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McDonald RA, Nagy SG, Chambers M, Broberg CA, Ahonen MJR, Schoenfisch MH. Nitric oxide-releasing prodrug for the treatment of complex Mycobacterium abscessus infections. Antimicrob Agents Chemother 2024; 68:e0132723. [PMID: 38206003 PMCID: PMC10848776 DOI: 10.1128/aac.01327-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/17/2023] [Indexed: 01/12/2024] Open
Abstract
Non-tuberculosis mycobacteria (NTM) can cause severe respiratory infection in patients with underlying pulmonary conditions, and these infections are extremely difficult to treat. In this report, we evaluate a nitric oxide (NO)-releasing prodrug [methyl tris diazeniumdiolate (MD3)] against a panel of NTM clinical isolates and as a treatment for acute and chronic NTM infections in vivo. Its efficacy in inhibiting growth or killing mycobacteria was explored in vitro alongside evaluation of the impact to primary human airway epithelial tissue. Airway epithelial tissues remained viable after exposure at concentrations of MD3 needed to kill mycobacteria, with no inherent toxic effect from drug scaffold after NO liberation. Resistance studies conducted via serial passage with representative Mycobacterium abscessus isolates demonstrated no resistance to MD3. When administered directly into the lung via intra-tracheal administration in mice, MD3 demonstrated significant reduction in M. abscessus bacterial load in both acute and chronic models of M. abscessus lung infection. In summary, MD3 is a promising treatment for complex NTM pulmonary infection, specifically those caused by M. abscessus, and warrants further exploration as a therapeutic.
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Affiliation(s)
| | - Sarah G. Nagy
- Department of Chemistry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Chris A. Broberg
- Department of Chemistry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Mark H. Schoenfisch
- Vast Therapeutics, Durham, North Carolina, USA
- Department of Chemistry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
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McLeod C, Smyth AR, Messer M, Schultz A, Wood J, Norman R, Blyth CC, Webb S, Elliott Z, Van Devanter D, Stephenson AL, Tong A, Snelling TL. Protocol for establishing a core outcome set for evaluation in studies of pulmonary exacerbations in people with cystic fibrosis. BMJ Open 2022; 12:e056528. [PMID: 36153014 PMCID: PMC9511571 DOI: 10.1136/bmjopen-2021-056528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Pulmonary exacerbations are associated with increased morbidity and mortality in people with cystic fibrosis (CF). There is no consensus about which outcomes should be evaluated in studies of pulmonary exacerbations or how these outcomes should be measured. Outcomes of importance to people with lived experience of the disease are frequently omitted or inconsistently reported in studies, which limits the value of such studies for informing practice and policy. To better standardise outcome reporting and measurement, we aim to develop a core outcome set for studies of pulmonary exacerbations in people with CF (COS-PEX) and consensus recommendations for measurement of core outcomes. METHODS AND ANALYSIS Preliminary work for development of COS-PEX has been reported, including (1) systematic reviews of outcomes and methods for measurement reported in existing studies of pulmonary exacerbations; (2) workshops with people affected by CF within Australia; and (3) a Bayesian knowledge expert elicitation workshop with health professionals to ascertain outcomes of importance. Here we describe a protocol for the additional stages required for COS-PEX development and consensus methods for measurement of core outcomes. These include (1) an international two-round online Delphi survey and (2) consensus workshops to review and endorse the proposed COS-PEX and to agree with methods for measurement. ETHICS AND DISSEMINATION National mutual ethics scheme approval has been provided by the Child and Adolescent Health Service Human Research Ethics Committee (RGS 4926). Results will be disseminated via consumer and research networks and peer-reviewed publications. This study is registered with the Core Outcome Measures in Effectiveness Trials database.
