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Wu M, Davis JD, Zhao C, Daley T, Oliver KE. Racial inequities and rare CFTR variants: Impact on cystic fibrosis diagnosis and treatment. J Clin Transl Endocrinol 2024; 36:100344. [PMID: 38765466 PMCID: PMC11099334 DOI: 10.1016/j.jcte.2024.100344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/21/2024] [Accepted: 04/14/2024] [Indexed: 05/22/2024] Open
Abstract
Cystic fibrosis (CF) has been traditionally viewed as a disease that affects White individuals. However, CF occurs among all races, ethnicities, and geographic ancestries. The disorder results from mutations in the CF transmembrane conductance regulator (CFTR). Varying incidence of CF is reported among Black, Indigenous, and People of Color (BIPOC), who typically exhibit worse clinical outcomes. These populations are more likely to carry rare CFTR variants omitted from newborn screening panels, leading to disparities in care such as delayed diagnosis and treatment. In this study, we present a case-in-point describing an individual of Gambian descent identified with CF. Patient genotype includes a premature termination codon (PTC) (c.2353C>T) and previously undescribed single nucleotide deletion (c.1970delG), arguing against effectiveness of currently available CFTR modulator-based interventions. Strategies for overcoming these two variants will likely include combinations of PTC suppressors, nonsense mediated decay inhibitors, and/or alternative approaches (e.g. gene therapy). Investigations such as the present study establish a foundation from which therapeutic treatments may be developed. Importantly, c.2353C>T and c.1970delG were not detected in the patient by traditional CFTR screening panels, which include an implicit racial and ethnic diagnostic bias as these tests are comprised of mutations largely observed in people of European ancestry. We suggest that next-generation sequencing of CFTR should be utilized to confirm or exclude a CF diagnosis, in order to equitably serve BIPOC individuals. Additional epidemiologic data, basic science investigations, and translational work are imperative for improving understanding of disease prevalence and progression, CFTR variant frequency, genotype-phenotype correlation, pharmacologic responsiveness, and personalized medicine approaches for patients with African ancestry and other historically understudied geographic lineages.
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Affiliation(s)
- Malinda Wu
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Pediatric Institute, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Jacob D. Davis
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Conan Zhao
- Interdisciplinary Graduate Program in Quantitative Biosciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Tanicia Daley
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Pediatric Institute, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Kathryn E. Oliver
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Pediatric Institute, Children’s Healthcare of Atlanta, Atlanta, GA, USA
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2
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Li Q, Ma LP. Case Report: Community-Acquired Burkholderia cepacia Pneumonia of a Patient with Pulmonary Tuberculosis. Am J Trop Med Hyg 2022; 107:86-88. [PMID: 35895374 DOI: 10.4269/ajtmh.21-1338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/26/2022] [Indexed: 11/07/2022] Open
Abstract
Community-acquired Burkholderia cepacia pneumonia is rare. We report a 29-year-old female who suffered pulmonary tuberculosis and developed community-acquired Burkholderia cepacia pneumonia, which was confirmed by the culture of the pulmonary tissue. The patient received antitubercular therapy. Meanwhile, she was treated with meropenem and minocycline. The patient was followed up for 6 months, and she achieved complete absorption of lung lesions.
