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Prevots DR, Marshall JE, Wagner D, Morimoto K. Global Epidemiology of Nontuberculous Mycobacterial Pulmonary Disease: A Review. Clin Chest Med 2023; 44:675-721. [PMID: 37890910 PMCID: PMC10625169 DOI: 10.1016/j.ccm.2023.08.012] [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] [Indexed: 10/29/2023]
Abstract
Nontuberculous mycobacterial (NTM) isolation and pulmonary disease (NTM-PD) have continued to increase in most regions of the world, driven mainly by Mycobacterium avium. Single-center studies also support increasing trends as well as a persistent burden of undiagnosed NTM among persons suspected of having tuberculosis (TB), in countries with moderate-to-high TB prevalence. Cumulative exposure to water and soil presents an increased risk to susceptible hosts, and trace metals in water supply are recently recognized risk factors. Establishing standard case definitions for subnational and national surveillance systems with mandatory notification of NTM-PD are needed to allow comparisons within and across countries and regions.
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Affiliation(s)
- D Rebecca Prevots
- Epidemiology and Population Studies Unit, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, 5601 Fishers Lane, Bethesda, MD 20852, USA.
| | - Julia E Marshall
- Epidemiology and Population Studies Unit, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, 5601 Fishers Lane, Bethesda, MD 20852, USA
| | - Dirk Wagner
- Division of Infectious Diseases, Department of Internal Medicine II, Medical Center- University of Freiburg, Faculty of Medicine, Hugstetter Street. 55, Freiburg b106, Germany
| | - Kozo Morimoto
- Division of Clinical Research, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), 3-1-24, Matsuyama, Kiyose, Tokyo, Japan
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Klever AM, Alexander KA, Almeida D, Anderson MZ, Ball RL, Beamer G, Boggiatto P, Buikstra JE, Chandler B, Claeys TA, Concha AE, Converse PJ, Derbyshire KM, Dobos KM, Dupnik KM, Endsley JJ, Endsley MA, Fennelly K, Franco-Paredes C, Hagge DA, Hall-Stoodley L, Hayes D, Hirschfeld K, Hofman CA, Honda JR, Hull NM, Kramnik I, Lacourciere K, Lahiri R, Lamont EA, Larsen MH, Lemaire T, Lesellier S, Lee NR, Lowry CA, Mahfooz NS, McMichael TM, Merling MR, Miller MA, Nagajyothi JF, Nelson E, Nuermberger EL, Pena MT, Perea C, Podell BK, Pyle CJ, Quinn FD, Rajaram MVS, Mejia OR, Rothoff M, Sago SA, Salvador LCM, Simonson AW, Spencer JS, Sreevatsan S, Subbian S, Sunstrum J, Tobin DM, Vijayan KKV, Wright CTO, Robinson RT. The Many Hosts of Mycobacteria 9 (MHM9): A conference report. Tuberculosis (Edinb) 2023; 142:102377. [PMID: 37531864 PMCID: PMC10529179 DOI: 10.1016/j.tube.2023.102377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 08/04/2023]
Abstract
The Many Hosts of Mycobacteria (MHM) meeting series brings together basic scientists, clinicians and veterinarians to promote robust discussion and dissemination of recent advances in our knowledge of numerous mycobacterial diseases, including human and bovine tuberculosis (TB), nontuberculous mycobacteria (NTM) infection, Hansen's disease (leprosy), Buruli ulcer and Johne's disease. The 9th MHM conference (MHM9) was held in July 2022 at The Ohio State University (OSU) and centered around the theme of "Confounders of Mycobacterial Disease." Confounders can and often do drive the transmission of mycobacterial diseases, as well as impact surveillance and treatment outcomes. Various confounders were presented and discussed at MHM9 including those that originate from the host (comorbidities and coinfections) as well as those arising from the environment (e.g., zoonotic exposures), economic inequality (e.g. healthcare disparities), stigma (a confounder of leprosy and TB for millennia), and historical neglect (a confounder in Native American Nations). This conference report summarizes select talks given at MHM9 highlighting recent research advances, as well as talks regarding the historic and ongoing impact of TB and other infectious diseases on Native American Nations, including those in Southwestern Alaska where the regional TB incidence rate is among the highest in the Western hemisphere.