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Affiliation(s)
- Charlie McLeod
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
- Infectious Diseases Department, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Alan Robert Smyth
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - Mitch Messer
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
| | - Andre Schultz
- Wal-Yan Respiratory Research Centre, Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
- Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Jamie Wood
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Richard Norman
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Christopher C Blyth
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
- Infectious Diseases Department, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Steve Webb
- Intensive Care Unit, St John of God Health Care, West Perth, Western Australia, Australia
- School of Population Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Zoe Elliott
- Consumer representative, University of Nottingham, Nottingham, UK
| | | | - Anne L Stephenson
- Department of Respirology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Allison Tong
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Thomas L Snelling
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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Giardina M, Barillà D, Crimi C, Arone A, Benedetto F, Lucanto C, Natoli R, Messina R, David A, Noto A. Ultrasound-guided placement of long peripheral cannula in children with cystic fibrosis. Pediatr Pulmonol 2022; 57:2060-2066. [PMID: 35574730 PMCID: PMC9545099 DOI: 10.1002/ppul.25978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/03/2022] [Accepted: 05/13/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The natural history of cystic fibrosis (CF) lung disease is a chronic deterioration of lung function with intermittent episodes of pulmonary infectious exacerbations (PExs). Reliable venous access is a milestone of effective management of such exacerbations, managed both in hospital and outpatient chronic therapy. The aim of our study was to analyze the feasibility of ultrasound-guided positioning of long peripheral catheters (LPC) as reliable midterm venous access in children affected by CF. METHODS In this single-center prospective study, over a 60-month period, we included paediatric CF subjects admitted with PExs and undergoing intravenous antibiotic treatment. LPCs were inserted in all participants by paediatric anaesthesiologists with ultrasound guide technique. Prospective data were collected assessing catheter positioning procedure and complications. RESULTS A total of 122 LPC insertions were performed in 55 CF children. Participants had a median age of 6.75 years (interquatile range: 3.7-13.5) at the time of catheter insertion. Implantation was successful on the first attempt in 86% of cases; 2 (1%) major insertion-related complications were reported. Eighty-eight percent of catheters were electively removed at the end of antibiotic therapy without any complication. Seven percent of the catheters were removed electively for occlusion and 2% for local dislodgment. CONCLUSIONS The results of the present study suggest that ultrasound-guided positioning of LPCs are safe alternative means of peripheral venous access in children with chronic diseases such as CF.
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Affiliation(s)
- Massimiliano Giardina
- Division of Anesthesia and Critical Care, A. O. U. Policlinico "G. Martino", Messina, Italy
| | - David Barillà
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Vascular Surgery, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Claudia Crimi
- Respiratory Medicine Unit, Policlinico "G. Rodolico-San Marco", University Hospital, Catania, Italy
| | - Amelia Arone
- IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Filippo Benedetto
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Vascular Surgery, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Cristina Lucanto
- Regional Centre for Cystic Fibrosis, A. O. U. Policlinico G.Martino, Messina, Italy
| | - Rossella Natoli
- School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Roberto Messina
- Division of Anesthesia and Critical Care, A. O. U. Policlinico "G. Martino", Messina, Italy
| | - Antonio David
- Department of Human Pathology of the Adult and Evolutive Age "Gaetano Barresi", Division of Anesthesia and Critical Care, University of Messina, Messina, Italy
| | - Alberto Noto
- Department of Human Pathology of the Adult and Evolutive Age "Gaetano Barresi", Division of Anesthesia and Critical Care, University of Messina, Messina, Italy
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Duration of intravenous antibiotic treatment for acute exacerbations of cystic fibrosis: A systematic review: Duration of treatment for acute exacerbations of cystic fibrosis. J Cyst Fibros 2021; 21:562-573. [PMID: 34588142 DOI: 10.1016/j.jcf.2021.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/07/2021] [Accepted: 08/22/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Acute exacerbations of Cystic Fibrosis (AECF) are associated with significant morbidity. Recommendations are to treat for 2-3 weeks despite limited data. Spirometry is a measure of clinical response yet appears to plateau at 7-10 days. While durations <9 days have been associated with poorer outcomes, a duration of 10 days may be as effective as 14 days, potentially conferring advantages in terms of cost and adverse events. A 2019 Cochrane review by Abbott et al. did not identify any randomised controlled trials (RCT) comparing durations of treatment. Utilising data from non-randomised studies (NRS), we report a systematic review of intravenous antibiotic treatment, exploring changes in FEV1 (Forced Expiratory Volume in 1 second), CRP (C-reactive protein) and peripheral WBC (white blood cell) count in studies with different treatment durations. STUDY DESIGN AND METHODS Systematic review of published literature following a search of MEDLINE, Embase, CINAHL and the Cochrane Clinical Trials register. Guidelines from the Preferred Reporting items for Systematic reviews and Meta-Analysis (PRISMA) and reporting Meta-analysis of Observational studies (MOOSE) statement were followed. RESULTS No randomised controlled trials were identified that specifically examined duration of treatment during AECF. This study included all relevant RCTs and also NRS, grouping according to study characteristics, such as length of treatment, location, year, and also characteristics of the patient population. 52 studies, comprising 79 subgroups, and 1,597 patients, were identified. Mean change (95%CI) in ppFEV1 was 10.13 (9.21-11.05). There was no significant difference in change in ppFEV1 for studies treating for 10-12 days; 8.85 (7.47-10.23), vs 13-15 days; 10.68 (9.53-11.82). Similar changes in CRP and WBC were seen irrespective of treatment duration. CONCLUSION This systematic review provides evidence that shorter durations of treatment may be associated with similar changes in FEV1, CRP and WBC compared with longer durations.