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Affiliation(s)
- Qiang Li
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
| | - Li-Ping Ma
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, China
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3
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Ling L, Yang C, Ma W, Zhao Y, Feng S, Tu Y, Wang N, Li Z, Lu L. Isolation, identification, and control of a resistant bacterium strain found in Ku shui rose pure dew. J FOOD PROCESS PRES 2021. [DOI: 10.1111/jfpp.15061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Lijun Ling
- College of Life Science Northwest Normal University Lanzhou P.R. China
- Bioactive Products Engineering Research Center for Gansu Distinctive Plants Northwest Normal University Lanzhou P.R. China
- Northwest Normal University Lanzhou City China
| | - Caiyun Yang
- College of Life Science Northwest Normal University Lanzhou P.R. China
- Bioactive Products Engineering Research Center for Gansu Distinctive Plants Northwest Normal University Lanzhou P.R. China
| | - Wenxia Ma
- College of Life Science Northwest Normal University Lanzhou P.R. China
- Bioactive Products Engineering Research Center for Gansu Distinctive Plants Northwest Normal University Lanzhou P.R. China
| | - Yunhua Zhao
- College of Life Science Northwest Normal University Lanzhou P.R. China
- Bioactive Products Engineering Research Center for Gansu Distinctive Plants Northwest Normal University Lanzhou P.R. China
| | - Shenglai Feng
- College of Life Science Northwest Normal University Lanzhou P.R. China
- Bioactive Products Engineering Research Center for Gansu Distinctive Plants Northwest Normal University Lanzhou P.R. China
| | - Yixin Tu
- College of Life Science Northwest Normal University Lanzhou P.R. China
- Bioactive Products Engineering Research Center for Gansu Distinctive Plants Northwest Normal University Lanzhou P.R. China
| | - Nan Wang
- College of Life Science Northwest Normal University Lanzhou P.R. China
- Bioactive Products Engineering Research Center for Gansu Distinctive Plants Northwest Normal University Lanzhou P.R. China
| | - Zibin Li
- College of Life Science Northwest Normal University Lanzhou P.R. China
- Bioactive Products Engineering Research Center for Gansu Distinctive Plants Northwest Normal University Lanzhou P.R. China
| | - Lu Lu
- College of Life Science Northwest Normal University Lanzhou P.R. China
- Bioactive Products Engineering Research Center for Gansu Distinctive Plants Northwest Normal University Lanzhou P.R. China
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4
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Kim C, delaRiva-Velasco E, Budhram A, Farri F, Krich D, Nolan SS, Gjonaj S, Paul L, Dozor AJ, Welter JJ. Incidence and prevalence of common respiratory pathogens before and after implementation of the Cystic Fibrosis Foundation Infection Prevention and Control Guideline. J Infect Prev 2020; 21:7-13. [PMID: 32030098 PMCID: PMC6978569 DOI: 10.1177/1757177419872538] [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: 03/15/2019] [Accepted: 07/28/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The 2013 Cystic Fibrosis Foundation's Infection Prevention and Control Guideline (CFF IP&C) was developed to reduce the risk of acquisition and transmission of respiratory pathogens in patients with cystic fibrosis (CF). OBJECTIVE We hypothesised that the incidence of common CF respiratory pathogens would decrease at our centre after implementation of the guideline. METHODS All patients with CF seen at our centre from August 2012 through August 2017 who had respiratory cultures were included. Patients were excluded from incidence analysis if they did not have at least one culture per year. Quarterly data were collected for one year before and three years after implementation of the guidelines to determine the incidence and prevalence of seven organisms commonly found in respiratory cultures of patients with CF. RESULTS Quarterly and annual incidence and prevalence rates of common organisms did not change during the study period. DISCUSSION There were no significant differences in the incidence or prevalence of common respiratory organisms in the first three years after implementation of the CF IP&C guideline. Long-term follow-up is needed to determine if changes occur over time.
