101
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Cystic Fibrosis Needs Attention in Iran. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2013. [DOI: 10.5812/pedinfect.11672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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102
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Mogayzel PJ, Naureckas ET, Robinson KA, Mueller G, Hadjiliadis D, Hoag JB, Lubsch L, Hazle L, Sabadosa K, Marshall B. Cystic Fibrosis Pulmonary Guidelines. Am J Respir Crit Care Med 2013; 187:680-9. [DOI: 10.1164/rccm.201207-1160oe] [Citation(s) in RCA: 455] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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103
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Ehrmann S, Roche-Campo F, Sferrazza Papa GF, Isabey D, Brochard L, Apiou-Sbirlea G. Aerosol therapy during mechanical ventilation: an international survey. Intensive Care Med 2013; 39:1048-56. [DOI: 10.1007/s00134-013-2872-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 01/31/2013] [Indexed: 11/28/2022]
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104
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Wee WB, Leung K, Coates AL. Modeling breath-enhanced jet nebulizers to estimate pulmonary drug deposition. J Aerosol Med Pulm Drug Deliv 2013; 26:387-96. [PMID: 23509934 DOI: 10.1089/jamp.2012.0984] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Predictable delivery of aerosol medication for a given patient and drug-device combination is crucial, both for therapeutic effect and to avoid toxicity. The gold standard for measuring pulmonary drug deposition (PDD) is gamma scintigraphy. However, these techniques expose patients to radiation, are complicated, and are relevant for only one patient and drug-device combination, making them less available. Alternatively, in vitro experiments have been used as a surrogate to estimate in vivo performance, but this is time-consuming and has few "in vitro to in vivo" correlations for therapeutics delivered by inhalation. An alternative method for determining inhaled mass and PDD is proposed by deriving and validating a mathematical model, for the individual breathing patterns of normal subjects and drug-device operating parameters. This model was evaluated for patients with cystic fibrosis (CF). METHODS This study is comprised of three stages: mathematical model derivation, in vitro testing, and in vivo validation. The model was derived from an idealized patient's respiration cycle and the steady-state operating characteristics of a drug-device combination. The model was tested under in vitro dynamic conditions that varied tidal volume, inspiration-to-expiration time, and breaths per minute. This approach was then extended to incorporate additional physiological parameters (dead space, aerodynamic particle size distribution) and validated against in vivo nuclear medicine data in predicting PDD in both normal subjects and those with CF. RESULTS The model shows strong agreement with in vitro testing. In vivo testing with normal subjects yielded good agreement, but less agreement for patients with chronic obstructive lung disease and bronchiectasis from CF. CONCLUSIONS The mathematical model was successful in accommodating a wide range of breathing patterns and drug-device combinations. Furthermore, the model has demonstrated its effectiveness in predicting the amount of aerosol delivered to "normal" subjects. However, challenges remain in predicting deposition in obstructive lung disease.
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Affiliation(s)
- Wallace B Wee
- 1 Division of Undergraduate Medicine, University of Toronto , Toronto, Ontario, Canada
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105
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Abstract
BACKGROUND Cystic fibrosis is a genetic disorder in which abnormal mucus in the lungs is associated with susceptibility to persistent infection. Pulmonary exacerbations are when symptoms of infection become more severe. Antibiotics are an essential part of treatment for exacerbations and inhaled antibiotics may be used alone or in conjunction with oral antibiotics for milder exacerbations or with intravenous antibiotics for more severe infections. Inhaled antibiotics do not cause the same adverse effects as intravenous antibiotics and may prove an alternative in people with poor access to their veins. OBJECTIVES To determine if treatment of pulmonary exacerbations with inhaled antibiotics in people with cystic fibrosis improves their quality of life, reduces time off school or work and improves their long-term survival. SEARCH METHODS We searched ClinicalTrials.gov and the Australia and New Zealand Clinical Trials Registry for relevant trials. Date of last search: 15 March 2012We also searched the Cochrane Cystic Fibrosis Group's Cystic Fibrosis Trials Register. Date of the last search: 01 June 2012. SELECTION CRITERIA Randomised controlled trials in people with cystic fibrosis with a pulmonary exacerbation in whom treatment with inhaled antibiotics was compared to placebo, standard treatment or another inhaled antibiotic for between one and four weeks. DATA COLLECTION AND ANALYSIS Two review authors independently selected eligible trials, assessed the risk of bias in each trial and extracted data. Authors of the included trials were contacted for more information. MAIN RESULTS Six trials with 208 participants were included in the review. Trials were heterogenous in design and interventions (however, all included trials compared inhaled versus intravenous antibiotic regimens). Risk of bias was difficult to assess in most trials. Results were not fully reported and only limited data were available for analysis. Four trials reported some results on forced expiratory volume at one second and found no significant differences between the inhaled antibiotic and the comparison intervention. In two of these trials using 300 mg of inhaled tobramycin, the change in forced expiratory volume at one second was similar to intravenous tobramycin; and in one trial the time until the next exacerbation was not different. No important adverse effects were reported. AUTHORS' CONCLUSIONS There is little useful high-level evidence to judge the effectiveness of inhaled antibiotics for the treatment of pulmonary exacerbations in people with cystic fibrosis. The included trials were not sufficiently powered to achieve their goals. Hence, we are unable to demonstrate whether one treatment was superior to the other or not. Further research is needed to establish whether inhaled tobramycin may be used as an alternative to intravenous tobramycin for some pulmonary exacerbations.
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Affiliation(s)
- Gerard Ryan
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Australia.
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106
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Schuster A, Haliburn C, Döring G, Goldman MH. Safety, efficacy and convenience of colistimethate sodium dry powder for inhalation (Colobreathe DPI) in patients with cystic fibrosis: a randomised study. Thorax 2012; 68:344-50. [PMID: 23135343 PMCID: PMC3595146 DOI: 10.1136/thoraxjnl-2012-202059] [Citation(s) in RCA: 158] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Purpose To assess efficacy and safety of a new dry powder formulation of inhaled colistimethate sodium in patients with cystic fibrosis (CF) aged ≥6 years with chronic Pseudomonas aeruginosa lung infection. Study design and methods A prospective, centrally randomised, phase III, open-label study in patients with stable CF aged ≥6 years with chronic P aeruginosa lung infection. Patients were randomised to Colobreathe dry powder for inhalation (CDPI, one capsule containing colistimethate sodium 1 662 500 IU, twice daily) or three 28-day cycles with twice-daily 300 mg/5 ml tobramycin inhaler solution (TIS). Study duration was 24 weeks. Results 380 patients were randomised. After logarithmic transformation of data due to a non-normal distribution, adjusted mean difference between treatment groups (CDPI vs TIS) in change in forced expiratory volume in 1 s (FEV1% predicted) at week 24 was −0.98% (95% CI −2.74% to 0.86%) in the intention-to-treat population (n=373) and −0.56% (95% CI −2.71% to 1.70%) in the per protocol population (n=261). The proportion of colistin-resistant isolates in both groups was ≤1.1%. The number of adverse events was similar in both groups. Significantly more patients receiving CDPI rated their device as ‘very easy or easy to use’ (90.7% vs 53.9% respectively; p<0.001). Conclusion CDPI demonstrated efficacy by virtue of non-inferiority to TIS in lung function after 24 weeks of treatment. There was no emergence of resistance of P aeruginosa to colistin. Overall, CDPI was well tolerated. Trial Reg No EudraCT 2004-003675-36.