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Affiliation(s)
- Abigail Marie Klever
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, USA; Infectious Diseases Institute, The Ohio State University, OH, USA
| | - Kathleen A Alexander
- Department of Fish and Wildlife Conservation, Virginia Tech, Blacksburg, VA, USA; CARACAL/Chobe Research Institute Kasane, Botswana
| | - Deepak Almeida
- Center for Tuberculosis Research, Johns Hopkins University, Baltimore, MD, USA
| | - Matthew Z Anderson
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, USA; Infectious Diseases Institute, The Ohio State University, OH, USA; Department of Microbiology, The Ohio State University, Columbus, OH, USA
| | | | - Gillian Beamer
- Host Pathogen Interactions and Population Health Program, Texas Biomedical Research Institute, San Antonio, TX, USA
| | - Paola Boggiatto
- Agricultural Research Service, United States Department of Agriculture, Ames, IA, USA
| | - Jane E Buikstra
- Center for Bioarchaeological Research, Arizona State University, Tempe, AZ, USA
| | - Bruce Chandler
- Division of Public Health, Alaska Department of Health, AK, USA
| | - Tiffany A Claeys
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, USA; Infectious Diseases Institute, The Ohio State University, OH, USA
| | - Aislinn E Concha
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA
| | - Paul J Converse
- Center for Tuberculosis Research, Johns Hopkins University, Baltimore, MD, USA
| | - Keith M Derbyshire
- Division of Genetics, The Wadsworth Center, New York State Department of Health, Albany, NY, USA; Department of Biomedical Sciences, University at Albany, Albany, NY, USA
| | - Karen M Dobos
- Department of Microbiology, Immunology, and Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, CO, USA
| | - Kathryn M Dupnik
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Janice J Endsley
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, USA
| | - Mark A Endsley
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, USA
| | - Kevin Fennelly
- Pulmonary Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Rockville, MD, USA
| | - Carlos Franco-Paredes
- Department of Microbiology, Immunology, and Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, CO, USA; Hospital Infantil de México Federico Gómez, México, USA
| | | | - Luanne Hall-Stoodley
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, USA; Infectious Diseases Institute, The Ohio State University, OH, USA
| | - Don Hayes
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Courtney A Hofman
- Department of Anthropology, University of Oklahoma, Norman, OK, USA; Laboratories of Molecular Anthropology and Microbiome Research, University of Oklahoma, Norman, OK, USA
| | - Jennifer R Honda
- Department of Cellular and Molecular Biology, University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Natalie M Hull
- Department of Civil, Environmental, and Geodetic Engineering, The Ohio State University, Columbus, OH, USA
| | - Igor Kramnik
- Pulmonary Center, The Department of Medicine, Boston University Chobanian & Aveedisian School of Medicine, National Emerging Infectious Diseases Laboratories, Boston University, Boston, MA, USA
| | - Karen Lacourciere
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Ramanuj Lahiri
- United States Department of Health and Human Services, Health Resources and Services Administration, Health Systems Bureau, National Hansen's Disease Program, Baton Rouge, LA, USA
| | - Elise A Lamont
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN, USA
| | - Michelle H Larsen
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Sandrine Lesellier
- French Agency for Food, Environmental & Occupational Health & Safety (ANSES), Laboratory for Rabies and Wildlife,Nancy, France
| | - Naomi R Lee
- Department of Chemistry and Biochemistry, Northern Arizona University, Flagstaff, AZ, USA
| | - Christopher A Lowry
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA
| | - Najmus S Mahfooz
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, USA; Infectious Diseases Institute, The Ohio State University, OH, USA
| | - Temet M McMichael
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, USA; Infectious Diseases Institute, The Ohio State University, OH, USA
| | - Marlena R Merling
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, USA; Infectious Diseases Institute, The Ohio State University, OH, USA
| | - Michele A Miller
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jyothi F Nagajyothi
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA
| | - Elizabeth Nelson
- Microbial Paleogenomics Unit, Dept of Genomes and Genetics, Institut Pasteur, Paris, France
| | - Eric L Nuermberger
- Center for Tuberculosis Research, Johns Hopkins University, Baltimore, MD, USA
| | - Maria T Pena
- United States Department of Health and Human Services, Health Resources and Services Administration, Health Systems Bureau, National Hansen's Disease Program, Baton Rouge, LA, USA
| | - Claudia Perea
- Animal & Plant Health Inspection Service, United States Department of Agriculture, Ames, IA, USA
| | - Brendan K Podell
- Department of Microbiology, Immunology, and Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, CO, USA
| | - Charlie J Pyle
- Department of Molecular Genetics & Microbiology, Duke University School of Medicine, Durham, NC, USA; Department of Immunology, Duke University School of Medicine, Durham, NC, USA
| | - Fred D Quinn
- Department of Infectious Diseases, College of Veterinary Medicine, University of Georgia, Athens, GA, USA
| | - Murugesan V S Rajaram
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, USA; Infectious Diseases Institute, The Ohio State University, OH, USA
| | - Oscar Rosas Mejia
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, USA; Infectious Diseases Institute, The Ohio State University, OH, USA
| | | | - Saydie A Sago
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA
| | - Liliana C M Salvador
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, USA
| | - Andrew W Simonson
- Department of Microbiology and Molecular Genetics and the Center for Vaccine Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John S Spencer
- Department of Microbiology, Immunology, and Pathology, Mycobacteria Research Laboratories, Colorado State University, Fort Collins, CO, USA
| | - Srinand Sreevatsan
- Pathobiology & Diagnostic Investigation Department, College of Veterinary Medicine, Michigan State University, East Lansing, MI, USA
| | - Selvakumar Subbian
- Public Health Research Institute (PHRI), New Jersey Medical School, Rutgers University, Newark, NJ, USA
| | | | - David M Tobin
- Department of Molecular Genetics & Microbiology, Duke University School of Medicine, Durham, NC, USA; Department of Immunology, Duke University School of Medicine, Durham, NC, USA
| | - K K Vidya Vijayan
- Department of Microbiology and Immunology, Center for AIDS Research, and Children's Research Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Caelan T O Wright
- Department of Molecular, Cellular, and Developmental Biology, University of Colorado Boulder, Boulder, CO, USA
| | - Richard T Robinson
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, USA; Infectious Diseases Institute, The Ohio State University, OH, USA.
