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Hua JL, Yang ZF, Cheng QJ, Han YP, Li ZT, Dai RR, He BF, Wu YX, Zhang J. Prevention of exacerbation in patients with moderate-to-very severe COPD with the intent to modulate respiratory microbiome: a pilot prospective, multi-center, randomized controlled trial. Front Med (Lausanne) 2024; 10:1265544. [PMID: 38249987 PMCID: PMC10797043 DOI: 10.3389/fmed.2023.1265544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/18/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction Considering the role of bacteria in the onset of acute exacerbation of COPD (AECOPD), we hypothesized that the use of influenza-Streptococcus pneumoniae vaccination, oral probiotics or inhaled amikacin could prevent AECOPD. Methods In this pilot prospective, muti-central, randomized trial, moderate-to-very severe COPD subjects with a history of moderate-to-severe exacerbations in the previous year were enrolled and assigned in a ratio of 1:1:1:1 into 4 groups. All participants were managed based on the conventional treatment recommended by GOLD 2019 report for 3 months, with three groups receiving additional treatment of inhaled amikacin (0.4 g twice daily, 5-7 days monthly for 3 months), oral probiotic Lactobacillus rhamnosus GG (1 tablet daily for 3 months), or influenza-S. pneumoniae vaccination. The primary endpoint was time to the next onset of moderate-to-severe AECOPD from enrollment. Secondary endpoints included CAT score, mMRC score, adverse events, and survival in 12 months. Results Among all 112 analyzed subjects (101 males, 96 smokers or ex-smokers, mean ± SD age 67.19 ± 7.39 years, FEV1 41.06 ± 16.09% predicted), those who were given dual vaccination (239.7 vs. 198.2 days, p = 0.044, 95%CI [0.85, 82.13]) and oral probiotics (248.8 vs. 198.2 days, p = 0.017, 95%CI [7.49, 93.59]) had significantly delayed onset of next moderate-to-severe AECOPD than those received conventional treatment only. For subjects with high symptom burden, the exacerbations were significantly delayed in inhaled amikacin group as compared to the conventional treatment group (237.3 vs. 179.1 days, p = 0.009, 95%CI [12.40,104.04]). The three interventions seemed to be safe and well tolerated for patient with stable COPD. Conclusion The influenza-S. pneumoniae vaccine and long-term oral probiotic LGG can significantly delay the next moderate-to-severe AECOPD. Periodically amikacin inhalation seems to work in symptomatic patients. The findings in the current study warrants validation in future studies with microbiome investigation.Clinical trial registration:https://clinicaltrials.gov/, identifier NCT03449459.
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Affiliation(s)
- Jian-lan Hua
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zi-feng Yang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Qi-jian Cheng
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yao-pin Han
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zheng-tu Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Ran-ran Dai
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bin-feng He
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yi-xing Wu
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jing Zhang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Lung Inflammation and Injury, Shanghai, China
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Gambazza S, Storms V, Purohit V. Adherence to inhaled antibiotics in people with cystic fibrosis: insights from a virtual patient advisory board. Expert Rev Respir Med 2023; 17:961-963. [PMID: 37817635 DOI: 10.1080/17476348.2023.2267427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/03/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND Chronic airway infection by Pseudomonas aeruginosa significantly impacts the health of people with cystic fibrosis (PwCF), presenting complex treatment challenges. RESEARCH DESIGN AND METHODS To gain insights into PwCF's experiences, a virtual European Patient Advisory Board was convened. Board explored inhaled antibiotic usage, treatment adherence, and associated challenges. Additionally, an online survey was conducted among PwCF to further understand real-life experiences and unmet needs, particularly related to CFTR modulators. RESULTS The Advisory Board proved instrumental in collecting valuable real-world perspectives, offering potential avenues for reshaping the care model for complex diseases like cystic fibrosis. CONCLUSIONS PwCF on CFTR modulators are questioning the necessity of continuing chronic medications and therapies. Physicians are urged to carefully consider the balance between simplifying antibiotic treatment and the risk of clinical deterioration due to bacterial infections when making treatment decisions. Furthermore, the development and global harmonization of diagnostic tools for chronic lung damage and treatment guidelines are crucial to justify the demanding routines that PwCF must endure to manage their condition.The heterogeneity in patient journeys, diagnostic challenges, treatment complexity, and issues related to adherence highlight the need for patient-centric, personalized care that emphasizes improving and maintaining treatment adherence to optimize cystic fibrosis management.
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Affiliation(s)
- Simone Gambazza
- Healthcare Professions Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | | | - Vinay Purohit
- Global Medical Affairs, Mylan Pharmaceuticals Private Limited (A Viatris Company), Bengaluru, India
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3
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Zhang XX, Chen ZM, He ZF, Guan WJ. Advances in pharmacotherapy for bronchiectasis in adults. Expert Opin Pharmacother 2023; 24:1075-1089. [PMID: 37161410 DOI: 10.1080/14656566.2023.2210763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
INTRODUCTION Bronchiectasis has become a growing concern of chronic airway disease because of the enormous socioeconomic burden. Four cardinal interdependent components - impaired airway defense, recurrent airway infections, inflammatory response, and airway damage, in conjunction with the underlying etiology, have collectively played a role in modulating the vicious vortex of the pathogenesis and progression of bronchiectasis. Current pharmacotherapy aims to target at these aspects to break the vicious vortex. AREAS COVERED The authors retrieve and review, in MEDLINE, Web of Science and ClinicalTrials.gov registry, the studies about pharmacotherapy for bronchiectasis from these aspects: antibiotics, mucoactive medications, bronchodilators, anti-inflammatory drug, and etiological treatment. EXPERT OPINION Future drug development and clinical trials of bronchiectasis need to pay more attention to the different phenotypes or endotypes of bronchiectasis. There is a need for the development of novel inhaled antibiotics that could reduce bacterial loads, improve quality-of-life, and decrease exacerbation risks. More efforts are needed to explore the next-generation neutrophil-targeted therapeutic drugs that are expected to ameliorate respiratory symptom burden, reduce exacerbation risks, and hinder airway destruction in bronchiectasis.
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Affiliation(s)
- Xiao-Xian Zhang
- Guangzhou Institute of Respiratory Health, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhao-Ming Chen
- Guangzhou Institute of Respiratory Health, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhen-Feng He
- Guangzhou Institute of Respiratory Health, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wei-Jie Guan
- Guangzhou Institute of Respiratory Health, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Thoracic Surgery, Guangzhou Institute for Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Respiratory Centre, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
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Gipsman A, Prero M, Toltzis P, Craven D. Inhaled antibiotics in children with tracheostomy tubes: A descriptive study. Pediatr Pulmonol 2023; 58:1028-1033. [PMID: 36541025 DOI: 10.1002/ppul.26288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 11/07/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Respiratory tract infections (RTIs) are common in children with tracheostomy tubes. Anecdotally, inhaled antibiotics are commonly prescribed, although to date there are no studies describing their use in this patient population. The objective of this study was to assess the variability of this practice at a single tertiary care children's hospital. METHODS All children admitted to our hospital with a tracheostomy tube who were prescribed inhaled antibiotics between 2013 and 2020 were included. Patient characteristics and data regarding inhaled antibiotic use were obtained retrospectively from the electronic medical record. RESULTS A total of 424 courses of inhaled antibiotics were prescribed during the study period. 296 (69.8%) courses were prescribed to treat an acute RTI, whereas 128 (30.2%) were prescribed prophylactically to prevent RTIs. 58.9% of children with tracheostomy tubes hospitalized during the study period received at least one course of inhaled antibiotics. The most common antibiotics prescribed were tobramycin and gentamicin; several different doses were used. In 53.2% of treatment courses, inhaled antibiotics were co-prescribed with systemic antibiotics. Therapy duration for treatment varied from 3 to 28 days. Respiratory cultures were used variably and antimicrobial susceptibility was often not taken into account when prescribing inhaled antibiotics. CONCLUSIONS Inhaled antibiotics were frequently prescribed as treatment and prophylaxis in children with tracheostomy tubes at our center, with significant variation in the prescribed antibiotic type, dose, frequency, duration, and co-prescription with systemic antibiotics. Prospective studies are needed to define best practice regarding inhaled antibiotics in this patient population.
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Affiliation(s)
- Alexander Gipsman
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Moshe Prero
- Department of Pulmonology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Philip Toltzis
- Department of Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Daniel Craven
- Department of Pulmonology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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Muacevic A, Adler JR. Inhaled Antibiotics in Non-cystic Fibrosis Bronchiectasis (NCFB): A Systematic Review of Efficacy and Limitations in Adult Patients. Cureus 2022; 14:e30660. [PMID: 36439573 PMCID: PMC9685586 DOI: 10.7759/cureus.30660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/24/2022] [Indexed: 12/01/2022] Open
Abstract
Non-cystic fibrosis bronchiectasis has recently been under the spotlight due to a better detection rate with advanced imaging techniques. Recurrent infections in such patients are the main cause of their deterioration. This invariably leads to a catastrophic wheel of decline in lung function, reinfection, and repeated hospital consultations. The main goal of their management is based on the principles of prevention and vigorous treatment of recurrent infections. This review aimed to gather recent therapeutic options for inhaled antibacterial use in such patients and compare them for their properties of safety and efficacy. Studies done in the last 10 years on adult patients were gathered using the Medical Subject Headings (MeSH) strategy and later sorted using the inclusion/exclusion criteria. Research engines used include Google Scholar, PubMed, and the Saudi Digital Library. Out of the 31,739 articles identified initially, 1362 were screened. The final eight selected papers were assessed for quality by using the quality assessment checklist, the Cochrane bias assessment tool, the Scale for the Assessment of Narrative Review Articles (SANRA) tools and cross-examined by co-authors. We concluded that the use of inhaled antibiotics as an adjuvant and follow-up treatment option is associated with better short and long-term prognoses in patients. They lead to lesser systemic side effects than the oral and intravenous varieties available on the market. However, the establishment of a hierarchy among the subgroups remains a grey area that needs further research.
