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Islam N, Reid D. Inhaled antibiotics: A promising drug delivery strategies for efficient treatment of lower respiratory tract infections (LRTIs) associated with antibiotic resistant biofilm-dwelling and intracellular bacterial pathogens. Respir Med 2024; 227:107661. [PMID: 38729529 DOI: 10.1016/j.rmed.2024.107661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/12/2024]
Abstract
Antibiotic-resistant bacteria associated with LRTIs are frequently associated with inefficient treatment outcomes. Antibiotic-resistant Streptococcus pneumoniae, Haemophilus influenzae, Pseudomonas aeruginosa, and Staphylococcus aureus, infections are strongly associated with pulmonary exacerbations and require frequent hospital admissions, usually following failed management in the community. These bacteria are difficult to treat as they demonstrate multiple adaptational mechanisms including biofilm formation to resist antibiotic threats. Currently, many patients with the genetic disease cystic fibrosis (CF), non-CF bronchiectasis (NCFB) and chronic obstructive pulmonary disease (COPD) experience exacerbations of their lung disease and require high doses of systemically administered antibiotics to achieve meaningful clinical effects, but even with high systemic doses penetration of antibiotic into the site of infection within the lung is suboptimal. Pulmonary drug delivery technology that reliably deliver antibacterials directly into the infected cells of the lungs and penetrate bacterial biofilms to provide therapeutic doses with a greatly reduced risk of systemic adverse effects. Inhaled liposomal-packaged antibiotic with biofilm-dissolving drugs offer the opportunity for targeted, and highly effective antibacterial therapeutics in the lungs. Although the challenges with development of some inhaled antibiotics and their clinicals trials have been studied; however, only few inhaled products are available on market. This review addresses the current treatment challenges of antibiotic-resistant bacteria in the lung with some clinical outcomes and provides future directions with innovative ideas on new inhaled formulations and delivery technology that promise enhanced killing of antibiotic-resistant biofilm-dwelling bacteria.
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Affiliation(s)
- Nazrul Islam
- Pharmacy Discipline, School of Clinical Sciences, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Centre for Immunology and Infection Control (CIIC), Queensland University of Technology, Brisbane, Queensland, Australia; Centre for Materials Science, Queensland University of Technology, Brisbane, Queensland, Australia.
| | - David Reid
- Lung Inflammation and Infection, QIMR Berghofer Medical Research Institute, Australia
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2
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Rofael SAD, Brown J, Lipman MCI, Lowe DM, Spratt D, Quaderi S, Hurst JR, McHugh TD. Impact of prophylactic and 'rescue pack' antibiotics on the airway microbiome in chronic lung disease. BMJ Open Respir Res 2023; 10:10/1/e001335. [PMID: 37085283 PMCID: PMC10124267 DOI: 10.1136/bmjresp-2022-001335] [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: 06/14/2022] [Accepted: 03/24/2023] [Indexed: 04/23/2023] Open
Abstract
The management of many chronic lung diseases involves multiple antibiotic prescriptions either to treat acute exacerbations or as prophylactic therapy to reduce the frequency of exacerbations and improve patients' quality of life. AIM To investigate the effects of antibiotics on the homeostasis of bacterial communities in the airways, and how this may contribute to antimicrobial resistance (AMR) among respiratory pathogens and microbiota. METHODS Within an observational cohort study, sputum was collected from 84 patients with chronic obstructive pulmonary disease and/or bronchiectasis at stable state: 47 were receiving antibiotic prophylaxis therapy. V3-V4 16S-rRNA sequencing on Illumina MiSeq, quantitative PCR for typical respiratory pathogens, bacteriology cultures and antimicrobial susceptibility testing of sputum isolates, resistome analysis on a subset of 17 sputum samples using MinION metagenomics sequencing were performed. FINDING The phylogenetic α-diversity and the total bacterial density in sputum were significantly lower in patients receiving prophylactic antibiotics (p=0.014 and 0.029, respectively). Antibiotic prophylaxis was associated with significantly lower relative abundance of respiratory pathogens such as Pseudomonas aeruginosa, Moraxella catarrhalis and members of family Enterobacteriaceae in the airway microbiome, but not Haemophilus influenzae and Streptococcus pneumoniae. No major definite directional shifts in the microbiota composition were identified with prophylactic antibiotic use at the cohort level. Surveillance of AMR and resistome analysis revealed a high frequency of resistance to macrolide and tetracycline in the cohort. AMR expressed by pathogenic bacterial isolates was associated with antibiotics prescribed as 'rescue packs' for prompt initiation of self-treatment of exacerbations (Spearman's rho=0.408, p=0.02). CONCLUSIONS Antibiotic prophylactic therapy suppresses recognised pathogenic bacteria in the sputum of patients with chronic lung disease. The use of antibiotic rescue packs may be driving AMR in this cohort rather than prophylactic antibiotics.
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Affiliation(s)
- Sylvia A D Rofael
- UCL Centre for Clinical Microbiology, Division of Infection & Immunity, University College London, London, UK
- Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
| | - James Brown
- UCL Respiratory, Divison of Medicine, University College London, London, UK
- Respiratory Medicine, Royal Free NHS Foundation Trust, London, UK
| | - Marc C I Lipman
- UCL Respiratory, Divison of Medicine, University College London, London, UK
- Respiratory Medicine, Royal Free NHS Foundation Trust, London, UK
| | - David M Lowe
- Institute for Immunity and Transplantation, Divison of Infection and Immunity, University College London, London, UK
| | - David Spratt
- Department of Microbial Diseases, UCL Eastman Dental Institute, University College London, London, UK
| | - Shumonta Quaderi
- UCL Respiratory, Divison of Medicine, University College London, London, UK
- Respiratory Medicine, Royal Free NHS Foundation Trust, London, UK
| | - John R Hurst
- UCL Respiratory, Divison of Medicine, University College London, London, UK
- Respiratory Medicine, Royal Free NHS Foundation Trust, London, UK
| | - Timothy D McHugh
- UCL Centre for Clinical Microbiology, Division of Infection & Immunity, University College London, London, UK
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3
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Pomares X, Montón C, Huertas D, Marín A, Cuevas E, Casabella A, Martí S, Oliva JC, Santos S. Efficacy of Low-Dose versus High-Dose Continuous Cyclic Azithromycin Therapy for Preventing Acute Exacerbations of COPD. Respiration 2021; 100:1070-1077. [PMID: 34365450 DOI: 10.1159/000517781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/07/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Long-term azithromycin therapy significantly reduces the frequency of COPD exacerbations (ECOPD). However, previous studies have used different dosing regimens, and the efficacy of these regimens has not been compared. OBJECTIVE Compare the efficacy of low-dose with high-dose continuous cyclic azithromycin (CC-A) in severe COPD. METHODS Patients with severe COPD and repeated exacerbations (ECOPD ≥4 or ≥3 with at least 1 hospital admission in the previous year) were prospectively recruited (January 2017 to December 2019) as a multicenter cohort (from 3 university hospitals in the Barcelona area) and treated with low-dose CC-A: 250 mg 3 times per week (250-CC-A group). This cohort was compared with a historical (January 2007 to December 2013) single-center cohort of severe COPD with frequent ECOPD treated with high-dose CC-A: 500 mg 3 times per week (500-CC-A group). To assess differences in ECOPD prevention according to the administration of low-dose or high-dose CC-A, moderate-to-severe ECOPD was evaluated during the 12-month period before and after starting CC-A therapy. RESULTS Fifty-eight patients with severe COPD were evaluated: 37 in the low-dose group and 21 in the high-dose group. The 250-CC-A therapy group achieved a mean reduction in moderate-to-severe ECOPD of 65.6% at 12 months after starting CC-A therapy (with a 61.5% reduction in hospitalizations), while the 500-CC-A group achieved a reduction of 60.5% (with a 44.8% reduction in hospitalizations). No significant differences between 250-CC-A and 500-CC-A dosages were observed in the mean annual reduction of moderate-to-severe ECOPD (p = 0.55) or hospitalizations (p = 0.07) with respect to the year prior to starting CC-A. CONCLUSIONS Low-dose 250-CC-A therapy over a 1-year period is similar to high-dose 500-CC-A in reducing exacerbation frequency in severe COPD patients with frequent ECOPD despite maximal medical therapy.
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Affiliation(s)
- Xavier Pomares
- Department of Respiratory Medicine, Hospital de Sabadell, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain
| | - Concepción Montón
- Department of Respiratory Medicine, Hospital de Sabadell, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,Health Services Research on Chronic Diseases Network-REDISSEC, Galdakao, Spain
| | - Daniel Huertas
- Department of Respiratory Medicine, Hospital Residència Sant Camil, Consorci Sanitari Alt Penedès-Garraf, Barcelona, Spain
| | - Alicia Marín
- CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain.,Department of Respiratory Medicine, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Ester Cuevas
- Department of Respiratory Medicine, Bellvitge University Hospital, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Antonio Casabella
- Laboratory of Microbiology, UDIAT Centre Diagnòstic, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Sara Martí
- CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain.,Department of Microbiology, Bellvitge University Hospital, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Joan Carles Oliva
- Epidemiology and Assessment Unit, Fundació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Salud Santos
- CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain.,Department of Respiratory Medicine, Bellvitge University Hospital, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
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Yan M, Saxena FE, Calzavara A, Brown KA, Garber G, Gershon AS, Johnstone J, Kumar M, Langford BJ, Lee S, Schwartz KL, Daneman N. Long-term macrolide therapy for chronic obstructive pulmonary disease: a population-based time series analysis. CMAJ Open 2021; 9:E576-E584. [PMID: 34021016 PMCID: PMC8177912 DOI: 10.9778/cmajo.20200157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Macrolides are recommended as an adjunctive treatment for patients with moderate to severe chronic obstructive pulmonary disease (COPD) who experience recurrent exacerbations. The objective of this study was to examine temporal trends in the provision of long-term macrolide therapy, specifically before and after publication of the landmark MACRO trial in August 2011 showing efficacy of macrolides for this indication. METHODS We performed an interrupted time series analysis using population-level health administrative data. The study cohort consisted of all Ontario residents who had COPD, were using at least 1 long-acting inhaler, and were aged 65 years and older between Apr. 1, 2004, and Mar. 31, 2018. We compared the baseline characteristics of eligible patients before and after publication of the MACRO trial. Our primary outcome was overall prevalence of long-term macrolide therapy; secondary outcomes were incidence of COPD-related hospitalizations, emergency department visits and outpatient exacerbations requiring high-dose steroids in each quarter. We performed an interrupted time series analysis to assess for changes in the incidence of macrolide prophylaxis by quarter-year over the study period. RESULTS The rate of long-term macrolide use increased from 0.8 per 1000 people in 2004 to 13.8 per 1000 people in 2018 (in the severe COPD group, the rate increased from 1.3 to 32.3 per 1000 people). The interrupted time series analysis showed that, before 2011, the prevalence of macrolide prophylaxis increased at a rate of 0.44 (95% confidence interval [CI] 0.39-0.50) per 1000 people per year; after 2011, the rate of increase grew by 1.18 (95% CI 1.07-1.29) per 1000 people to 1.63 (95% CI 1.56-1.69) per 1000 people per year. The seasonal pattern of COPD-related health care visits remained stable over the study period, and there was no detectable reduction in hospitalizations or emergency department visits at the population level. INTERPRETATION In the past decade, there has been a significant rise in the use of long-term macrolide therapy for patients with COPD. As this practice becomes increasingly common, it will be important to monitor its potential benefits on COPD exacerbations but also its potential effects on adverse events and antimicrobial resistance patterns.