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Bolden N, Mell JC, Logan JB, Planet PJ. Phylogenomics of nontuberculous mycobacteria respiratory infections in people with cystic fibrosis. Paediatr Respir Rev 2023; 46:63-70. [PMID: 36828670 PMCID: PMC10659050 DOI: 10.1016/j.prrv.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023]
Abstract
Nontuberculous mycobacteria (NTM) can cause severe pulmonary disease in people with cystic fibrosis (pwCF). These infections present unique challenges for diagnosis and treatment, prompting a recent interest in understanding NTM transmission and pathogenesis during chronic infection. Major gaps remain in our knowledge regarding basic pathogenesis, immune evasion strategies, population dynamics, recombination potential, and the evolutionary implications of host and antibiotic pressures of long-term NTM infections in pwCF. Phylogenomic techniques have emerged as an important tool for tracking global patterns of transmission and are beginning to be used to ask fundamental biological questions about adaptation to the host during pathogenesis. In this review, we discuss the burden of NTM lung disease (NTM-LD), highlight the use of phylogenomics in NTM research, and address the clinical implications associated with these studies.
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Affiliation(s)
- Nicholas Bolden
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Joshua Chang Mell
- Center for Genomic Sciences, Drexel University College of Medicine, Philadelphia, PA, United States; Department of Microbiology & Immunology, Drexel University, Philadelphia, PA, United States.
| | - Jennifer Bouso Logan
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Pulmonary Medicine and Cystic Fibrosis Center, Lehigh Valley Reilly Children's Hospital, PA, United States.
| | - Paul J Planet
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Comparative Genomics, American Museum of Natural History, New York, NY, United States.
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Abstract
Nontuberculous mycobacteria (NTM) are important pathogens, with a longitudinal prevalence of up to 20% within the cystic fibrosis (CF) population. Diagnosis of NTM pulmonary disease in people with CF (pwCF) is challenging, as a majority have NTM infection that is transient or indolent, without evidence of clinical consequence. In addition, the radiographic and clinical manifestations of chronic coinfections with typical CF pathogens can overlap those of NTM, making diagnosis difficult. Comprehensive care of pwCF must be optimized to assess the true clinical impact of NTM and to improve response to treatment. Treatment requires prolonged, multidrug therapy that varies depending on NTM species, resistance pattern, and extent of disease. With a widespread use of highly effective modulator therapy (HEMT), clinical signs and symptoms of NTM disease may be less apparent, and sensitivity of sputum cultures further reduced. The development of a disease-specific approach to the diagnosis and treatment of NTM infection in pwCF is a research priority, as a lifelong strategy is needed for this high-risk population.
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Mauch RM, Jensen PØ, Qvist T, Kolpen M, Moser C, Pressler T, Nolasco da Silva MT, Høiby N. Adaptive Immune Response to Mycobacterium abscessus Complex (MABSC) in Cystic Fibrosis and the Implications of Cross-Reactivity. Front Cell Infect Microbiol 2022; 12:858398. [PMID: 35548464 PMCID: PMC9084186 DOI: 10.3389/fcimb.2022.858398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background We aimed to characterise the adaptive immune response to Mycobacterium abscessus complex (MABSC) and its cross-reactivity with Mycobacterium avium complex (MAC) and Mycobacterium bovis (Bacille Calmette-Guérin, BCG) in cystic fibrosis (CF) patients and non-CF controls in terms of lymphocyte proliferation and immunophenotyping, cytokine production and anti-MABSC IgG plasma levels. Methods In this cross-sectional analysis, peripheral blood mononuclear cells (PBMC) from CF patients with MABSC (CF/MABSC, n=12), MAC infection history (CF/MAC, n=5), no NTM history (CF/NTM-, n=15), BCG-vaccinated (C/BCG+, n=9) and non-vaccinated controls (C/BCG-, n=8) were cultured for four days under stimulation with an in-house MABSC lysate and we used flow cytometry to assess lymphocyte proliferation (given by lymphoblast formation) and immunophenotypes. Cytokine production was assessed after overnight whole blood stimulation with the same lysate, and anti-MABSC IgG levels were measured in plasma from non-stimulated blood. Results All CF/MABSC patients had increased CD3+ and CD19+ lymphoblast formation upon PBMC stimulation with MABSC lysate. There was a higher rate of CD3+ than CD19+ lymphoblasts, predominance of CD4+ over CD8+ lymphoblasts, IFN-γ, TNF-α and IL-2 production, low production of the Th17-associated IL-17, and discrete or no production of Th2/B cell-associated cytokines soluble CD40 ligand (CD40L), IL-4 and IL-5, indicating a Th1-dominated phenotype and infection restricted to the lungs. A similar pattern was seen in C/BCG+ controls, and CF/MAC patients, pointing to cross-reactivity. MABSC-IgG levels were higher in CF/MABSC patients than in both control groups, but not CF/NTM- patients, most of whom also had CD3+ and/or CD19+ lymphoblast formation upon PBMC stimulation, indicating previous exposure, subclinical or latent infection with MABSC or other NTM. Conclusion The anti-MABSC immune response is Th1-skewed and underlines the cross-reactivity in the anti-mycobacterial immune response. The results, together with published clinical observations, indicate that BCG vaccination may cross-react against NTM in CF patients, and this should be investigated. Due to cross-reactivity, it would also be interesting to investigate whether a combination of MABSC-induced cytokine production by blood cells and anti-MABSC IgG measurement can be useful for identifying latent or subclinical infection both with MABSC and other NTM in CF patients.