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Affiliation(s)
- Antje Schuster
- Department of Paediatrics, University of Düsseldorf, Düsseldorf, Germany.
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107
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Yu Q, Griffin EF, Moreau-Marquis S, Schwartzman JD, Stanton BA, O'Toole GA. In vitro evaluation of tobramycin and aztreonam versus Pseudomonas aeruginosa biofilms on cystic fibrosis-derived human airway epithelial cells. J Antimicrob Chemother 2012; 67:2673-81. [PMID: 22843834 DOI: 10.1093/jac/dks296] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Aztreonam for inhalation solution (AZLI) was recently approved by the FDA for treating cystic fibrosis (CF) patients infected with Pseudomonas aeruginosa. Here we investigated the effect of aztreonam alone or in combination with tobramycin on P. aeruginosa biofilms grown on CF airway epithelial cells. METHODS P. aeruginosa biofilms, produced by laboratory strains or clinical isolates, were formed on confluent CF airway cells before treatment overnight with aztreonam or tobramycin alone or in combination. Alternatively, antibiotics were added 1 h after bacterial inoculation to assess their ability to impair biofilm formation at 5 h. Bacterial cfu remaining after treatment were then determined by plate counting. RESULTS In the absence of antibiotics, all strains developed biofilms that disrupted CF airway epithelial monolayers overnight. Tobramycin reduced the cfu of all strains grown as biofilms. Aztreonam reduced the cfu of some strains by ∼1 log unit without preserving the integrity of cystic fibrosis airway cell monolayers, while decreasing the biofilms of other clinical isolates by ∼4 log units and protecting the monolayers from being compromised. The combination of aztreonam and tobramycin reduced the cfu of two strains by an additional 0.5 and 2 log units, respectively. Of all the mechanisms explored, Psl exopolysaccharide production might explain the variations in biofilm tolerance to aztreonam in some of the strains. CONCLUSIONS Effects of aztreonam on P. aeruginosa biofilms in the in vitro co-culture model are strain-dependent. The simultaneous application of aztreonam and tobramycin may be beneficial for a subset of CF patients by eliminating susceptible P. aeruginosa strains.
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Affiliation(s)
- Qianru Yu
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, NH 03755, USA
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108
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Ruddy J, Emerson J, Moss R, Genatossio A, McNamara S, Burns JL, Anderson G, Rosenfeld M. Sputum tobramycin concentrations in cystic fibrosis patients with repeated administration of inhaled tobramycin. J Aerosol Med Pulm Drug Deliv 2012; 26:69-75. [PMID: 22620494 DOI: 10.1089/jamp.2011.0942] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Dosing of tobramycin solution for inhalation (TSI) in cystic fibrosis (CF) patients was based on single-dose pharmacokinetic studies. This investigation was prompted by evidence of possible antibiotic accumulation in respiratory secretions with repeated dosing. The objectives were to evaluate whether tobramycin accumulates in respiratory secretions with repeated inhalation, compare total and biologically active tobramycin concentrations in CF sputum, and evaluate sputum induction for obtaining secretions for drug concentration assay. METHODS Individuals with CF ≥10 years of age were enrolled at the beginning of a course of TSI, 300 mg twice daily for 28 days. Two study visits were conducted, 1-2 days and 24-28 days after initiation of TSI treatment. Induced sputum and expectorated sputum samples were collected for measurement of trough and peak tobramycin concentrations at each visit. Total tobramycin concentrations were measured by high-pressure liquid chromatography and bioactive concentrations by bioassay. RESULTS Twenty participants completed the study. Trough concentrations were similar at visits 1 and 2, as were peak concentrations. Trough bioactive and total tobramycin concentrations were similar (mean ratio 1.2, 95% CI 0.56, 1.87), but peak bioactive concentrations were significantly lower than peak total concentrations (mean ratio 0.33, 95% CI 0.23, 0.44). Sputum induction was well tolerated. CONCLUSIONS No evidence of significant drug accumulation in respiratory secretions with repeat dosing of TSI was seen. Peak bioactive concentrations, although lower than peak total concentrations, were still generally well within the bactericidal range. Sputum induction as a method for determining airway drug concentrations appears safe and feasible.
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Affiliation(s)
- Jennifer Ruddy
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA 98105, USA
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109
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Taylor-Robinson D, Whitehead M, Diderichsen F, Olesen HV, Pressler T, Smyth RL, Diggle P. Understanding the natural progression in %FEV1 decline in patients with cystic fibrosis: a longitudinal study. Thorax 2012; 67:860-6. [PMID: 22555277 PMCID: PMC3446776 DOI: 10.1136/thoraxjnl-2011-200953] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Forced expiratory volume in 1 s as a percentage of predicted (%FEV1) is a key outcome in cystic fibrosis (CF) and other lung diseases. As people with CF survive for longer periods, new methods are required to understand the way %FEV1 changes over time. An up to date approach for longitudinal modelling of %FEV1 is presented and applied to a unique CF dataset to demonstrate its utility at the clinical and population level. METHODS AND FINDINGS The Danish CF register contains 70,448 %FEV1 measures on 479 patients seen monthly between 1969 and 2010. The variability in the data is partitioned into three components (between patient, within patient and measurement error) using the empirical variogram. Then a linear mixed effects model is developed to explore factors influencing %FEV1 in this population. Lung function measures are correlated for over 15 years. A baseline %FEV1 value explains 63% of the variability in %FEV1 at 1 year, 40% at 3 years, and about 30% at 5 years. The model output smooths out the short-term variability in %FEV1 (SD 6.3%), aiding clinical interpretation of changes in %FEV1. At the population level significant effects of birth cohort, pancreatic status and Pseudomonas aeruginosa infection status on %FEV1 are shown over time. CONCLUSIONS This approach provides a more realistic estimate of the %FEV1 trajectory of people with chronic lung disease by acknowledging the imprecision in individual measurements and the correlation structure of repeated measurements on the same individual over time. This method has applications for clinicians in assessing prognosis and the need for treatment intensification, and for use in clinical trials.