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Affiliation(s)
- Marie Yan
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Farah E Saxena
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Andrew Calzavara
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Kevin A Brown
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Gary Garber
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Andrea S Gershon
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Jennie Johnstone
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Matthew Kumar
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Bradley J Langford
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Samantha Lee
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Kevin L Schwartz
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont
| | - Nick Daneman
- Department of Medicine (Yan, Garber, Gershon), University of Toronto, Toronto, Ont.; Department of Medicine (Yan), University of British Columbia, Vancouver, BC; ICES (Saxena, Calzavara, Brown, Gershon, Kumar, Lee, Schwartz, Daneman), Toronto, Ont.; Dalla Lana School of Public Health (Brown, Johnstone), University of Toronto, Toronto, Ont.; Public Health Ontario (Brown, Garber, Johnstone, Langford, Schwartz, Daneman), Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Gershon, Daneman); Sinai Health System (Johnstone); Unity Health Toronto (Schwartz), Toronto, Ont.
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Di Pasquale M, Aliberti S, Mantero M, Gramegna A, Blasi F. Pharmacotherapeutic management of bronchial infections in adults: non-cystic fibrosis bronchiectasis and chronic obstructive pulmonary disease. Expert Opin Pharmacother 2020; 21:1975-1990. [PMID: 32808825 DOI: 10.1080/14656566.2020.1793958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Effective management of both acute and chronic bronchial infections is mandatory due to their high frequency rate, the relevant morbidity and mortality and the significant burden to health care systems, especially with the aging of population. Bacteria are the main causative pathogens, followed by viruses, and less commonly by fungi. The clinical evaluation of new therapeutic associations is mandatory to cope with the increases in resistance, in association with better infection control and antimicrobial policies. AREAS COVERED The authors searched Medline for any article published in English language up until March 1, 2020 that concerns the treatment of acute exacerbations and chronic infections in chronic obstructive respiratory disease and bronchiectasis. EXPERT OPINION As acute exacerbations are a main common and detrimental event in patients with COPD and bronchiectasis, effective antimicrobial therapies and regimens should be optimized. The development of new molecules or combination regimens is vital to patients with severe and/or difficult-to-treat infections. Moreover, chronic infection control is mandatory in these patients to their improve quality of life, respiratory function and prognosis as well as for reducing health care costs.
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Affiliation(s)
- Marta Di Pasquale
- Department of Pathophysiology and Transplantation, University of Milan, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy
| | - Stefano Aliberti
- Department of Pathophysiology and Transplantation, University of Milan, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy
| | - Marco Mantero
- Department of Pathophysiology and Transplantation, University of Milan, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, University of Milan, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy
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The learning hospital: From theory to practice in a hospital infection prevention program. Infect Control Hosp Epidemiol 2020; 41:86-97. [DOI: 10.1017/ice.2019.318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AbstractThe learning hospital is distinguished by ceaseless evolution of erudition, enhancement, and implementation of clinical best practices. We describe a model for the learning hospital within the framework of a hospital infection prevention program and argue that a critical assessment of safety practices is possible without significant grant funding. We reviewed 121 peer-reviewed manuscripts published by the VCU Hospital Infection Prevention Program over 16 years. Publications included quasi-experimental studies, observational studies, surveys, interrupted time series analyses, and editorials. We summarized the articles based on their infection prevention focus, and we provide a brief summary of the findings. We also summarized the involvement of nonfaculty learners in these manuscripts as well as the contributions of grant funding. Despite the absence of significant grant funding, infection prevention programs can critically assess safety strategies under the learning hospital framework by leveraging a diverse collaboration of motivated nonfaculty learners. This model is a valuable adjunct to traditional grant-funded efforts in infection prevention science and is part of a successful horizontal infection control program.
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Vermeersch K, Gabrovska M, Aumann J, Demedts IK, Corhay JL, Marchand E, Slabbynck H, Haenebalcke C, Haerens M, Hanon S, Jordens P, Peché R, Fremault A, Lauwerier T, Delporte A, Vandenberk B, Willems R, Everaerts S, Belmans A, Bogaerts K, Verleden GM, Troosters T, Ninane V, Brusselle GG, Janssens W. Azithromycin during Acute Chronic Obstructive Pulmonary Disease Exacerbations Requiring Hospitalization (BACE). A Multicenter, Randomized, Double-Blind, Placebo-controlled Trial. Am J Respir Crit Care Med 2019; 200:857-868. [DOI: 10.1164/rccm.201901-0094oc] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Kristina Vermeersch
- Laboratory of Respiratory Diseases, Department of Chronic Diseases, Metabolism and Ageing
- Department of Respiratory Diseases and
| | - Maria Gabrovska
- Department of Pneumology, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Joseph Aumann
- Department of Pneumology, Jessa Ziekenhuis, Hasselt, Belgium
| | - Ingel K. Demedts
- Department of Respiratory Medicine, AZ Delta Roeselare-Menen, Roeselare, Belgium
| | - Jean-Louis Corhay
- Department of Pneumology, Centre Hospitalier Universitaire, Liège, Belgium
| | - Eric Marchand
- Department of Pneumology, CHU-UCL-Namur, Yvoir, Belgium
- Faculty of Medicine, NARILIS, Laboratory of Respiratory Physiology, University of Namur, Namur, Belgium
| | - Hans Slabbynck
- Department of Respiratory Medicine, ZNA Middelheim, Antwerpen, Belgium
| | | | | | - Shane Hanon
- Department of Pneumology, UZ Brussel, Jette, Belgium
| | - Paul Jordens
- Department of Pneumology, Onze-Lieve-Vrouw Ziekenhuis, Aalst, Belgium
| | - Rudi Peché
- Department of Pneumology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Antoine Fremault
- Department of Pneumology, Grand Hôpital de Charleroi, Charleroi, Belgium
| | - Tine Lauwerier
- Department of Pneumology, Imelda Ziekenhuis, Bonheiden, Belgium
| | - Anja Delporte
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium; and
| | - Bert Vandenberk
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Rik Willems
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Stephanie Everaerts
- Laboratory of Respiratory Diseases, Department of Chronic Diseases, Metabolism and Ageing
- Department of Respiratory Diseases and
| | - Ann Belmans
- I-BioStat, and
- Universiteit Hasselt, Hasselt, Belgium
| | - Kris Bogaerts
- I-BioStat, and
- Universiteit Hasselt, Hasselt, Belgium
| | - Geert M. Verleden
- Laboratory of Respiratory Diseases, Department of Chronic Diseases, Metabolism and Ageing
- Department of Respiratory Diseases and
| | - Thierry Troosters
- Laboratory of Respiratory Diseases, Department of Chronic Diseases, Metabolism and Ageing
- Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Vincent Ninane
- Department of Pneumology, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Guy G. Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium; and
| | - Wim Janssens
- Laboratory of Respiratory Diseases, Department of Chronic Diseases, Metabolism and Ageing
- Department of Respiratory Diseases and
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Blood eosinophil count and GOLD stage predict response to maintenance azithromycin treatment in COPD patients with frequent exacerbations. Respir Med 2019; 154:27-33. [DOI: 10.1016/j.rmed.2019.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/31/2019] [Accepted: 06/07/2019] [Indexed: 11/18/2022]
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Davidson RJ. In vitro activity and pharmacodynamic/pharmacokinetic parameters of clarithromycin and azithromycin: why they matter in the treatment of respiratory tract infections. Infect Drug Resist 2019; 12:585-596. [PMID: 30881064 PMCID: PMC6413744 DOI: 10.2147/idr.s187226] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Clarithromycin and azithromycin are second-generation macrolides established and widely used for treating a range of upper and lower respiratory tract infections. Extensive clinical trials data indicate that these drugs are highly effective in these applications and broadly comparable in their clinical and microbiological effectiveness. However, consideration of pharmacokinetic, metabolic, and tissue-penetration data, including the significant antibacterial activity of the metabolite 14-hydroxy-clarithromycin, plus the findings of pharmacodynamic modeling, provide evidence that the long half-life and lower potency of azithromycin predispose this agent to select for resistant isolates. Comparison of the "mutant-prevention concentrations" of clarithromycin and azithromycin, and examination of large-scale epidemiological data from Canada, also support the view that these drugs differ materially in their propensity to promote resistance among bacterial strains implicated in common respiratory infections, and that clarithromycin may offer important advantages over azithromycin that should be considered when choosing a macrolide to treat these conditions.
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Affiliation(s)
- Ross J Davidson
- Department of Pathology and Laboratory Medicine, Division of Microbiology, Queen Elizabeth II Health Sciences Center, Halifax, NS, Canada,
- Department of Medicine,
- Department of Pathology,
- Department of Microbiology & Immunology, Dalhousie University, Halifax, NS, Canada,
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10
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Cui Y, Luo L, Li C, Chen P, Chen Y. Long-term macrolide treatment for the prevention of acute exacerbations in COPD: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis 2018; 13:3813-3829. [PMID: 30538443 PMCID: PMC6254503 DOI: 10.2147/copd.s181246] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Acute exacerbation of COPD (AECOPD) is associated with an increased hospitalization and mortality. Azithromycin and erythromycin are the recommended drugs to reduce the risk of exacerbations. However, the most suitable duration of therapy and drug-related adverse events are still a matter of debate. The aim of this meta-analysis was to assess the current evidence regarding the efficacy and safety of long-term macrolide treatment for COPD. Materials and methods We comprehensively searched PubMed, Embase, the Cochrane Library, and the Web of Science and performed a systematic review and cumulative meta-analysis of all randomized controlled trials (RCTs) and retrospective studies. Results Eleven RCTs and one retrospective study including a total of 2,151 cases were carried out. Long-term macrolide treatment significantly reduced the total number of cases with one or more exacerbations (OR=0.40; 95% CI=0.24–0.65; P<0.01) and the rate of exacerbations per patient per year (risk ratio [RR]=0.60; 95% CI=0.45–0.78; P<0.01). Subgroup analyses showed that the minimum duration for drug efficacy for both azithromycin and erythromycin therapy was 6 months. In addition, macrolide therapy could improve the St George Respiratory Questionnaire (SGRQ) total score (P<0.01) but did not achieve the level of clinical significance. The frequency of hospitalizations was not significantly different between the treatment and control groups (P=0.50). Moreover, chronic azithromycin treatment was more likely to increase adverse events (P<0.01). Conclusion Prophylactic azithromycin or erythromycin treatment has a significant effect in reducing the frequency of AECOPD in a time-dependent manner. However, long-term macrolide treatment could increase the occurrence of adverse events and macrolide resistance. Future large-scale, well-designed RCTs with extensive follow-up are required to identify patients in whom the benefits outweigh risks.