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Affiliation(s)
- Renan Marrichi Mauch
- Center for Investigation in Pediatrics, School of Medical Sciences, University of Campinas, Campinas, Brazil.,Clinical Microbiology Department, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark.,Costerton Biofilm Center, Department of Immunology and Microbiology, Faculty of Health and Medical Sciences (Panum Institute), University of Copenhagen, Copenhagen, Denmark
| | - Peter Østrup Jensen
- Clinical Microbiology Department, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark.,Costerton Biofilm Center, Department of Immunology and Microbiology, Faculty of Health and Medical Sciences (Panum Institute), University of Copenhagen, Copenhagen, Denmark.,Institute of Inflammation Research, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark
| | - Tavs Qvist
- Cystic Fibrosis Adult Clinic , Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark
| | - Mette Kolpen
- Clinical Microbiology Department, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark.,Costerton Biofilm Center, Department of Immunology and Microbiology, Faculty of Health and Medical Sciences (Panum Institute), University of Copenhagen, Copenhagen, Denmark
| | - Claus Moser
- Clinical Microbiology Department, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark.,Costerton Biofilm Center, Department of Immunology and Microbiology, Faculty of Health and Medical Sciences (Panum Institute), University of Copenhagen, Copenhagen, Denmark
| | - Tacjana Pressler
- Cystic Fibrosis Adult Clinic , Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark
| | | | - Niels Høiby
- Clinical Microbiology Department, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark.,Costerton Biofilm Center, Department of Immunology and Microbiology, Faculty of Health and Medical Sciences (Panum Institute), University of Copenhagen, Copenhagen, Denmark
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Hayes D, Shukla RK, Cheng Y, Gecili E, Merling MR, Szczesniak RD, Ziady AG, Woods JC, Hall-Stoodley L, Liyanage NP, Robinson RT. Tissue-localized immune responses in people with cystic fibrosis and respiratory nontuberculous mycobacteria infection. JCI Insight 2022; 7:157865. [PMID: 35536650 DOI: 10.1172/jci.insight.157865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/29/2022] [Indexed: 11/17/2022] Open
Abstract
Nontuberculous mycobacteria (NTM) are an increasingly common cause of respiratory infection in people with cystic fibrosis (PwCF). Relative to those with no history of NTM infection (CF-NTMNEG), PwCF and a history of NTM infection (CF-NTMPOS) are more likely to develop severe lung disease and experience complications over the course of treatment. In other mycobacterial infections (e.g. tuberculosis), an overexuberant immune response causes pathology and compromises organ function; however, since the immune profiles of CF-NTMPOS and CF-NTMNEG airways are largely unexplored, it is unknown which if any immune responses distinguish these cohorts or concentrate in damaged tissues. Here we evaluated lung lobe-specific immune profiles of three cohorts (CF-NTMPOS, CF-NTMNEG, and non-CF adults) and found that CF-NTMPOS airways are distinguished by a hyper-inflammatory cytokine profile. Importantly, the CF-NTMPOS airway immune profile was dominated by B cells, classical macrophages and the cytokines which support their accumulation. These and other immunological differences between cohorts, including the near absence of NK cells and complement pathway members, were enriched in the most damaged lung lobes. The implications of these findings for our understanding of lung disease in PwCF are discussed, as are how they may inform the development of host-directed therapies to improve NTM disease treatment.