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Affiliation(s)
- David Taylor-Robinson
- Department of Public Health and Policy, Whelan Building, University of Liverpool, Liverpool L69 3GB, UK.
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Zeitler K, Salvas B, Stevens V, Brown J. Aztreonam lysine for inhalation: new formulation of an old antibiotic. Am J Health Syst Pharm 2012; 69:107-15. [PMID: 22215356 DOI: 10.2146/ajhp100624] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The pharmacology, safety, efficacy, pharmacokinetics, pharmacodynamics, current place in therapy, and potential future therapeutic uses of inhaled aztreonam are reviewed. SUMMARY Inhaled aztreonam, a newly formulated lysine salt of the original monobactam antibiotic, is approved for the treatment of respiratory symptoms in patients with cystic fibrosis (CF) who are colonized with Pseudomonas aeruginosa. Its spectrum of activity is limited to susceptible gram-negative organisms, including P. aeruginosa. Lyophilized aztreonam lysine is diluted with 0.17% sodium chloride and administered using the Altera nebulizer system, which produces appropriate-sized particles for proper deposition in the lungs to achieve high sputum and low systemic concentrations. Mean sputum drug concentrations are highest 10 minutes after dose administration, and plasma concentrations peak one hour after inhalation. Aztreonam is excreted via active tubular secretion and glomerular filtration. Caution is advised in patients with renal or hepatic impairment, breastfeeding women, and patients age 65 years or older. Like the older i.v. formulation, inhaled aztreonam displays time-dependent killing. Phase III clinical trials have shown improvements in respiratory symptoms, decreased P. aeruginosa sputum density, prolonged time intervals between antibiotic treatments, and efficacy without the development of resistance in the face of repeated exposures. This formulation is available only from select specialty pharmacies and should only be used with the Altera nebulizer system. CONCLUSION Inhaled aztreonam has shown efficacy and safety in patients seven years of age or older with CF who have P. aeruginosa airway infections. This product may complement existing therapies and offers the advantage of a new inhaled formulation to aid in treatment regimens.
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Affiliation(s)
- Kristen Zeitler
- School of Pharmacy and Pharmaceutical Science, State University of New York at Buffalo, Buffalo, NY 14260, USA
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111
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Ballmann M, Smyth A, Geller DE. Therapeutic approaches to chronic cystic fibrosis respiratory infections with available, emerging aerosolized antibiotics. Respir Med 2012; 105 Suppl 2:S2-8. [PMID: 22208546 DOI: 10.1016/s0954-6111(11)70021-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chronic airway infection and inflammation are key events in the clinical course of cystic fibrosis (CF). The most relevant, best investigated strain of bacteria in these circumstances is Pseudomonas aeruginosa. Since pulmonary infection with P. aeruginosa is localized in the lower conducting airways, treatment is accessible with the use of inhaled aerosolized antibiotics. Tobramycin inhalation solution was the first antibiotic to be developed and approved (in 1998) for use as an aerosolized antibiotic in patients with CF. The only other aerosolized antibiotic indicated for this use is aztreonam lysine solution for inhalation, which has been approved by both European and US authorities. In prospective, randomized, controlled trails, both agents exhibited a very acceptable safety profile, along with an increase in forced expiratory volume in 1 second and other clinically relevant endpoints. New developments focus on such components as reducing the treatment burden by using dry power inhalers, decreasing inhalation frequency to once daily, penetrating P. aeruginosa biofilms, and combining two antibiotics in one solution for inhalation. However, the ideal aerosolized antibiotic regimen for the treatment of chronic P. aeruginosa infection has yet not been selected.
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Affiliation(s)
- Manfred Ballmann
- Ruhr University Paediatric Clinic at St Josef Hospital, Bochum, Germany.
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112
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Geller DE, Madge S. Technological and behavioral strategies to reduce treatment burden and improve adherence to inhaled antibiotics in cystic fibrosis. Respir Med 2012; 105 Suppl 2:S24-31. [PMID: 22208547 DOI: 10.1016/s0954-6111(11)70024-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Aerosolized antibiotics are a common treatment option for patients with cystic fibrosis and chronic airway infection, as high doses can be delivered topically to the site of the infection while systemic exposure is minimized. Patients also use other aerosolized therapies (e.g. mucus-active agents, airway-wetting agents, and bronchodilators), adding significantly increase timed and complexity to their daily regimen, and often leading to lower adherence rates. A number of novel technological strategies are available that may reduce dose frequency and increase the speed of drug delivery. Psychologically based therapies may also be used to help modify behavior and thus improve adherence to treatment. Clinicians need to explore both technological and psychological strategies that will assist in the successful maintenance of treatment requirements.
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113
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Abstract
This review summarizes recent clinical data examining the use of aerosolized antimicrobial therapy for the treatment of respiratory tract infections in mechanically ventilated patients in the intensive care unit. Aerosolized antibiotics provide high concentrations of drug in the lung without the systemic toxicity associated with the intravenous antibiotics. First introduced in the 1960s as a treatment of tracheobronchitis and bronchopneumonia caused by Pseudomonas aeruginosa, now, more than 40 years later, there is a resurgence of interest in using this mode of delivery as a primary therapy for ventilator-associated tracheobronchitis and an adjunctive therapy for ventilator-associated pneumonia.
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Affiliation(s)
- Lucy B Palmer
- Pulmonary, Critical Care and Sleep Division, SUNY at Stony Brook, NY 11794-8172, USA.
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114
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Aerosolized antibiotic therapy for chronic cystic fibrosis airway infections: continuous or intermittent? Respir Med 2011; 105 Suppl 2:S9-17. [DOI: 10.1016/s0954-6111(11)70022-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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115
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VanDevanter DR, Ballmann M, Flume PA. Applying clinical outcome variables to appropriate aerosolized antibiotics for the treatment of patients with cystic fibrosis. Respir Med 2011; 105 Suppl 2:S18-23. [DOI: 10.1016/s0954-6111(11)70023-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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116
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Rognon A, Curti C, Montana M, Terme T, Rathelot P, Vanelle P. Efficacité et avenir de l’aérosolthérapie dans le traitement des infections à Pseudomonas aeruginosa chez les patients atteints de mucoviscidose. Therapie 2011; 66:481-91. [DOI: 10.2515/therapie/2011074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 06/10/2011] [Indexed: 11/20/2022]
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117
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Abstract
No official guidelines exist for perioperative antibiotic use in noncardiac thoracic surgery. Despite some conflicting data and few randomized clinical trials there exists strong evidence supporting the use of perioperative antibiotic prophylaxis in pulmonary resection. This article discusses the evidence-based indications for antibiotic prophylaxis after lung resection, esophageal surgery, and lung transplantation.
