Cochrane Review: Immunostimulants for preventing respiratory tract infection in children

Bacterial immunotherapy is highly effective in reducing recurrent upper respiratory tract infections in children: a prospective observational study

PURPOSE

Whilst immunotherapy is an appealing option as it could reduce the burden of recurrent pediatric respiratory tract infections (RTI), there is limited evidence on its effectiveness and more research was requested in order to better understand this therapeutic modality.

METHODS

We performed a prospective cohort study involving 57 subjects to assess the safety and effectiveness a 3-month regimen of either typified or patient-specific bacterial lysates could have in reducing the number of RTIs in children aged 0 to 11 years with histories of recurrent episodes.

RESULTS

After a 6-month follow-up, the number of RTIs and school absenteeism dropped sharply and significantly, from an adjusted mean (standard error) of 0.6 (0.04) episodes/month to 0.1 (0.03) episodes/month (74.7% reduction, P < 0.001), and from an adjusted mean score of 4.6 (1.06) points to 0.0 (0.01) points over 10 (99.5% reduction, P < 0.001), respectively. There was also a significant decrease in the severity of symptoms. No adverse reactions were observed.

CONCLUSION

The use of the study product is associated with a decreased risk of recurrent RTIs in children, with a very favorable safety profile that warrants further investigation in randomized clinical trials.

Immunostimulants versus placebo for preventing exacerbations in adults with chronic bronchitis or chronic obstructive pulmonary disease

BACKGROUND

Individuals with chronic obstructive pulmonary disease (COPD) or chronic bronchitis may experience recurrent exacerbations, which negatively impact prognosis and quality of life, and can impose a significant socioeconomic burden on the individual and wider society. Immunostimulants are a broad category of therapies that may theoretically enhance non-specific immunity against several respiratory insults, thereby reducing exacerbation risk and severity. However, evidence to date for their use in this population is limited.

OBJECTIVES

To determine the efficacy of immunostimulants in preventing respiratory exacerbations in adults with chronic obstructive pulmonary disease, chronic bronchitis, or both.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest literature search was conducted on 25 January 2022.  SELECTION CRITERIA: We included parallel randomised controlled trials (RCTs) that compared immunostimulant therapy, administered by any method and with the intention of preventing (rather than treating) exacerbations, with placebo for a minimum treatment duration of one month in adults with chronic bronchitis or COPD, or both. We excluded participants with other respiratory conditions.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were number of participants with no exacerbations during the study period and all-cause mortality, secondary outcomes were respiratory-related mortality, quality of life, number of participants requiring antibiotics, exacerbation duration, respiratory-related hospitalisation duration and adverse events/side effects. We used GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