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Affiliation(s)
- Don Hayes
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, United States of America
| | - Rajni Kant Shukla
- Department of Microbial Infection and Immunity, The Ohio State University, columbus, United States of America
| | - Yizi Cheng
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, United States of America
| | - Emrah Gecili
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, United States of America
| | - Marlena R Merling
- Department of Microbial Infection and Immunity, The Ohio State University, columbus, United States of America
| | - Rhonda D Szczesniak
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, United States of America
| | - Assem G Ziady
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, United States of America
| | - Jason C Woods
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, United States of America
| | - Luanne Hall-Stoodley
- Department of Microbial Infection and Immunity, The Ohio State University, columbus, United States of America
| | - Namal Pm Liyanage
- Department of Microbial Infection and Immunity, The Ohio State University, columbus, United States of America
| | - Richard T Robinson
- Department of Microbial Infection and Immunity, The Ohio State University, columbus, United States of America
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Ricotta EE, Adjemian J, Blakney RA, Lai YL, Kadri SS, Prevots DR. Extrapulmonary Nontuberculous Mycobacteria Infections in Hospitalized Patients, United States, 2009-2014. Emerg Infect Dis 2021; 27:845-852. [PMID: 33622461 PMCID: PMC7920686 DOI: 10.3201/eid2703.201087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Nontuberculous mycobacteria (NTM) cause pulmonary and extrapulmonary infections in susceptible persons. To characterize the epidemiology of skin and soft tissue (SST) and disseminated extrapulmonary infections caused by NTM in the United States, we used a large electronic health record database to examine clinical, demographic, and laboratory data for hospitalized patients with NTM isolated from extrapulmonary sources during 2009–2014. Using all unique inpatients as the denominator, we estimated prevalence and summarized cases by key characteristics. Of 9,196,147 inpatients, 831 had confirmed extrapulmonary NTM. The 6-year prevalence was 11 cases/100,000 inpatients; source-specific prevalence was 4.4 SST infections/100,000 inpatients and 3.7 disseminated infections/100,000 inpatients. NTM species varied across geographic region; rapidly growing NTM were most prevalent in southern states. Infection with Mycobacterium avium complex was more common among patients with concurrent HIV and fungal infection, a relevant finding because treatment is more effective for M. avium complex than for other NTM infections.
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8
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Ho D, Belmonte O, Andre M, Gazaille V, Perisson C, Gachelin E, Allyn J, Payet A, Coolen-Allou N. High Prevalence of Nontuberculous Mycobacteria in Cystic Fibrosis Patients in Tropical French Reunion Island. Pediatr Infect Dis J 2021; 40:e120-e122. [PMID: 33427803 DOI: 10.1097/inf.0000000000002999] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reunion Island is a French overseas department located in a tropical area, where cystic fibrosis incidence is high. Cystic fibrosis (CF) patients are at risk of developing nontuberculous mycobacteria (NTM) infection. Epidemiologic studies are lacking in Reunion Island. METHODS From 2002 to 2015, a retrospective review was performed in university hospitals on Reunion Island. All CF patients having at least 1 positive NTM isolate were included. Clinical, radiologic, and microbiologic data were collected from patient records. RESULTS Fifty-one CF patients were included. The overall estimated prevalence of NTM was 26.4% in total CF population and 36.9% in patients over 12 years of age. Mycobacterium abscessus and Mycobacterium avium were the most frequently identified species found in 31 patients (60.8%) and 14 patients (27.4%), respectively. A rare NTM species: Mycobacterium simiae was found in 4 patients (7.8%). Twenty-nine patients (56.9%) met the American Thoracic Society (ATS) criteria for infection. They were more likely younger with a low body mass index and more frequently infected by Mycobacterium abscessus (22/29). CONCLUSION The overall prevalence of NTM in tropical Reunion Island is 3 times higher than in metropolitan France. A different environmental exposure in a tropical climate or risk factors related to cystic fibrosis or its treatment in Reunion patients could explain it.
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Affiliation(s)
| | - Olivier Belmonte
- Service de Microbiologie, CHU La Réunion site Félix Guyon, Saint Denis, Réunion
| | | | | | - Caroline Perisson
- Service de Pédiatrie, CHU La Réunion Site Sud Réunion, Saint Pierre, Réunion
| | | | - Jérôme Allyn
- Service de Réanimation Médicale, CHU La Réunion site Félix Guyon, Saint Denis, Réunion
| | - Annabelle Payet
- Service de Pneumologie, CHU La Réunion Site Sud Réunion, Saint Pierre, Réunion
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Reynaud Q, Bricca R, Cavalli Z, Nove-Josserand R, Durupt S, Reix P, Burgel PR, Durieu I. Risk factors for nontuberculous mycobacterial isolation in patients with cystic fibrosis: A meta-analysis. Pediatr Pulmonol 2020; 55:2653-2661. [PMID: 32603551 DOI: 10.1002/ppul.24913] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND To better understand the mechanisms of infection with nontuberculous mycobacteria (NTM) in patients with cystic fibrosis (CF), we explore different risk factors associated with NTM positivity in a meta-analysis. METHODS Studies published before 31 July 2019 were selected from MEDLINE. Combined odds ratios (ORs) were calculated by pooling the ORs of each study. The weighted mean difference (WMD) was used for continuous numerical measurements. Summary data were pooled using fixed- or random-effects models according to the presence of heterogeneity (P < .1 or I2 > 50%). RESULTS Nineteen studies with a total of 23 418 patients, of whom 1421 (6%) were diagnosed as NTM positive, were included. Older age was significantly associated with NTM positivity (WMD = 2.12, 95% confidence interval [CI]: 1.11-3.13; P < .01, fixed-effects model). The OR for Staphylococcus aureus colonization was 1.66 (95% CI: 1.21-2.26; P = .001) in 11 studies (8091 patients), the OR for Aspergillus fumigatus colonization was 3.59 (95% CI: 3.05-4.23; P < .001) in 11 studies (20 480 patients), and the OR for Stenotrophomonas maltophilia colonization was 3.41 (95% CI: 2.66-4.39; P < .01) in seven studies (14 935 patients). Oral corticosteroids were significantly associated with NTM positivity (OR = 1.98, 95% CI: 1.24-3.16; P < .01, 6 studies, 1936 patients). No other factor showed a significant association. CONCLUSION Older age, S. aureus, S. maltophilia, and A. fumigatus chronic colonization, and oral corticosteroids were significantly associated with an increased risk of NTM positivity. CF patients with more severe conditions should be closely monitored for NTM.