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Affiliation(s)
- Christy Kim
- New York Medical College and Maria Fareri Children’s Hospital at Westchester Medical Center Division of Pediatric Pulmonology, Allergy and Sleep Medicine and the Armond V. Mascia Cystic Fibrosis Center, Valhalla, NY, USA
| | - Elizabeth delaRiva-Velasco
- New York Medical College and Maria Fareri Children’s Hospital at Westchester Medical Center Division of Pediatric Pulmonology, Allergy and Sleep Medicine and the Armond V. Mascia Cystic Fibrosis Center, Valhalla, NY, USA
| | - Arvind Budhram
- New York Medical College and Maria Fareri Children’s Hospital at Westchester Medical Center Division of Pediatric Pulmonology, Allergy and Sleep Medicine and the Armond V. Mascia Cystic Fibrosis Center, Valhalla, NY, USA
| | - Folashade Farri
- New York Medical College and Maria Fareri Children’s Hospital at Westchester Medical Center Division of Pediatric Pulmonology, Allergy and Sleep Medicine and the Armond V. Mascia Cystic Fibrosis Center, Valhalla, NY, USA
| | - Daniel Krich
- New York Medical College and Maria Fareri Children’s Hospital at Westchester Medical Center Division of Pediatric Pulmonology, Allergy and Sleep Medicine and the Armond V. Mascia Cystic Fibrosis Center, Valhalla, NY, USA
| | - Sheila S Nolan
- New York Medical College and Maria Fareri Children’s Hospital at Westchester Medical Center Division of Pediatric Infectious Disease, Valhalla, NY, USA
| | - Suzette Gjonaj
- New York Medical College and Maria Fareri Children’s Hospital at Westchester Medical Center Division of Pediatric Pulmonology, Allergy and Sleep Medicine and the Armond V. Mascia Cystic Fibrosis Center, Valhalla, NY, USA
| | - Lisa Paul
- Westchester Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Valhalla, NY, USA
| | - Allen J Dozor
- New York Medical College and Maria Fareri Children’s Hospital at Westchester Medical Center Division of Pediatric Pulmonology, Allergy and Sleep Medicine and the Armond V. Mascia Cystic Fibrosis Center, Valhalla, NY, USA
| | - John J Welter
- New York Medical College and Maria Fareri Children’s Hospital at Westchester Medical Center Division of Pediatric Pulmonology, Allergy and Sleep Medicine and the Armond V. Mascia Cystic Fibrosis Center, Valhalla, NY, USA
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5
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Potential for Therapeutic Benefit among Cystic Fibrosis Populations Excluded from Clinical Trials or Labeling of Marketed Therapies. Ann Am Thorac Soc 2017; 13:1890-1893. [PMID: 27518252 DOI: 10.1513/annalsats.201606-462ps] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Remarkable advances in the management of individuals born with cystic fibrosis (CF) would not have been realized without empiric trial and error by CF clinicians with treatments developed and available for other purposes. As the testing and registration of CF-specific treatments have increased, so too have associated health care costs, particularly those of chronic medications. The transition of CF from a lethal pediatric disease to a life-shortening one with an adult majority, concurrent with sharp increases in chronic medication costs, has placed many CF treatments under increased scrutiny by third-party payers, particularly when prescribed to individuals from CF subpopulations that may not have been included in registration trials. Despite overall health improvements in the CF cohort and the increasing availability of CF-specific therapies, many physicians remain tasked with managing the health of patients from subpopulations that may be too young, too sick, or too complicated to have been included in clinical trials. An understanding of why particular CF subpopulations may have been excluded from registration trials, as well as consideration of a treatment's described mechanism of action, can support assessment for the potential for benefit (and risk) in these populations and help physicians advocate for patient access to treatments.
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6
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Kayria M, Chris O, Dhasmana DJ, Nilesh M, Hodson ME, Khin G, Diana B, Simmonds NJ. Burkholderia cepacia complex and limited cutaneous vasculitis in patients with cystic fibrosis: a case series. JRSM Open 2017; 8:2054270417692732. [PMID: 28491333 PMCID: PMC5405907 DOI: 10.1177/2054270417692732] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
There is a high association of reactive skin presentations, mainly limited cutaneous vasculitis in patients with cystic fibrosis and Burkholderia cepcia complex chronic infection. This may be due to raised levels of circulating inflammatory mediators.