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Affiliation(s)
- Stephanie H Chang
- Division of Cardiothoracic Surgery, Washington University in St Louis School of Medicine, 660 South Euclid, Campus Box 8234, St Louis, MO 63110-1013, USA
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118
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Vandevanter DR, Geller DE. Tobramycin administered by the TOBI(®) Podhaler(®) for persons with cystic fibrosis: a review. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2011; 4:179-88. [PMID: 22915944 PMCID: PMC3417888 DOI: 10.2147/mder.s16360] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
From its introduction, the antibiotic tobramycin has been an important tool in the management of persons with cystic fibrosis (CF) and chronic Pseudomonas aeruginosa lung infections. Initially an intravenous rescue treatment for pulmonary exacerbations, tobramycin delivered by inhalation has become a mainstay of chronic suppressive CF infection management. Platforms for tobramycin aerosol delivery have steadily improved, with increased lung deposition complimented by decreased device complexities, loaded tobramycin doses, delivery times, and treatment burdens. Most recently, a unique tobramycin inhalation powder (TIP) formulation with a portable delivery system, the TOBI® Podhaler® (Novartis AG, Basel, Switzerland) has been developed and approved in Europe, Canada, and Chile. Four capsules, each containing 28 mg of TIP are successively pierced and inhaled via the T-326 Dry Powder Inhaler Device (Novartis AG, Basel, Switzerland). No external power source is required to deliver an efficacious tobramycin dose in minutes. By comparison, tobramycin inhalation solution (TIS) (TOBI®; Novartis), is delivered by LC® Plus (PARI Respiratory Equipment Inc, Midlothian, VA) jet nebulizer powered by an air compressor over 15–20 minutes. Comparative pharmacokinetics, safety, and efficacy studies of TIS and TIP in CF subjects with P. aeruginosa ≥ 6 years old demonstrate that: tobramycin lung deposition with 112 mg TIP is comparable to that attained with 300 mg TIS, TIP is more effective than placebo and not inferior to TIS with respect to pulmonary function benefit, and TIP has significantly faster treatment times and achieves higher patient satisfaction than TIS. TIP is associated with an increased frequency of mild to moderate local adverse events (cough, dysphonia, and dysgeusia) compared with TIS, however, these become less frequent as subjects gain TIP experience. These results suggest that the TOBI Podhaler may better meet the needs of many CF patients and families by reducing treatment time and complexity and improving patient satisfaction compared with TIS.
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Affiliation(s)
- Donald R Vandevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH
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119
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Quon BS, Mayer-Hamblett N, Aitken ML, Smyth AR, Goss CH. Risk factors for chronic kidney disease in adults with cystic fibrosis. Am J Respir Crit Care Med 2011; 184:1147-52. [PMID: 21799076 DOI: 10.1164/rccm.201105-0932oc] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
RATIONALE Adults with cystic fibrosis (CF) possess multiple potential risk factors for chronic kidney disease, including CF-related diabetes (CFRD) and lifetime nephrotoxic drug exposure. OBJECTIVES To determine whether cumulative intravenous (IV) aminoglycoside exposure and CFRD increase the risk of chronic kidney disease in adults with CF. METHODS This was a cohort study using adults (≥ 18 yr) in the CF Foundation registry from 2001-2008. Chronic kidney disease (stage 3 or greater) was defined by an estimated glomerular filtration rate of less than 60 ml/min/1.73 m(2). Time-dependent multivariable Cox proportional hazards models were used to determine whether cumulative number of acute pulmonary exacerbations (surrogate for IV aminoglycoside exposure) and CFRD requiring insulin increase the risk of chronic kidney disease, adjusting for confounders. MEASUREMENTS AND MAIN RESULTS The study cohort included 11,912 adults with a median follow-up of 4 years. During the study period, 204 subjects had chronic kidney disease, with an annual disease prevalence of 2.3%. Disease prevalence doubled with every 10-year increase in age. CFRD requiring insulin therapy substantially increased the risk of chronic kidney disease (1-4 yr of CFRD requiring insulin vs. no CFRD, hazard ratio [HR] = 2.40, 95% confidence interval [CI] 1.74-3.32; ≥ 5 yr, HR = 4.56, 95% CI 2.84-7.31). Pulmonary exacerbations did not significantly increase the risk of chronic kidney disease (one to five exacerbations vs. none, HR = 0.79, 95% CI 0.56-1.11; six to nine exacerbations, HR = 0.92, 95% CI 0.58-1.46; ≥ 10 exacerbations, HR = 1.16, 95% CI 0.75-1.81). CONCLUSIONS CF-related diabetes is a significant risk factor for chronic kidney disease in adults with CF, but additional studies examining IV aminoglycoside exposure directly are required.
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Affiliation(s)
- Bradley S Quon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, USA.
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120
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Abstract
There are multiple aetiologies for childhood bronchiectasis unrelated to cystic fibrosis. Some of these aetiologies, such as those predisposing to recurrent lung infections, e.g. immunodeficiencies, require treatment of the underlying condition and disease-specific pulmonary pathogens within the airway. Regardless of aetiology, the treatments for bronchiectasis include antibiotics, airway clearance regimens, immunizations to prevent infections, and in some cases asthma therapies. The grade of evidence for specific treatments is low with few randomized controlled trials in children. Extrapolations of care provided to adults with bronchiectasis and patients with cystic fibrosis may not always be justified. Comprehensive care programs for children with bronchiectasis have demonstrated clinically relevant improvements over 2-7 year periods. Multi-center research is needed to rigorously evaluate current treatment practices for children with this disorder.
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Affiliation(s)
- Gregory J Redding
- Professor of Pediatrics, University of Washington School of Medicine, Chief, Pulmonary and Sleep Medicine Division, Seattle Children's Hospital, Seattle, Washington, USA.