This review included 36 studies involving 6192 participants. Studies were published between 1981 and 2015. Duration ranged from three to 14 months. The mean age of study participants varied between 35.2 and 82 years. Twelve studies examined participants with COPD only. Seventeen studies reported baseline lung function values; most indicated a moderate-to-severe degree of airflow limitation. Nineteen studies indicated inclusion of participants with a mean baseline exacerbation frequency of two or more in the preceding year. Immunostimulants investigated were OM-85, AM3, RU41740 (Biostim), Ismigen, Diribiotine CK, thymomodulin, pidotimod, D53 (Ribomunyl), Lantigen B, Symbioflor, and hyaluronan; routes of administration were oral, sublingual, and subcutaneous. The risk of bias of the included studies was mostly low or unclear. Participants receiving immunostimulants for a mean duration of six months were slightly more likely to be free of exacerbations during that time (odds ratio (OR) 1.48, 95% confidence interval (CI) 1.15 to 1.90; 15 RCTs, 2961 participants; moderate-certainty evidence). The overall number needed to treat with immunostimulants for a mean of six months, to prevent one participant from experiencing an exacerbation, was 11 (95% CI 7 to 29). This outcome was associated with a moderate degree of unexplained heterogeneity (I2 = 53%). Type of immunostimulant, baseline lung function, baseline exacerbation frequency, treatment duration, and follow-up duration did not modify the effect size, although due to heterogeneity and limited study and participant numbers within some subgroups, the validity of the subgroup treatment effect estimates were uncertain. Immunostimulants probably result in little to no difference in all-cause mortality (OR 0.64, 95% CI 0.37 to 1.10; 5 RCTs, 1558 participants; moderate-certainty evidence) and respiratory-related mortality (OR 0.40, 95% CI 0.15 to 1.07; 2 RCTs, 735 participants; low-certainty evidence) compared to placebo; however, the effects were imprecise and data quality limited the certainty of these results.  There was a small improvement in health-related quality of life, as measured by the St George's Respiratory Questionnaire (SGRQ), with immunostimulant compared to placebo (mean difference -4.59, 95% CI -7.59 to -1.59; 2 RCTs, 617 participants; very-low certainty evidence). The effect estimate just met the minimum clinically important difference (MCID) score of 4 units; however, the CI width means the possibility of a non-meaningful difference cannot be excluded. The pooled result from five studies indicated that immunostimulants likely reduce the number of participants requiring antibiotics over a mean duration of six months (OR 0.34, 95% CI 0.18 to 0.63; 542 participants; moderate-certainty evidence). This outcome had a low-to-moderate degree of heterogeneity (I2 = 38%), but the direction of effect was consistent across all studies. There was no evidence of a difference in the odds of experiencing an adverse event with immunostimulant compared to placebo, over a mean duration of six months (OR 1.01, 95% CI 0.84 to 1.21; 20 RCTs, 3780 participants; high-certainty evidence). The CI limits for the associated risk ratio (RR) did not cross thresholds for appreciable harm or benefit (RR 1.02, 95% CI 0.92 to 1.13). An additional seven studies reported no events rates in either study arm. Meta-analyses were not performed for the outcomes of exacerbation duration and respiratory-related hospitalisation duration, due to high levels of heterogeneity across the included studies (exacerbation duration: I2 = 92%; respiratory-related hospitalisation duration: I2 = 83%). Results from an effect direction plot and binomial probability test for exacerbation duration indicated that a significant proportion of studies (94% (95% CI 73% to 99%); P = 0.0002) favoured intervention, possibly indicating that immunostimulants are efficacious in reducing the mean exacerbation duration compared to placebo. However, the degree of uncertainty associated with this estimate remained high due to data quality and heterogeneity. Three studies reported mean duration of respiratory-related hospitalisation, two of which demonstrated a direction of effect that favoured immunostimulant over placebo.

AUTHORS' CONCLUSIONS

In participants with chronic bronchitis or COPD, we are moderately confident that treatment with immunostimulants is associated with a small reduction in the likelihood of having an exacerbation and a moderate reduction in the requirement for antibiotics. Low numbers of events limit interpretation of the effect of immunostimulants on all-cause and respiratory-related mortality. We are uncertain whether immunostimulants improve quality of life, and whether they are associated with a reduction in exacerbation and respiratory-related hospitalisation durations, although immunostimulants were generally associated with a positive effect direction in the studies that examined these outcomes. Immunostimulants appear to be safe and well-tolerated, and are not associated with an increased risk of adverse events.

Prevention of recurrent respiratory infections : Inter-society Consensus

Recurrent respiratory infections (RRIs) are a common clinical condition in children, in fact about 25% of children under 1 year and 6% of children during the first 6 years of life have RRIs. In most cases, infections occur with mild clinical manifestations and the frequency of episodes tends to decrease over time with a complete resolution by 12 years of age. However, RRIs significantly reduce child and family quality of life and lead to significant medical and social costs.Despite the importance of this condition, there is currently no agreed definition of the term RRIs in the literature, especially concerning the frequency and type of infectious episodes to be considered. The aim of this consensus document is to propose an updated definition and provide recommendations with the intent of guiding the physician in the complex process of diagnosis, management and prevention of RRIs.

Bacterial Mucosal Immunotherapy with MV130 Prevents Recurrent Wheezing in Children: A Randomized, Double-Blind, Placebo-controlled Clinical Trial

Rationale: Recurrent wheezing in children represents a severe public health concern. Wheezing attacks (WA), mainly associated with viral infections, lack effective preventive therapies. Objectives: To evaluate the efficacy and safety of mucosal sublingual immunotherapy based on whole inactivated bacteria (MV130) in preventing WA in children. Methods: A Phase 3 randomized, double-blind, placebo-controlled, parallel-group trial including a cohort of 120 children <3 years old with ⩾3 WA during the previous year was conducted. Children with a positive skin test to common aeroallergens in the area where the clinical trial was performed were excluded from the trial. Subjects received MV130 or placebo daily for 6 months. The primary endpoint was the number of WA within 1 year after the first dose comparing MV130 and placebo. Measurements and Main Results: There was a significant lower number of WA in MV130 versus the placebo group, 3.0 (interquartile range [IQR], 2.0-4.0) versus 5.0 (IQR, 3.0-7.0) (P < 0.001). As secondary outcomes, a decrease in the duration of WA and a reduction in symptoms and medication scores in the MV130 versus placebo group were found. No adverse events were reported related to the active treatment. Conclusions: Mucosal bacterial immunotherapy with MV130 shows safety and clinical efficacy against recurrent WA in children.Clinical trial registered with www.clinicaltrials.gov (NCT01734811).