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Aziz DA, Abbas A, Alam A, Aziz N. Role of inhaled antibiotics in children and adolescents with cystic fibrosis: Experience from the tertiary care center. Lung India 2022; 39:274-278. [PMID: 35488686 PMCID: PMC9200202 DOI: 10.4103/lungindia.lungindia_370_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Cystic fibrosis (CF) remains under-diagnosed in Pakistan. CF population has increased tendency for Pseudomonas aeruginosa (Pa) infection and it is one of the leading causes of mortality. Utilizing inhaled antibiotics (IAs) for the treatment of Pa infection has been well established in the literature. There is limited data available on CF in Pakistan, especially regarding the efficacy of IAs. The aim of this study is to investigate the role of IAs on Pa infection in children and adolescents with CF. Methodology CF patients enrolled between January 2012 and December 2019 were selected as part of this retrospective cohort study. CF patients from 2 to 18 years of age who cultured Pa on any respiratory sample and who had never been Pa-free in at least two sputum cultures in the previous 12 months were included. Patients were divided into an IA group and a noninhaled antibiotic (NIA) group based on the treatment they received. Follow-up was done between 3 and 6 months posttherapy on Pseudomonas growth in the sputum. The number of pulmonary exacerbations were documented for 6 months follow-up. Results Eighty-one children with CF were enrolled during the study period, of which 39 were in the IA group and 42 were in the NIA group. There was no significant difference in their demographics and initial clinical characteristics. The mean pulmonary exacerbations after 6 months were lower in the IA group as compared to the NIA group (1.102 ± 0.50 vs. 2.45 ± 0.89: P = 0.001). Follow-up between 3 and 6 months showed greater Pseudomonas colonization in the IA group versus the NIA group (53.84% vs. 92.85%: P = 0.001). Conclusion IAs in combination with airway clearance therapy and oral or IV antibiotics are an effective regimen for children with CF.
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Affiliation(s)
- Danish Abdul Aziz
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Aiza Abbas
- Aga Khan University Hospital, Karachi, Pakistan
| | - Anusha Alam
- Aga Khan University Hospital, Karachi, Pakistan
| | - Namrah Aziz
- Aga Khan University Hospital, Karachi, Pakistan
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Giacobbe DR, Roberts JA, Abdul-Aziz MH, de Montmollin E, Timsit JF, Bassetti M. Treatment of ventilator-associated pneumonia due to carbapenem-resistant Gram-negative bacteria with novel agents: a contemporary, multidisciplinary ESGCIP perspective. Expert Rev Anti Infect Ther 2022; 20:963-979. [PMID: 35385681 DOI: 10.1080/14787210.2022.2063838] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION : In the past 15 years, treatment of VAP caused by carbapenem-resistant Gram-negative bacteria (CR-GNB) has represented an intricate challenge for clinicians. AREAS COVERED In this perspective article, we discuss the available clinical data about novel agents for the treatment of CR-GNB VAP, together with general PK/PD principles for the treatment of VAP, in the attempt to provide some suggestions for optimizing antimicrobial therapy of CR-GNB VAP in the daily clinical practice. EXPERT OPINION Recently, novel BL and BL/BLI combinations have become available that have shown potent in vitro activity against CR-GNB and have attracted much interest as novel, less toxic, and possibly more efficacious options for the treatment of CR-GNB VAP compared with previous standard of care. Besides randomized controlled trials, a good solution to enrich our knowledge on how to use these novel agents at best in the near future, while at the same time remaining adherent to current evidence-based guidelines, is to improve our collaboration to conduct larger multinational observational studies to collect sufficiently large populations treated in real life with those novel agents for which guidelines currently do not provide a recommendation (in favor or against) for certain causative organisms.
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Affiliation(s)
- Daniele Roberto Giacobbe
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID)
| | - Jason A Roberts
- Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID).,University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia.,Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Etienne de Montmollin
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Claude Bernard University Hospital, Paris, France.,INSERM IAME UMR 1137, University of Paris, Sorbonne Paris Cite, Paris, France
| | - Jean-François Timsit
- Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID).,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Claude Bernard University Hospital, Paris, France.,INSERM IAME UMR 1137, University of Paris, Sorbonne Paris Cite, Paris, France
| | - Matteo Bassetti
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID)
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Gipsman A, Prero M, Toltzis P, Craven D. Tracheobronchitis in children with tracheostomy tubes: Overview of a challenging problem. Pediatr Pulmonol 2022; 57:814-821. [PMID: 34981895 DOI: 10.1002/ppul.25814] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/16/2021] [Accepted: 12/30/2021] [Indexed: 12/21/2022]
Abstract
Tracheobronchitis is common in children with tracheostomy tubes. These children are predisposed to respiratory infections due to the bypassing of normal upper airway defense mechanisms by the tracheostomy, bacterial colonization of the tracheostomy tube itself, and underlying medical conditions. Diagnosis of bacterial tracheobronchitis is challenging due to the difficulty in differentiating between bacterial colonization and infection, as well as between viral and bacterial etiologies. Difficulty in diagnosis complicates management decisions, and there are currently no consensus guidelines to assist clinicians in the treatment of these patients. Frequent administration of systemic antibiotics causes adverse effects and leads to the emergence of resistant organisms. Topical administration of antibiotics via nebulization or direct instillation may lead to a significantly higher concentration of drug in the upper and lower airways without causing systemic side effects, although therapeutic trials in children with tracheostomy tubes are lacking. Several preventative measures such as regular airway clearance and the use of a speaking valve may mitigate the risk of developing respiratory infections.
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Affiliation(s)
- Alexander Gipsman
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Moshe Prero
- Department of Pulmonology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Philip Toltzis
- Department of Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Daniel Craven
- Department of Pulmonology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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Cusack R, Garduno A, Elkholy K, Martín-Loeches I. Novel investigational treatments for ventilator-associated pneumonia and critically ill patients in the intensive care unit. Expert Opin Investig Drugs 2022; 31:173-192. [PMID: 35040388 DOI: 10.1080/13543784.2022.2030312] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is common; its prevalence has been highlighted by the Covid-19 pandemic. Even young patients can suffer severe nosocomial infection and prolonged mechanical ventilation. Multidrug-resistant bacteria can spread alarmingly fast around the globe and new antimicrobials are struggling to keep pace; hence physicians must stay abreast of new developments in the treatment of nosocomial pneumonia and VAP. AREAS COVERED This narrative review examines novel antimicrobial investigational drugs and their implementation in the ICU setting for VAP. The paper highlights novel approaches such as monoclonal antibody treatments for P. aeruginosa and S. aureus, and phage antibiotic synthesis. The paper also examines mechanisms of resistance in gram-negative bacteria, virulence factors and inhaled antibiotics and questions what may be on the horizon in terms of emerging treatment strategies. EXPERT OPINION The post-antibiotic era is rapidly approaching and the need for personalised medicine, point-of-care microbial sensitivity testing and development of biomarkers for severe infections is clear. Results from emerging and new antibiotics are encouraging, but infection control measures and de-escalation protocols must be employed to prolong their usefulness in critical illness.
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Affiliation(s)
- Rachael Cusack
- Department of Clinical Medicine, Trinity College Dublin.,Department of Intensive Care Medicine, St. James's Hospital, Dublin, (Ireland)
| | - Alexis Garduno
- Department of Clinical Medicine, Trinity College Dublin.,Intensive Care Translational Research, Trinity College Dublin
| | - Khalid Elkholy
- Department of Intensive Care Medicine, St. James's Hospital, Dublin, (Ireland)
| | - Ignacio Martín-Loeches
- Department of Clinical Medicine, Trinity College Dublin.,Department of Intensive Care Medicine, St. James's Hospital, Dublin, (Ireland).,Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, (Ireland)
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Papaioannou O, Karampitsakos T, Katsaras M, Sampsonas F, Tzouvelekis A. Clinical improvement in Job syndrome following administration of co-trimoxazole, omalizumab and inhaled tobramycin. Adv Respir Med 2021; 89:ARM.a2021.0079. [PMID: 34668182 DOI: 10.5603/arm.a2021.0079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/03/2021] [Accepted: 05/08/2021] [Indexed: 11/25/2022]
Abstract
Established treatment regimens for the autosomal dominant hyperimmunoglobulin E syndrome, denominated Job syndrome, are lacking. Thus, Job syndrome still exerts a dramatic impact on patients' quality of life. Our aim was to present safety and effectiveness of a regimen including co-trimoxazole, omalizumab and inhaled tobramycin in Job syndrome. A 26-year-old woman diagnosed with Job syndrome since infancy through sequencing revealing G342D mutation in STAT3 gene was initiated in the above mentioned treatment regimen; she was followed for 6 months, and to date, none recurrent pulmonary or skin infection was noticed. Furthermore, a considerable improvement in skin lesions was observed. A combination of anti-IgE and longitudinal use of inhaled antibiotics seems well-founded in Job syndrome.