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Affiliation(s)
- Yanan Cui
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China,
| | - Lijuan Luo
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China,
| | - Chenbei Li
- Biomedical Clinical Medicine, The Queen Marry University of London of Nanchang University, Jiangxi, China
| | - Ping Chen
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China,
| | - Yan Chen
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China,
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11
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Herath SC, Normansell R, Maisey S, Poole P. Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev 2018; 10:CD009764. [PMID: 30376188 PMCID: PMC6517028 DOI: 10.1002/14651858.cd009764.pub3] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There has been renewal of interest in the use of prophylactic antibiotics to reduce the frequency of exacerbations and improve quality of life in chronic obstructive pulmonary disease (COPD). OBJECTIVES To determine whether or not regular (continuous, intermittent or pulsed) treatment of COPD patients with prophylactic antibiotics reduces exacerbations or affects quality of life. SEARCH METHODS We searched the Cochrane Airways Group Trials Register and bibliographies of relevant studies. The latest literature search was performed on 27 July 2018. SELECTION CRITERIA Randomised controlled trials (RCTs) that compared prophylactic antibiotics with placebo in patients with COPD. DATA COLLECTION AND ANALYSIS We used the standard Cochrane methods. Two independent review authors selected studies for inclusion, extracted data, and assessed risk of bias. We resolved discrepancies by involving a third review author. MAIN RESULTS We included 14 studies involving 3932 participants in this review. We identified two further studies meeting inclusion criteria but both were terminated early without providing results. All studies were published between 2001 and 2015. Nine studies were of continuous macrolide antibiotics, two studies were of intermittent antibiotic prophylaxis (three times per week) and two were of pulsed antibiotic regimens (e.g. five days every eight weeks). The final study included one continuous, one intermittent and one pulsed arm. The antibiotics investigated were azithromycin, erythromycin, clarithromycin, doxycyline, roxithromycin and moxifloxacin. The study duration varied from three months to 36 months and all used intention-to-treat analysis. Most of the pooled results were of moderate quality. The risk of bias of the included studies was generally low.The studies recruited participants with a mean age between 65 and 72 years and mostly at least moderate-severity COPD. Five studies only included participants with frequent exacerbations and two studies recruited participants requiring systemic steroids or antibiotics or both, or who were at the end stage of their disease and required oxygen. One study recruited participants with pulmonary hypertension secondary to COPD and a further study was specifically designed to asses whether eradication of Chlamydia pneumoniae reduced exacerbation rates.The co-primary outcomes for this review were the number of exacerbations and quality of life.With use of prophylactic antibiotics, the number of participants experiencing one or more exacerbations was reduced (odds ratio (OR) 0.57, 95% CI 0.42 to 0.78; participants = 2716; studies = 8; moderate-quality evidence). This represented a reduction from 61% of participants in the control group compared to 47% in the treatment group (95% CI 39% to 55%). The number needed to treat for an additional beneficial outcome with prophylactic antibiotics given for three to 12 months to prevent one person from experiencing an exacerbation (NNTB) was 8 (95% CI 5 to 17). The test for subgroup difference suggested that continuous and intermittent antibiotics may be more effective than pulsed antibiotics (P = 0.02, I² = 73.3%).The frequency of exacerbations per patient per year was also reduced with prophylactic antibiotic treatment (rate ratio 0.67; 95% CI 0.54 to 0.83; participants = 1384; studies = 5; moderate-quality evidence). Although we were unable to pool the result, six of the seven studies reporting time to first exacerbation identified an increase (i.e. benefit) with antibiotics, which was reported as statistically significant in four studies.There was a statistically significant improvement in quality of life as measured by the St George's Respiratory Questionnaire (SGRQ) with prophylactic antibiotic treatment, but this was smaller than the four unit improvement that is regarded as being clinically significant (mean difference (MD) -1.94, 95% CI -3.13 to -0.75; participants = 2237; studies = 7, high-quality evidence).Prophylactic antibiotics showed no significant effect on the secondary outcomes of frequency of hospital admissions, change in forced expiratory volume in one second (FEV1), serious adverse events or all-cause mortality (moderate-quality evidence). There was some evidence of benefit in exercise tolerance, but this was driven by a single study of lower methodological quality.The adverse events that were recorded varied among the studies depending on the antibiotics used. Azithromycin was associated with significant hearing loss in the treatment group, which was in many cases reversible or partially reversible. The moxifloxacin pulsed study reported a significantly higher number of adverse events in the treatment arm due to the marked increase in gastrointestinal adverse events (P < 0.001). Some adverse events that led to drug discontinuation, such as development of long QTc or tinnitus, were not significantly more frequent in the treatment group than the placebo group but pose important considerations in clinical practice.The development of antibiotic resistance in the community is of major concern. Six studies reported on this, but we were unable to combine results. One study found newly colonised participants to have higher rates of antibiotic resistance. Participants colonised with moxifloxacin-sensitive pseudomonas at initiation of therapy rapidly became resistant with the quinolone treatment. A further study with three active treatment arms found an increase in the degree of antibiotic resistance of isolates in all three arms after 13 weeks treatment. AUTHORS' CONCLUSIONS Use of continuous and intermittent prophylactic antibiotics results in a clinically significant benefit in reducing exacerbations in COPD patients. All studies of continuous and intermittent antibiotics used macrolides, hence the noted benefit applies only to the use of macrolide antibiotics prescribed at least three times per week. The impact of pulsed antibiotics remains uncertain and requires further research.The studies in this review included mostly participants who were frequent exacerbators with at least moderate-severity COPD. There were also older individuals with a mean age over 65 years. The results of these studies apply only to the group of participants who were studied in these studies and may not be generalisable to other groups.Because of concerns about antibiotic resistance and specific adverse effects, consideration of prophylactic antibiotic use should be mindful of the balance between benefits to individual patients and the potential harms to society created by antibiotic overuse. Monitoring of significant side effects including hearing loss, tinnitus, and long QTc in the community in this elderly patient group may require extra health resources.
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Affiliation(s)
- Samantha C Herath
- Westmead Public HospitalDepartment of Respiratory and Sleep MedicineSydneyNew South WalesAustralia
| | - Rebecca Normansell
- St George's, University of LondonCochrane Airways, Population Health Research InstituteLondonUKSW17 0RE
| | - Samantha Maisey
- St George's University of LondonPopulation Health Research InstituteLondonUK
| | - Phillippa Poole
- University of AucklandDepartment of MedicinePrivate Bag 92019AucklandNew Zealand
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Pomares X, Montón C, Bullich M, Cuevas O, Oliva JC, Gallego M, Monsó E. Clinical and Safety Outcomes of Long-Term Azithromycin Therapy in Severe COPD Beyond the First Year of Treatment. Chest 2018; 153:1125-1133. [PMID: 29427576 DOI: 10.1016/j.chest.2018.01.044] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 01/11/2018] [Accepted: 01/26/2018] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Exacerbations of COPD (ECOPD) are a major cause of mortality and morbidity. Continuous cyclic azithromycin (CC-A) reduces the exacerbation rate, but it is unknown whether it remains effective and safe beyond the first year. METHODS This study was a retrospective analysis of patients with severe COPD (Global Initiative for Chronic Obstructive Lung Disease grade D) with ≥ 4 moderate to severe ECOPD who received CC-A (500 mg three times per week) as add-on therapy. Patients treated over 24 months were considered long-term continuous cyclic azithromycin (LT-CC-A) users, and ECOPD, hospitalizations, and length of hospital stays during the first, second, and third years were compared with the previous 12 months. Microbiologic monitoring, assessment of macrolide resistance, and analysis of side effects were maintained throughout the study period. RESULTS A total of 109 patients with severe COPD treated with CC-A (39 for ≥ 24 months) comprised the LT-CC-A group (35.8%). This group presented average reductions in ECOPD from baseline of 56.2% at 12 months, 70% at 24 months, and 41% at 36 months, paralleled by respective reductions in hospitalizations of 62.6%, 75.8%, and 39.8%. ECOPD due to common microorganisms fell by 12.5% and 17.3% at 12 and 24 months of LT-CC-A, respectively, with a 50% increase in macrolide resistance. Pseudomonas aeruginosa ECOPD rose by 7.2% and 13.1% at these two time points. CC-A therapy was well tolerated with few side effects: digestive disorders in the short term (7.1%) and hearing loss in the long term (5.1%). CONCLUSIONS LT-CC-A therapy over a 24- to 36-month period in patients with COPD (Global Initiative for Chronic Obstructive Lung Disease grade D) achieved sustained reductions in ECOPD and hospitalizations of > 50% with few adverse events, although macrolide resistance increased.
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Affiliation(s)
- Xavier Pomares
- Department of Respiratory Medicine, Hospital de Sabadell, Institut Universitari Parc Taulí-UAB, Sabadell, Spain; CIBER de Enfermedades Respiratorias, CIBERES, Bunyola, Spain.
| | - Concepción Montón
- Department of Respiratory Medicine, Hospital de Sabadell, Institut Universitari Parc Taulí-UAB, Sabadell, Spain; Health Services Research on Chronic Diseases Network-REDISSEC, Galdakao, Spain
| | - Miriam Bullich
- Department of Respiratory Medicine, Hospital de Sabadell, Institut Universitari Parc Taulí-UAB, Sabadell, Spain
| | - Oscar Cuevas
- Laboratory of Microbiology, Institut Universitari Parc Taulí-UAB, Sabadell, Spain
| | - Joan Carles Oliva
- Epidemiology and Assessment Unit, Fundació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Miguel Gallego
- Department of Respiratory Medicine, Hospital de Sabadell, Institut Universitari Parc Taulí-UAB, Sabadell, Spain; CIBER de Enfermedades Respiratorias, CIBERES, Bunyola, Spain
| | - Eduard Monsó
- Department of Respiratory Medicine, Hospital de Sabadell, Institut Universitari Parc Taulí-UAB, Sabadell, Spain; CIBER de Enfermedades Respiratorias, CIBERES, Bunyola, Spain
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13
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Fernandes FLA, Cukier A, Camelier AA, Fritscher CC, da Costa CH, Pereira EDB, Godoy I, Cançado JED, Romaldini JG, Chatkin JM, Jardim JR, Rabahi MF, de Nucci MCNM, Sales MDPU, Castellano MVCDO, Aidé MA, Teixeira PJZ, Maciel R, Corrêa RDA, Stirbulov R, Athanazio RA, Russo R, Minamoto ST, Lundgren FLC. Recommendations for the pharmacological treatment of COPD: questions and answers. J Bras Pneumol 2017; 43:290-301. [PMID: 29365005 PMCID: PMC5687967 DOI: 10.1590/s1806-37562017000000153] [Citation(s) in RCA: 12] [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] [Received: 05/08/2017] [Accepted: 07/04/2017] [Indexed: 11/22/2022] Open
Abstract
The treatment of COPD has become increasingly effective. Measures that range from behavioral changes, reduction in exposure to risk factors, education about the disease and its course, rehabilitation, oxygen therapy, management of comorbidities, and surgical and pharmacological treatments to end-of-life care allow health professionals to provide a personalized and effective therapy. The pharmacological treatment of COPD is one of the cornerstones of COPD management, and there have been many advances in this area in recent years. Given the greater availability of drugs and therapeutic combinations, it has become increasingly challenging to know the indications for, limitations of, and potential risks and benefits of each treatment modality. In order to critically evaluate recent evidence and systematize the major questions regarding the pharmacological treatment of COPD, 24 specialists from all over Brazil gathered to develop the present recommendations. A visual guide was developed for the classification and treatment of COPD, both of which were adapted to fit the situation in Brazil. Ten questions were selected on the basis of their relevance in clinical practice. They address the classification, definitions, treatment, and evidence available for each drug or drug combination. Each question was answered by two specialists, and then the answers were consolidated in two phases: review and consensus by all participants. The questions answered are practical questions and help select from among the many options the best treatment for each patient and his/her peculiarities.