Trained Immunity-Based Vaccine in B Cell Hematological Malignancies With Recurrent Infections: A New Therapeutic Approach

Infectious complications are a major cause of morbidity and mortality in B-cell hematological malignancies (HM). Prophylaxis for recurrent infections in HM patients with antibody deficiency consists of first-line antibiotics and when unsuccessful, gammaglobulin replacement therapy (IgRT). Recent knowledge of trained immunity-based vaccines (TIbV), such as the sublingual polybacterial formulation MV130, has shown a promising strategy in the management of patients with recurrent infections. We sought to determine the clinical benefit of MV130 in a cohort of HM patients with recurrent respiratory tract infections (RRTIs) who underwent immunization with MV130 for 3 months. Clinical information included the frequency of infections, antibiotic use, number of visits to the GP and hospitalizations previous and after MV130 immunotherapy. Improvement on infection rate was classified as: clear (>60% reduction of infection), partial (26%-60%) and low (≤25%) improvement. Fifteen HM patients (aged 42 to 80 years; nine females) were included in the study. All patients reduced their infection rate. Analysis of paired data revealed that the median (range, min - max) of respiratory infectious rate significantly decreased from 4.0 (8.0-3.0) to 2.0 (4.0-0.0) (p<0.001) at 12 months of MV130. A clear clinical improvement was observed in 53% (n = 8) of patients, partial improvement in 40% (n = 6) and low improvement in 7% (n = 1). These data correlated with a decrease on antibiotic consumption from 3.0 (8.0-1.0) to 1.0 (2.0-0.0) (p = 0.002) during 12 months after initiation of treatment with MV130. The number of infectious-related GP or emergency room visits declined from 4.0 (8.0-2.0) to 2.0 (3.0-0.0) (p<0.001), in parallel with a reduction in hospital admissions due to infections (p = 0.032). Regarding safety, no adverse events were observed. On the other hand, immunological assessment of serum IgA and IgG levels demonstrated an increase in specific antibodies to MV130-contained bacteria following MV130 immunotherapy. In conclusion, MV130 may add clinical benefit reducing the rate of infections and enhancing humoral immune responses in these vulnerable patients.

A pharmacology-based comprehensive review on medicinal plants and phytoactive constituents possibly effective in the management of COVID-19

Arisen in China, COVID-19 (SARS-CoV-II) is a novel coronavirus that has been expanding fast worldwide. Till now, no definite remedial drug or vaccine has been identified for COVID-19 treatment. Still, for a majority of infected patients, supportive therapy is the cornerstone of the management plan. To the importance of managing the COVID-19 pandemic, this article proposed to collecting capable medicinal plants and bioactive components in both treat and supportive therapy of this novel viral infection. Clinical points in the pathogenesis, symptoms, and complications of COVID-19 were considered. The effective plants and bioactives that may play a role in supportive therapy/management of COVID-19 were searched, collected through the "Scopus" database and listed in three sections. Numerous medicinal plants such as Citrus Spp., Camellia sinensis, and Glycyrrhiza glabra can interference with COVID-19 pathogenesis via inhibition of virus replication and entry to its host cells. Also, some anti-inflammatory herbal medicine such as Andrographis paniculata, Citrus spp., and Cuminum cyminum can relieve fever and cough in COVID-19 patients. Medicinal plants such as G. glabra, Thymus vulgaris, Allium sativum, Althea officinalis, and Panax ginseng may modulate the immune system and possess prevention and supportive therapy. However, more clinical data are required to confirm these hypotheses.

Bacterial Lysates as Immunotherapies for Respiratory Infections: Methods of Preparation

Bacterial lysates, prepared from the microorganisms most frequently involved in human Respiratory Tract Infections (RTIs) have been in the market for several decades, and at present, several different brands are available in many countries worldwide. They all claimed to exert local and systemic immunomodulatory effects but different clinical trials show disparate results between them. The lack of consistency of predicted therapeutic effects has undermined their clinical use and hampered licensing in several countries. One explanation for such lack of consistency in the results is that their methods of preparation are also very different. Here, we review the available literature describing methods of preparation of bacterial lysates, including patent disclosure documents. We found a great variety of methodologies of preparation and a lack of standardized procedures among them. The main conclusion of our study is that there is a clear need for standardized protocols of production to obtain comparable results in clinical trials worldwide.

