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Elmassry MM, Colmer-Hamood JA, Kopel J, San Francisco MJ, Hamood AN. Anti- Pseudomonas aeruginosa Vaccines and Therapies: An Assessment of Clinical Trials. Microorganisms 2023; 11:916. [PMID: 37110338 PMCID: PMC10144840 DOI: 10.3390/microorganisms11040916] [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: 02/14/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Pseudomonas aeruginosa is a Gram-negative opportunistic pathogen that causes high morbidity and mortality in cystic fibrosis (CF) and immunocompromised patients, including patients with ventilator-associated pneumonia (VAP), severely burned patients, and patients with surgical wounds. Due to the intrinsic and extrinsic antibiotic resistance mechanisms, the ability to produce several cell-associated and extracellular virulence factors, and the capacity to adapt to several environmental conditions, eradicating P. aeruginosa within infected patients is difficult. Pseudomonas aeruginosa is one of the six multi-drug-resistant pathogens (ESKAPE) considered by the World Health Organization (WHO) as an entire group for which the development of novel antibiotics is urgently needed. In the United States (US) and within the last several years, P. aeruginosa caused 27% of deaths and approximately USD 767 million annually in health-care costs. Several P. aeruginosa therapies, including new antimicrobial agents, derivatives of existing antibiotics, novel antimicrobial agents such as bacteriophages and their chelators, potential vaccines targeting specific virulence factors, and immunotherapies have been developed. Within the last 2-3 decades, the efficacy of these different treatments was tested in clinical and preclinical trials. Despite these trials, no P. aeruginosa treatment is currently approved or available. In this review, we examined several of these clinicals, specifically those designed to combat P. aeruginosa infections in CF patients, patients with P. aeruginosa VAP, and P. aeruginosa-infected burn patients.
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Affiliation(s)
- Moamen M. Elmassry
- Department of Biological Sciences, Texas Tech University, Lubbock, TX 79409, USA
| | - Jane A. Colmer-Hamood
- Department of Medical Education, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- Department of Immunology and Molecular Microbiology, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Jonathan Kopel
- Department of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Michael J. San Francisco
- Department of Biological Sciences, Texas Tech University, Lubbock, TX 79409, USA
- Honors College, Texas Tech University, Lubbock, TX 79409, USA
| | - Abdul N. Hamood
- Department of Immunology and Molecular Microbiology, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
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Abstract
INTRODUCTION Pseudomonas aeruginosa is a common respiratory pathogen that contributes to chronic pulmonary infection in individuals with cystic fibrosis. Guidelines recommend early intervention upon positive P. aeruginosa culture. Tobramycin has in vitro activity against Gram-negative bacteria, including P. aeruginosa, and TOBI Podhaler is indicated for the management of individuals with cystic fibrosis with P. aeruginosa infection. The dry powder inhaler formulation decreases the time required for treatment compared with nebulized solution and therefore may improve quality of life and adherence, which have a positive impact on disease progression. AREAS COVERED In this review, we discuss the safety and efficacy of tobramycin inhaled powder and provide insights into appropriate individuals who might benefit from a dry powder inhaler, keeping in mind that patient preference is an important consideration for therapy selection. EXPERT OPINION Providing a less burdensome alternative to delivering inhaled antibiotics that is more portable with a significantly shorter administration time may help improve adherence, and therefore improve outcomes. Continued development of new antibiotics to add to current regimens for eradication and control of airway microbiology, combined with more efficient delivery systems such as tobramycin inhaled powder, will help evolve the treatment of patients with CF.