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Affiliation(s)
- Ourania Papaioannou
- Department of Respiratory Medicine, University Hospital of Patras, University of Patras, Greece.
| | - Theodoros Karampitsakos
- Department of Respiratory Medicine, University Hospital of Patras, University of Patras, Greece
| | - Matthaios Katsaras
- Department of Respiratory Medicine, University Hospital of Patras, University of Patras, Greece
| | - Fotios Sampsonas
- Department of Respiratory Medicine, University Hospital of Patras, University of Patras, Greece
| | - Argyrios Tzouvelekis
- Department of Respiratory Medicine, University Hospital of Patras, University of Patras, Greece
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Plaunt AJ, Rose SJ, Kang JY, Chen KJ, LaSala D, Heckler RP, Dorfman A, Smith BT, Chun D, Viramontes V, Macaluso A, Li Z, Zhou Y, Mark L, Basso J, Leifer FG, Corboz MR, Chapman RW, Cipolla D, Perkins WR, Malinin VS, Konicek DM. Development and Preclinical Evaluation of New Inhaled Lipoglycopeptides for the Treatment of Persistent Pulmonary Methicillin-Resistant Staphylococcus aureus Infections. Antimicrob Agents Chemother 2021; 65:e0031621. [PMID: 33941518 DOI: 10.1128/AAC.00316-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Chronic pulmonary methicillin-resistant Staphylococcus aureus (MRSA) disease in cystic fibrosis (CF) has a high probability of recurrence following treatment with standard-of-care antibiotics and represents an area of unmet need associated with reduced life expectancy. We developed a lipoglycopeptide therapy customized for pulmonary delivery that not only demonstrates potent activity against planktonic MRSA, but also against protected colonies of MRSA in biofilms and within cells, the latter of which have been linked to clinical antibiotic failure. A library of next-generation potent lipoglycopeptides was synthesized with an emphasis on attaining superior pharmacokinetics (PK) and pharmacodynamics to similar compounds of their class. Our strategy focused on hydrophobic modification of vancomycin, where ester and amide functionality were included with carbonyl configuration and alkyl length as key variables. Candidates representative of each carbonyl attachment chemistry demonstrated potent activity in vitro, with several compounds being 30 to 60 times more potent than vancomycin. Selected compounds were advanced into in vivo nose-only inhalation PK evaluations in rats, where RV94, a potent lipoglycopeptide that utilizes an inverted amide linker to attach a 10-carbon chain to vancomycin, demonstrated the most favorable lung residence time after inhalation. Further in vitro evaluation of RV94 showed superior activity to vancomycin against an expanded panel of Gram-positive organisms, cellular accumulation and efficacy against intracellular MRSA, and MRSA biofilm killing. Moreover, in vivo efficacy of inhaled nebulized RV94 in a 48 h acute model of pulmonary MRSA (USA300) infection in neutropenic rats demonstrated statistically significant antibacterial activity that was superior to inhaled vancomycin.
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Abstract
BACKGROUND The optimum antibiotic therapy for non-cystic fibrosis bronchiectasis (NCFB) has yet to be determined. A meta-analysis was conducted to evaluate the efficacy and safety of inhaled antibiotics in adults with stable NCFB. METHODS PubMed, EMBASE, MEDLINE and the Cochrane Central Register of Controlled Trials were searched through November 2019. RESULTS A total of 16 randomized controlled trials (RCTs), recruiting 2748 NCFB patients, were finally included. Inhaled antibiotics treatment significantly reduced the sputum bacterial load [standard mean difference (SMD) = -0.74, 95% CI: -1.16-0.32, p < 0.001, I2 = 68.1%], prolonged median time [hazard risk (HR) = 0.73, 95% confidence interval (CI): 0.57-0.93, p < 0.001, I2 = 53.6%] and reduced frequency [incidence rate ratio (IRR) = 0.74, 95% CI 0.63-0.87, p < 0.001, I2 = 20.5%] of exacerbations, with good tolerance. However, it failed to improve Pseudomonas aeruginosa eradication, [forced expiratory volume in 1 s (FEV1)] % predicted, quality of life questionnaire (QoL-B) and St. George's respiratory questionnaire (SGRQ) scores, and may induce higher risk of P. aeruginosa resistance. Subgroup analysis showed Ciprofloxacin was more effective than other antibiotics in reducing bacterial load (SMD = -1.35, 95% CI: -1.85-0.85, I2 = 63.4%, p = 0.042). CONCLUSION Inhaled antibiotics therapy holds great promise for stable NCFB as it is effective in reducing sputum bacterial load and the risk of acute attack, delaying disease progression, and is well tolerated. Although this study brings some constructive ideas in the field of clinical medication, further clinical trials should be carried out, particularly in solving drug-resistance and improving health-related quality of life (HRQoL), which we believe will finally provide benefits for patients suffering from bronchiectasis. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Meng-Jiao Xu
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital, China Medical University, Shenyang, China
| | - Bing Dai
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital, China Medical University, Shenyang, 110001, China
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Los-Arcos I, Berastegui C, Martín-Gómez MT, Grau S, Campany-Herrero D, Deu M, Sacanell J, Campillo N, Bravo C, Len O. Nebulized Micafungin Treatment for Scopulariopsis/ Microascus Tracheobronchitis in Lung Transplant Recipients. Antimicrob Agents Chemother 2021; 65:e02174-20. [PMID: 33722884 DOI: 10.1128/AAC.02174-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/06/2021] [Indexed: 02/02/2023] Open
Abstract
Scopulariopsis/Microascus isolates cause infections with high mortality in lung transplant recipients. Treatment is challenging due to antimicrobial resistance. We describe two cases of Scopulariopsis/Microascus tracheobronchitis in lung transplant recipients successfully treated with nebulized micafungin. This antifungal was well tolerated and achieved high concentrations in epithelial lining fluid up to 14 h after nebulization without significant plasma concentrations. Nebulized micafungin may be a safe and effective option for the treatment of fungal tracheobronchitis.
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14
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Martínez-García MÁ, Faner R, Oscullo G, de la Rosa-Carrillo D, Soler-Cataluña JJ, Ballester M, Muriel A, Agusti A. Risk Factors and Relation with Mortality of a New Acquisition and Persistence of Pseudomonas aeruginosa in COPD Patients. COPD 2021; 18:333-340. [PMID: 33941014 DOI: 10.1080/15412555.2021.1884214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The isolation of Pseudomonas aeruginosa (PA) in patients with chronic obstructive pulmonary disease (COPD) is associated with increased mortality. Yet, factors associated with first PA sputum isolation, and PA persistence have not been investigated before. The objective of the present study was to investigate risk factors for new acquisition and persistence of PA infection and their relationship with all-cause mortality in patients with COPD. Post-hoc analysis of prospectively collected cohort of 170 COPD patients (GOLD II-IV) who were free of previous PA isolation and followed up every 3-6 months for 85 [50.25-110.25] months. PA was isolated for the first time in 41 patients (24.1%) after 36 [12-60] months of follow-up. Risk factor for first PA isolation were high cumulative smoking exposure, severe airflow limitation, previous severe exacerbations, high fibrinogen levels and previous isolation of Haemophilus Influenzae. PA was isolated again one or more times during follow-up in 58.5% of these patients. This was significantly associated with the presence of CT bronchiectasis and persistence of severe exacerbations, whereas the use of inhaled antibiotic treatment after the first PA isolation (at the discretion of the attending physician) reduced PA persistence. During follow-up, 79 patients (46.4%) died. A single PA isolation did not increase mortality, but PA persistence did (HR 3.06 [1.8-5.2], p = 0.001). We conclude that PA occurs frequently in clinically stable COPD patients, risk factors for a first PA isolation and PA persistence are different, and the latter (but not the former) is associated with increased all-cause mortality.
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Affiliation(s)
| | - Rosa Faner
- Centro de Investigación Biomedica en Red (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Institut d'investigacions biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Grace Oscullo
- Respiratory Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | | | - Marta Ballester
- Pneumology Unit, Hospital General de Requena, Valencia, Spain6
| | - Alfonso Muriel
- Biostatistic Unit, Hospital Ramón y Cajal, Madrid, Spain
| | - Alvar Agusti
- Centro de Investigación Biomedica en Red (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Institut d'investigacions biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Respiratory Institute, Hospital Clinic, University of Barcelona, IDIBAPS, Barcelona, Spain
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15
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Taccetti G, Francalanci M, Pizzamiglio G, Messore B, Carnovale V, Cimino G, Cipolli M. Cystic Fibrosis: Recent Insights into Inhaled Antibiotic Treatment and Future Perspectives. Antibiotics (Basel) 2021; 10:338. [PMID: 33810116 DOI: 10.3390/antibiotics10030338] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 02/08/2023] Open
Abstract
Although new inhaled antibiotics have profoundly improved respiratory diseases in cystic fibrosis (CF) patients, lung infections are still the leading cause of death. Inhaled antibiotics, i.e., colistin, tobramycin, aztreonam lysine and levofloxacin, are used as maintenance treatment for CF patients after the development of chronic Pseudomonas aeruginosa (P. aeruginosa) infection. Their use offers advantages over systemic therapy since a relatively high concentration of the drug is delivered directly to the lung, thus, enhancing the pharmacokinetic/pharmacodynamic parameters and decreasing toxicity. Notably, alternating treatment with inhaled antibiotics represents an important strategy for improving patient outcomes. The prevalence of CF patients receiving continuous inhaled antibiotic regimens with different combinations of the anti-P. aeruginosa antibiotic class has been increasing over time. Moreover, these antimicrobial agents are also used for preventing acute pulmonary exacerbations in CF. In this review, the efficacy and safety of the currently available inhaled antibiotics for lung infection treatment in CF patients are discussed, with a particular focus on strategies for eradicating P. aeruginosa and other pathogens. Moreover, the effects of long-term inhaled antibiotic therapy for chronic P. aeruginosa infection and for the prevention of pulmonary exacerbations is reviewed. Finally, how the mucus environment and microbial community richness can influence the efficacy of aerosolized antimicrobial agents is discussed.