Paediatric Recurrent Ear, Nose and Throat Infections and Complications: Can We Do More?

Recurrent respiratory tract infections (rRTIs), of which there are three main groups-otitis media, tonsillitis and sinusopathies-are very common in paediatric populations and are associated with significant morbidity and mortality due to complications. These infections substantially reduce quality of life for paediatric patients and their families and are a significant personal, medical and economic burden on the patients, the patients' families and the healthcare system. Most rRTIs are of viral origin; however, indiscriminate use of antibiotics in their treatment has led to development of bacterial resistance. Effective management of rRTIs to reduce the burden of disease and to avoid overuse of antibiotics has become a great therapeutic challenge. New strategies for the management of paediatric rRTIs include focus on prevention using non-specific immunomodulators to boost the body's natural defences against infection and to downregulate infection- and allergen-induced airway inflammation. The oral immunomodulator, OM-85, a bacterial lysate, acts on the innate and adaptive branches of the immune system, conferring protection against viral and bacterial infections, and controls inflammation, thereby reducing tissue damage. OM-85 has demonstrated good tolerability and clinical efficacy in reducing the number and duration of RTIs in children with recurrent airway infections. It has also been reported to reduce the use of concomitant medications, including antibiotics, time to cure and school absenteeism. OM-85 is efficacious and well tolerated when administered concomitantly with inactivated influenza vaccine (IIV) and has been shown to reduce wheezing attacks induced by RTI in young children. Clinical results show that the greater the risk of rRTIs, the greater the benefit with OM-85. OM-85 may be considered a promising tool to add to the limited armamentarium of the ear, nose and throat (ENT) physician dealing with rRTIs and their complications, such as recurrent wheeze and asthma inception.

Preschool Wheezing: Trajectories and Long-Term Treatment

Wheezing is very common in infancy affecting one in three children during the first 3 years of life. Several wheeze phenotypes have been identified and most rely on temporal pattern of symptoms. Assessing the risk of asthma development is difficult. Factors predisposing to onset and persistence of wheezing such as breastfeeding, atopy, indoor allergen exposure, environmental tobacco smoke and viral infections are analyzed. Inhaled corticosteroids are recommended as first choice of controller treatment in all preschool children irrespective of phenotype, but they are particularly beneficial in terms of fewer exacerbations in atopic children. Other therapeutic options include the addition of montelukast or the intermittent use of inhaled corticosteroids. Overuse of inhaled steroids must be avoided. Therefore, adherence to treatment and correct administration of the medications need to be checked at every visit.

A randomized, placebo-controlled, double-blinded, single-centre, phase IV trial to assess the efficacy and safety of OM-85 in children suffering from recurrent respiratory tract infections

BACKGROUND

Over many years, OM-85, a lysate of 21 common bacterial respiratory pathogens, has been demonstrated to prevent respiratory recurrences in children. However, further studies are needed to explore the true importance of OM-85 in the prevention of respiratory tract infections (RTIs) in children. This study was planned to further contribute to the evaluation of the role played by OM-85 in prevention of recurrent RTIs in children.

METHODS

This study was a randomized (3:3:1), placebo-controlled, double-blind, single-centre, phase IV trial carried out in Italy to assess the efficacy of OM-85 (Broncho-Vaxom®; Vifor Pharma; Meyrin 2/Geneva, Switzerland) in reducing the number of new RTI episodes in 288 children aged 1 to 6 years with a history of recurrent RTIs and to compare the efficacy of the standard 3-month regimen with that of administration of OM-85 for 6 months during a 6-month study period.

RESULTS

The number of RTIs and of children who experienced at least one RTI were significantly lower among patients receiving OM-85 for 3 months than among those given placebo (33% vs 65.1%, p < 0.0001). Differences were statistically significant for upper RTIs (i.e., common cold/viral pharyngitis and acute otitis media; p < 0.0001 and p = 0.006, respectively). Days of absence from day-care for children and working days lost by parents were significantly lower in the group with children treated with OM-85 for 3 months than in the placebo group (p = 0.007 and p = 0.004, respectively). No difference was seen between children who received OM-85 for 3 and those who received OM-85 for 6 months. The prevalence of atopy as well as the history of recurrent wheezing and age of the study child did not influence the results. Benefit was maximally evident among children with a history of frequent recurrences. OM-85 was well tolerated and safe, even in children who received an influenza vaccination.