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Affiliation(s)
- Stanley B Fiel
- Department of Medicine, Morristown Medical Center, Morristown, NJ
| | - Erica A Roesch
- University Hospitals, Rainbow Babies and Children's Hospital and Case Western Reserve University, Cleveland, OH
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Spencer S, Donovan T, Chalmers JD, Mathioudakis AG, McDonnell MJ, Tsang A, Leadbetter P. Intermittent prophylactic antibiotics for bronchiectasis. Cochrane Database Syst Rev 2022; 1:CD013254. [PMID: 34985761 PMCID: PMC8729825 DOI: 10.1002/14651858.cd013254.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Bronchiectasis is a common but under-diagnosed chronic disorder characterised by permanent dilation of the airways arising from a cycle of recurrent infection and inflammation. Symptoms including chronic, persistent cough and productive phlegm are a significant burden for people with bronchiectasis, and the main aim of treatment is to reduce exacerbation frequency and improve quality of life. Prophylactic antibiotic therapy aims to break this infection cycle and is recommended by clinical guidelines for adults with three or more exacerbations a year, based on limited evidence. It is important to weigh the evidence for bacterial suppression against the prevention of antibiotic resistance and further evidence is required on the safety and efficacy of different regimens of intermittently administered antibiotic treatments for people with bronchiectasis. OBJECTIVES To evaluate the safety and efficacy of intermittent prophylactic antibiotics in the treatment of adults and children with bronchiectasis. SEARCH METHODS We identified trials from the Cochrane Airways Trials Register, which contains studies identified through multiple electronic searches and handsearches of other sources. We also searched trial registries and reference lists of primary studies. We conducted searches on 6 September 2021, with no restriction on language of publication. SELECTION CRITERIA We included randomised controlled trials (RCTs) of at least three months' duration comparing an intermittent regime of prophylactic antibiotics with placebo, usual care or an alternate intermittent regimen. Intermittent prophylactic administration was defined as repeated courses of antibiotics with on-treatment and off-treatment intervals of at least 14 days' duration. We included adults and children with a clinical diagnosis of bronchiectasis confirmed by high resolution computed tomography (HRCT), plain film chest radiograph, or bronchography and a documented history of recurrent chest infections. We excluded studies where participants received high dose antibiotics immediately prior to enrolment or those with a diagnosis of cystic fibrosis, allergic bronchopulmonary aspergillosis (ABPA), primary ciliary dyskinesia, hypogammaglobulinaemia, sarcoidosis, or a primary diagnosis of COPD. Our primary outcomes were exacerbation frequency and serious adverse events. We did not exclude studies on the basis of review outcomes. DATA COLLECTION AND ANALYSIS We analysed dichotomous data as odds ratios (ORs) or relative risk (RRs) and continuous data as mean differences (MDs) or standardised mean differences (SMDs). We used standard methodological procedures expected by Cochrane. We conducted GRADE assessments for the following primary outcomes: exacerbation frequency; serious adverse events and secondary outcomes: antibiotic resistance; hospital admissions; health-related quality of life. MAIN RESULTS We included eight RCTs, with interventions ranging from 16 to 48 weeks, involving 2180 adults. All evaluated one of three types of antibiotics over two to six cycles of 28 days on/off treatment: aminoglycosides, ß-lactams or fluoroquinolones. Two studies also included 12 cycles of 14 days on/off treatment with fluoroquinolones. Participants had a mean age of 63.6 years, 65% were women and approximately 85% Caucasian. Baseline FEV1 ranged from 55.5% to 62.6% predicted. None of the studies included children. Generally, there was a low risk of bias in the included studies. Antibiotic versus placebo: cycle of 14 days on/off. Ciprofloxacin reduced the frequency of exacerbations compared to placebo (RR 0.75, 95% CI 0.61 to 0.93; I2 = 65%; 2 studies, 469 participants; moderate-certainty evidence), with eight people (95% CI 6 to 28) needed to treat for an additional beneficial outcome. The intervention increased the risk of antibiotic resistance more than twofold (OR 2.14, 95% CI 1.36 to 3.35; I2 = 0%; 2 studies, 624 participants; high-certainty evidence). Serious adverse events, lung function (FEV1), health-related quality of life, and adverse effects did not differ between groups. Antibiotic versus placebo: cycle of 28 days on/off. Antibiotics did not reduce overall exacerbation frequency (RR 0.92, 95% CI 0.82 to 1.02; I2 = 0%; 8 studies, 1695 participants; high-certainty evidence) but there were fewer severe exacerbations (OR 0.59, 95% CI 0.37 to 0.93; I2 = 54%; 3 studies, 624 participants), though this should be interpreted with caution due to low event rates. The risk of antibiotic resistance was more than twofold higher based on a pooled analysis (OR 2.20, 95% CI 1.42 to 3.42; I2 = 0%; 3 studies, 685 participants; high-certainty evidence) and consistent with unpooled data from four further studies. Serious adverse events, time to first exacerbation, duration of exacerbation, respiratory-related hospital admissions, lung function, health-related quality of life and adverse effects did not differ between study groups. Antibiotic versus usual care. We did not find any studies that compared intermittent antibiotic regimens with usual care. Cycle of 14 days on/off versus cycle of 28 days on/off. Exacerbation frequency did not differ between the two treatment regimens (RR 1.02, 95% CI 0.84 to 1.24; I2 = 71%; 2 studies, 625 participants; moderate-certainty evidence) However, inconsistencies in the results from the two trials in this comparison indicate that the apparent aggregated similarities may not be reliable. There was no evidence of a difference in antibiotic resistance between groups (OR 1.00, 95% CI 0.68 to 1.48; I2 = 60%; 2 studies, 624 participants; moderate-certainty evidence). Serious adverse events, adverse effects, lung function and health-related quality of life did not differ between the two antibiotic regimens. AUTHORS' CONCLUSIONS Overall, in adults who have frequent chest infections, long-term antibiotics given at 14-day on/off intervals slightly reduces the frequency of those infections and increases antibiotic resistance. Intermittent antibiotic regimens result in little to no difference in serious adverse events. The impact of intermittent antibiotic therapy on children with bronchiectasis is unknown due to an absence of evidence, and further research is needed to establish the potential risks and benefits.