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Affiliation(s)
- Quitterie Reynaud
- Centre de ressources et de compétences pour la mucoviscidose adulte, Service de médecine interne et vasculaire, Hospices Civils de Lyon, Lyon, France.,EA HESPER 7425, Université Claude Bernard Lyon 1, Lyon, France
| | - Romain Bricca
- Centre de ressources et de compétences pour la mucoviscidose adulte, Service de médecine interne et vasculaire, Hospices Civils de Lyon, Lyon, France
| | - Zoe Cavalli
- Centre de ressources et de compétences pour la mucoviscidose adulte, Service de médecine interne et vasculaire, Hospices Civils de Lyon, Lyon, France
| | - Raphaële Nove-Josserand
- Centre de ressources et de compétences pour la mucoviscidose adulte, Service de médecine interne et vasculaire, Hospices Civils de Lyon, Lyon, France
| | - Stéphane Durupt
- Centre de ressources et de compétences pour la mucoviscidose adulte, Service de médecine interne et vasculaire, Hospices Civils de Lyon, Lyon, France
| | - Philippe Reix
- UMR CNRS 5558, Equipe Evaluation et Modélisation des Effets Thérapeutiques, Laboratoire de Biométrie et Biologie Evolutive, Université de Lyon, Lyon, France.,Centre de ressources et de compétences pour la mucoviscidose pédiatrique, Service de pneumologie pédiatrique, Hospices Civils de Lyon, Lyon, France
| | - Pierre Régis Burgel
- Centre de Référence Maladies Rares Mucoviscidose de l'adulte. Site Coordonnateur National, Hôpital Cochin, APHP, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Isabelle Durieu
- Centre de ressources et de compétences pour la mucoviscidose adulte, Service de médecine interne et vasculaire, Hospices Civils de Lyon, Lyon, France.,EA HESPER 7425, Université Claude Bernard Lyon 1, Lyon, France
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10
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Szczesniak R, Rice JL, Brokamp C, Ryan P, Pestian T, Ni Y, Andrinopoulou ER, Keogh RH, Gecili E, Huang R, Clancy JP, Collaco JM. Influences of environmental exposures on individuals living with cystic fibrosis. Expert Rev Respir Med 2020; 14:737-748. [PMID: 32264725 DOI: 10.1080/17476348.2020.1753507] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Natural, social, and constructed environments play a critical role in the development and exacerbation of respiratory diseases. However, less is known regarding the influence of these environmental/community risk factors on the health of individuals living with cystic fibrosis (CF), compared to other pulmonary disorders. AREAS COVERED Here, we review current knowledge of environmental exposures related to CF, which suggests that environmental/community risk factors do interact with the respiratory tract to affect outcomes. Studies discussed in this review were identified in PubMed between March 2019 and March 2020. Although the limited data available do not suggest that avoiding potentially detrimental exposures other than secondhand smoke could improve outcomes, additional research incorporating novel markers of environmental exposures and community characteristics obtained at localized levels is needed. EXPERT OPINION As we outline, some environmental exposures and community characteristics are modifiable; if not by the individual, then by policy. We recommend a variety of strategies to advance understanding of environmental influences on CF disease progression.