CONCLUSIONS

The use of OM-85 for 3 months in 3 series of 10 consecutive days each time reduces the risk of recurrent RTIs in children, with a favourable safety profile. The greater effect observed in children prone to several respiratory episodes than in non-prone children seems to indicate that this lysate should be administered especially to children with a proven high susceptibility to RTIs.

Cost-effectiveness analysis of OM-85 vs placebo in the prevention of acute respiratory tract infections (ARTIs) in children that attend day-care centers

BACKGROUND

Children that attend day-care centers frequently contract acute respiratory tract infections (ARTIs). ARTIs represent a burden for both children and parents. Systematic reviews on the use of immunostimulants for the prevention of juvenile recurrent ARTIs have provided moderate evidence of efficacy and safety. The aim of the study was to establish whether the immunostimulant, OM-85, was cost-effective in preventing ARTIs in children 2-6 years old that attended day-care centers or preschools in Mexico. We performed a systematic review to evaluate the efficacy of OM-85. For costs, we assumed an institutional perspective, which included the costs of care and supplies over a study period of six months, during the autumn-winter seasons. We created decision trees and constructed a model to identify pharmacoeconomic parameters. We generated 1000 estimations with the bootstrap method to calculate descriptive statistics of pharmacoeconomic parameters. We evaluated cost-effectiveness compared to treatment without immunostimulants.

RESULTS

The mean (SD) incidences of ARTIs were 5.59 ± 0.29 without immunostimulants and 2.97 ± 0.32 with OM-85, during the study period. The mean (25th, 75th percentile) direct costs of ARTIs were 57.04 (37.11, 76.39) US$ (US dollars) without immunostimulants and 48.53 (37.35, 58.93) US$ with OM-85, with a mean increment of - 8.51(- 17.08, 0.75) US$, and a mean cost-effectiveness of - 17.94 (- 36.48, 1.66) US$. The direct costs plus the cost of one parent missing work to care for the child with ARTI were 125.76 (102.83, 150.16) US$, without immunostimulant and 85.21 (72.15, 98.81) US$, with OM-85. The increment was - 40.55 (- 68.29, - 13.95) US$, and the cost-effectiveness was - 86.89 (- 142.37, - 29.34) US$.Part of the cost reduction was ascribed to the reduced use of medications, particularly antibiotics.

CONCLUSIONS

Our results were consistent with previous clinical studies conducted in closed institutions in Mexico. OM-85 reduced the number of ARTIs and the frequency of antibiotics use. We concluded that OM-85 was cost-effective for preventing ARTIs in children that attended day-care centers, particularly when parental absenteeism was covered by the institutions.

Mucosal bacterial immunotherapy with MV130 highly reduces the need of tonsillectomy in adults with recurrent tonsillitis

Recurrent tonsillitis in adults is a common ENT disease. The current standard treatment is tonsillectomy. However, continuous prophylaxis with antibiotics has been prescribed in order to avoid tonsillectomy. The objective was to evaluate if the bacterial immunotherapy (Bactek MV130) together with the prophylactic antibiotic therapy can produce clinical improvement and to avoid the tonsillectomy. Material and methods: The medical records of 88 patients with recurrent tonsillitis were reviewed. Sixty-six were treated during 3 months with a course of antibiotics and 22 received, in addition to the antibiotics, immunotherapy with Bactek MV130 during this Globally, 53 (60%) patients had clinical improvement and 35 were tonsillectomized. In the The group of patients who received only antibiotic, 35 (53%) avoided tonsillectomy and 31 (47%) did not. In the group that, in addition to antibiotics, were treated with Bactek MV130, 18 patients (82%) experi- enced clinical improvement avoiding tonsillectomy and 4 (18%) didn't improve and the tonsils were surgically removed. The difference between both groups was significant (P = 0.023).he results obtained in this evaluation support this combined treatment as an effective strategy to reduce the need of tonsillectomy.