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121
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Rose LM, Neale R. Development of the first inhaled antibiotic for the treatment of cystic fibrosis. Sci Transl Med 2011; 2:63mr4. [PMID: 21178134 DOI: 10.1126/scitranslmed.3001634] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Tobramycin Inhalation Solution USP (TOBI), a therapy developed to treat lung infections associated with cystic fibrosis (CF), was presented as a demonstration case for collaborative pharmaceutical development at a Clinical and Translational Science Awards Industry Forum on "Promoting Efficient and Effective Collaborations Among Academia, Government, and Industry" held in February 2010. TOBI was developed by PathoGenesis Corporation (Seattle, WA) in collaboration with the academic inventors, the National Institutes of Health, the U.S. Food and Drug Administration, and the CF Foundation. The presenters, representing the academic, industry, and foundation partners, each reviewed the program from their perspectives and identified challenges that existed during the discovery, development, and commercialization of TOBI. The attendees were asked to consider other collaborative opportunities that might have further improved TOBI development, including the optimal roles of the academic researchers, foundations, and other agencies when industry drives development and commercialization decisions.
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Affiliation(s)
- Lynn M Rose
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98101, USA. lynn.rose@seattlechildrens
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122
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Coates AL, Denk O, Leung K, Ribeiro N, Chan J, Green M, Martin S, Charron M, Edwardes M, Keller M. Higher tobramycin concentration and vibrating mesh technology can shorten antibiotic treatment time in cystic fibrosis. Pediatr Pulmonol 2011; 46:401-8. [PMID: 21438171 DOI: 10.1002/ppul.21376] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Revised: 08/31/2010] [Accepted: 09/03/2010] [Indexed: 11/08/2022]
Abstract
Poor adherence to recommended therapy in cystic fibrosis (CF) is often because of the time demands of therapy. Tobramycin (TOBI®, 300 mg at 60 mg/ml) inhaled from the PARI LC PLUS® nebulizer requires about 20 min. This study determined if equivalent levels of pulmonary deposition could be achieved in shorter time using 1.5 ml of 100 mg/ml tobramycin solution delivered by an investigational eFlow® nebulizer. Sixteen males with stable CF, 8 children and 8 adults, and an FEV(1) > 45% predicted inhaled both preparations on two occasions with (99m) Tc-DTPA added to the tobramycin. Blood samples were taken for quantification of tobramycin in the serum. The PARI LC PLUS® delivered 45.4 (39.3-51.6), mean and 95% CI, mg to the lungs in 17.0 ± 2.5 min (mean ± SD) with serum levels of 1,089 ± 388 µg/L. The investigational eFlow® delivered 46.3(40.3-51.7) mg in 4.0 ± 1.0 min with blood levels of 909 ± 458 µg/L. Only the time of delivery was significantly different with P < 0.0001 (paired t-test). Tolerability of the treatment was comparable for both inhalation regimes, but the shorter treatment was preferred by all patients. These results demonstrate the possibility of delivering equivalent levels of tobramycin much faster into the lungs of CF patients when using eFlow®, a very efficient electronic nebulizer.
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Affiliation(s)
- Allan L Coates
- Physiology and Experimental Medicine, Research Institute of Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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Affiliation(s)
- Greg L Plosker
- Adis, a Wolters Kluwer Business, 41 Centorian Drive, Mairangi Bay, Auckland, New Zealand.
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Abstract
BACKGROUND Inhaled antibiotics are commonly used to treat persistent airway infection that contributes to lung damage in people with cystic fibrosis (CF). OBJECTIVES To examine the evidence that inhaled antibiotic treatment in people with CF reduces frequency of exacerbations of infection, and improves lung function, quality of life and survival. To examine adverse effects of inhaled antibiotic treatment. SEARCH STRATEGY Trials were identified from the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register.Last search: 31 January 2011. SELECTION CRITERIA Trials were selected if inhaled antibiotic treatment was used for at least four weeks in people with CF, treatment allocation was randomised or quasi-randomised, and there was a control group (either placebo, no placebo or another inhaled antibiotic). DATA COLLECTION AND ANALYSIS Two authors independently selected trials, judged the risk of bias and extracted data from these trials. MAIN RESULTS The searches identified 176 citations to 78 trials. Nineteen trials, with 1724 participants, met the inclusion criteria. Adequate meta-analysis was not possible because of the variability of study design and reporting of results. Seventeen trials with 1562 participants compared an inhaled antibiotic with placebo or usual treatment for a duration between 1 and 32 months. Inhaled tobramycin was studied in eight trials. Lung function (measured as forced expired volume in one second) was higher and exacerbations of lung infection (by different measures) were less in the antibiotic-treated group. Resistance to antibiotics increased more in the antibiotic-treated group than in placebo group when results were reported. No auditory or renal impairment was found; analysis showed tinnitus, voice alteration, hemoptysis and cough were more frequent with tobramycin than placebo. One trial, compared tobramycin with colistin in 115 participants, after one month the mean difference in forced expiratory volume at one second was 6.33 (95% confidence interval -0.04 to 12.70) favouring tobramycin. AUTHORS' CONCLUSIONS Inhaled antibiotic treatment probably improves lung function and reduces exacerbation rate, but a pooled estimate of the level of benefit is not possible. The best evidence is for inhaled tobramycin. More evidence, from trials of longer duration, is needed to determine whether this benefit is maintained and to determine the significance of development of antibiotic-resistant organisms.
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Affiliation(s)
- Gerard Ryan
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Ground Floor B Block, Verdun Street, Nedlands, Western Australia 6009, Australia
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125
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George PM, Banya W, Pareek N, Bilton D, Cullinan P, Hodson ME, Simmonds NJ. Improved survival at low lung function in cystic fibrosis: cohort study from 1990 to 2007. BMJ 2011; 342:d1008. [PMID: 21357627 PMCID: PMC3045791 DOI: 10.1136/bmj.d1008] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To evaluate the survival of patients with cystic fibrosis whose lung function has deteriorated to a forced expiratory volume in one second (FEV(1)) below 30% predicted in the recent treatment era and to explore factors associated with any change in survival. Design Cohort study. SETTING Adult cystic fibrosis unit in London. PARTICIPANTS 276 patients (147 (53%) male) whose FEV(1) was first observed to be less than 30% predicted between 1 January 1990 and 31 December 2003. MAIN OUTCOME MEASURE Survival during follow-up to 31 December 2007 in two year sub-cohorts. RESULTS Median survival improved from 1.2 years in the 1990-1 group to 5.3 years in the 2002-3 group, with a marked improvement in survival from 1994. The use of nebulised recombinant human DNase was significantly associated with a reduced risk of death (hazard ratio 0.59, 95% confidence interval 0.44 to 0.79). Significantly increased risks were associated with a body mass index under 19 (hazard ratio 1.52, 1.10 to 2.10), long term oxygen therapy (3.52, 2.49 to 4.99), and nebulised antibiotics (1.84, 1.05 to 3.22). CONCLUSION A marked improvement has occurred in the survival of patients with cystic fibrosis with an FEV(1) less than 30% predicted. Secondary analyses suggest that some of this improvement may be due to use of recombinant human DNase.