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Affiliation(s)
- Rhonda Szczesniak
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati , Cincinnati, OH, USA
| | - Jessica L Rice
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins University School of Medicine , Baltimore, MD, USA
| | - Cole Brokamp
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati , Cincinnati, OH, USA
| | - Patrick Ryan
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati , Cincinnati, OH, USA
| | - Teresa Pestian
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA
| | - Yizhao Ni
- Department of Pediatrics, University of Cincinnati , Cincinnati, OH, USA.,Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA
| | | | - Ruth H Keogh
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine , London, UK
| | - Emrah Gecili
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA
| | - Rui Huang
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Mathematical Sciences, University of Cincinnati , Cincinnati, OH, USA
| | - John P Clancy
- Department of Pediatrics, University of Cincinnati , Cincinnati, OH, USA.,Department of Clinical Research, Cystic Fibrosis Foundation , Bethesda, MD, USA
| | - Joseph M Collaco
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins University School of Medicine , Baltimore, MD, USA
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11
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Retrospective Analysis of Nontuberculous Mycobacterial Infection and Monochloramine Disinfection of Municipal Drinking Water in Michigan. mSphere 2019; 4:4/4/e00160-19. [PMID: 31270167 PMCID: PMC6609225 DOI: 10.1128/msphere.00160-19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Infections by nontuberculous mycobacteria (NTM) result in significant morbidity, mortality, and health care costs. NTM are primarily acquired from environmental sources, including exposure to municipally treated drinking water. Higher levels of NTM have been reported in drinking water disinfected with monochloramine than in drinking water disinfected with chlorine. Our results suggest that municipal drinking water disinfection with monochloramine compared to chlorine is not associated with higher risk of NTM infection. This is important given that regulations that limit drinking water concentrations of disinfection by-products, which are formed primarily when chlorine disinfection is used, incentivize drinking water utilities to change from chlorine disinfection to monochloramine disinfection. Infections by nontuberculous mycobacteria (NTM) are primarily acquired from environmental sources, including exposure to municipally treated drinking water. Higher levels of NTM have been reported in drinking water disinfected with monochloramine than in that disinfected with chlorine. However, the relationships between water treatment practices and NTM infection are unclear. The objective of this study was to examine a possible relationship between residual disinfectant used for municipal drinking water treatment (monochloramine or chlorine) and NTM infection. We retrospectively reviewed NTM diagnostic tests performed at a single health care center during a 15-year period. Information on municipal water treatment practices, including disinfectant and primary source water type, was obtained for 140 cities. Based on a logistic regression model, municipal drinking water disinfection with monochloramine compared to chlorine was not associated with NTM infection (P = 0.24). An additional model variable examining water source showed that the likelihood of having an NTM infection was 1.46 times higher for patients residing in cities with drinking water derived from surface water than for those residing in cities with drinking water derived from groundwater (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.03 to 2.08; P = 0.04). In an inverse propensity score weighted regression, monochloramine disinfection was also not associated with NTM infection. A moderate effect on NTM infection rates was observed in the weighted regression for municipal drinking water derived from surface water, though the results were not statistically significant (OR, 1.24; 95% CI, 0.92 to 1.69; P = 0.17). IMPORTANCE Infections by nontuberculous mycobacteria (NTM) result in significant morbidity, mortality, and health care costs. NTM are primarily acquired from environmental sources, including exposure to municipally treated drinking water. Higher levels of NTM have been reported in drinking water disinfected with monochloramine than in drinking water disinfected with chlorine. Our results suggest that municipal drinking water disinfection with monochloramine compared to chlorine is not associated with higher risk of NTM infection. This is important given that regulations that limit drinking water concentrations of disinfection by-products, which are formed primarily when chlorine disinfection is used, incentivize drinking water utilities to change from chlorine disinfection to monochloramine disinfection.
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12
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Dowdell K, Haig SJ, Caverly LJ, Shen Y, LiPuma JJ, Raskin L. Nontuberculous mycobacteria in drinking water systems - the challenges of characterization and risk mitigation. Curr Opin Biotechnol 2019; 57:127-136. [PMID: 31003169 DOI: 10.1016/j.copbio.2019.03.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 03/05/2019] [Accepted: 03/05/2019] [Indexed: 12/18/2022]
Abstract
Nontuberculous mycobacteria (NTM) pulmonary infections are a growing concern worldwide, with a disproportionate incidence in persons with pre-existing health conditions. NTM have frequently been found in municipally-treated drinking water and building plumbing, leading to the hypothesis that an important source of NTM exposure is drinking water. The identification and quantification of NTM in environmental samples are complicated by genetic variability among NTM species, making it challenging to determine if clinically relevant NTM are present. Additionally, their unique cellular features and lifestyles make NTM and their nucleic acids difficult to recover. This review highlights a recent work focused on quantification and characterization of NTM and on understanding the influence of source water, treatment plants, distribution systems, and building plumbing on the abundance of NTM in drinking water.
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Affiliation(s)
- Katherine Dowdell
- Department of Civil and Environmental Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Sarah-Jane Haig
- Department of Civil and Environmental Engineering, University of Michigan, Ann Arbor, MI, USA; Department of Civil and Environmental Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lindsay J Caverly
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Yun Shen
- Department of Civil and Environmental Engineering, University of Michigan, Ann Arbor, MI, USA
| | - John J LiPuma
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Lutgarde Raskin
- Department of Civil and Environmental Engineering, University of Michigan, Ann Arbor, MI, USA.
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13
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Savant AP, McColley SA. Cystic fibrosis year in review 2017. Pediatr Pulmonol 2018; 53:1307-1317. [PMID: 29927544 DOI: 10.1002/ppul.24081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 05/31/2018] [Indexed: 12/18/2022]
Abstract
In this article, we highlight cystic fibrosis (CF) reports published in Pediatric Pulmonology during 2017. We also include articles from a variety of journals that are related or are of special interest to clinicians.