Immunity-targeted approaches to the management of chronic and recurrent upper respiratory tract disorders in children

Background

Upper respiratory tract infections (URTIs), including rhinitis, nasopharyngitis, tonsillitis and otitis media (OM), comprise of 88% of total respiratory infections, especially in children. Therefore effective prevention and treatment of RTIs remain a high priority worldwide. Preclinical and clinical data highlight the rationale for the use and effectiveness of immunity‐targeted approaches, including targeted immunisations and non‐specific immunomodulation in the prevention and management of recurrent upper RTIs.

Objective of review

The idea of this review was to summarise the current evidence and address key questions concerning the use of conservative and immunity‐targeted approaches to recurrent and chronic URTIs, with a focus on the paediatric population.

Search strategy/Evaluation method

Literature searches were conducted in March 2017 and updated in September 2017 using: Academic Search Complete; CENTRAL; Health Source: Nursing/Academic Edition; MEDLINE; clinicaltrials.gov; and Cochrane databases. In total, 84 articles were retrieved and reviewed. Two independent researchers focused on primary and secondary endpoints in systematic reviews, meta‐analyses and randomised, controlled trials, using immunity‐directed strategies as the control group or within a subpopulation of larger studies. Existing guidelines and interventional/observational studies on novel applications were also included.

Results

Children are particularly susceptible to RTIs due to the relative immaturity of their immune systems, as well as other potential predisposing factors such as day care attendance and/or toxic environmental factors (eg increased pathogenic microbial exposure and air pollutants). Recurrent URTIs can affect otherwise healthy children, leading to clinical sequelae and complications, including the development of chronic conditions or the need for surgery. Available pre‐clinical and clinical data highlight the rationale for the use and effectiveness of immunity‐targeted approaches, including targeted immunisations (flu and pneumococcal vaccines) and non‐specific immunomodulation (bacterial lysates), in the prevention and management of recurrent croup, tonsillitis, otitis media, recurrent acute rhinosinusitis and chronic rhinosinusitis.

Conclusions

In this review, we summarise the current evidence and provide data demonstrating that some immunity‐targeted strategies, including vaccination and immunomodulation, have proved effective in the treatment and prevention of recurrent and chronic URTIs in children.

Pulmonary Artery Sling Presenting as Pneumonia and Inhalation of a Foreign Body

Pulmonary artery sling is a rare cause of respiratory distress created by compression of the lower trachea and right mainstem bronchus due to an aberrant origin of the left pulmonary artery. The condition is frequently associated with recurrent respiratory infections and other congenital malformations including tracheal rings. We present the case of an infant presenting with pulmonary distress and a history of recurrent respiratory infection. The infant underwent surgery to remove a foreign object; however, the symptoms did not resolve. Bronchoscopy revealed bronchus stenosis, and subsequent echocardiogram and CT scans revealed the presence of a pulmonary artery sling. We prescribed infection prophylaxis with the immunomodulator OM-85 to mitigate the risk of further infections prior to surgery. PAS and bronchus stenosis were corrected successfully by surgical intervention leading to resolution of symptoms of respiratory distress and a reduction in the incidence of respiratory infection.

The Contribution of Complementary and Alternative Medicine to Reduce Antibiotic Use: A Narrative Review of Health Concepts, Prevention, and Treatment Strategies

AIM

The aim of this narrative review was to explore the potential contributions of CAM to reduce antibiotic use.

METHODS

We searched PubMed, Embase, and Cochrane Database of Systematic Reviews with a specific, limited set of search terms and collected input from a group of expert CAM researchers to answer the question: What is known about the contribution of CAM health and health promotion concepts, infection prevention, and infection treatment strategies to reduce antibiotic use? Results. The worldview-related CAM health concepts enable health promotion oriented infection prevention and treatment aimed at strengthening or supporting the self-regulating ability of the human organism to cope with diseases. There is some evidence that the CAM concepts of health (promotion) are in agreement with current conceptualization of health and that doctors who practice both CAM and conventional medicine prescribe less antibiotics, although selection bias of the presented studies cannot be ruled out. There is some evidence that prevention and some treatment strategies are effective and safe. Many CAM treatment strategies are promising but overall lack high quality evidence.

CONCLUSIONS

CAM prevention and treatment strategies may contribute to reducing antibiotic use, but more rigorous research is necessary to provide high quality evidence of (cost-)effectiveness.

Evidence that a primary anti-viral stimulation of the immune response by OM-85 reduces susceptibility to a secondary respiratory bacterial infection in mice

BACKGROUND

Viral respiratory infections may promote bacterial super-infection decreasing the host immune response efficiency. However, using a mice model we recently demonstrated that preventive treatment with the bacterial extract OM-85 reduces the susceptibility to a secondary Streptococcus (S.) pneumoniae infection after influenza virus (I.V.) challenge.