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16
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Abstract
INTRODUCTION Respiratory infections are a major cause of morbidity and mortality. As an alternative to systemic drug administration, inhaled drug delivery can produce high drug concentrations in the lung tissue to overcome resistant bacteria. The development of inhaled fixed-dose combination powders (I-FDCs) is promising next step in this field, as it would enable simultaneous drug-drug or drug-adjuvant delivery at the site of infection, thereby promoting synergistic activity and improving patient compliance. AREAS COVERED This review covers the clinical and pharmaceutical rationales for the development of I-FDCs for the treatment of respiratory infections, relevant technologies for particle and powder generation, and obstacles which must be addressed to achieve regulatory approval. EXPERT OPINION I-FDCs have been widely successful in the treatment of asthma and chronic obstructive pulmonary disease; however, application of I-FDCs towards the treatment of respiratory infections carries additional challenges related to the high dose requirements and physicochemical characteristics of anti-infective drugs. At present, co-spray drying is an especially promising approach for the development of composite fixed-dose anti-infective particles for inhalation. Though the majority of fixed-dose research has thus far focused on the combination of multiple antibiotics, future work may shift to the additional inclusion of immunomodulatory agents or repurposed non-antibiotics.
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Affiliation(s)
| | - Shivam Sharma
- Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
| | - Hugh Smyth
- College of Pharmacy, University of Texas at Austin, Austin, USA
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17
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Jutras C, Autmizguine J, Chomton M, Marquis C, Nguyen TTD, Roumeliotis N, Emeriaud G. Inhaled Antibiotics for the Prevention of Respiratory Tract Infections in Children With a Tracheostomy. Front Pediatr 2021; 9:633039. [PMID: 33614559 PMCID: PMC7893104 DOI: 10.3389/fped.2021.633039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/13/2021] [Indexed: 11/26/2022] Open
Abstract
Objective: To describe the use of prophylactic inhaled antibiotics in children with a tracheostomy and assess if its use is associated with a reduction in exposition to broad-spectrum antibiotics and a lower risk of acquired respiratory tract infections. Methods: A case series study was performed in a tertiary care university affiliated hospital. All consecutive children (<18 years old) with a tracheostomy, hospitalized between January 2004 and November 2016, and treated with prophylactic inhaled antibiotics were identified. We analyzed the 3 month- period before and after initiation of prophylactic inhaled antibiotics and described exposure to broad spectrum antibiotics, the number of respiratory tract infections and the associated adverse events. Results: Six children (median age: 11 months, range: 8-100) were included. One received colimycin, 3 received tobramycin and 2 were treated with both antibiotics in alternance. The median duration of treatment was 74 days (22-173) with one patient still being treated at the end of the study. Patients were exposed to systemic antibiotics for 18 days (2-49) in the 3 months preceding the treatment vs. 2 days (0-15) in the 3 months following the treatment initiation (p = 0.115). The number of respiratory tract infections went from median of 2 (0-3) to 1 (0-1) during the same periods (p = 0.07). Adverse events most commonly reported were cough (n = 2) and increased respiratory secretions post-inhalation (n = 4). Only one new bacterial resistance was observed. Conclusions: This series of consecutive cases underlines the need for future studies evaluating the potential benefit of prophylactic inhaled antibiotics in children with a tracheostomy.
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Affiliation(s)
- Camille Jutras
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte Justine, Université de Montréal, Montréal, QC, Canada
| | - Julie Autmizguine
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte Justine, Université de Montréal, Montréal, QC, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montréal, QC, Canada.,Research Center, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Maryline Chomton
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte Justine, Université de Montréal, Montréal, QC, Canada
| | - Christopher Marquis
- Department of Pharmacy, Centre Hospitalier Universitaire Sainte Justine, Université de Montréal, Montréal, QC, Canada
| | - The Thanh-Diem Nguyen
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte Justine, Université de Montréal, Montréal, QC, Canada.,Research Center, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Nadia Roumeliotis
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte Justine, Université de Montréal, Montréal, QC, Canada
| | - Guillaume Emeriaud
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte Justine, Université de Montréal, Montréal, QC, Canada.,Research Center, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
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18
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Martínez-García MÁ, Oscullo G, Barreiro E, Cuenca S, Cervera A, Padilla-Galo A, de la Rosa D, Navarro A, Giron R, Carbonero F, Castro Otero M, Casas F. Inhaled Dry Powder Antibiotics in Patients with Non-Cystic Fibrosis Bronchiectasis: Efficacy and Safety in a Real-Life Study. J Clin Med 2020; 9:E2317. [PMID: 32708262 DOI: 10.3390/jcm9072317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Nebulised antibiotics are habitually used in patients with bronchiectasis, but the use of dry powder inhaled antibiotics (DPIA) in these patients is extremely limited. This study seeks to analyse the efficacy and safety of DPIA in bronchiectasis patients. MATERIAL AND METHODS Multi-centre study of historic cohorts. All the hospital centres in Spain were contacted in order to collect data on patients with a diagnosis of bronchiectasis who had taken at least one dose of DPIA. Its efficacy was analysed in clinical, functional and microbiological terms by comparing the year before and the year after the prescription of DPIA. Adverse effects and variables associated with these effects, or any need to withdraw the drug, were also analysed. RESULTS 164 patients from 33 Spanish centres were included; 86% and 14% of these were treated with dry powder colistin and tobramycin, respectively. Chronic bronchial infection by Pseudomonas aeruginosa was present in 86% of these patients, and DPIA significantly reduced the number of exacerbations, the quantity and purulence of sputum and the isolation of pathogenic microorganisms. The most common adverse effect was cough (40%), particularly in cases of Chronic Obstructive Pulmonary Disease (COPD) and a previous cough and in those patients who had difficulties in handling the device. These factors were associated with a higher level of withdrawal of the treatment. There were no serious adverse effects. CONCLUSIONS Our study suggests that DPIA are clinically efficacious and safe for treating bronchiectasis patients. Cough was shown to be the most common side-effect and reason for withdrawal of the treatment.
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19
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Blanco-Aparicio M, Saleta Canosa JL, Valiño López P, Martín Egaña MT, Vidal García I, Montero Martínez C. Eradication of Pseudomonas aeruginosa with inhaled colistin in adults with non-cystic fibrosis bronchiectasis. Chron Respir Dis 2020; 16:1479973119872513. [PMID: 31480862 PMCID: PMC6724485 DOI: 10.1177/1479973119872513] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The persistent isolation of Pseudomonas aeruginosa in the airways of non-cystic fibrosis bronchiectasis (NCFB) patients is associated with a worsening of the symptoms, increase of exacerbations, poor quality of life and functional impairment. The objective of this study was the analysis of the eradication rate of P. aeruginosa in the sputum of patients with NCFB treated with inhaled colistin and the effects of the treatment in the exacerbations. This was a prospective, cohort, study of 67 NCFB patients treated with inhaled colistin at the Hospital of A Coruña (Spain). We recorded dyspnoea, exacerbations, lung function and sputum cultures of P. aeruginosa in the patients. The mean age of the patients was 67.25 ± 14.6 years (59.7% male). The percentages of eradication of P. aeruginosa in sputum at 3, 6, 9 and 12 months were 61.2%, 50.7%, 43.3% and 40.3%, respectively. We observed a significant decrease in exacerbations after 1 year of colistin treatment (1.98 ± 3.62) versus the previous year (3.40 ± 4.21, p < 0.001). We conclude that treatment with inhaled colistin in patients with NCFB and P. aeruginosa in sputum can achieve high rates of eradication even in patients with several previous positive cultures, as well as a significant decrease of exacerbations and hospital admissions.
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Affiliation(s)
| | | | - Paz Valiño López
- 1 Department of Pneumology, Hospital Universitario A Coruña, A Coruña, Spain
| | | | - Iria Vidal García
- 1 Department of Pneumology, Hospital Universitario A Coruña, A Coruña, Spain
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20
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Koulenti D, Arvaniti K, Judd M, Lalos N, Tjoeng I, Xu E, Armaganidis A, Lipman J. Ventilator-Associated Tracheobronchitis: To Treat or Not to Treat? Antibiotics (Basel) 2020; 9:antibiotics9020051. [PMID: 32023886 PMCID: PMC7168312 DOI: 10.3390/antibiotics9020051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 01/26/2020] [Accepted: 01/29/2020] [Indexed: 01/08/2023] Open
Abstract
Ventilator-associated tracheobronchitis (VAT) is an infection commonly affecting mechanically ventilated intubated patients. Several studies suggest that VAT is associated with increased duration of mechanical ventilation (MV) and length of intensive care unit (ICU) stay, and a presumptive increase in healthcare costs. Uncertainties remain, however, regarding the cost/benefit balance of VAT treatment. The aim of this narrative review is to discuss the two fundamental and inter-related dilemmas regarding VAT, i.e., (i) how to diagnose VAT? and (ii) should we treat VAT? If yes, should we treat all cases or only selected ones? How should we treat in terms of antibiotic choice, route, treatment duration?