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Affiliation(s)
- Adrienne P Savant
- Division of Pulmonary Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Stanley Manne Children's Research Institute, Chicago, Illinois
| | - Susanna A McColley
- Division of Pulmonary Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Stanley Manne Children's Research Institute, Chicago, Illinois
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14
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Adjemian J, Olivier KN, Prevots DR. Epidemiology of Pulmonary Nontuberculous Mycobacterial Sputum Positivity in Patients with Cystic Fibrosis in the United States, 2010-2014. Ann Am Thorac Soc 2018; 15:817-826. [PMID: 29897781 PMCID: PMC6137684 DOI: 10.1513/annalsats.201709-727oc] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 02/22/2018] [Indexed: 01/13/2023] Open
Abstract
RATIONALE Pulmonary nontuberculous mycobacteria (NTM) disease represents a significant threat to patients with cystic fibrosis (CF), with an estimated annual prevalence of 12%. Prior studies reported an increasing annual NTM prevalence in the general population, though similar trends in persons with CF have not been assessed. OBJECTIVES In this study we aimed to identify the prevalence, geographic patterns, temporal trends, and risk factors for NTM positivity by mycobacterial species among persons with CF throughout the United States. METHODS Using annualized CF Patient Registry (CFFPR) data from 2010 to 2014, we identified patients with mycobacterial culture results to estimate the annual and period prevalence of pathogenic NTM species by demographic and geographic factors. Regression models were used to estimate the annual percent change over time and risk factors for NTM isolation. Geographic patterns were described and mapped. RESULTS Of 16,153 included persons with CF, 3,211 (20%) had a pathogenic NTM species isolated at least once over the 5-year period; 1,949 (61%) had Mycobacterium avium complex (MAC), and 1,249 (39%) had M. abscessus. The period prevalence was 12% for MAC (confidence interval [CI], 12-13%), 8% for M. abscessus (CI, 7-8%), and 4% for other NTM species (CI, 3.8-4.3%). The period prevalence for MAC was nearly three times greater among patients ≥60 years old with a body mass index < 19 (33% [CI, 16-51%]); this trend was not present for patients with M. abscessus (4% [CI, 0-11%]). NTM prevalence showed a significant relative increase of 5% per year, from 11.0% in 2010 to 13.4% in 2014 (P = 0.0008), although this varied by geographic area. For M. abscessus, the states with the highest prevalence were Hawaii (50%), Florida (17%), and Louisiana (16%), and for MAC they were Nevada (24%), Kansas (21%), and Hawaii and Arizona (both 20%). Study participants with either MAC or M. abscessus were significantly more likely to have been diagnosed with CF at an older age (P < 0.0001), have a lower body mass index (P < 0.0001), higher forced expiratory volume in 1 second % predicted (P < 0.01), and fewer years on chronic macrolide therapy (P < 0.0001). CONCLUSIONS NTM remains highly prevalent among adults and children with CF in the United States, with one in five affected, and appears to be increasing over time. Prevalence varies by geographic region and by patient-level factors, including older age and receiving an initial CF diagnosis later in life. Routine screening for NTM, including mycobacterial speciation, especially in high-risk geographic areas, is critical to increase our understanding of its epidemiology and changes in prevalence over time.
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Affiliation(s)
- Jennifer Adjemian
- Epidemiology Unit, Laboratory of Clinical Infectious Diseases, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
- United States Public Health Service, Commissioned Corps, Rockville, Maryland; and
| | - Kenneth N. Olivier
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - D. Rebecca Prevots
- Epidemiology Unit, Laboratory of Clinical Infectious Diseases, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
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15
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Clinical, Radiological, and Microbiological Characteristics of Mycobacterium simiae Infection in 97 Patients. Antimicrob Agents Chemother 2018; 62:AAC.00395-18. [PMID: 29760130 DOI: 10.1128/aac.00395-18] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/05/2018] [Indexed: 11/20/2022] Open
Abstract
Mycobacterium simiae is a rare species of slow-growing nontuberculous mycobacteria (NTM). From 2002 to 2017, we conducted a retrospective study that included all patients with NTM-positive respiratory samples detected in two university hospitals of the French overseas department of Reunion Island. We recorded the prevalence of M. simiae in this cohort, as well as the clinical, radiological, and microbiological features of patients with at least 1 sample positive for M. simiae In our cohort, 97 patients (15.1%) were positive for M. simiae Twenty-one patients (21.6%) met the American Thoracic Society (ATS) criteria for infection. M. simiae infection was associated with bronchiectasis, micronodular lesions, and weight loss. Antibiotic susceptibility testing was performed for 60 patients, and the isolates were found to have low susceptibility to antibiotics, except for amikacin, fluoroquinolones, and clarithromycin. Treatment failed for 4 of the 8 patients treated for M. simiae infection. Here, we describe a specific cluster corresponding to a large cohort of patients with M. simiae, a rare nontuberculous mycobacterium associated with low pathogenicity and poor susceptibility to antibiotics.
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16
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Prevalence and clinical outcomes of nontuberculous mycobacteria in a Brazilian cystic fibrosis reference center. Pathog Dis 2018; 76:5017445. [DOI: 10.1093/femspd/fty051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/25/2018] [Indexed: 12/12/2022] Open
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17
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Mycobactéries atypiques dans la mucoviscidose à La Réunion. Rev Mal Respir 2018. [DOI: 10.1016/j.rmr.2017.10.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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