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Affiliation(s)
- Muttardi Kayria
- Department of Cystic Fibrosis, Royal Brompton Hospital, London SW3 6NP, UK.,Department of Dermatology, Royal Free Hospital, London NW3 2QG, UK
| | - Orchard Chris
- Department of Cystic Fibrosis, Royal Brompton Hospital, London SW3 6NP, UK
| | - Devesh J Dhasmana
- Department of Cystic Fibrosis, Royal Brompton Hospital, London SW3 6NP, UK
| | - Morar Nilesh
- Department of Dermatology, Chelsea and Westminster Hospital, London SW10 9NH, UK
| | - Margaret E Hodson
- Department of Cystic Fibrosis, Royal Brompton Hospital, London SW3 6NP, UK
| | - Gyi Khin
- Department of Cystic Fibrosis, Royal Brompton Hospital, London SW3 6NP, UK
| | - Bilton Diana
- Department of Cystic Fibrosis, Royal Brompton Hospital, London SW3 6NP, UK
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7
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Complete genome sequence of sequential Pandoraea apista isolates from the same cystic fibrosis patient supports a model of chronic colonization with in vivo strain evolution over time. Diagn Microbiol Infect Dis 2016; 87:1-6. [PMID: 28336132 DOI: 10.1016/j.diagmicrobio.2016.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/07/2016] [Accepted: 10/07/2016] [Indexed: 12/15/2022]
Abstract
Pandoraea apista in the family Burkholderiaceae is an emerging opportunistic pathogen in cystic fibrosis patients. Here, we describe a case from which 3 separate isolates of P. apista were recovered over a 1-year period. Using a combination of first-, second-, and third-generation sequencing technologies, we sequenced and de novo assembled the complete genomes of these 3 P. apista isolates. The genome of P. apista TF81F4 sequenced in this study was 5.58 Mb with a GC% of 62.3%, differed in sequence from other Pandoraea species by >20%, and included a number of previously undescribed loci. Three P. apista isolates cultured over a 12-month period were >99.999% identical by nucleotide, consistent with a model of chronic colonization by a single strain. Over time, the isolates accumulated point mutations, deletions, and insertions in a stepwise fashion, indicating in vivo strain evolution within the cystic fibrosis lung niche.
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8
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Sainsbury AW, Yu-Mei R, Ågren E, Vaughan-Higgins RJ, Mcgill IS, Molenaar F, Peniche G, Foster J. Disease Risk Analysis and Post-Release Health Surveillance for a Reintroduction Programme: the Pool Frog Pelophylax lessonae. Transbound Emerg Dis 2016; 64:1530-1548. [PMID: 27393743 DOI: 10.1111/tbed.12545] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Indexed: 11/30/2022]
Abstract
There are risks from disease in undertaking wild animal reintroduction programmes. Methods of disease risk analysis have been advocated to assess and mitigate these risks, and post-release health and disease surveillance can be used to assess the effectiveness of the disease risk analysis, but results for a reintroduction programme have not to date been recorded. We carried out a disease risk analysis for the reintroduction of pool frogs (Pelophylax lessonae) to England, using information gained from the literature and from diagnostic testing of Swedish pool frogs and native amphibians. Ranavirus and Batrachochytrium dendrobatidis were considered high-risk disease threats for pool frogs at the destination site. Quarantine was used to manage risks from disease due to these two agents at the reintroduction site: the quarantine barrier surrounded the reintroduced pool frogs. Post-release health surveillance was carried out through regular health examinations of amphibians in the field at the reintroduction site and collection and examination of dead amphibians. No significant health or disease problems were detected, but the detection rate of dead amphibians was very low. Methods to detect a higher proportion of dead reintroduced animals and closely related species are required to better assess the effects of reintroduction on health and disease.