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Affiliation(s)
- Frederico Leon Arrabal Fernandes
- . Divisão de Pneumologia, Instituto do Coração - InCor − Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Alberto Cukier
- . Divisão de Pneumologia, Instituto do Coração - InCor − Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Aquiles Assunção Camelier
- . Universidade do Estado da Bahia - UNEB - Salvador (BA) Brasil
- . Escola Bahiana de Medicina e Saúde Pública, Salvador (BA) Brasil
| | - Carlos Cezar Fritscher
- . Faculdade de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul − PUCRS− Porto Alegre (RS)Brasil
| | | | | | - Irma Godoy
- . Departamento de Medicina Interna, Área de Pneumologia, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | | | - José Gustavo Romaldini
- . Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo,São Paulo (SP) Brasil
| | - Jose Miguel Chatkin
- . Faculdade de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul − PUCRS− Porto Alegre (RS)Brasil
| | - José Roberto Jardim
- . Faculdade de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo (SP) Brasil
| | | | | | | | | | - Miguel Abidon Aidé
- . Faculdade de Medicina, Universidade Federal Fluminense, Niterói (RJ) Brasil
| | - Paulo José Zimermann Teixeira
- . Departamento de Clínica Médica, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS) Brasil
- . Universidade FEEVALE, Campus II, Novo Hamburgo (RS) Brasil
| | - Renato Maciel
- . Disciplina de Pneumologia, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte (MG) Brasil
| | - Ricardo de Amorim Corrêa
- . Faculdade de Medicina, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil
| | - Roberto Stirbulov
- . Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo,São Paulo (SP) Brasil
| | - Rodrigo Abensur Athanazio
- . Divisão de Pneumologia, Instituto do Coração - InCor − Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Rodrigo Russo
- . Departamento de Medicina, Universidade Federal de São João Del Rei - UFSJ − São João Del Rei (MG) Brasil
| | - Suzana Tanni Minamoto
- . Departamento de Medicina Interna, Área de Pneumologia, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
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14
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Webley WC, Hahn DL. Infection-mediated asthma: etiology, mechanisms and treatment options, with focus on Chlamydia pneumoniae and macrolides. Respir Res 2017; 18:98. [PMID: 28526018 PMCID: PMC5437656 DOI: 10.1186/s12931-017-0584-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 05/15/2017] [Indexed: 12/30/2022] Open
Abstract
Asthma is a chronic respiratory disease characterized by reversible airway obstruction and airway hyperresponsiveness to non-specific bronchoconstriction agonists as the primary underlying pathophysiology. The worldwide incidence of asthma has increased dramatically in the last 40 years. According to World Health Organization (WHO) estimates, over 300 million children and adults worldwide currently suffer from this incurable disease and 255,000 die from the disease each year. It is now well accepted that asthma is a heterogeneous syndrome and many clinical subtypes have been described. Viral infections such as respiratory syncytial virus (RSV) and human rhinovirus (hRV) have been implicated in asthma exacerbation in children because of their ability to cause severe airway inflammation and wheezing. Infections with atypical bacteria also appear to play a role in the induction and exacerbation of asthma in both children and adults. Recent studies confirm the existence of an infectious asthma etiology mediated by Chlamydia pneumoniae (CP) and possibly by other viral, bacterial and fungal microbes. It is also likely that early-life infections with microbes such as CP could lead to alterations in the lung microbiome that significantly affect asthma risk and treatment outcomes. These infectious microbes may exacerbate the symptoms of established chronic asthma and may even contribute to the initial development of the clinical onset of the disease. It is now becoming more widely accepted that patterns of airway inflammation differ based on the trigger responsible for asthma initiation and exacerbation. Therefore, a better understanding of asthma subtypes is now being explored more aggressively, not only to decipher pathophysiologic mechanisms but also to select treatment and guide prognoses. This review will explore infection-mediated asthma with special emphasis on the protean manifestations of CP lung infection, clinical characteristics of infection-mediated asthma, mechanisms involved and antibiotic treatment outcomes.
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Affiliation(s)
- Wilmore C. Webley
- University of Massachusetts Amherst, 240 Thatcher Rd. Life Science Laboratory Building N229, Amherst, MA 01003 USA
| | - David L. Hahn
- University of Wisconsin School of Medicine and Public Health, 1100 Delaplaine Court, Madison, WI 53715 USA
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15
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Vermeersch K, Gabrovska M, Deslypere G, Demedts IK, Slabbynck H, Aumann J, Ninane V, Verleden GM, Troosters T, Bogaerts K, Brusselle GG, Janssens W. The Belgian trial with azithromycin for acute COPD exacerbations requiring hospitalization: an investigator-initiated study protocol for a multicenter, randomized, double-blind, placebo-controlled trial. Int J Chron Obstruct Pulmon Dis 2016; 11:687-96. [PMID: 27099485 PMCID: PMC4820219 DOI: 10.2147/copd.s95501] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Long-term use of macrolide antibiotics is effective to prevent exacerbations in chronic obstructive pulmonary disease (COPD). As risks and side effects of long-term intervention outweigh the benefits in the general COPD population, the optimal dose, duration of treatment, and target population are yet to be defined. Hospitalization for an acute exacerbation (AE) of COPD may offer a targeted risk group and an obvious risk period for studying macrolide interventions. Methods/design Patients with COPD, hospitalized for an AE, who have a smoking history of ≥10 pack-years and had ≥1 exacerbation in the previous year will be enrolled in a multicenter, randomized, double-blind, placebo-controlled trial (NCT02135354). On top of a standardized treatment of systemic corticosteroids and antibiotics, subjects will be randomized to receive either azithromycin or placebo during 3 months, at an uploading dose of 500 mg once a day for 3 days, followed by a maintenance dose of 250 mg once every 2 days. The primary endpoint is the time-to-treatment failure during the treatment phase (ie, from the moment of randomization until the end of intervention). Treatment failure is a novel composite endpoint defined as either death, the admission to intensive care or the requirement of additional systemic steroids or new antibiotics for respiratory reasons, or the diagnosis of a new AE after discharge. Discussion We investigate whether azithromycin initiated at the onset of a severe exacerbation, with a limited duration and at a low dose, might be effective and safe in the highest risk period during and immediately after the acute event. If proven effective and safe, this targeted approach may improve the treatment of severe AEs and redirect the preventive use of azithromycin in COPD to a temporary intervention in the subgroup with the highest unmet needs.
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Affiliation(s)
- Kristina Vermeersch
- KU Leuven, Laboratory of Respiratory Diseases, Department of Clinical and Experimental Medicine, Faculty of Medicine, Leuven, Belgium
| | - Maria Gabrovska
- Department of Pneumology, Centre Hospitalier Universitaire Saint-Pierre, Brussels, Belgium
| | - Griet Deslypere
- Department of Pneumology, Jessa Ziekenhuis, Hasselt, Belgium
| | - Ingel K Demedts
- Department of Respiratory Medicine, AZ Delta Roeselare-Menen, Roeselare, Belgium
| | - Hans Slabbynck
- Department of Respiratory Medicine, ZNA Middelheim, Antwerpen, Belgium
| | - Joseph Aumann
- Department of Pneumology, Jessa Ziekenhuis, Hasselt, Belgium
| | - Vincent Ninane
- Department of Pneumology, Centre Hospitalier Universitaire Saint-Pierre, Brussels, Belgium
| | - Geert M Verleden
- KU Leuven, Laboratory of Respiratory Diseases, Department of Clinical and Experimental Medicine, Faculty of Medicine, Leuven, Belgium
| | - Thierry Troosters
- KU Leuven, Laboratory of Respiratory Diseases, Department of Clinical and Experimental Medicine, Faculty of Medicine, Leuven, Belgium; KU Leuven, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, Leuven, Belgium
| | - Kris Bogaerts
- KU Leuven, Department of Public Health and Primary Care, I-BioStat, Leuven, Belgium; Hasselt University, Hasselt, Belgium
| | - Guy G Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Wim Janssens
- KU Leuven, Laboratory of Respiratory Diseases, Department of Clinical and Experimental Medicine, Faculty of Medicine, Leuven, Belgium
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Søgaard M, Madsen M, Løkke A, Hilberg O, Sørensen HT, Thomsen RW. Incidence and outcomes of patients hospitalized with COPD exacerbation with and without pneumonia. Int J Chron Obstruct Pulmon Dis 2016; 11:455-65. [PMID: 27042038 PMCID: PMC4780743 DOI: 10.2147/copd.s96179] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Pneumonia may be a major contributor to hospitalizations for chronic obstructive pulmonary disease (COPD) exacerbation and influence their outcomes. Methods We examined hospitalization rates, health resource utilization, 30-day mortality, and risk of subsequent hospitalizations for COPD exacerbations with and without pneumonia in Denmark during 2006–2012. Results We identified 179,759 hospitalizations for COPD exacerbations, including 52,520 first-time hospitalizations (29.2%). Pneumonia was frequent in first-time exacerbations (36.1%), but declined in successive exacerbations to 25.6% by the seventh or greater exacerbation. Pneumonic COPD exacerbations increased 20% from 0.92 per 1,000 population in 2006 to 1.10 per 1,000 population in 2012. Nonpneumonic exacerbations decreased by 6% from 1.74 per 1,000 population to 1.63 per 1,000 population during the same period. A number of markers of health resource utilization were more prevalent in pneumonic exacerbations than in nonpneumonic exacerbations: length of stay (median 7 vs 4 days), intensive care unit admission (7.7% vs 12.5%), and several acute procedures. Thirty-day mortality was 12.1% in first-time pneumonic COPD exacerbations versus 8.3% in first-time nonpneumonic cases (adjusted HR [aHR] 1.20, 95% confidence interval [CI] 1.17–1.24). Pneumonia also predicted increased mortality associated with a second exacerbation (aHR 1.14, 95% CI 1.11–1.18), and up to a seventh or greater exacerbation (aHR 1.10, 95% CI 1.07–1.13). In contrast, the aHR of a subsequent exacerbation was 8%–13% lower for patients with pneumonic exacerbations. Conclusions Pneumonia is frequent among patients hospitalized for COPD exacerbations and is associated with increased health care utilization and higher mortality. Nonpneumonic COPD exacerbations predict increased risk of subsequent exacerbations.
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Affiliation(s)
- Mette Søgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus C, Denmark
| | - Morten Madsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus C, Denmark
| | - Anders Løkke
- Department of Respiratory Medicine, Aarhus University Hospital, Aarhus C, Denmark
| | - Ole Hilberg
- Department of Respiratory Medicine, Aarhus University Hospital, Aarhus C, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus C, Denmark
| | - Reimar W Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus C, Denmark
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Taylor SP, Sellers E, Taylor BT. Azithromycin for the Prevention of COPD Exacerbations: The Good, Bad, and Ugly. Am J Med 2015; 128:1362.e1-6. [PMID: 26291905 DOI: 10.1016/j.amjmed.2015.07.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 07/15/2015] [Accepted: 07/23/2015] [Indexed: 01/08/2023]
Abstract
Long-term azithromycin therapy has been shown to reduce exacerbations of chronic obstructive pulmonary disease (COPD), and is recommended by recent society guidelines for use in COPD patients who are at risk for recurrent exacerbations. However, concerns about adverse effects have limited its widespread adoption. Physicians deciding whether to use long-term azithromycin therapy must weigh each patient's individual risk of cardiovascular complications and both the individual and population impact of macrolide resistance against the expected benefit. This review will summarize evidence on the effectiveness and safety of chronic azithromycin for the prevention of COPD exacerbations.
