Kevin P Fennelly
- Department of Medicine, Center for the Study of Emerging and Re-Emerging Pathogens, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ 07103, USA.
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Fennelly KP, Iseman MD. Health care workers and tuberculosis: the battle of a century. Int J Tuberc Lung Dis 1999; 3:363-4. [PMID: 10331721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
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Fennelly KP, Nardell EA. The Relative Efficacy of Respirators and Room Ventilation in Preventing Occupational Tuberculosis. Infect Control Hosp Epidemiol 1998. [DOI: 10.2307/30141420] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
OBJECTIVES To evaluate the relative efficacy of personal respiratory protection as the concentrations of infectious aerosols increase or as room ventilation rates decrease. METHODS We modified the Wells-Riley mathematical model of airborne transmission of disease by adding a variable for respirator leakage. We modeled three categories of infectiousness using various room ventilation rates and classes of respirators over a 10-hour exposure period. RESULTS The risk of infection decreases exponentially with increasing room ventilation or with increasing personal respiratory protection. The relative efficacy of personal respiratory protection decreases as room ventilation rates increase or as the concentrations of infectious aerosols decrease. CONCLUSIONS These modeling data suggest that the risk of occupational tuberculosis probably can be lowered considerably by using relatively simple respirators combined with modest room ventilation rates for the infectious aerosols likely to be present in isolation rooms of newly diagnosed patients. However, more sophisticated respirators may be needed to achieve a comparable risk reduction for exposures to more highly concentrated aerosols, such as may be generated during cough-inducing procedures or autopsies involving infectious patients. There is probably minimal benefit to the use of respirators in well-ventilated isolation rooms with patients receiving appropriate therapy.
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Affiliation(s)
- K P Fennelly
- National Jewish Medical and Research Center and the University of Colorado Health Sciences Center, Denver 80206, USA.
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Fennelly KP. The role of masks in preventing nosocomial transmission of tuberculosis. Int J Tuberc Lung Dis 1998; 2:S103-9. [PMID: 9755974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- K P Fennelly
- Division of Environmental and Occupational Health Sciences, Personal Respiratory Protection Program, National Jewish Medical and Research Center, Denver, Colorado 80206, USA.
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Abstract
Vocal cord dysfunction (VCD) is a poorly understood entity that is often misdiagnosed as asthma. We report eleven cases of VCD in which there was a temporal association between VCD onset and occupational or environmental exposure. We conducted a case-control study to determine if the characteristics of irritant-exposed VCD (IVCD) cases differed from non-exposed VCD controls. Chart review of VCD patients at the authors' institution produced 11 cases that met IVCD case criteria. Thirty-three control VCD subjects were selected by age matching. There were statistical differences between the groups in ethnicity and chest discomfort. There were no statistical differences between the groups for gender, tobacco, smoking habits, symptoms, or pulmonary function parameters. Varied irritant exposures were associated with IVCD. IVCD should be considered in patients presenting with respiratory symptoms occurring after irritant exposures.
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Affiliation(s)
- J J Perkner
- Department of Medicine, National Jewish Medical and Research Center, Denver, CO 80206, USA
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Abstract
Although there are no data demonstrating the effectiveness of personal respiratory protection in the prevention of occupational tuberculosis, there are sound theoretical bases supporting the use of respirators to reduce the risk of inhalational exposure. The major factor that limits the effectiveness of most respirators is the leakage between the face and the mask. There are data suggesting that traditional fit testing of respirators does not adequately predict the degree of protection in actual use, and more research is needed in that area. There is a large range of infectiousness of aerosols of TB, and classes of respirators vary greatly in the degree of protection they offer. I have argued that respirator selection should be based on anticipated exposures. High-risk exposures to TB are often associated with cough-inducing procedures or with aerosolization of infected tissues during autopsies. In my opinion, the most reasonable type of respirator for such high-risk situations in health care settings is a PAPR hood. The concentration of infectious aerosols in well-ventilated respiratory isolation rooms is likely to be very low, and the new N95 respirators offer a reasonable balance of comfort, cost, practicality, and protection. Preliminary data from mathematical modeling studies suggest there may be little additional benefit from more sophisticated personal respiratory protection in such settings. Additional research is needed to more accurately assess exposures to TB, to determine the size and aerodynamic behavior of TB generated by infectious patients, and to more accurately define the role and effectiveness of personal respiratory protection against TB.
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Affiliation(s)
- K P Fennelly
- Section of Occupational and Environmental Medicine, Division of Pulmonary Medicine, National Jewish Center for Immunology and Respiratory Medicine, Denver, Colorado, USA
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