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Current and Future Treatments in Primary Ciliary Dyskinesia. Int J Mol Sci 2021; 22:ijms22189834. [PMID: 34575997 PMCID: PMC8470068 DOI: 10.3390/ijms22189834] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 01/05/2023] Open
Abstract
Primary ciliary dyskinesia (PCD) is a rare genetic ciliopathy in which mucociliary clearance is disturbed by the abnormal motion of cilia or there is a severe reduction in the generation of multiple motile cilia. Lung damage ensues due to recurrent airway infections, sometimes even resulting in respiratory failure. So far, no causative treatment is available and treatment efforts are primarily aimed at improving mucociliary clearance and early treatment of bacterial airway infections. Treatment guidelines are largely based on cystic fibrosis (CF) guidelines, as few studies have been performed on PCD. In this review, we give a detailed overview of the clinical studies performed investigating PCD to date, including three trials and several case reports. In addition, we explore precision medicine approaches in PCD, including gene therapy, mRNA transcript and read-through therapy.
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Amikacin Liposome Inhalation Suspension for Mycobacterium avium Complex Lung Disease: A 12-Month Open-Label Extension Clinical Trial. Ann Am Thorac Soc 2021; 18:1147-1157. [PMID: 33326356 PMCID: PMC8328368 DOI: 10.1513/annalsats.202008-925oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Rationale: Patients with refractory Mycobacterium avium complex (MAC) lung disease have limited treatment options. In the CONVERT study, amikacin liposome inhalation suspension (ALIS) added to guideline-based therapy (GBT) increased culture conversion rates versus GBT alone by Month 6. Limited data are available regarding >6-month treatment in a refractory population. Objectives: Evaluate 12-month safety, tolerability, and efficacy of ALIS+GBT. Methods: Adults with refractory MAC lung disease not achieving culture conversion by CONVERT Month 6 could enroll in this open-label extension (INS-312) to receive 590 mg once-daily ALIS+GBT for 12 months. Two cohorts enrolled: the “ALIS-naive” cohort included patients randomized to GBT alone in CONVERT, and the “prior-ALIS” cohort included those randomized to ALIS+GBT in CONVERT. Safety and tolerability of ALIS over 12 months (primary endpoint) and culture conversion by Months 6 and 12 were assessed. Results: In the ALIS-naive cohort, 83.3% of patients (n = 75/90) experienced respiratory treatment-emergent adverse events (TEAEs), and 35.6% (n = 32) had serious TEAEs; 26.7% (n = 24) achieved culture conversion by Month 6 and 33.3% (n = 30) by Month 12. In the prior-ALIS cohort, 46.6% of patients (n = 34/73) experienced respiratory TEAEs, and 27.4% (n = 20) had serious TEAEs; 9.6% (n = 7) achieved culture conversion by Month 6 (≤14 mo ALIS exposure) and 13.7% (n = 10) by Month 12 (≤20 mo ALIS exposure). Nephrotoxicity-related TEAEs and measured hearing decline were infrequent in both cohorts. Conclusions: In up to 20 months of ALIS use, respiratory TEAEs were common, nephrotoxicity and hearing decline were infrequent, and culture conversion continued beyond 6 months of therapy. Clinical trial registered with www.clinicaltrials.gov (NCT02628600).
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Treatment of Pulmonary Disease of Cystic Fibrosis: A Comprehensive Review. Antibiotics (Basel) 2021; 10:antibiotics10050486. [PMID: 33922413 PMCID: PMC8144952 DOI: 10.3390/antibiotics10050486] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/13/2021] [Accepted: 04/17/2021] [Indexed: 01/08/2023] Open
Abstract
Cystic fibrosis (CF) is a genetic disease that causes absence or dysfunction of a protein named transmembrane conductance regulatory protein (CFTR) that works as an anion channel. As a result, the secretions of the organs where CFTR is expressed are very viscous, so their functionality is altered. The main cause of morbidity is due to the involvement of the respiratory system as a result of recurrent respiratory infections by different pathogens. In recent decades, survival has been increasing, rising by around age 50. This is due to the monitoring of patients in multidisciplinary units, early diagnosis with neonatal screening, and advances in treatments. In this chapter, we will approach the different therapies used in CF for the treatment of symptoms, obstruction, inflammation, and infection. Moreover, we will discuss specific and personalized treatments to correct the defective gene and repair the altered protein CFTR. The obstacle for personalized CF treatment is to predict the drug response of patients due to genetic complexity and heterogeneity of uncommon mutations.