METHODS

To better characterize the efficacy of OM-85 against S. pneumoniae super-infection, a post-hoc analysis was conducted, comparing efficacy (survival) and morbidity signs (clinical score, body temperature and weight loss) in the OM-85 and the control (BLANC) groups of mice after: a) I.V. infection; b) primary S. pneumoniae infection and c) post-I.V. S. pneumoniae super-infection.

RESULTS

After a sublethal I.V. dose, all mice stayed alive at day 5 and no differences in morbidity signs were detected between the OM-85 and the BLANC groups. However, OM-85 pretreatment led to a significantly reduction of the viral load in the lung on day 5 post viral infection and, on day 10, reduced neutrophilic inflammation while increasing influenza-specific CD8 + T-cell proportion in the airways. Conversely to viral infection, exposure to S. pneumoniae induced a dramatic reduction of survival, with no mice surviving on day 3 post infection in the BLANC group, whereas a partial protective effect was observed in OM-85 pre-treated mice (20% of mice surviving at day 3, and 10% at day 4 and 5). The morbidity data substantiated the survival results. Interestingly, in the "super-infection" study, when mice were exposed to a sublethal I.V. dose followed by a secondary S. pneumoniae infection, all mice died by day 4 in the BLANC group. In contrast, in the OM-85 treated group, the survival rate was 70% at day 4 and still 50% at day 5, with positive effects on the clinical scores and on the body temperature already detectable at days 1 and 2.

CONCLUSIONS

The efficacy of OM-85 pre-treatment against S. pneumoniae super-infection reflects a strong and immediate immune reaction from the host, an event that can be explained in part by a "non-specific" activation of the immune system, a positive "immune effect" of the general OM-85- induced immune response against I.V.

Nonspecific immunomodulators for recurrent respiratory tract infections, wheezing and asthma in children: a systematic review of mechanistic and clinical evidence

PURPOSE OF REVIEW

To provide an overview of the mechanistic and clinical evidence for the use of nonspecific immunomodulators in paediatric respiratory tract infection (RTI) and wheezing/asthma prophylaxis.

RECENT FINDINGS

Nonspecific immunomodulators have a long history of empirical use for the prevention of RTIs in vulnerable populations, such as children. The past decade has seen an increase in both the number and quality of studies providing mechanistic and clinical evidence for the prophylactic potential of nonspecific immunomodulators against both respiratory infections and wheezing/asthma in the paediatric population. Orally administered immunomodulators result in the mounting of innate and adaptive immune responses to infection in the respiratory mucosa and anti-inflammatory effects in proinflammatory environments. Clinical data reflect these mechanistic effects in reductions in the recurrence of respiratory infections and wheezing events in high-risk paediatric populations. A new generation of clinical studies is currently underway with the power to position the nonspecific bacterial lysate immunomodulator OM-85 as a potential antiasthma prophylactic.

SUMMARY

An established mechanistic and clinical role for prophylaxis against paediatric respiratory infections by nonspecific immunomodulators exists. Clinical trials underway promise to provide high-quality data to establish whether a similar role exists in wheezing/asthma prevention.

[The use of fenspiride for the combined treatment of exacerbation of chronic laryngitis]

The present study was carried out based at the Department of Otorhinolaryngology of I.P. Pavlov First State Medical University of Saint-Petersburg. The objective of this work was to elucidate the efficacy and safety of fenspiride therapy for the treatment of exacerbation of chronic laryngitis associated with an acute respiratory infection. The patients comprising the main group received fenspiride (Eurespal, 'Servier', France) at the standard dose in addition to the conventional therapy with the use of antibiotics, inhalation, and voice rest. The patients in the group of comparison were treated following the conventional protocol without fenspiride. The clinical symptoms evaluated based on the scoring system, the results of videolaryngoscopy, and computer-assisted analysis of the voice were compared before and after treatment in the patients of both groups. The results of the study have confirmed the high effectiveness and safety of fenspiride therapy of exacerbation of chronic laryngitis.