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Affiliation(s)
- P M George
- Department of Cystic Fibrosis, Royal Brompton Hospital, London SW3 6NP, UK
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126
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Wertz DA, Chang CL, Stephenson JJ, Zhang J, Kuhn RJ. Economic impact of tobramycin in patients with cystic fibrosis in a managed care population. J Med Econ 2011; 14:759-68. [PMID: 21942462 DOI: 10.3111/13696998.2011.621004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Guidelines recommend chronic use of tobramycin solution for inhalation (TSI) for cystic fibrosis (CF) patients with moderate-to-severe lung disease and persistent airway Pseudomonas aeruginosa. This study evaluated the economic impact of TSI in managed care CF patients. METHODS Patients (0-64 years) with ≥2 CF medical claims between 01/01/04-03/31/09 were identified. For TSI users, the index date was the first TSI claim in the period; for non-users, a pseudo-index date was determined and randomly assigned by simulating the distribution of index dates of TSI users. Maximum sample size was obtained for patients with ≥3 months pre- and ≥12 months post-index eligibility. Users were categorized by number of TSI prescriptions filled during 12-month post-index period as low (1 fill), medium (2-3 fills) and high adherence (≥4 fills). Differences in per member per month (PMPM) costs pre-index to post-index were analyzed using paired t-tests. RESULTS A total of 388 TSI users (mean age 19 years, 48% female) and 444 non-users (mean age 30 years, 54% female) met study criteria. In users, total and CF-related PMPM costs decreased $959 (17%) and $113 (3%), respectively, after starting TSI. Among TSI users, CF-related inpatient PMPM costs decreased by $1171 (49%; p=0.01), while CF-related prescription PMPM costs increased by $992 (p<0.01). CF-related inpatient PMPM costs decreased by $381 (38%; p=0.16) for low and $1425 (50%; p=0.21) for medium users and decreased by $1829 (51%; p=0.02) for high users. LIMITATIONS Limitations include use of administrative claims data, small sample size due to disease rarity, random assignment of pseudo-index date to non-users and differences in baseline characteristics between TSI users and non-users. CONCLUSION All-cause and CF-related PMPM medical costs significantly decreased after TSI initiation. Among TSI users, total healthcare costs decreased, although not significantly, due to PMPM increases in prescription costs. A trend towards greater decrease in inpatient PMPM costs was observed with increasing TSI adherence.
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127
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Lenney W, Edenborough F, Kho P, Kovarik JM. Lung deposition of inhaled tobramycin with eFlow rapid/LC Plus jet nebuliser in healthy and cystic fibrosis subjects. J Cyst Fibros 2011; 10:9-14. [DOI: 10.1016/j.jcf.2010.08.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Revised: 06/24/2010] [Accepted: 08/31/2010] [Indexed: 10/19/2022]
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128
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Microbiological insights into respiratory infections and the opportunities for inhaled therapy. J Drug Deliv Sci Technol 2011. [DOI: 10.1016/s1773-2247(11)50047-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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129
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Hauser AR, Jain M, Bar-Meir M, McColley SA. Clinical significance of microbial infection and adaptation in cystic fibrosis. Clin Microbiol Rev 2011; 24:29-70. [PMID: 21233507 PMCID: PMC3021203 DOI: 10.1128/cmr.00036-10] [Citation(s) in RCA: 287] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A select group of microorganisms inhabit the airways of individuals with cystic fibrosis. Once established within the pulmonary environment in these patients, many of these microbes adapt by altering aspects of their structure and physiology. Some of these microbes and adaptations are associated with more rapid deterioration in lung function and overall clinical status, whereas others appear to have little effect. Here we review current evidence supporting or refuting a role for the different microbes and their adaptations in contributing to poor clinical outcomes in cystic fibrosis.
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Affiliation(s)
- Alan R Hauser
- Department of Microbiology/Immunology, Northwestern University, 303 E. Chicago Ave., Searle 6-495, Chicago, IL 60611, USA.
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130
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131
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Le J, Ashley ED, Neuhauser MM, Brown J, Gentry C, Klepser ME, Marr AM, Schiller D, Schwiesow JN, Tice S, VandenBussche HL, Wood GC. Consensus Summary of Aerosolized Antimicrobial Agents: Application of Guideline Criteria. Pharmacotherapy 2010; 30:562-84. [DOI: 10.1592/phco.30.6.562] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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132
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Macrolide and clindamycin resistance in Streptococcus milleri group isolates from the airways of cystic fibrosis patients. Antimicrob Agents Chemother 2010; 54:2823-9. [PMID: 20404127 DOI: 10.1128/aac.01845-09] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Organisms belonging to the Streptococcus milleri group (SMG) are known for their role in pyogenic infections but have recently been implicated as etiological agents of pulmonary exacerbation in adult patients with cystic fibrosis (CF). The prolonged exposure of CF patients to antibiotics prompted us to investigate the susceptibility profiles of 118 SMG isolates from the airways of CF patients to 12 antibiotics compared to 43 SMG isolates from patients with invasive infections. We found that approximately 60% of all isolates failed to grow using the standard medium for disc diffusion, Mueller-Hinton blood agar (MHBA), so we explored the usefulness of brain heart infusion (BHI) agar for susceptibility testing. Zone-of-inhibition comparisons between BHI and MHBA showed strong correlations for six antibiotics, and interpretations were similar for both medium types. For ceftriaxone and cefepime, both groups of isolates were highly susceptible. Tetracycline resistance levels were comparable between the two groups (22% in CF isolates and 17.4% in invasive isolates). However, more than half of the CF isolates were not susceptible to azithromycin, erythromycin, and clindamycin, compared to 11%, 13%, and 6.5% of invasive isolates, respectively. There were 5-fold and 8-fold increased risks of azithromycin and clindamycin resistance, respectively, for the isolates from the airways of CF patients relative to the invasive isolates. Macrolide resistance was strongly linked to chronic azithromycin therapy in CF patients. This study shows that BHI agar is a suitable alternative for antimicrobial susceptibility testing for the SMG and that SMG isolates from the airways of CF patients are more resistant to macrolides and clindamycin than strains isolated from patients with invasive infections.