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Pulmonary Exacerbations in Adults With Cystic Fibrosis: A Grown-up Issue in a Changing Cystic Fibrosis Landscape. Chest 2021; 159:93-102. [PMID: 32966813 PMCID: PMC7502225 DOI: 10.1016/j.chest.2020.09.084] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 09/11/2020] [Accepted: 09/14/2020] [Indexed: 11/24/2022] Open
Abstract
Pulmonary exacerbations (PExs) are significant life events in people with cystic fibrosis (CF), associated with declining lung function, reduced quality of life, hospitalizations, and decreased survival. The adult CF population is increasing worldwide, with many patients surviving prolonged periods with severe multimorbid disease. In many countries, the number of adults with CF exceeds the number of children, and PExs are particularly burdensome for adults as they tend to require longer courses and more IV treatment than children. The approach to managing PExs is multifactorial and needs to evolve to reflect this changing adult population. This review discusses PEx definitions, precipitants, treatments, and the wider implications to health-care resources. It reviews current management strategies, their relevance in particular to adults with CF, and highlights some of the gaps in our knowledge. A number of studies are underway to try to answer some of the unmet needs, such as the optimal length of treatment and the use of nonantimicrobial agents alongside antibiotics. An overview of these issues is provided, concluding that with the changing landscape of adult CF care, the definitions and management of PExs may need to evolve to enable continued improvements in outcomes across the age spectrum of CF.
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Somayaji R, Nichols DP, Bell SC. Cystic fibrosis - Ten promising therapeutic approaches in the current era of care. Expert Opin Investig Drugs 2020; 29:1107-1124. [PMID: 32744089 DOI: 10.1080/13543784.2020.1805733] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Cystic fibrosis (CF) is a genetic disease affecting multiple organ systems. Research and innovations in novel therapeutic agents and health care delivery have resulted in dramatic improvements in quality of life and survival for people with CF. Despite this, significant disease burden persists for many and this is compounded by disparities in treatment access and care which globally necessitates further work to improve outcomes. Because of the advent of numerous therapies which include gene-targeted modulators in parallel with specialized care delivery models, innovative efforts continue. AREAS COVERED In this review, we discuss the available data on investigational agents in clinical development and currently available treatments for CF. We also evaluate approaches to care delivery, consider treatment gaps, and propose future directions for advancement. EXPERT OPINION Since the discovery of the CF gene, CFTR modulators have provided a hallmark of success, even though it was thought not previously possible. This has led to reinvigorated efforts and innovations in treatment approaches and care delivery. Numerous challenges remain because of genetic and phenotypic heterogeneity, access issues, and therapeutic costs, but the collaborative approach between stakeholders for continued innovation fuels optimism. Abbreviations: CF cystic fibrosis; CFF Cystic Fibrosis Foundation (USA); CFTR cystic fibrosis transmembrane regulator; CRISPR clustered regularly interspaced short palindromic repeats; COX cyclo oxygenase; FDA US Food and Drug Administration; FEV1% forced expiratory volume in one second % predicted; F508del deletion of phenylalanine (F) in the 508th position (most common mutation); G551D substitution of the amino acid glycine by aspartate at position 551 in the nucleotide binding domain-1 of the CFTR gene; LMIC low- and middle-income country; LTB4 leukotriene B4; MDT multi-disciplinary care team; NO nitric oxide; NSAIDs non-steroidal anti-inflammatory drugs; SLPI secretory leukocyte protease inhibitor.
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Affiliation(s)
- Ranjani Somayaji
- Departments of Medicine; Microbiology, Immunology & Infectious Disease; Community Health Sciences, University of Calgary , Calgary, AB, Canada.,Snyder Institute for Chronic Diseases , Calgary, AB, Canada.,O'Brien Institute for Public Health , Calgary, AB, Canada
| | - Dave P Nichols
- Department of Pediatrics, Seattle Children's Hospital , Seattle, WA, USA.,Department of Pediatrics, University of Washington , Seattle, WA, USA.,Seattle Children's Research Institute , Seattle, WA, USA
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital , Brisbane, QLD, Australia.,Children's Health Research Centre, Faculty of Medicine, The University of Queensland , Brisbane, QLD, Australia.,Translational Research Institute , Brisbane, QLD, Australia
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