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Affiliation(s)
- Despoina Koulenti
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane 4029, Australia; (M.J.); (N.L.); (I.T.); (E.X.); (J.L.)
- 2nd Critical Care Department, ‘Attikon’ University Hospital, Athens 11632, Greece;
- Correspondence:
| | - Kostoula Arvaniti
- Department of Critical Care Medicine, ‘Papageorgiou’ General Hospital of Thessaloniki, Thessaloniki 56429, Greece;
| | - Mathew Judd
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane 4029, Australia; (M.J.); (N.L.); (I.T.); (E.X.); (J.L.)
| | - Natasha Lalos
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane 4029, Australia; (M.J.); (N.L.); (I.T.); (E.X.); (J.L.)
| | - Iona Tjoeng
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane 4029, Australia; (M.J.); (N.L.); (I.T.); (E.X.); (J.L.)
| | - Elena Xu
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane 4029, Australia; (M.J.); (N.L.); (I.T.); (E.X.); (J.L.)
| | | | - Jeffrey Lipman
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane 4029, Australia; (M.J.); (N.L.); (I.T.); (E.X.); (J.L.)
- Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane 4029, Australia
- Royal Brisbane Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane 4029, Australia
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21
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van Velzen AJ, Uges JWF, Heijerman HGM, Arets BGM, Nuijsink M, van der Wiel-Kooij EC, van Maarseveen EM, van Zanten GA, Pullens B, Touw DJ, Janssens HM. Pharmacokinetics and safety of tobramycin nebulization with the I-neb and PARI-LC Plus in children with cystic fibrosis: A randomized, crossover study. Br J Clin Pharmacol 2019; 85:1984-1993. [PMID: 31112621 PMCID: PMC6710527 DOI: 10.1111/bcp.13988] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/30/2019] [Accepted: 05/07/2019] [Indexed: 12/27/2022] Open
Abstract
AIMS We aimed to compare the pharmacokinetics (PK) and safety profile of tobramycin inhalation solution (TIS) using the I-neb device to the standard PARI-LC Plus nebulizer in children with cystic fibrosis. METHODS A randomized, open-label, crossover study was performed. In 2 separate study visits, blood samples from 22 children were collected following TIS nebulization with I-neb (75 mg) and PARI-LC Plus (300 mg). Study visits were separated by 1 month, in which 1 of the study nebulizers was used twice daily. Tobramycin PK for both nebulizers was established using measured tobramycin concentrations and Bayesian PK modelling software. Hearing and renal function tests were performed to test for aminoglycoside associated toxicity. In addition to standard estimated glomerular filtration rate values, biomarkers for tubular injury (KIM-1 and NAG) were measured. Patient and nebulizer satisfaction were assessed. RESULTS Inhalations were well tolerated and serum trough concentrations below the predefined toxic limit were reached with no significant differences in PK parameters between nebulizers. Results of audiometry and estimated glomerular filtration rate revealed no abnormalities. However, increased urinary NAG/creatinine ratios at visit 2 for both nebulizers suggest TIS-induced subclinical tubular kidney injury. Nebulization time was 50% shorter and patient satisfaction was significantly higher with the I-neb. CONCLUSIONS Nebulization of 75 mg TIS with the I-neb in children with cystic fibrosis resulted in comparable systemic exposure to 300 mg TIS with the PARI-LC Plus and was well tolerated and preferred over the PARI-LC Plus. Long-term safety of TIS nebulization should be monitored clinically, especially regarding the effects on tubular kidney injury.
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Affiliation(s)
| | | | - Harry G M Heijerman
- Department of Pulmonology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Bert G M Arets
- Department of Pediatric Pulmonology, University Medical Center Utrecht-Wilhelmina Children's hospital, Utrecht, The Netherlands
| | - Marianne Nuijsink
- Department of Pediatric Pulmonology, Haga Teaching Hospital-Juliana Children's hospital, The Hague, The Netherlands
| | - Els C van der Wiel-Kooij
- Department of Pediatrics, div Respiratory Medicine and Allergology, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
| | - Erik M van Maarseveen
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gijsbert A van Zanten
- Department of Otorhinolaryngology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bas Pullens
- Department of Otorhinolaryngology, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hettie M Janssens
- Department of Pediatrics, div Respiratory Medicine and Allergology, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands
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Lenhard JR, Bulman ZP, Tsuji BT, Kaye KS. Shifting Gears: The Future of Polymyxin Antibiotics. Antibiotics (Basel) 2019; 8:E42. [PMID: 31013818 DOI: 10.3390/antibiotics8020042] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/05/2019] [Accepted: 04/09/2019] [Indexed: 11/17/2022] Open
Abstract
The manuscripts contained in this special edition of Antibiotics represent a current review of the polymyxins as well as highlights from the 3rd International Polymyxin Conference, which was held in Madrid, Spain, April 25 to 26, 2018. The role of the polymyxin antibiotics has evolved over time based on the availability of alternative agents. After high rates of nephrotoxicity caused the drug class to fall out of favor, polymyxins were once against utilized in the 21st century to combat drug-resistant pathogens. However, the introduction of safer agents with activity against drug-resistant organisms has brought the future utility of polymyxins into question. The present review investigates the future niche of polymyxins by evaluating currently available and future treatment options for difficult-to-treat pathogens. The introduction of ceftazidime-avibactam, meropenem-vaborbactam and plazomicin are likely to decrease polymyxin utilization for infections caused by Enterobacteriaceae. Similarly, the availability of ceftolozane-tazobactam will reduce the use of polymyxins to counter multidrug-resistant Pseudomonas aeruginosa. In contrast, polymyxins will likely continue be an important option for combatting carbapenem-resistant Acinetobacter baumannii until better options become commercially available. Measuring polymyxin concentrations in patients and individualizing therapy may be a future strategy to optimize clinical outcomes while minimizing nephrotoxicity. Inhaled polymyxins will continue to be an adjunctive option for pulmonary infections but further clinical trials are needed to clarify the efficacy of inhaled polymyxins. Lastly, safer polymyxin analogs will potentially be an important addition to the antimicrobial armamentarium.
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23
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Biagi M, Butler D, Tan X, Qasmieh S, Wenzler E. A Breath of Fresh Air in the Fog of Antimicrobial Resistance: Inhaled Polymyxins for Gram-Negative Pneumonia. Antibiotics (Basel) 2019; 8:E27. [PMID: 30884839 DOI: 10.3390/antibiotics8010027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 03/08/2019] [Accepted: 03/12/2019] [Indexed: 01/08/2023] Open
Abstract
Despite advancements in therapy, pneumonia remains the leading cause of death due to infectious diseases. Novel treatment strategies are desperately needed to optimize the antimicrobial therapy of patients suffering from this disease. One such strategy that has recently garnered significant attention is the use of inhaled antibiotics to rapidly achieve therapeutic concentrations directly at the site of infection. In particular, there is significant interest in the role of inhaled polymyxins for the treatment of nosocomial pneumonia, including ventilator-associated pneumonia, due to their retained activity against multi-drug resistant Gram-negative pathogens, including Acinetobacter baumannii and Pseudomonas aeruginosa. This review will provide a comprehensive overview of the pharmacokinetic/pharmacodynamic profile, clinical outcomes, safety, and potential role of inhaled polymyxins in clinical practice.
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Abstract
Bronchiectasis is an important clinical syndrome because of its increasing prevalence, substantial economic burden on health care, and associated morbidity. Until recently, the disease was considered an orphan and essentially neglected from a therapeutic standpoint, but many recent advances have been made in the field. Several national registries have formed to provide databases from which to study patients with bronchiectasis. Experts published a consensus definition of a bronchiectasis-specific exacerbation that will serve as a unified definition for future clinical trials. Several inhaled antibiotic trials aimed at reducing exacerbation frequency have been completed. Researchers have investigated nonculture techniques, such as 16S ribosomal RNA (rRNA) and whole genome sequencing, to characterize the microbiological characteristics. Studies of anti-Pseudomonas antibodies are providing interesting insight into varying host responses to chronic Pseudomonas infection. After three successful trials demonstrating that macrolides reduce exacerbations in bronchiectasis, other antiinflammatory agents have been investigated, and a trial of a novel antiinflammatory drug is ongoing. A relatively robust study has been published in airway clearance, a therapy that is accepted universally as beneficial but that has never been accompanied by strong evidence. To build on the successes with bronchiectasis thus far, investigators must develop better definitions of phenotypes of bronchiectasis. In this regard, clinical tools have been developed to quantify disease severity and predict prognosis. Studies of different clinical phenotypes of bronchiectasis in patients with bronchiectasis have been published. With continued advances in the field of bronchiectasis, there is hope that evidenced-based therapies will become available.