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133
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Falagas ME, Michalopoulos A, Metaxas EI. Pulmonary drug delivery systems for antimicrobial agents: facts and myths. Int J Antimicrob Agents 2010; 35:101-6. [DOI: 10.1016/j.ijantimicag.2009.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Accepted: 10/02/2009] [Indexed: 11/24/2022]
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134
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Tiddens HAWM, Donaldson SH, Rosenfeld M, Paré PD. Cystic fibrosis lung disease starts in the small airways: can we treat it more effectively? Pediatr Pulmonol 2010; 45:107-17. [PMID: 20082341 DOI: 10.1002/ppul.21154] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The aims of this article are to summarize existing knowledge regarding the pathophysiology of small airways disease in cystic fibrosis (CF), to speculate about additional mechanisms that might play a role, and to consider the available or potential options to treat it. In the first section, we review the evidence provided by pathologic, physiologic, and imaging studies suggesting that obstruction of small airways begins early in life and is progressive. In the second section we discuss how the relationships between CF transmembrane conductance regulator (CFTR), ion transport, the volume of the periciliary liquid layer and airway mucus might lead to defective mucociliary clearance in small airways. In addition, we discuss how chronic endobronchial bacterial infection and a chronic neutrophilic inflammatory response increase the viscosity of CF secretions and exacerbate the clearance problem. Next, we discuss how the mechanical properties of small airways could be altered early in the disease process and how remodeling can contribute to small airways disease. In the final section, we discuss how established therapies impact small airways disease and new directions that may lead to improvement in the treatment of small airways disease. We conclude that there are many reasons to believe that small airways play an important role in the pathophysiology of (early) CF lung disease. Therapy should be aimed to target the small airways more efficiently, especially with drugs that can correct the basic defect at an early stage of disease.
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Affiliation(s)
- Harm A W M Tiddens
- Department of Pediatric Pulmonology and Allergology, Erasmus MC-Sophia, Rotterdam, the Netherlands.
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135
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Ryan G, Remmington T, Jahnke N. Inhaled antibiotics for pulmonary exacerbations in cystic fibrosis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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136
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Adi H, Young PM, Chan HK, Salama R, Traini D. Controlled release antibiotics for dry powder lung delivery. Drug Dev Ind Pharm 2010; 36:119-26. [DOI: 10.3109/03639040903099769] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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137
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Yankaskas JR. Bronchitis, bronchiectasis and cystic fibrosis. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00026-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Abstract
PURPOSE OF REVIEW This review will summarize recent clinical data examining the efficacy of aerosolized antimicrobial therapy in treating respiratory tract infections in mechanically ventilated patients in the ICU. RECENT FINDINGS Aerosolized antibiotics provide high levels of drug in the lung and reduce the systemic toxicity associated with intravenous antibiotics. First introduced in the 1970s as a form of prophylaxis for ventilator-associated pneumonia (VAP), now, more than 30 years later, there is a resurgence of interest in using this mode of delivery as primary or adjunctive treatment for ventilator-associated tracheobronchitis (VAT) or VAP. Increasingly resistant organisms are colonizing and infecting critically ill patients, and direct delivery of antibiotic to the lung is being re-evaluated as a means to treat these highly resistant organisms that may not respond to systemic therapy. There are new data emerging that suggest these agents may effectively treat these pathogens when used in targeted, time limited protocols. SUMMARY Aerosolized antibiotic therapy may provide an efficacious means of treating respiratory tract infection when targeted at mechanically ventilated patients with proximal airway infection, VAT (with or without VAP) and with highly resistant organisms.
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139
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Razvi S, Quittell L, Sewall A, Quinton H, Marshall B, Saiman L. Respiratory Microbiology of Patients With Cystic Fibrosis in the United States, 1995 to 2005. Chest 2009; 136:1554-1560. [DOI: 10.1378/chest.09-0132] [Citation(s) in RCA: 166] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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140
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Chuchalin A, Amelina E, Bianco F. Tobramycin for inhalation in cystic fibrosis: Beyond respiratory improvements. Pulm Pharmacol Ther 2009; 22:526-32. [DOI: 10.1016/j.pupt.2009.06.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Revised: 05/05/2009] [Accepted: 06/30/2009] [Indexed: 10/20/2022]
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141
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Trends in pathogens colonising the respiratory tract of adult patients with cystic fibrosis, 1985–2005. J Cyst Fibros 2009; 8:386-91. [DOI: 10.1016/j.jcf.2009.08.003] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 08/06/2009] [Accepted: 08/07/2009] [Indexed: 11/23/2022]
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142
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Aminoglycoside therapy against Pseudomonas aeruginosa in cystic fibrosis: A review. J Cyst Fibros 2009; 8:361-9. [DOI: 10.1016/j.jcf.2009.08.004] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Revised: 07/30/2009] [Accepted: 08/10/2009] [Indexed: 11/23/2022]
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143
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Kreindler JL. Cystic fibrosis: exploiting its genetic basis in the hunt for new therapies. Pharmacol Ther 2009; 125:219-29. [PMID: 19903491 DOI: 10.1016/j.pharmthera.2009.10.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Accepted: 10/16/2009] [Indexed: 01/11/2023]
Abstract
Cystic fibrosis (CF) is caused by mutations in the gene encoding the cystic fibrosis transmembrane conductance regulator (CFTR), an anion channel expressed in epithelial cells throughout the body. In the lungs, absence or dysfunction of CFTR results in altered epithelial salt and water transport eventuating in impaired mucociliary clearance, chronic infection and inflammation, and tissue damage. CF lung disease is the major cause of morbidity and mortality in CF despite the many therapies aimed at reducing it. However, recent technological advances combined with two decades of research driven by the discovery of the CFTR gene have resulted in the development and clinical testing of novel therapies aimed at the principal underlying defect in CF, thereby ushering in a new age of therapy for CF.
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Affiliation(s)
- James L Kreindler
- Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, 3615 Civic Center Boulevard, Abramson Research Center, Rm 1016-D, Philadelphia, PA 19104, USA.
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144
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Traini D, Young PM. Delivery of antibiotics to the respiratory tract: an update. Expert Opin Drug Deliv 2009; 6:897-905. [PMID: 19637984 DOI: 10.1517/17425240903110710] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The use of inhaled medications for the treatment of pulmonary diseases has become an increasingly popular drug delivery route over the past few decades. This delivery route allows for a drug to be delivered directly to the site of the disease, with a lower dose than more conventional oral or intravenous delivery methods, with reduced systemic absorption and consequently reduced risk of adverse effects. For asthma this delivery route has become the 'golden standard' of therapy. It is not unexpected therefore, that there has been great interest in the prospect of using inhaled antibiotics for the treatment of both chronic and recurrent respiratory infections. Since the early 1980s, several investigations have demonstrated that antibiotics could be delivered safely by means of inhalation, using nebulisers as their delivery systems. Lately, antibiotics delivery via inhalation have seen a 'revival' in interest and most of these studies have focused on delivering antibiotics to the lungs by means of a dry powder format. This review focuses on recent advances in antibiotic inhalation therapy.