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Affiliation(s)
| | - Eric Sellers
- Department of Internal Medicine, Medical University of South Carolina, Charleston
| | - Brice T Taylor
- Department of Internal Medicine, Division of Pulmonary and Critical Care, Carolinas Medical Center, Charlotte, NC
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Honoré I, Burgel PR. Primary ciliary dyskinesia in adults. Rev Mal Respir 2015; 33:165-89. [PMID: 26654126 DOI: 10.1016/j.rmr.2015.10.743] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 04/08/2015] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Primary ciliary dyskinesia is an autosomal recessive genetic disorder leading to structural and/or functional abnormalities of motor cilia. Impaired mucociliary clearance is responsible for the development of a multi-organ disease, which particularly affects the upper and lower airways. STATE OF THE ART In adults, primary ciliary dyskinesia is mainly characterized by bronchiectasis and chronic ear and sinus disorders. Situs inversus is found in half of patients and fertility disorders are commonly associated. Diagnosis is based on specialized tests: reduced level of nasal nitric oxide concentrations is suggestive of primary ciliary dyskinesia, but only a nasal or bronchial biopsy/brushing with analysis of beat pattern by videomicroscopy and/or analysis of cilia morphology by electronic microscopy can confirm the diagnosis. However, the diagnosis is difficult to achieve due to the limited access to these specialized tests and to difficulties in interpreting them. Genetic tests are under development and may provide new diagnostic tools. Treatment is symptomatic, based on airway clearance techniques (e.g., physiotherapy) and systemic and/or inhaled antibiotics. Prognosis is related to the severity of the respiratory impairment, which can be moderate or severe. PERSPECTIVES AND CONCLUSIONS Diagnosis and management of primary ciliary dyskinesia remain poorly defined and should be supported by specialized centers to standardize the diagnosis, improve the treatment and promote research.
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Affiliation(s)
- I Honoré
- Department of respiratory medicine, Cochin hospital, Assistance publique-Hôpitaux de Paris, 75014 Paris, France
| | - P-R Burgel
- Department of respiratory medicine, Cochin hospital, Assistance publique-Hôpitaux de Paris, 75014 Paris, France; Paris Descartes university, Sorbonne Paris Cité, 75005 Paris, France.
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19
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Targeting immune pathways for therapy in asthma and chronic obstructive pulmonary disease. Ann Am Thorac Soc 2015; 11 Suppl 5:S322-8. [PMID: 25525740 DOI: 10.1513/annalsats.201403-118aw] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Asthma and chronic obstructive pulmonary disease (COPD) are highly prevalent chronic inflammatory diseases of the airways, with differences in etiology, pathogenesis, immunologic mechanisms, clinical presentation, comorbidities, prognosis, and response to treatment. In mild to moderate early-onset allergic asthma, the Th2-driven eosinophilic airway inflammation and the ensuing disease can be well controlled with maintenance treatment with inhaled corticosteroids (ICS). In real-life settings, asthma control can be improved by facilitating adherence to ICS treatment and by optimizing inhaler technique. In patients with uncontrolled severe asthma, old and novel therapies targeting specific immunologic pathways should be added according to the underlying endotype/phenotype. In COPD, there is a high unmet need for safe and effective antiinflammatory treatments that not only prevent exacerbations but also have a beneficial impact on the course of the disease and improve survival. Although several new approaches aim to target the chronic neutrophilic pulmonary inflammation per se in patients with COPD, strategies that target the underlying causes of the pulmonary neutrophilia (e.g., smoking, chronic infection, and oxidative stress) might be more successful. In both chronic airway diseases (especially in more difficult, complex cases), the choice of the optimal treatment should be based not only on arbitrary clinical labels but also on the underlying immunopathology.
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20
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Barjaktarevic IZ, Arredondo AF, Cooper CB. Positioning new pharmacotherapies for COPD. Int J Chron Obstruct Pulmon Dis 2015; 10:1427-42. [PMID: 26244017 PMCID: PMC4521666 DOI: 10.2147/copd.s83758] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
COPD imposes considerable worldwide burden in terms of morbidity and mortality. In recognition of this, there is now extensive focus on early diagnosis, secondary prevention, and optimizing medical management of the disease. While established guidelines recognize different grades of disease severity and offer a structured basis for disease management based on symptoms and risk, it is becoming increasingly evident that COPD is a condition characterized by many phenotypes and its control in a single patient may require clinicians to have access to a broader spectrum of pharmacotherapies. This review summarizes recent developments in COPD management and compares established pharmacotherapy with new and emerging pharmacotherapies including long-acting muscarinic antagonists, long-acting β-2 sympathomimetic agonists, and fixed-dose combinations of long-acting muscarinic antagonists and long-acting β-2 sympathomimetic agonists as well as inhaled cortiocosteroids, phosphodiesterase inhibitors, and targeted anti-inflammatory drugs. We also review the available oral medications and new agents with novel mechanisms of action in early stages of development. With several new pharmacological agents intended for the management of COPD, it is our goal to familiarize potential prescribers with evidence relating to the efficacy and safety of new medications and to suggest circumstances in which these therapies could be most useful.
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Affiliation(s)
- Igor Z Barjaktarevic
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Anthony F Arredondo
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Christopher B Cooper
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA ; Department of Physiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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21
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Brill SE, Law M, El-Emir E, Allinson JP, James P, Maddox V, Donaldson GC, McHugh TD, Cookson WO, Moffatt MF, Nazareth I, Hurst JR, Calverley PMA, Sweeting MJ, Wedzicha JA. Effects of different antibiotic classes on airway bacteria in stable COPD using culture and molecular techniques: a randomised controlled trial. Thorax 2015; 70:930-8. [PMID: 26179246 PMCID: PMC4602260 DOI: 10.1136/thoraxjnl-2015-207194] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 06/03/2015] [Indexed: 11/17/2022]
Abstract
Background Long-term antibiotic therapy is used to prevent exacerbations of COPD but there is uncertainty over whether this reduces airway bacteria. The optimum antibiotic choice remains unknown. We conducted an exploratory trial in stable patients with COPD comparing three antibiotic regimens against placebo. Methods This was a single-centre, single-blind, randomised placebo-controlled trial. Patients aged ≥45 years with COPD, FEV1<80% predicted and chronic productive cough were randomised to receive either moxifloxacin 400 mg daily for 5 days every 4 weeks, doxycycline 100 mg/day, azithromycin 250 mg 3 times a week or one placebo tablet daily for 13 weeks. The primary outcome was the change in total cultured bacterial load in sputum from baseline; secondary outcomes included bacterial load by 16S quantitative PCR (qPCR), sputum inflammation and antibiotic resistance. Results 99 patients were randomised; 86 completed follow-up, were able to expectorate sputum and were analysed. After adjustment, there was a non-significant reduction in bacterial load of 0.42 log10 cfu/mL (95% CI −0.08 to 0.91, p=0.10) with moxifloxacin, 0.11 (−0.33 to 0.55, p=0.62) with doxycycline and 0.08 (−0.38 to 0.54, p=0.73) with azithromycin from placebo, respectively. There were also no significant changes in bacterial load measured by 16S qPCR or in airway inflammation. More treatment-related adverse events occurred with moxifloxacin. Of note, mean inhibitory concentrations of cultured isolates increased by at least three times over placebo in all treatment arms. Conclusions Total airway bacterial load did not decrease significantly after 3 months of antibiotic therapy. Large increases in antibiotic resistance were seen in all treatment groups and this has important implications for future studies. Trial registration number clinicaltrials.gov (NCT01398072).
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Affiliation(s)
- Simon E Brill
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Martin Law
- Medical Research Council Biostatistics Unit Hub for Trials Methodology Research, Cambridge, UK
| | - Ethaar El-Emir
- National Heart and Lung Institute, Imperial College London, London, UK
| | - James P Allinson
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Phillip James
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Victoria Maddox
- Centre for Clinical Microbiology, University College London, London, UK
| | - Gavin C Donaldson
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Timothy D McHugh
- Centre for Clinical Microbiology, University College London, London, UK
| | - William O Cookson
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Miriam F Moffatt
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Sciences, University College London, London, UK
| | - John R Hurst
- Centre for Respiratory Medicine, University College London, London, UK
| | | | - Michael J Sweeting
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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22
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Park KH, Park HJ, Lee JH, Park JW. Single center experience of five diffuse panbronchiolitis patients clinically presenting as severe asthma. J Korean Med Sci 2015; 30:823-8. [PMID: 26028938 PMCID: PMC4444486 DOI: 10.3346/jkms.2015.30.6.823] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 10/27/2014] [Indexed: 11/21/2022] Open
Abstract
Diffuse panbronchiolitis (DPB) is a bronchiolitis affecting the whole lung fields which can be treated by macrolide. Especially East Asian patients are more susceptible to diffuse panbronchiolitis. As asthma and DPB both can cause airway obstruction, differential diagnosis is important for the 2 diseases. Here we report 5 patients with DPB clinically presenting as severe asthma in Korea, who were well treated by macrolide. Among the 5 patients, 2 could stop their asthma inhalers and the other 3 could reduce asthma medications after diagnosis and treatment of DPB. In conclusion, considering DPB as differential diagnosis for asthmatics in Asian ethnic groups is important.
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Affiliation(s)
- Kyung Hee Park
- Department of Internal Medicine and Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Jung Park
- Department of Internal Medicine and Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Jae-Hyun Lee
- Department of Internal Medicine and Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Jung-Won Park
- Department of Internal Medicine and Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
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23
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Kitchlu A, Abdelshaheed T, Tullis E, Gupta S. Gaps in the inpatient management of chronic obstructive pulmonary disease exacerbation and impact of an evidence-based order set. Can Respir J 2015; 22:157-62. [PMID: 25886627 PMCID: PMC4470549 DOI: 10.1155/2015/587026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Evidence-based, guideline-recommended practices improve multiple outcomes in patients admitted with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), but are incompletely implemented in actual practice. Admission order sets with evidence-based diagnostic and therapeutic guidance have enabled quality improvement and guideline implementation in other conditions. OBJECTIVE To characterize the magnitude of care gaps and the effect of order sets on quality of care in patients with AECOPD. METHODS The authors prospectively designed a standardized chart review protocol to document process of care and health care utilization before and after implementation of AECOPD order sets at an academic hospital in Toronto, Ontario. RESULTS A total of 243 total AECOPD admissions and multiple important care gaps were identified. There were 74 admissions in the pre-order set period (January to June 2009) and 169 in the order set period (October 2009 to September 2010). The order set was used in 78 of 169 (46.2%) admissions. In the order set period, we observed improvements in respiratory therapy educational referrals (five of 74 [6.8%] versus 48 of 169 [28.4%]; P<0.01); venous thromboembolism prophylaxis prescriptions (when indicated) (15 of 68 [22.1%] versus 100 of 134 [74.6%]; P<0.01); systemic steroid prescriptions (55 of 74 (74.3%) versus 151 of 169 [89.4%]; P<0.01]); and appropriate antibiotic prescriptions (nine of 24 [37.5%] versus 61 of 88 [69.3%]; P<0.01). The mean (± SD) length of stay also decreased from 6.5 ± 7.7 days before order sets to 4.1 ± 5.0 days with order sets (P=0.017). CONCLUSIONS Care gaps in inpatient AECOPD management were large and evidence-based order sets may improve guideline adherence at the point of care. Randomized trials including patient outcomes are required to further evaluate this knowledge translation intervention.