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Affiliation(s)
- Pamela J McShane
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL.
| | - Gregory Tino
- Section of Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA
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25
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Paredes Aller S, Quittner AL, Salathe MA, Schmid A. Assessing effects of inhaled antibiotics in adults with non-cystic fibrosis bronchiectasis--experiences from recent clinical trials. Expert Rev Respir Med 2018; 12:769-782. [PMID: 30025482 DOI: 10.1080/17476348.2018.1503540] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Non-cystic fibrosis bronchiectasis (NCFB) results from a permanent and progressive destruction of the airways leading to poor lung function. NCFB is characterized by recurrent lung infection, sputum production, and cough, often requiring long-term antibiotic therapy and hospitalization. At present, there are no approved therapies available. Clinical trials of inhaled antibiotics have shown promise against sputum bacterial load, but mixed results on clinical outcomes. Areas covered: The objective of this review is to provide an overview of NCFB and critically evaluate the evidence supporting the outcome measures used in recent clinical trials of inhaled antibiotics. These include quantitative changes in bacterial load, sputum purulence and yield, inflammatory markers, and lung function, as well as clinical changes in exacerbations, exacerbation frequency, hospitalizations, and health-related quality of life. Expert commentary: Recently completed large trials of inhaled antibiotics in NCFB did not consistently meet pre-specified end points, suggesting that we have not yet found the best enrollment criteria or outcome measures to evaluate efficacy, although reduced exacerbation frequency may be clinically most meaningful. Future trials may focus on specific patient populations at high risk with new information obtained through analyses of large international patient registries. ABBREVIATIONS 6-MWT: Six-Minute Walk Test; AIR-BX: Aztreonam for Inhalation Solution in Patients with Non-Cystic Fibrosis Bronchiectasis trial; BSI: Bronchiectasis Severity Index; CAT: COPD Assessment Test; CF: Cystic Fibrosis; CFTR: Cystic Fibrosis Transmembrane Conductance Regulator; CFU: Colony-Forming Units; COPD: Chronic Obstructive Pulmonary Disease; CRP: C-Reactive Protein; DPI: Dry Powder for Inhalation; EMA: European Medicines Agency; ERS: European Respiratory Society; FACED: FEV1, Age, Chronic colonization by P. aeruginosa, Extension of bronchiectasis and Dyspnea; FDA: US Food and Drug Administration; FEV1: Forced Expiration in 1 s; FVC: Forced Vital Capacity; HFCC: High-Frequency Chest Compression; HRCT: High-Resolution Computed Tomography; HRQoL: Health-Related Quality of Life; LCQ: Leicester Cough Questionnaire; MID: Minimal Important Difference; NCFB: Non-Cystic Fibrosis Bronchiectasis; NTM: Nontuberculous Mycobacteria; ORBIT: Once-daily Respiratory Bronchiectasis Inhalation Treatment trial; PRO: Patient-Reported Outcomes; QoL-B: Quality of Life-Bronchiectasis; SGRQ: St. George's Respiratory Questionnaire; SWT: Shuttle Walk Test; TORCH: Towards a Revolution in COPD Health trial; UPLIFT: Understanding Potential Long-term Impacts on Function with Tiotropium trial.
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Affiliation(s)
- Sheyla Paredes Aller
- a Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine , University of Miami , Miami , FL , USA
| | - Alexandra L Quittner
- b Miami Children's Research Institute , Nicklaus Children's Research Institute , Miami , FL , USA
| | - Matthias A Salathe
- a Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine , University of Miami , Miami , FL , USA
| | - Andreas Schmid
- a Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine , University of Miami , Miami , FL , USA
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Athanazio R, da Costa JC, de la Rosa Carrillo D, Martínez-García MÁ. Current and future pharmacotherapy options for non-cystic fibrosis bronchiectasis. Expert Rev Respir Med 2018; 12:569-584. [PMID: 29806511 DOI: 10.1080/17476348.2018.1481392] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION In recent years, there has been an increasing number of clinical trials investigating the effect of pharmacological treatments on patients with bronchiectasis. Areas covered: This review provides an overview of current drugs used in bronchiectasis patients as well as those that could make a future contribution to the management of this disease. Expert commentary: Bronchiectasis is a very heterogeneous disease, so it can be studied from a phenotypic standpoint and its pathophysiological mechanisms (endotypes) can be defined. This provides an interesting field of research as it enables the identification of patients suitable for inclusion in specific clinical trials on new drugs.
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Affiliation(s)
- Rodrigo Athanazio
- a Pulmonary Division , Heart Institute (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , Brazil
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Abstract
INTRODUCTION Until recently considered as a minor health problem, the role of bronchiectasis is now increasingly recognized. New specific drugs are being approved for treatment of bronchiectasis. Possibly they will offer better perspectives to bronchiectatic subjects with evolving course. Areas covered: We provide an overview of aetiopathogenesis, clinics and non-pharmacological management, extending the topic of pharmacological treatment. Present therapies were extrapolated from other chronic lung diseases, but newer promising specific drugs are being awaited. Therapy aims at improving mobilisation of bronchial secretions and, if any, reversing airflow obstruction. Antibiotics are indicated to treat exacerbations, eradicate or reduce sputum bacterial load. Expert commentary: Over the last years evidence is mounted that bronchiectatic subjects with accelerated course of disease should be referred to secondary and tertiary centres. This requires increased awareness on the role and the frequency of bronchiectasis in primary care. Long-term continuous or cyclical use of antibiotics is recommended to stabilize or improve the course of evolving disease. Macrolides are a currently preferred option. Inhaled antibiotics are gaining importance and are the object of ongoing research interest. Practical challenges of inhaled antibiotic treatment remain the need of defining the best therapeutic regimen and optimizing true adherence.
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Affiliation(s)
- Andrea S Melani
- a Fisiopatologia e Riabilitazione Respiratoria, Dipartimento Vasi, Cuore e Torace, Policlinico Le Scotte , Azienda Ospedaliera Universitaria Senese , Siena , Italy
| | - Nicola Lanzarone
- b Clinica delle Malattie dell'Apparato Respiratorio, Dipartimento di Medicine Specialistica, Policlinico Le Scotte , Azienda Ospedaliera Universitaria Senese , Siena , Italy
| | - Paola Rottoli
- a Fisiopatologia e Riabilitazione Respiratoria, Dipartimento Vasi, Cuore e Torace, Policlinico Le Scotte , Azienda Ospedaliera Universitaria Senese , Siena , Italy.,b Clinica delle Malattie dell'Apparato Respiratorio, Dipartimento di Medicine Specialistica, Policlinico Le Scotte , Azienda Ospedaliera Universitaria Senese , Siena , Italy
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AbdulWahab A, Zahraldin K, Sid Ahmed MA, Jarir SA, Muneer M, Mohamed SF, Hamid JM, Hassan AAI, Ibrahim EB. The emergence of multidrug-resistant Pseudomonas aeruginosa in cystic fibrosis patients on inhaled antibiotics. Lung India 2017; 34:527-531. [PMID: 29098998 PMCID: PMC5684810 DOI: 10.4103/lungindia.lungindia_39_17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Multidrug-resistant Pseudomonas aeruginosa (MDR-PA) is an important and growing issue in the care of patients with cystic fibrosis (CF), and a major cause of morbidity and mortality. OBJECTIVE The objective of the study was to describe the frequency of MDR-PA recovered from the lower respiratory samples of pediatric and adult CF patients, and its antibiotic resistance pattern to commonly used antimicrobial agents including β-lactams, aminoglycosides, and fluoroquinolones. MATERIALS AND METHODS The lower respiratory isolates of P. aeruginosa were obtained from inpatients and outpatients CF clinics from a tertiary care teaching hospital for the period from October 2014 to September 2015. The identification and antimicrobial susceptibility for all the isolates were performed by using the BD Phoenix™ and E-test in compliance with Clinical and Laboratory Standards Institute (CLSI) guidelines. RESULTS A total of 61 P. aeruginosa samples were isolated from thirty CF patients from twenty families. Twelve sputum samples were positive for MDR-PA (seven nonmucoid and five mucoid isolates) from five CF patients (five families) with moderate-to-very severe lung disease given MDR-PA frequency of 19.7%. The median age of the study group was 20 (range 10-30) years. Three CF patients were on chronic inhaled tobramycin and two on nebulized colistin. The antimicrobial patterns of isolates MDR-PA showed the highest rate of resistance toward each gentamycin, amikacin, and cefepime (100%), followed by 91.7% to ciprofloxacin, 75% to tobramycin, 58.3% to meropenem, and 50% to piperacillin-tazobactam. None of the isolates were resistant to colistin during the study period. CONCLUSION The study results emphasize that the emergence of a significant problem in the clinical isolates of P. aeruginosa in CF patients that dictate appropriate attention to the antibiotic management after proper surveillance.