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Affiliation(s)
- Sally Spencer
- Health Research Institute, Faculty of Health, Social Care & Medicine, Edge Hill University, Ormskirk, UK
| | - Tim Donovan
- Medical Sciences, Institute of Health, University of Cumbria, Lancaster, UK
| | - James D Chalmers
- University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Alexander G Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Melissa J McDonnell
- Department of Respiratory Medicine, Galway University Hospital, Galway, Ireland
| | - Anthony Tsang
- Edge Hill University, Ormskirk, UK
- Department of Nursing, Faculty of Health, Social and Psychology, Manchester Metropolitan University, Manchester, UK
| | - Peter Leadbetter
- Medical School, Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
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Livnat G, Yaari N, Stein N, Bentur L, Hanna M, Harel M, Adir Y, Shteinberg M. 4-week daily airway clearance using oscillating positive-end expiratory pressure versus autogenic drainage in bronchiectasis patients: a randomised controlled trial. ERJ Open Res 2021; 7:00426-2021. [PMID: 34760994 PMCID: PMC8573225 DOI: 10.1183/23120541.00426-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 08/25/2021] [Indexed: 12/03/2022] Open
Abstract
Background Airway clearance is a fundamental component of bronchiectasis care. Lung clearance index (LCI) is a measurement of ventilation inhomogeneity. Its responsiveness to long-term airway clearance is unknown. We aimed to compare two methods of daily airway clearance over 4 weeks: autogenic drainage (AD) and oscillating positive airway pressure (oPEP), and to determine effects of airway clearance on LCI and clinical outcomes. Methods Adults with bronchiectasis naive to airway clearance were randomised to daily airway clearance with either AD or oPEP. Difference in LCI as primary outcome, spirometry, sputum volume and purulence, and quality of life were at randomisation and after 4 weeks of airway clearance. Results 51 patients (32 women and 19 men, mean age 66.2±12.8 years) were randomised and 49 completed the study (25 AD and 24 oPEP). The LCI and forced expiratory volume in 1 s did not change between visits between groups (difference between groups 0.02), nor between visits in either group. Sputum quantity decreased in 12 out of 24 (50%) of the oPEP group, and in six out of 25 (24%) of the AD group (p=0.044). The “treatment burden” worsened or was unchanged in 70% of participants randomised to AD and 55% randomised to oPEP (p=0.038). Conclusion Sputum quantity decreased in more participants randomised to oPEP group after 1 month of daily airway clearance, with a better treatment burden. The effects of 4 weeks of airway clearance on LCI were not significant in either treatment group. People with bronchiectasis were randomised to 4 weeks of two methods of daily airway clearance, autogenic drainage (AD) and oscillating PEP (oPEP). Sputum volume decreased in more people randomised to oPEP than AD. LCI did not change in either group.https://bit.ly/3gNj2bi
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Affiliation(s)
- Galit Livnat
- Pediatric Pulmonology, Carmel Medical Center, Haifa, Israel.,Cystic Fibrosis Center, Carmel Medical Center, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Naama Yaari
- Dept of Physical Therapy, Carmel Medical Center, Haifa, Israel
| | - Nili Stein
- Dept of Community Medicine and Epidemiology, Carmel Medical Center, Haifa, Israel
| | - Lea Bentur
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Pediatric Pulmonology and CF Center, The Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Moneera Hanna
- Pediatric Pulmonology and CF Center, The Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Maya Harel
- Pulmonology Institute, Carmel Medical Center, Haifa, Israel
| | - Yochai Adir
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Pulmonology Institute, Carmel Medical Center, Haifa, Israel
| | - Michal Shteinberg
- Cystic Fibrosis Center, Carmel Medical Center, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Pulmonology Institute, Carmel Medical Center, Haifa, Israel
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Elborn JS, Flume PA, Van Devanter DR, Procaccianti C. Management of chronic Pseudomonas aeruginosa infection with inhaled levofloxacin in people with cystic fibrosis. Future Microbiol 2021; 16:1087-1104. [PMID: 34384254 DOI: 10.2217/fmb-2021-0150] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
People with cystic fibrosis (CF) are highly susceptible to bacterial infections of the airways. By adulthood, chronic Pseudomonas aeruginosa (Pa) is the most prevalent infective organism and is difficult to eradicate owing to its adaptation to the CF lung microenvironment. Long-term suppressive treatment with inhaled antimicrobials is the standard care for reducing exacerbation frequency, improving quality of life and increasing measures of lung function. Levofloxacin (a fluoroquinolone antimicrobial) has been approved as an inhaled solution in Europe and Canada, for the treatment of adults with CF with chronic P. aeruginosa pulmonary infections. Here, we review the clinical principles relating to the use of inhaled antimicrobials and inhaled levofloxacin for the management of P. aeruginosa infections in patients with CF.