Oral Astragalus (Huang qi) for preventing frequent episodes of acute respiratory tract infection in children

BACKGROUND

Acute respiratory tract infections (ARTIs) are common in children and can involve both upper and lower airways. Many children experience frequent ARTI episodes or recurrent respiratory tract infections (RRTIs) in early life, which creates challenges for paediatricians, primary care physicians, parents and carers of children.In China, Astragalus (Huang qi), alone or in combination with other herbs, is used by Traditional Chinese Medicine (TCM) practitioners in the form of a water extract, to reduce the risk of ARTIs; it is believed to stimulate the immune system. Better understanding of the therapeutic mechanisms of Astragalus may provide insights into ARTI prevention, and consequently reduced antibiotic use.

OBJECTIVES

To assess the effectiveness and safety of oral Astragalus for preventing frequent episodes of acute respiratory tract infections (ARTIs) in children in community settings.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 12, 2015), MEDLINE (Ovid) (1946 to 31 December 2015), Embase (Elsevier) (1974 to 31 December 2015), AMED (Ovid) (1985 to 31 December 2015), Chinese National Knowledge Infrastructure (CNKI) (1979 to 31 December 2015) and Chinese Scientific Journals full text database (CQVIP) (1989 to 31 December 2015), China Biology Medicine disc (CBM 1976 to 31 December 2015) and Wanfang Data Knowledge Service Platform (WanFang) (1998 to 31 December 2015).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing oral Astragalus as a sole Chinese herbal preparation with placebo to prevent frequent episodes of ARTIs in children.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures for this review. We assessed search results to identify relevant studies. We planned to extract data using standardised forms. Disagreements were to be resolved through discussion. Risk of bias was to be assessed using the Cochrane 'Risk of bias' tool. We planned to use mean difference (MD) or standardised mean difference (SMD) for continuous data and risk ratio (RR) or odds ratio (OR) to analyse dichotomous data, both with 95% confidence intervals (CIs).

MAIN RESULTS

We identified 6080 records: 3352 from English language databases, 2724 from Chinese databases, and four from other sources. Following initial screening and deduplication, we obtained 120 full-text papers for assessment. Of these, 21 were not RCTs; 55 did not meet the inclusion criteria because: participants were aged over 14 years; definition was not included for recurrent or frequent episodes;Astragalus preparation was not an intervention; Astragalus preparation was in the formula but was not the sole agent; the Astragalus preparation was not administered orally; or Astragalus was used for treatment rather than prevention of ARTI. A further 44 studies were excluded because they were not placebo-controlled, although other inclusion criteria were fulfilled.No RCTs met our inclusion criteria.

AUTHORS' CONCLUSIONS

We found insufficient evidence to enable assessment of the effectiveness and safety of oral Astragalus as a sole intervention to prevent frequent ARTIs in children aged up to 14 years.

Non-specific immune stimulation in respiratory tract infections. Separating the wheat from the chaff

Parents of children suffering from recurrent respiratory infections can be persuaded by advertisements to pressure their family physicians and pediatricians for "immune-stimulating enhancements". However, the evidence base behind these immune stimulants is usually lacking. Often there is no peer-reviewed studies available that support claims made by "immune-booster" supplements. In this review, we critically analyze most of the marketed immuno-active drugs (including vitamin preparations, dietary supplements, homeopathic remedies, Ecchinacea, bacterial lysates, and probiotics) and identify the necessity to exclude an immunodeficiency in every child suffering from recurrent respiratory tract infections.

Prevention of respiratory tract infections with bacterial lysate OM-85 bronchomunal in children and adults: a state of the art

Respiratory tract infections (RTIs) are a leading cause of morbidity and also represent a cause of death in some parts of the world. The treatment of RTIs implies a continuous search for stronger therapies and represents an economical burden for health services and society. In this context the prevention of infections is absolutely required. The use of bacterial lysates as immuno-modulators to boost immunological response is widely debated. Aim of this review is to summarize the main clinical studies on the effect of the bacterial lysate OM-85 in treating RTIs in susceptible subjects - namely children and chronic obstructive pulmonary disease (COPD)-affected adults. Results from clinical trials and recent systematic reviews are reported.The results show that mean number of RTIs decreases upon treatment with OM-85, as measured by frequency of exacerbations or number of antibiotic courses. Data from systematic reviews indicated that OM-85 is particularly beneficial in children at high risk of RTIs. In COPD-affected adults, clinical studies showed that treatment with OM-85 reduced exacerbations, although systematic reviews did not legitimate the protective effect of OM-85 toward COPD as significant.The use of OM-85 could be efficacious in reducing exacerbation frequency of RTIs in children and adults at risk. However further high-quality studies are needed to better explain the mechanism of action and confirm the beneficial results of OM85.