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Affiliation(s)
- Abhijat Kitchlu
- Department of Medicine, Core Internal Medicine Training Program, University of Toronto, Toronto
| | - Tamer Abdelshaheed
- Department of Medicine, Division of Respirology, McMaster University, Hamilton
| | - Elizabeth Tullis
- Department of Medicine, Division of Respirology, University of Toronto
- The Keenan Research Centre in the Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario
| | - Samir Gupta
- Department of Medicine, Division of Respirology, University of Toronto
- The Keenan Research Centre in the Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario
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Siekmeier R, Hofmann T, Scheuch G. Inhalation of macrolides: a novel approach to treatment of pulmonary infections. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2015; 839:13-24. [PMID: 25252902 DOI: 10.1007/5584_2014_50] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Systemic antibiotic treatment is established for many pulmonary diseases, e.g., cystic fibrosis (CF), bronchiectasis and chronic obstructive pulmonary disease (COPD) where recurrent bacterial infections cause a progressive decline in lung function. In the last decades inhalative administration of antibiotics was introduced into clinical routine, especially tobramycin, colistin, and aztreonam for treatment of CF and bronchiectasis. Even though they are important in systemic treatment of these diseases due to their antimicrobial spectrum and anti-inflammatory and immunomodulatory properties, macrolides (e.g., azithromycin, clarithromycin, erythromycin, and telithromycin) up to now are not administered by inhalation. The number of in vitro aerosol studies and in vivo inhalation studies is also sparse. We analyzed publications on preparation and administration of macrolide aerosols available in PUBMED focusing on recent publications. Studies with solutions and dry powder aerosols were published. Publications investigating physicochemical properties of aerosols demonstrated that macrolide aerosols may serve for inhalation and will achieve sufficient lung deposition and that the bitter taste can be masked. In vivo studies in rats demonstrated high concentrations and areas under the curve sufficient for antimicrobial treatment in alveolar macrophages and epithelial lining fluid without lung toxicity. The obtained data demonstrate the feasibility of macrolide inhalation which should be further investigated.
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Affiliation(s)
- R Siekmeier
- Drug Regulatory Affairs, Pharmaceutical Institute, University Bonn, Bonn, Germany,
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Abstract
PURPOSE OF REVIEW Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with adverse outcomes and thus prevention of exacerbations is crucial. New data attest that long-term macrolide therapy decreases the risk of COPD exacerbations. We review the key studies that analyzed the effect of long-term use of macrolide antibiotics on the prevention of exacerbations, focusing on the higher quality evidence. Health-related quality of life, sputum bacteriology and development of resistance, inflammatory markers, lung function, cost-benefit analysis, and lung function in relation to long-term macrolide therapy are also discussed. RECENT FINDINGS Two well designed, randomized, placebo-controlled trials report that select patients treated for 1 year with erythromycin or azithromycin, in addition to usual care, have prolonged time to and lower frequency of COPD exacerbations. There are more hearing decrements and higher prevalence of macrolide-resistant bacteria among the patients treated with macrolide therapy. SUMMARY Prevention of COPD exacerbations is paramount given the adverse consequences on quality of life, lung function, and survival. Macrolide therapy for 1 year, in addition to usual therapy, decreases the risk of COPD exacerbations but carries the risk of hearing decrements and development of macrolide-resistant bacteria.
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Abstract
PURPOSE OF REVIEW Severe asthma is a heterogeneous syndrome, encompassing several distinct clinical phenotypes. Different molecular and cellular pathways or endotypes determine the type of underlying airway inflammation in patients with severe asthma, which can be categorized as eosinophilic asthma (allergic and nonallergic) or noneosinophilic asthma (neutrophilic and paucigranulocytic). In this review, we discuss the potential role of macrolides in the treatment of severe asthma in adults. RECENT FINDINGS Maintenance treatment with low-dose macrolides such as erythromycin and azithromycin provides clinical benefit in several chronic neutrophilic airway diseases, including cystic fibrosis (CF), non-CF bronchiectasis and exacerbation-prone chronic obstructive pulmonary disease. Although several short-term studies of macrolides in mild-to-moderate asthma have failed to improve lung function, the AzIthromycin in Severe Asthma trial has demonstrated a significant reduction in the rate of exacerbations in patients with exacerbation-prone noneosinophilic severe asthma. As chronic macrolide use is associated with the risks of population antimicrobial resistance, this add-on treatment should be restricted to severe asthma patients at greatest unmet need despite optimal asthma management. SUMMARY Further clinical, translational and basic research is needed to better phenotype patients with severe asthma, to determine the risk-benefit ratio of macrolide maintenance treatment in neutrophilic severe asthma and to elucidate the principal mechanisms of action of macrolides.
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Pomares Amigó X, Montón Soler C. Preventing COPD exacerbations: Budget impact of a respiratory day hospital and long-term azithromycin therapy. Respir Med 2014; 108:1064. [DOI: 10.1016/j.rmed.2013.04.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 03/26/2013] [Accepted: 04/04/2013] [Indexed: 11/27/2022]
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Wong EHC, Porter JD, Edwards MR, Johnston SL. The role of macrolides in asthma: current evidence and future directions. THE LANCET RESPIRATORY MEDICINE 2014; 2:657-70. [PMID: 24948430 DOI: 10.1016/s2213-2600(14)70107-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Macrolides, such as clarithromycin and azithromycin, possess antimicrobial, immunomodulatory, and potential antiviral properties. They represent a potential therapeutic option for asthma, a chronic inflammatory disorder characterised by airway hyper-responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing. Results from clinical trials, however, have been contentious. The findings could be confounded by many factors, including the heterogeneity of asthma, treatment duration, dose, and differing outcome measures. Recent evidence suggests improved effectiveness of macrolides in patients with sub-optimally controlled severe neutrophilic asthma and in asthma exacerbations. We examine the evidence from clinical trials and discuss macrolide properties and their relevance to the pathophysiology of asthma. At present, the use of macrolides in chronic asthma or acute exacerbations is not justified. Further work, including proteomic, genomic, and microbiome studies, will advance our knowledge of asthma phenotypes, and help to identify a macrolide-responsive subgroup. Future clinical trials should target this subgroup and place emphasis on clinically relevant outcomes such as asthma exacerbations.
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Affiliation(s)
- Ernie H C Wong
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College London, London, UK; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK; Centre for Respiratory Infection, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - James D Porter
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College London, London, UK; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK; Centre for Respiratory Infection, London, UK
| | - Michael R Edwards
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College London, London, UK; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK; Centre for Respiratory Infection, London, UK
| | - Sebastian L Johnston
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College London, London, UK; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK; Centre for Respiratory Infection, London, UK; Imperial College Healthcare NHS Trust, London, UK.
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Morton B, Pennington SH, Gordon SB. Immunomodulatory adjuvant therapy in severe community-acquired pneumonia. Expert Rev Respir Med 2014; 8:587-96. [PMID: 24898699 DOI: 10.1586/17476348.2014.927736] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Severe pneumonia has a high mortality (38.2%) despite evidence-based therapy. Rising rates of antimicrobial resistance increase the urgency to develop new treatment strategies. Multiple adjuvant therapies for pneumonia have been investigated but none are currently licensed. Profound immune dysregulation occurs in patients with severe infection. An initial hyper-inflammatory response is followed by a secondary hypo-inflammatory response with 'immune-paralysis'. There is focus on the development of immunostimulatory agents to improve host ability to combat primary infection and reduce secondary infections. Successful treatments must be targeted to immune response; promising biomarkers exist but have not yet reached common bedside practice. We explore evidence for adjuvant therapies in community-acquired pneumonia. We highlight novel potential treatment strategies using a broad-based search strategy to include publications in pneumonia and severe sepsis. We explore reasons for the failure to develop effective adjuvant therapies and highlight the need for targeted therapy specific to immune activity.
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Affiliation(s)
- Ben Morton
- Liverpool School of Tropical Medicine - Clinical Sciences, Pembroke Place, Liverpool L3 5QA, UK
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30
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Zhong Y, Wang X, Dong S, Zhou W, Mao B, Min J, Jiang H, Diao X. Modified Weijing formula for the treatment of acute exacerbations of chronic obstructive pulmonary disease: A systematic review of randomized controlled trials. Eur J Integr Med 2014. [DOI: 10.1016/j.eujim.2013.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Uzun S, Djamin RS, Kluytmans JAJW, Mulder PGH, van't Veer NE, Ermens AAM, Pelle AJ, Hoogsteden HC, Aerts JGJV, van der Eerden MM. Azithromycin maintenance treatment in patients with frequent exacerbations of chronic obstructive pulmonary disease (COLUMBUS): a randomised, double-blind, placebo-controlled trial. THE LANCET RESPIRATORY MEDICINE 2014; 2:361-8. [PMID: 24746000 DOI: 10.1016/s2213-2600(14)70019-0] [Citation(s) in RCA: 179] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Macrolide resistance is an increasing problem; there is therefore debate about when to implement maintenance treatment with macrolides in patients with chronic obstructive pulmonary disease (COPD). We aimed to investigate whether patients with COPD who had received treatment for three or more exacerbations in the previous year would have a decrease in exacerbation rate when maintenance treatment with azithromycin was added to standard care. METHODS We did a randomised, double-blind, placebo-controlled, single-centre trial in The Netherlands between May 19, 2010, and June 18, 2013. Patients (≥18 years) with a diagnosis of COPD who had received treatment for three or more exacerbations in the previous year were randomly assigned, via a computer-generated randomisation sequence with permuted block sizes of ten, to receive 500 mg azithromycin or placebo three times a week for 12 months. Randomisation was stratified by use of long-term, low-dose prednisolone (≤10 mg daily). Patients and investigators were masked to group allocation. The primary endpoint was rate of exacerbations of COPD in the year of treatment. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00985244. FINDINGS We randomly assigned 92 patients to the azithromycin group (n=47) or the placebo group (n=45), of whom 41 (87%) versus 36 (80%) completed the study. We recorded 84 exacerbations in patients in the azithromycin group compared with 129 in those in the placebo group. The unadjusted exacerbation rate per patient per year was 1·94 (95% CI 1·50-2·52) for the azithromycin group and 3·22 (2·62-3·97) for the placebo group. After adjustment, azithromycin resulted in a significant reduction in the exacerbation rate versus placebo (0·58, 95% CI 0·42-0·79; p=0·001). Three (6%) patients in the azithromycin group reported serious adverse events compared with five (11%) in the placebo group. During follow-up, the most common adverse event was diarrhoea in the azithromycin group (nine [19%] patients vs one [2%] in the placebo group; p=0·015). INTERPRETATION Maintenance treatment with azithromycin significantly decreased the exacerbation rate compared with placebo and should therefore be considered for use in patients with COPD who have the frequent exacerbator phenotype and are refractory to standard care. FUNDING SoLong Trust.