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Affiliation(s)
- Daniela Traini
- University of Sydney, Faculty of Pharmacy (A15), Advanced Drug Delivery Group, NSW, Australia.
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145
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Inhaled medication and inhalation devices for lung disease in patients with cystic fibrosis: A European consensus. J Cyst Fibros 2009; 8:295-315. [DOI: 10.1016/j.jcf.2009.04.005] [Citation(s) in RCA: 187] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2009] [Revised: 04/05/2009] [Accepted: 04/08/2009] [Indexed: 12/12/2022]
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146
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Rottier BL, van Erp CJ, Sluyter TS, Heijerman HG, Frijlink HW, de Boer AH. Changes in Performance of the Pari eFlow® Rapid and Pari LC Plus™ during 6 Months Use by CF Patients. J Aerosol Med Pulm Drug Deliv 2009; 22:263-9. [DOI: 10.1089/jamp.2008.0712] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Bart L. Rottier
- Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Cyril J.P. van Erp
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, The Netherlands
| | | | | | - Henderik W. Frijlink
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, The Netherlands
| | - Anne H. de Boer
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, The Netherlands
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147
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Safdar A, Shelburne SA, Evans SE, Dickey BF. Inhaled therapeutics for prevention and treatment of pneumonia. Expert Opin Drug Saf 2009; 8:435-49. [PMID: 19538104 DOI: 10.1517/14740330903036083] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The lungs are the most common site of serious infection owing to their large surface area exposed to the external environment and minimum barrier defense. However, this architecture makes the lungs readily available for topical therapy. Therapeutic aerosols include those directed towards improving mucociliary clearance of pathogens, stimulation of innate resistance to microbial infection, cytokine stimulation of immune function and delivery of antibiotics. In our opinion inhaled antimicrobials are underused, especially in patients with difficult-to-treat lung infections. The use of inhaled antimicrobial therapy has become an important part of the treatment of airway infection with Pseudomonas aeruginosa in cystic fibrosis and the prevention of invasive fungal infection in patients undergoing heart and lung transplantation. Cytokine inhaled therapy has also been explored in the treatment of neoplastic and infectious disease. The choice of pulmonary drug delivery systems remains critical as air-jet and ultrasonic nebulizer may deliver sub-optimum drug concentration if not used properly. In future development of this field, we recommend an emphasis on the study of the use of aerosolized hypertonic saline solution to reduce pathogen burden in the airways of subjects infected with microbes of low virulence, stimulation of innate resistance to prevent pneumonia in immunocompromised subjects using cytokines or synthetic pathogen-associated molecular pattern analogues and more opportunities for the use of inhaled antimicrobials. These therapeutics are still in their infancy but show great promise.
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Affiliation(s)
- Amar Safdar
- The University of Texas, Department of Infectious Diseases, M. D. Anderson Cancer Center, Infection Control and Employee Health, 402, 1515 Holcombe Boulevard, Texas 77030, Houston, USA.
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148
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Abstract
BACKGROUND Inhaled drug delivery after lung transplantation provides a unique opportunity for direct treatment of a solid organ transplant. At present, no inhaled therapies are approved for this population though several have received some development. Primary potential applications include inhaled immunosuppressive and anti-infective drugs. OBJECTIVES The objective of this article is to review potential applications of inhaled medications for lung transplant recipients, the techniques used to develop inhaled drugs and the challenges of aerosol delivery in this specific population. METHODS The results of relevant studies are reviewed and two developmental examples are presented. RESULTS/CONCLUSIONS Inhaled medications may provide significant advantages for lung transplant recipients. Past studies with inhaled cyclosporine and amphotericin-B provide useful guidance for clinical development of new preparations.
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Affiliation(s)
- T E Corcoran
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, NW628 UPMC MUH, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA.
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149
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Máiz L, Lamas A, Fernández-Olmos A, Suárez L, Cantón R. Unorthodox long-term aerosolized ampicillin use for methicillin-susceptible Staphylococcus aureus lung infection in a cystic fibrosis patient. Pediatr Pulmonol 2009; 44:512-5. [PMID: 19360847 DOI: 10.1002/ppul.20983] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Staphylococcus aureus is a significant cause of pulmonary colonization in cystic fibrosis (CF) patients. The optimal strategy of therapy in chronically infected patients with this pathogen is not yet established. We report a successful long-term aerosolized ampicillin treatment of a 14-year-old girl with chronic symptomatic S. aureus lung infection.
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Affiliation(s)
- Luis Máiz
- Cystic Fibrosis Unit, Department of Pulmonology, Hospital Ramón y Cajal, Madrid, Spain.
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150
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Grotta MB, Etchebere ECDSC, Ribeiro AF, Romanato J, Ribeiro MAGDO, Ribeiro JD. Pulmonary deposition of inhaled tobramycin prior to and after respiratory therapy and use of inhaled albuterol in cystic fibrosis patients colonized with Pseudomonas aeruginosa. J Bras Pneumol 2009; 35:35-43. [PMID: 19219329 DOI: 10.1590/s1806-37132009000100006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Accepted: 06/05/2008] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate whether respiratory therapy followed by the use of inhaled albuterol modifies the pulmonary deposition of inhaled tobramycin in patients with cystic fibrosis (CF) and whether pulmonary deposition correlates with disease severity or genotype. METHODS A prospective study was carried out including patients with CF older than 6 years of age and colonized with Pseudomonas aeruginosa. Exclusion criteria were pulmonary exacerbation, changes in therapy between the study phases and FEV1 < 25%. All patients were submitted to pulmonary scintigraphy by means of a scintillation camera equipped with a low energy all purpose collimator in order to evaluate drug penetration following the administration of inhaled 99mTc-tobramycin, as well as to pulmonary perfusion with 99mTc-macroaggregated albumin (phase 1). One month later, the same procedure was performed following respiratory therapy and administration of inhaled albuterol (phase 2). RESULTS We included 24 patients (12 males) aged 5-27 years (mean +/- SD: 12.85 +/- 6.64 years). The Shwachman score (SS) was excellent/good in 8 patients, moderate/fair in 16 and poor in 0. Genotyping revealed that 7 patients were DeltaF508 homozygotes, 13 were DeltaF508 heterozygotes; and 4 presented other mutations. In all patients, lung deposition of tobramycin decreased in phase 2, especially in those with moderate/fair SS (p = 0.017) and in heterozygotes (p = 0.043). CONCLUSIONS The use of a respiratory therapy technique and the administration of inhaled albuterol immediately prior to the use of inhaled tobramycin decreased the pulmonary deposition of the latter in CF patients, and this reduction correlates with disease severity and genotype.
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