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Affiliation(s)
- Atqah AbdulWahab
- Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
- Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Khalid Zahraldin
- Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
| | - Mazen A Sid Ahmed
- Department of Laboratory Medicine and Pathology, Microbiology Division, Hamad Medical Corporation, Doha, Qatar
- The Life Science Centre - Biology, School of Science and Technology, Örebro University, Örebro, Sweden
| | | | | | - Shehab F. Mohamed
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Jemal M Hamid
- Department of Laboratory Medicine and Pathology, Microbiology Division, Hamad Medical Corporation, Doha, Qatar
| | | | - Emad Bashir Ibrahim
- Weill Cornell Medicine-Qatar, Doha, Qatar
- Department of Laboratory Medicine and Pathology, Microbiology Division, Hamad Medical Corporation, Doha, Qatar
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Henkle E, Aksamit TR, Barker AF, Curtis JR, Daley CL, Anne Daniels ML, DiMango A, Eden E, Fennelly K, Griffith DE, Johnson M, Knowles MR, Leitman A, Leitman P, Malanga E, Metersky ML, Noone PG, O'Donnell AE, Olivier KN, Prieto D, Salathe M, Thomashow B, Tino G, Turino G, Wisclenny S, Winthrop KL. Pharmacotherapy for Non-Cystic Fibrosis Bronchiectasis: Results From an NTM Info & Research Patient Survey and the Bronchiectasis and NTM Research Registry. Chest 2017; 152:1120-1127. [PMID: 28479113 DOI: 10.1016/j.chest.2017.04.167] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 03/31/2017] [Accepted: 04/05/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Non-cystic fibrosis bronchiectasis ("bronchiectasis") is a chronic inflammatory lung disease often associated with nontuberculous mycobacteria (NTM) infection. Very little data exist to guide bronchiectasis management decisions. We sought to describe patterns of inhaled corticosteroid (ICS) and antibiotic therapy in the United States. METHODS We invited 2,000 patients through NTM Info & Research (NTMir) to complete an anonymous electronic survey. We separately queried baseline clinical and laboratory data from the US Bronchiectasis and NTM Research Registry (BRR). RESULTS Among 511 NTMir survey responders with bronchiectasis, whose median age was 67 years, 85 (17%) reported asthma and 99 (19%) reported COPD. History of ICS use was reported by 282 (55%), 171 (61%) of whom were treated 1 year or longer, and 150 (53%) were currently taking ICSs. Fewer reported ever taking azithromycin for non-NTM bronchiectasis (203 responders [40%]) or inhaled tobramycin (78 responders [15%]). The median age of 1,912 BRR patients was 69 years; 528 (28%) had asthma and 360 (19%) had COPD. Among 740 patients (42%) without NTM, 314 were taking ICSs at baseline. Among patients without NTM who were taking ICSs, only 178 (57%) had a concurrent diagnosis of COPD or asthma that could explain ICS use. Fewer were taking suppressive macrolides (96 patients [13%]), and of the 70 patients (10%) taking inhaled suppressive antibiotics, 48 (68%) had chronic Pseudomonas aeruginosa infection. CONCLUSIONS ICS use was common in two national samples of patients with bronchiectasis, with relatively few patients taking suppressive antibiotic therapies. Further research is needed to clarify the safety and effectiveness of these therapies in patients with bronchiectasis.
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Affiliation(s)
| | - Timothy R Aksamit
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Alan F Barker
- Division of Pulmonology and Critical Care, Department of Medicine, Oregon Health & Science University, Portland, OR
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham AL
| | - Charles L Daley
- Division of Mycobacterial and Respiratory Infections, National Jewish Health, Denver, CO
| | - M Leigh Anne Daniels
- Department of Medicine and the Marsico Lung Institute, and UNC Center for Bronchiectasis Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Angela DiMango
- Center for Chest Disease, Columbia College of Physicians and Surgeons, New York, NY
| | | | - Kevin Fennelly
- Pulmonary Clinical Medicine Section, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - David E Griffith
- Pulmonary Infectious Disease Section, University of Texas Health Science Center Northesast, Tyler, TX
| | - Margaret Johnson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Michael R Knowles
- Department of Medicine and the Marsico Lung Institute, and UNC Center for Bronchiectasis Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | - Mark L Metersky
- Division of Pulmonary and Critical Care Medicine, University of Connecticut School of Medicine, Farmington, CT
| | - Peadar G Noone
- Department of Medicine and the Marsico Lung Institute, and UNC Center for Bronchiectasis Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Anne E O'Donnell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Georgetown University Hospital, Washington, DC
| | - Kenneth N Olivier
- Pulmonary Clinical Medicine Section, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | | | - Matthias Salathe
- Division of Pulmonary and Critical Care Medicine, Miller School of Medicine, University of Miami, Miami, FL
| | - Byron Thomashow
- Center for Chest Disease, Columbia College of Physicians and Surgeons, New York, NY
| | - Gregory Tino
- Department of Medicine, Penn Presbyterian Medical Center and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Kevin L Winthrop
- OHSU-PSU School of Public Health, Portland, OR; Division of Infectious Disease, Department of Medicine, Oregon Health & Science University, Portland, OR
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Nicolau DP, Dimopoulos G, Welte T, Luyt CE. Can we improve clinical outcomes in patients with pneumonia treated with antibiotics in the intensive care unit? Expert Rev Respir Med 2016; 10:907-18. [PMID: 27181707 DOI: 10.1080/17476348.2016.1190277] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Pneumonia in the intensive care unit (ICU) is associated with high morbidity, mortality and healthcare costs. However, treatment outcomes with conventional intravenous (IV) antibiotics remain suboptimal, and there is an urgent need for improved therapy options. AREAS COVERED We review how clinical outcomes in patients with pneumonia treated in the ICU could be improved; we discuss the importance of choosing appropriate outcome measures in clinical trials, highlight the current suboptimal outcomes in patients with pneumonia, and outline potential solutions. We have included key studies and papers based on our clinical expertise, therefore a systematic literature review was not conducted. Expert commentary: Reasons for poor outcomes in patients with nosocomial pneumonia in the ICU include inappropriate initial therapy, increasing bacterial resistance and the complexities of IV dosing in critically ill patients. Robust clinical trial endpoints are needed to enable an accurate assessment of the success of new treatment approaches, but progress in this field has been slow. In addition, only very few new antimicrobials are currently in development for nosocomial pneumonia; two potential alternative solutions to improve outcomes could therefore include the optimization of pharmacokinetic/pharmacodynamics (PK/PD) and dosing of existing therapies, and the refinement of antimicrobial delivery by inhalation.
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Affiliation(s)
- David P Nicolau
- a Center for Anti-infective Research and Development , Hartford Hospital , Hartford , CT , USA
| | - George Dimopoulos
- b Department of Critical Care Medicine, Medical School , University of Athens , Athens , Greece
| | - Tobias Welte
- c Department of Respiratory Medicine , Hannover Medical School , Hannover , Germany
| | - Charles-Edouard Luyt
- d Service de Réanimation, Institut de Cardiologie , Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris , Paris , France.,e UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition , Sorbonne Universités , Paris , France
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Gauthier TP, Wasko J, Unger NR, Abbo LM, Fernandez M, Aragon L. Cost Reduction of Inhaled Tobramycin by Use of Preservative-Free Intravenous Tobramycin Given via Inhalation. Antibiotics (Basel) 2015; 5:antibiotics5010002. [PMID: 27025517 PMCID: PMC4810404 DOI: 10.3390/antibiotics5010002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/04/2015] [Accepted: 12/23/2015] [Indexed: 11/29/2022] Open
Abstract
This study evaluates drug cost outcomes related to automatic therapeutic substitution of branded tobramycin solution for inhalation (TOBI®) with inhaled generic preservative-free intravenous tobramycin (PFIT). A retrospective single-center evaluation of inhaled tobramycin use from 2008 through 2012 was performed. Number of doses dispensed and acquisition costs were obtained. Hourly wage data was acquired, pharmacy production costs were estimated and total cost-savings calculated. Days of therapy (DOTs) were determined for each year. Quality assurance and safety data was collected. In 2008, TOBI® drug costs and doses dispensed were $118,665 and 1769, respectively. Following implementation of the interchange in May 2009, TOBI® utilization ceased. PFIT costs in 2010 through 2012 averaged $34,775 annually and TOBI® cost-avoidance exceeded $94,000 annually when accounting for pharmacy production costs, which were determined to be at most $5.28 per dose. The maximum estimated pharmacy production cost ranged from $8812 to $11,299 annually. PFIT doses dispensed exceeded 1650 each year and annual DOTs ranged from 815 to 1069. The 40-month savings were calculated to be $374,706. Quality assurance and safety data identified one patient who refused PFIT due to odor complaints and one patient who was inappropriately administered a dose orally. Therapeutic substitution of TOBI® with PFIT can produce immediate and sustained savings with an acceptable safety profile.
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Affiliation(s)
- Timothy P Gauthier
- Department of Pharmacy, Miami Veterans Affairs Healthcare System, 1201 NW 16th Street, Miami, FL 33125, USA.
| | - Justin Wasko
- Department of Pharmacy, University of Minnesota Medical Center, 420 Delaware Street, Minneapolis, MN 55455, USA.
| | - Nathan R Unger
- College of Pharmacy, Nova Southeastern University, 11501 North Military Trail, Palm Beach Gardens, FL 33410, USA.
| | - Lilian M Abbo
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, 2101 NW 117th Avenue, Miami, FL 33172, USA.
| | - Margaret Fernandez
- Department of Pharmacy, Jackson Memorial Hospital, 1611 NW 12th Avenue, Miami, FL 33125, USA.
| | - Laura Aragon
- Department of Pharmacy, Jackson Memorial Hospital, 1611 NW 12th Avenue, Miami, FL 33125, USA.