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Affiliation(s)
- Sevim Uzun
- Department of Respiratory Medicine, Amphia Hospital, Breda, Netherlands
| | - Remco S Djamin
- Department of Respiratory Medicine, Amphia Hospital, Breda, Netherlands
| | | | | | | | - Anton A M Ermens
- Laboratory for Clinical Chemistry and Haematology, Amphia Hospital, Breda, Netherlands
| | - Aline J Pelle
- Centre of Research on Psychology in Somatic Diseases, University of Tilburg, Tilburg, Netherlands
| | - Henk C Hoogsteden
- Department of Respiratory Medicine, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Joachim G J V Aerts
- Department of Respiratory Medicine, Amphia Hospital, Breda, Netherlands; Department of Respiratory Medicine, Erasmus Medical Centre, Rotterdam, Netherlands
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Grobost V, Rigal E, Pavier Y, Vidal M, Mrozek N, Beytout J, Laurichesse H, Lesens O. Suppressive therapy using azithromycin in 2 rare cases of recurrent staphylococcal infections. Diagn Microbiol Infect Dis 2014; 79:90-2. [PMID: 24629578 DOI: 10.1016/j.diagmicrobio.2014.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 01/08/2014] [Accepted: 01/12/2014] [Indexed: 10/25/2022]
Abstract
Recurrent staphylococcal skin and soft tissue infections may recur despite decontamination and multiple courses of antibiotic therapy and may dramatically impair the patient's quality of life. We report successful use of long-term azithromycin prophylaxis in a recurrent laryngitis and a scalp folliculitis due to methicillin-susceptible Staphylococcus aureus.
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Affiliation(s)
- Vincent Grobost
- Department of Infectious Diseases, Clermont-Ferrand University Hospital, France: CHU Gabriel Montpied, 58 Av. Montalembert 63003 Clermont-Ferrand, France.
| | - Emilie Rigal
- Department of Dermatology, CHU Estaing, 1 Place Lucie et Raymond Aubrac 63100 Clermont-Ferrand, France
| | - Yoann Pavier
- Department of Otorhinolaryngology, Clermont-Ferrand University Hospital, France: CHU Gabriel Montpied, 58 Av. Montalembert 63003 Clermont-Ferrand, France
| | - Magali Vidal
- Department of Infectious Diseases, Clermont-Ferrand University Hospital, France: CHU Gabriel Montpied, 58 Av. Montalembert 63003 Clermont-Ferrand, France
| | - Natacha Mrozek
- Department of Infectious Diseases, Clermont-Ferrand University Hospital, France: CHU Gabriel Montpied, 58 Av. Montalembert 63003 Clermont-Ferrand, France
| | - Jean Beytout
- Department of Infectious Diseases, Clermont-Ferrand University Hospital, France: CHU Gabriel Montpied, 58 Av. Montalembert 63003 Clermont-Ferrand, France
| | - Henri Laurichesse
- Department of Infectious Diseases, Clermont-Ferrand University Hospital, France: CHU Gabriel Montpied, 58 Av. Montalembert 63003 Clermont-Ferrand, France
| | - Olivier Lesens
- Department of Infectious Diseases, Clermont-Ferrand University Hospital, France: CHU Gabriel Montpied, 58 Av. Montalembert 63003 Clermont-Ferrand, France
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Jouneau S, Desrues B. [Long-term macrolide treatment in adult chronic bronchial diseases: benefits and limits]. Presse Med 2014; 43:510-9. [PMID: 24631048 DOI: 10.1016/j.lpm.2013.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 07/03/2013] [Accepted: 08/19/2013] [Indexed: 10/25/2022] Open
Abstract
Decreased frequency of pulmonary exacerbations, mainly related to immunomodulatory effects of macrolide antibiotics, has been demonstrated in bronchiectasis and chronic obstructive pulmonary diseases (COPD). Due to its tolerance, azithromycin is the antibiotic of choice for maintenance therapy at the dose of 250 mg per day or 500 mg × 3 per week (for body weight >55 kg). Maintenance therapy with macrolide could be proposed in selected patients with bronchiectasis or COPD with more than 3 acute exacerbations in the previous year or decreased lung function despite compliance with optimum treatment. The risk of sudden cardiac death with azithromycin is rare and controversial. It should be avoided in patients with a high baseline risk of cardiovascular disease, QT>450 msec, pulse rate>100 bpm and potential drug interactions, particularly those known to cause QT prolongation. It is recommended to search for hearing deficit (audiometry) and sputum culture positive for mycobacteria. Patients must also be aware that it can rapidly lead to macrolide resistance in commensal or pathogenic flora. Follow-up evaluation every 3 month can be proposed with medical history (hearing deficit) and electrocardiography. After one year, the treatment should be stopped in the absence of reduction in the frequency of exacerbations.
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Affiliation(s)
- Stéphane Jouneau
- Centre hospitalier universitaire de Rennes, hôpital Pontchaillou, service de pneumologie, 35033 Rennes cedex 9, France; IRSET-UMR Inserm U1085, 35043 Rennes cedex, France
| | - Benoît Desrues
- Centre hospitalier universitaire de Rennes, hôpital Pontchaillou, service de pneumologie, 35033 Rennes cedex 9, France.
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King PT, MacDonald M, Bardin PG. Bacteria in COPD; their potential role and treatment. TRANSLATIONAL RESPIRATORY MEDICINE 2013; 1:13. [PMID: 27234394 PMCID: PMC6733427 DOI: 10.1186/2213-0802-1-13] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 08/06/2013] [Indexed: 12/22/2022]
Abstract
The role of bacterial infection in chronic obstructive pulmonary disease (COPD) and how it should be treated has been an ongoing source of controversy. For many years bacterial infection has not been thought to have an important effect in the pathology of this condition. Recent advances in diagnostic techniques, particularly the use 16S sequencing has demonstrated that there are a large range of bacteria present in the lower respiratory tract, both in terms of exacerbations and chronic colonization. A proportion of the bacteria present in the lower respiratory have also been shown to produce inflammation and hence are likely to be relevant for the pathogenesis of COPD. The accurate diagnosis of bacterial infection in individual patients remains a major challenge. The trials that have assessed the effect of antibiotics in COPD have generally been of low quality and have not been placebo controlled. Recent studies of macrolides for long-term treatment in COPD have found significantly reduced rates of exacerbations. Major challenges remain in accurately defining the potential role of bacteria in the inflammatory process and how best to optimize the use of antibiotics without the overuse of this limited resource. Alternative strategies to treat infection in COPD remain very limited.
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Affiliation(s)
- Paul T King
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, Melbourne, 3168 Australia
- Department of Medicine, Monash Medical Centre, Monash University, Melbourne, Australia
| | - Martin MacDonald
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, Melbourne, 3168 Australia
- Department of Medicine, Monash Medical Centre, Monash University, Melbourne, Australia
| | - Philip G Bardin
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, Melbourne, 3168 Australia
- Monash Institute of Medical Research, Monash Medical Centre, Melbourne, Australia
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Abstract
BACKGROUND There has been renewal of interest in the use of prophylactic antibiotics to reduce the frequency of exacerbations and improve quality of life in chronic obstructive pulmonary disease (COPD). OBJECTIVES To determine whether or not regular treatment of COPD patients with prophylactic antibiotics reduces exacerbations or affects quality of life. SEARCH METHODS We searched the Cochrane Airways Group Trials Register and bibliographies of relevant studies. The latest literature search was August 2013. SELECTION CRITERIA Randomised controlled trials (RCTs) that compared prophylactic antibiotics with placebo in patients with COPD. DATA COLLECTION AND ANALYSIS We used the standard methods of The Cochrane Collaboration. Data were extracted and analysed by two independent review authors. MAIN RESULTS Seven RCTs involving 3170 patients were included in this systematic review. All studies were published between 2001 and 2011. Five studies were of continuous antibiotics and two studies were of intermittent antibiotic prophylaxis (termed 'pulsed' for this review). The antibiotics investigated were azithromycin, erythromycin, clarithromycin and moxifloxacin. Azithromycin, erythromycin and clarithromycin are macrolides while moxifloxacin is a fourth-generation synthetic fluoroquinolone antibacterial agent. The study duration varied from three months to 36 months and all used intention-to-treat analysis. Most of the results were of moderate quality. The risk of bias of the included studies was generally low, and we did not downgrade the quality of evidence for risk of bias.The trials recruited participants with a mean age of 66 years and with at least a moderate severity of COPD. Three trials included participants with frequent exacerbations and two trials recruited participants requiring systemic steroids or antibiotics, or both, or who were at the end stage of their disease and required oxygen.The primary outcomes for this review were the number of exacerbations and quality of life.With use of continuous prophylactic antibiotics the number of patients experiencing an exacerbation was reduced (odds ratio (OR) 0.55; 95% confidence interval (CI) 0.39 to 0.77, 3 studies, 1262 participants, high quality). This represented a reduction from 69% of participants in the control group compared to 54% in the treatment group (95% CI 46% to 63%) and the number needed to treat to prevent one exacerbation (NNTb) was therefore 8 (95% CI 5 to 18). The frequency of exacerbations was also reduced with continuous prophylactic antibiotic treatment (rate ratio 0.73; 95% CI 0.58 to 0.91).Use of pulsed antibiotic treatment showed a non-significant reduction in the number of people with exacerbations (OR 0.87; 95% CI 0.69 to 1.09, 1 study, 1149 participants, moderate quality) and the test for interaction showed that this result was significantly different from the effect on exacerbations with continuous antibiotics.There was a statistically significant improvement in quality of life with both continuous and pulsed antibiotic treatment but this was smaller than the four unit improvement that is regarded as being clinically significant (MD -1.78; 95% CI -2.95 to -0.61, 2 studies, 1962 participants, moderate quality).Neither pulsed nor continuous antibiotics showed a significant effect on the secondary outcomes of frequency of hospital admissions, change in lung function, serious adverse events or all-cause mortality (moderate quality evidence).The adverse events that were recorded varied among the trials depending on the different antibiotics used. Azithromycin was associated with a significant hearing loss in the treatment group. The moxifloxacin pulsed study reported a significantly higher number of adverse events in the treatment arm due to the marked increase in gastrointestinal adverse events (P < 0.001). Some adverse events that led to drug discontinuation, such as development of long QTc or tinnitus, were not significantly more frequent in the treatment group than the placebo group but pose important considerations in clinical practice.The development of antibiotic resistance in the community is of major concern. One study found newly colonised patients to have higher rates of antibiotic resistance. Patients colonised with moxifloxacin-sensitive pseudomonas at initiation of therapy rapidly became resistant with the quinolone treatment. AUTHORS' CONCLUSIONS Use of continuous prophylactic antibiotics results in a clinically significant benefit in reducing exacerbations in COPD patients. All trials of continuous antibiotics used macrolides hence the noted benefit applies only to the use of continuous macrolide antibiotics. The impact of pulsed antibiotics remains uncertain and requires further research.The trials in this review included patients who were frequent exacerbators and needed treatment with antibiotics or systemic steroids, or who were on supplemental oxygen. There were also older individuals with a mean age of 66 years. The results of these trials apply only to the group of patients who were studied in these trials and may not be generalisable to other groups.Because of concerns about antibiotic resistance and specific adverse effects, consideration of prophylactic antibiotic use should be mindful of the balance between benefits to individual patients and the potential harms to society created by antibiotic overuse.