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Affiliation(s)
- J Stuart Elborn
- Faculty of Medicine, Health & Life Sciences, Queen's University Belfast, Belfast, BT9 7BL, UK
| | - Patrick A Flume
- Departments of Medicine & Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Donald R Van Devanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
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Lee A, Gilpin D. Balancing the benefits of antimicrobial therapy with the threat of antimicrobial resistance development. J Cyst Fibros 2021; 20:377-378. [PMID: 34103153 DOI: 10.1016/j.jcf.2021.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Andrew Lee
- Halo Research Group, Queen's University Belfast, Belfast, UK; Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.
| | - Deirdre Gilpin
- Halo Research Group, Queen's University Belfast, Belfast, UK; School of Pharmacy, Queen's University Belfast, Belfast, UK
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Sibila O. Reducing Pseudomonas sputum density in bronchiectasis. Eur Respir J 2021; 57:57/1/2003390. [DOI: 10.1183/13993003.03390-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 11/05/2022]
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Loebinger MR, Polverino E, Chalmers JD, Tiddens HA, Goossens H, Tunney M, Ringshausen FC, Hill AT, Pathan R, Angyalosi G, Blasi F, Elborn SJ, Haworth CS. Efficacy and safety of TOBI Podhaler in Pseudomonas aeruginosa-infected bronchiectasis patients: iBEST study. Eur Respir J 2020; 57:13993003.01451-2020. [DOI: 10.1183/13993003.01451-2020] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/18/2020] [Indexed: 12/24/2022]
Abstract
The study aimed to determine the efficacy of a safe and well-tolerated dose and regimen of tobramycin inhalation powder (TIP) on Pseudomonas aeruginosa sputum density in patients with bronchiectasis.This is a phase II, double-blind, randomised study in bronchiectasis patients aged ≥18 years with chronic P. aeruginosa infection. Patients were randomised 1:1:1 to either cohort A: three capsules of TIP once daily (84 mg); cohort B: five capsules once daily (140 mg) or cohort C: four capsules twice daily (224 mg). Within each cohort, patients were further randomised 2:2:1 either to TIP continuously, TIP cyclically (alternating 28 days of TIP and placebo) or placebo for 16 weeks, respectively and were followed up for 8 weeks.Overall, 107 patients were randomised to cohorts A (n=34), B (n=36) and C (n=37). All three TIP doses significantly reduced the P. aeruginosa sputum density from baseline to day 29 versus placebo in a dose-dependent manner (p≤0.0001, each). A smaller proportion of patients in the continuous-TIP (34.1%) and cyclical-TIP (35.7%) groups experienced pulmonary exacerbations versus placebo (47.6%) and also required fewer anti-pseudomonal antibiotics (38.6% on continuous TIP and 42.9% on cyclical TIP) versus placebo (57.1%) although not statistically significant. Pulmonary exacerbation of bronchiectasis was the most frequent (37.4%) adverse event. Overall, TIP was well tolerated, however, 23.4% of the patients discontinued the study drug due to adverse events.Continuous- and cyclical-TIP regimens with all three doses were safe and effective in reducing the P. aeruginosa sputum density in patients with bronchiectasis and chronic P. aeruginosa infection.
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