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Noni M, Katelari A, Kaditis A, Theochari I, Lympari I, Alexandrou-Athanassoulis H, Doudounakis SE, Dimopoulos G. Candida albicans chronic colonisation in cystic fibrosis may be associated with inhaled antibiotics. Mycoses 2015; 58:416-21. [PMID: 26058475 DOI: 10.1111/myc.12338] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 04/22/2015] [Accepted: 05/04/2015] [Indexed: 01/01/2023]
Abstract
Candida albicans is increasingly recognised as a coloniser of the respiratory tract in cystic fibrosis (CF) patients. Yet, the potential role, if any, of the micro-organism in the progress of the disease remains unclear. In this study, we investigated the association between inhaled antibiotics and C. albicans chronic colonisation in patients with CF. A cohort of 121 CF patients born from 1988 to 1996 was, respectively, studied. The medical records of each patient were reviewed from the first time they attended the CF Centre until the occurrence of C. albicans chronic colonisation or their last visit for the year 2010. Chronic colonisation was defined as the presence of C. albicans in more than 50% of cultures in a given year. A number of possible confounders were included in the multivariate logistic regression analysis to identify an independent association between inhaled antibiotics and C. albicans chronic colonisation. Fifty-four (44.6%) of the 121 patients enrolled in the study developed chronic colonisation by the micro-organism. Multivariate logistic regression analysis determined the independent effect of inhaled antibiotic treatment on the odds of chronic colonisation (OR 1.112, 95% CI [1.007-1.229], P = 0.036). Candida albicans chronic colonisation may be associated with the duration of inhaled antibiotic treatment.
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Affiliation(s)
- Maria Noni
- Department of Cystic Fibrosis, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Anna Katelari
- Department of Cystic Fibrosis, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Athanasios Kaditis
- Department of Cystic Fibrosis, "Aghia Sophia" Children's Hospital, Athens, Greece.,Pulmonology Unit, 1st Department of Pediatrics, Medical School, University of Athens, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Ioanna Theochari
- Department of Cystic Fibrosis, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Ioulia Lympari
- Department of Cystic Fibrosis, "Aghia Sophia" Children's Hospital, Athens, Greece
| | | | | | - George Dimopoulos
- Department of Critical Care, Medical School, University of Athens, University Hospital "Attikon", Athens, Greece
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Antoniu S. Novel inhaled combined antibiotic formulations in the treatment of Pseudomonas aeruginosa airways infections in cystic fibrosis. Expert Rev Anti Infect Ther 2015; 13:897-905. [PMID: 25921312 DOI: 10.1586/14787210.2015.1041925] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In cystic fibrosis, chronic airways infection caused by Pseudomonas aeruginosa can be treated with inhaled antibiotics such as inhaled tobramycin, aztreonam or colistin. However, biofilm formation induced by this bacterium can reduce the effectiveness of such therapies and can contribute to antibiotic resistance. Inhaled antibiotic combination might represent an optimal antibiofilm strategy in this setting. This review discusses the rationale for combining the antibiotics as well as some emerging or existing combinations. Most of the combinations except for fosfomycin/tobramycin are at an early stage of development. The latter combination was found to be effective in Phase II clinical studies and is planned to be tested in Phase III trials. The clinical data on long-term efficacy are currently missing, but the existing evidence as well as the unmet therapeutic need can prompt the further evaluation of such compounds.
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Affiliation(s)
- Sabina Antoniu
- Department of Interdisciplinary - Palliative Care Nursing, University of Medicine and Pharmacy, Grigore T Popa Iasi, Romania, 16 Universităţii Str, Iasi, 700115
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Justicia JL, Solé A, Quintana-Gallego E, Gartner S, de Gracia J, Prados C, Máiz L. Management of pulmonary exacerbations in cystic fibrosis: still an unmet medical need in clinical practice. Expert Rev Respir Med 2015; 9:183-94. [PMID: 25692532 DOI: 10.1586/17476348.2015.1016504] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Pulmonary exacerbation (PEx) is a hallmark of cystic fibrosis. Although several criteria have been proposed for the definition of PEx, no consensus has yet been reached. Very often, many PEx cases go unreported. A standardized and validated definition is needed to reduce variability in clinical practice. The pathophysiology of recurrent episodes remains unclear, and both onset and risk are multifactorial. PEx leads to increased healthcare costs, impaired quality of life and a cycle in which PEx causes loss of lung function, which predisposes to further episodes. The number of episodes affects survival. Although early diagnosis and aggressive treatment are highly recommended, measures to prevent the emergence of new PEx are even more important. In particular, inhaled antibiotics administered under new treatment schedules could play a key role in preventing exacerbations and thus delay decline in lung function and reduce mortality. The primary objective is zero exacerbations.
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Abstract
INTRODUCTION Bacterial infections play an important role as etiological agents in acute exacerbations of chronic obstructive pulmonary disease (AECOPD), and exacerbations of non-cystic fibrosis (CF) bronchiectasis. In acute bronchitis and asthma exacerbations their role is less well defined than with patients with COPD. The clinical features, causative pathogens and therapies of common acute respiratory tract infections are detailed in this review. AREAS COVERED This article covers medical literature published in any language from 2000 to 2014, on 'lower respiratory tract infections', identified using PubMed, MEDLINE and ClinicalTrial.gov. The search terms used were 'COPD exacerbations', 'bronchiectasis', 'macrolides' and 'inhaled antibiotics'. EXPERT OPINION Given that almost half of AECOPD are caused by bacteria, administration of antibacterial agents is recommended for patients with severe exacerbations or severe underlying COPD. Chronic prophylactic use of macrolides seems to be of benefit, particularly in patients with bronchiectasis and chronic mucous hypersecretion. In an effort to manage chronic airway infection non-CF bronchiectasis due to drug-resistant pathogens, aerosolized antibiotics may be of value, and the data from recent studies are examined to demonstrate the potential value of this therapy, which is often used as an adjunctive measure to systemic antimicrobial therapy.
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Affiliation(s)
| | - Liapikou Adamantia
- Sotiria Hospital, 6th Respiratory Department , Mesogion 152, 11527, Athens , Greece +30 2107763458 ;
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Abstract
Inhaled antibiotics have been used to treat chronic airway infections since the 1940s. The earliest experience with inhaled antibiotics involved aerosolizing antibiotics designed for parenteral administration. These formulations caused significant bronchial irritation due to added preservatives and nonphysiologic chemical composition. A major therapeutic advance took place in 1997, when tobramycin designed for inhalation was approved by the U.S. Food and Drug Administration (FDA) for use in patients with cystic fibrosis (CF) with chronic Pseudomonas aeruginosa infection. Attracted by the clinical benefits observed in CF and the availability of dry powder antibiotic formulations, there has been a growing interest in the use of inhaled antibiotics in other lower respiratory tract infections, such as non-CF bronchiectasis, ventilator-associated pneumonia, chronic obstructive pulmonary disease, mycobacterial disease, and in the post-lung transplant setting over the past decade. Antibiotics currently marketed for inhalation include nebulized and dry powder forms of tobramycin and colistin and nebulized aztreonam. Although both the U.S. Food and Drug Administration and European Medicines Agency have approved their use in CF, they have not been approved in other disease areas due to lack of supportive clinical trial evidence. Injectable formulations of gentamicin, tobramycin, amikacin, ceftazidime, and amphotericin are currently nebulized "off-label" to manage non-CF bronchiectasis, drug-resistant nontuberculous mycobacterial infections, ventilator-associated pneumonia, and post-transplant airway infections. Future inhaled antibiotic trials must focus on disease areas outside of CF with sample sizes large enough to evaluate clinically important endpoints such as exacerbations. Extrapolating from CF, the impact of eradicating organisms such as P. aeruginosa in non-CF bronchiectasis should also be evaluated.
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Affiliation(s)
- Bradley S. Quon
- James Hogg Research Centre, St. Paul’s Hospital, and Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher H. Goss
- University of Washington, Department of Medicine, Pulmonary and Critical Care Medicine, University of Washington Medical Center, Seattle, Washington
| | - Bonnie W. Ramsey
- Center for Clinical and Translational Research, Seattle Children’s Research Institute and Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Kirkby S, Novak K, McCoy K. Aztreonam (for inhalation solution) for the treatment of chronic lung infections in patients with cystic fibrosis: an evidence-based review. Core Evid 2011; 6:59-66. [PMID: 22022288 PMCID: PMC3195667 DOI: 10.2147/ce.s11181] [Citation(s) in RCA: 21] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Indexed: 12/04/2022]
Abstract
Cystic fibrosis (CF) is a genetic disease caused by abnormal chloride transport across cellular membranes. In the respiratory tract, this molecular defect causes obstruction of the airways by mucus and chronic endobronchial infection. The majority of patients suffer early death from chronic respiratory disease. Pseudomonas aeruginosa is the predominant chronic airway pathogen in older children and adults with CF and is associated with worse outcomes. However, overall survival in CF has been greatly improved in recent decades due in large part to the aggressive treatment of chronic infections such as P. aeruginosa. While intravenous and oral antibiotics are commonly used in the management of CF respiratory infections, inhaled anti-infective therapies offer the benefit of delivering the drug directly to the site of infection and avoiding potential toxicities associated with systemic absorption. Aztreonam lysine (AZLI) has recently been developed as an inhaled antibiotic for chronic use in CF patients with endobronchial P. aeruginosa infection. This paper reviews background data and the clinical studies which contributed to AZLI’s formal FDA approval and growing role in the management of CF pulmonary disease.
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Affiliation(s)
- Stephen Kirkby
- Section of Pulmonary Medicine, Nationwide Children's Hospital
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