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Affiliation(s)
- Samantha C Herath
- Woolcock Institute of Medical Research, 431 Glebe Point Road, Sydney, New South Wales, Australia, 2037
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Yang IA, Ko FWS, Lim TK, Hancox RJ. Year in review 2012: asthma and chronic obstructive pulmonary disease. Respirology 2013; 18:565-72. [PMID: 23316705 DOI: 10.1111/resp.12049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 01/08/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Ian A Yang
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, Australia.
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Porcel JM, Leung CC, Restrepo MI, Takahashi K, Lee P. Year in review 2012: lung cancer, respiratory infections, tuberculosis, pleural diseases, bronchoscopic intervention and imaging. Respirology 2013; 18:573-83. [PMID: 23317457 DOI: 10.1111/resp.12048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 01/08/2013] [Indexed: 12/24/2022]
Affiliation(s)
- José M Porcel
- Pleural Diseases Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, Biomedical Research Institute of Lleida, Lleida, Spain.
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Systemic inflammatory responses and lung injury following hip fracture surgery increases susceptibility to infection in aged rats. Mediators Inflamm 2013; 2013:536435. [PMID: 24163505 PMCID: PMC3791802 DOI: 10.1155/2013/536435] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Revised: 08/12/2013] [Accepted: 08/13/2013] [Indexed: 12/19/2022] Open
Abstract
Pulmonary infections frequently occur following hip fracture surgery in aged patients. However, the underlying reasons are not fully understood. The present study investigates the systemic inflammatory response and pulmonary conditions following hip fracture surgery as a means of identifying risk factors for lung infections using an aged rodent model. Aged, male Sprague-Dawley rats (8 animals per group) underwent a sham procedure or hip fracture plus femoral intramedullary pinning. Animals were sacrificed 1, 3, and 7 days after the injury. Markers of systemic inflammation and pulmonary injury were analyzed. Both sham-operated and injured/surgical group animals underwent intratracheal inoculation with Pseudomonas aeruginosa 1, 3, and 7 days after surgery. P. aeruginosa counts in blood and bronchoalveolar lavage (BAL) fluid and survival rates were recorded. Serum TNF-α, IL-6, IL-1β, and IL-10 levels and markers of pulmonary injury were significantly increased at 1 and 3 days following hip fracture and surgery. Animals challenged with P. aeruginosa at 1 and 3 days after injury had a significantly decreased survival rate and more P. aeruginosa recovered from blood and BAL fluid. This study shows that hip fracture and surgery in aged rats induced a systemic inflammatory response and lung injury associated with increased susceptibility to infection during the acute phase after injury and surgery.
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Rab A, Rowe SM, Raju SV, Bebok Z, Matalon S, Collawn JF. Cigarette smoke and CFTR: implications in the pathogenesis of COPD. Am J Physiol Lung Cell Mol Physiol 2013; 305:L530-41. [PMID: 23934925 DOI: 10.1152/ajplung.00039.2013] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disorder consisting of chronic bronchitis and/or emphysema. COPD patients suffer from chronic infections and display exaggerated inflammatory responses and a progressive decline in respiratory function. The respiratory symptoms of COPD are similar to those seen in cystic fibrosis (CF), although the molecular basis of the two disorders differs. CF is a genetic disease caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene encoding a chloride and bicarbonate channel (CFTR), leading to CFTR dysfunction. The majority of COPD cases result from chronic oxidative insults such as cigarette smoke. Interestingly, environmental stresses including cigarette smoke, hypoxia, and chronic inflammation have also been implicated in reduced CFTR function, and this suggests a common mechanism that may contribute to both the CF and COPD. Therefore, improving CFTR function may offer an excellent opportunity for the development of a common treatment for CF and COPD. In this article, we review what is known about the CF respiratory phenotype and discuss how diminished CFTR expression-associated ion transport defects may contribute to some of the pathological changes seen in COPD.
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Affiliation(s)
- Andras Rab
- Dept. of Cell, Developmental and Integrative Biology, Univ. of Alabama at Birmingham, 1918 Univ. Blvd., MCLM 395, Birmingham, AL 35294.
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Guarascio AJ, Ray SM, Finch CK, Self TH. The clinical and economic burden of chronic obstructive pulmonary disease in the USA. CLINICOECONOMICS AND OUTCOMES RESEARCH 2013; 5:235-45. [PMID: 23818799 PMCID: PMC3694800 DOI: 10.2147/ceor.s34321] [Citation(s) in RCA: 202] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is the third most common cause of death in the USA. In 2010, the cost of COPD in the USA was projected to be approximately US$50 billion, which includes $20 billion in indirect costs and $30 billion in direct health care expenditures. These costs can be expected to continue to rise with this progressive disease. Costs increase with increasing severity of disease, and hospital stays account for the majority of these costs. Patients are diagnosed with COPD following a multifactorial assessment that includes spirometry, clinical presentation, symptomatology, and risk factors. Smoking cessation interventions are the most influential factor in COPD management. The primary goal of chronic COPD management is stabilization of chronic disease and prevention of acute exacerbations. Bronchodilators are the mainstay of COPD therapy. Patients with few symptoms and low exacerbation risk should be treated with a short-acting bronchodilator as needed for breathlessness. Progression of symptoms, as well as possible decline in forced expiratory volume in the first second of expiration (FEV1), warrant the use of long-acting bronchodilators. For patients with frequent exacerbations with or without consistent symptoms, inhaled corticosteroids should be considered in addition to a long-acting beta2-agonist (LABA) or long-acting muscarinic antagonist (LAMA) and may even consist of "triple therapy" with all three agents with more severe disease. Phosphodiesterase-4 inhibitors may be an option in patients with frequent exacerbations and symptoms of chronic bronchitis. In addition to a variety of novel ultra-LABAs, LAMAs and combination bronchodilator and inhaled corticosteroid (ICS) therapies, other bronchodilators with a variety of mechanisms are also being considered, to expand therapeutic options for the treatment of COPD. With more than 50 new medications in the pipeline for the treatment of COPD, optimal management will continue to evolve and grow more complex as benefits of therapy are balanced with the limitations and needs of each patient.
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Affiliation(s)
| | - Shauntá M Ray
- University of Tennessee College of Pharmacy, Knoxville, USA
| | - Christopher K Finch
- University of Tennessee College of Pharmacy, Memphis, TN, USA
- Methodist University Hospital, Memphis, TN, USA
| | - Timothy H Self
- University of Tennessee College of Pharmacy, Memphis, TN, USA
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Serisier DJ. Risks of population antimicrobial resistance associated with chronic macrolide use for inflammatory airway diseases. THE LANCET RESPIRATORY MEDICINE 2013; 1:262-74. [PMID: 24429132 DOI: 10.1016/s2213-2600(13)70038-9] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Macrolide antibiotics have established efficacy in the management of cystic fibrosis and diffuse panbronchiolitis-uncommon lung diseases with substantial morbidity and the potential for rapid progression to death. Emerging evidence suggests benefits of maintenance macrolide treatment in more indolent respiratory diseases including chronic obstructive pulmonary disease and non-cystic fibrosis bronchiectasis. In view of the greater patient population affected by these disorders (and potential for macrolide use to spread to disorders such as chronic cough), widespread use of macrolides, particularly azithromycin, has the potential to substantially influence antimicrobial resistance rates of a range of respiratory microbes. In this Personal View, I explore theories around population (rather than patient) macrolide resistance, appraise evidence linking macrolide use with development of resistance, and highlight the risks posed by injudicious broadening of their use, particularly of azithromycin. These risks are weighed against the potential benefits of macrolides in less aggressive inflammatory airway disorders. A far-sighted approach to maintenance macrolide use in non-cystic fibrosis inflammatory airway diseases is needed, which minimises risks of adversely affecting community macrolide resistance: combining preferential use of erythromycin and restriction of macrolide use to those patients at greatest risk represents an appropriately cautious management approach.
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Affiliation(s)
- David J Serisier
- Department of Respiratory Medicine, Mater Adult Hospital, South Brisbane, QLD, Australia; University of Queensland and Mater Medical Research Institute, Mater Health Services, South Brisbane, QLD, Australia.
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IL-17A in human respiratory diseases: innate or adaptive immunity? Clinical implications. Clin Dev Immunol 2013; 2013:840315. [PMID: 23401702 PMCID: PMC3562607 DOI: 10.1155/2013/840315] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 12/26/2012] [Indexed: 01/28/2023]
Abstract
Since the discovery of IL-17 in 1995 as a T-cell cytokine, inducing IL-6 and IL-8 production by fibroblasts, and the report of a separate T-cell lineage producing IL-17(A), called Th17 cells, in 2005, the role of IL-17 has been studied in several inflammatory diseases. By inducing IL-8 production and subsequent neutrophil attraction towards the site of inflammation, IL-17A can link adaptive and innate immune responses. More specifically, its role in respiratory diseases has intensively been investigated. We here review its role in human respiratory diseases and try to unravel the question whether IL-17A only provides a link between the adaptive and innate respiratory immunity or whether this cytokine might also be locally produced by innate immune cells. We furthermore briefly discuss the possibility to reduce local IL-17A production as a treatment option for respiratory diseases.
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Grandy S, Fox KM, Hardy E. Prevalence and recurrence of urinary tract and genital infections among adults with and without type 2 diabetes mellitus in the general population: a longitudinal cohort study. ACTA ACUST UNITED AC 2013. [DOI: 10.7243/2050-0866-2-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Effets immunomodulateurs des macrolides au cours des pathologies respiratoires chroniques. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-012-0639-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rowe SM, Borowitz DS, Burns JL, Clancy JP, Donaldson SH, Retsch-Bogart G, Sagel SD, Ramsey BW. Progress in cystic fibrosis and the CF Therapeutics Development Network. Thorax 2012; 67:882-90. [PMID: 22960984 PMCID: PMC3787701 DOI: 10.1136/thoraxjnl-2012-202550] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Cystic fibrosis (CF), the most common life-shortening genetic disorder in Caucasians, affects approximately 70 000 individuals worldwide. In 1998, the Cystic Fibrosis Foundation (CFF) launched the CF Therapeutics Development Network (CF-TDN) as a central element of its Therapeutics Development Programme. Designed to accelerate the clinical evaluation of new therapies needed to fulfil the CFF mission to control and cure CF, the CF-TDN has conducted 75 clinical trials since its inception, and has contributed to studies as varied as initial safety and proof of concept trials to pivotal programmes required for regulatory approval. This review highlights recent and significant research efforts of the CF-TDN, including a summary of contributions to studies involving CF transmembrane conductance regulator (CFTR) modulators, airway surface liquid hydrators and mucus modifiers, anti-infectives, anti-inflammatories, and nutritional therapies. Efforts to advance CF biomarkers, necessary to accelerate the therapeutic goals of the network, are also summarised.
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Affiliation(s)
- Steven M Rowe
- Department of Medicine, University of Alabama at Birmingham, 1819 University Boulevard (MCLM 768), Birmingham, AL 35294, USA.
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