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Affiliation(s)
- A W Sainsbury
- Institute of Zoology, Zoological Society of London, London, UK
| | - R Yu-Mei
- Royal Veterinary College, London, UK
| | - E Ågren
- National Veterinary Institute, Uppsala, Sweden
| | | | - I S Mcgill
- Institute of Zoology, Zoological Society of London, London, UK.,Prion Interest Group, Brighton, UK
| | - F Molenaar
- Institute of Zoology, Zoological Society of London, London, UK
| | - G Peniche
- Institute of Zoology, Zoological Society of London, London, UK
| | - J Foster
- Amphibian and Reptile Conservation, Wareham, Dorset, UK
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9
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Vonberg RP, Gastmeier P. Isolation of Infectious Cystic Fibrosis Patients: Results of a Systematic Review. Infect Control Hosp Epidemiol 2016; 26:401-9. [PMID: 15865277 DOI: 10.1086/502558] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AbstractObjective:Respiratory tract infections significantly contribute to morbidity and mortality among cystic fibrosis (CF) patients. Therefore, pathogen transmission needs to be prevented. There are several guidelines for the care of CF patients, but no transparent systematic literature review has been published.Methods:We conducted a systematic literature review (January 1966 to September 2004) dealing with segregation of CF patients colonized withBurkholderia cepaciaspecies,Pandoraeaspecies,Pseudomonas aeruginosa, Stenotrophomonas maltophilia,orAlcaligenesspecies. Quality of studies was evaluated by taking patient population size, existence of control-patients, patient randomization, diagnostic approach, and bacteria typing methods into account.Results:One hundred ninety-nine studies were found. Evidence and quality of 102 publications were evaluated. In 99 publications, recommendations concerning segregation measures for infectious CF patients were determined including a total of 11,576 patients. No randomized, controlled trials had been conducted. Fifty of 56 authors strongly recommended isolation of CF patients infected withB. cepaciaorPandoraeaspecies. In 31 of 39 studies, interpatient spread ofPseudomonas aeruginosawas documented or had been brought to an end by isolation of patients. Only five studies had addressed S.maltophiliaorAlcaligenesspecies.Conclusions:Patients colonized withB. cepaciaorPandoraeaspecies are to be separated from noncolonized patients in single rooms. Patients harboring multidrug-resistantPseudomonas aeruginosa, S. maltophilia,orAlcaligenesspecies may not share a room with immunocompromised patients, in intensive care units, or with other CF patients anywhere in the hospital.
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Affiliation(s)
- Ralf-Peter Vonberg
- Institute for Medical Microbiology and Hospital Epidemiology, Medical School Hannover, Hannover, Germany.
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10
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Saiman L, Siegel JD, LiPuma JJ, Brown RF, Bryson EA, Chambers MJ, Downer VS, Fliege J, Hazle LA, Jain M, Marshall BC, O’Malley C, Pattee SR, Potter-Bynoe G, Reid S, Robinson KA, Sabadosa KA, Schmidt HJ, Tullis E, Webber J, Weber DJ. Infection Prevention and Control Guideline for Cystic Fibrosis: 2013 Update. Infect Control Hosp Epidemiol 2016; 35 Suppl 1:S1-S67. [DOI: 10.1086/676882] [Citation(s) in RCA: 270] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The 2013 Infection Prevention and Control (IP&C) Guideline for Cystic Fibrosis (CF) was commissioned by the CF Foundation as an update of the 2003 Infection Control Guideline for CF. During the past decade, new knowledge and new challenges provided the following rationale to develop updated IP&C strategies for this unique population:1.The need to integrate relevant recommendations from evidence-based guidelines published since 2003 into IP&C practices for CF. These included guidelines from the Centers for Disease Control and Prevention (CDC)/Healthcare Infection Control Practices Advisory Committee (HICPAC), the World Health Organization (WHO), and key professional societies, including the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA). During the past decade, new evidence has led to a renewed emphasis on source containment of potential pathogens and the role played by the contaminated healthcare environment in the transmission of infectious agents. Furthermore, an increased understanding of the importance of the application of implementation science, monitoring adherence, and feedback principles has been shown to increase the effectiveness of IP&C guideline recommendations.2.Experience with emerging pathogens in the non-CF population has expanded our understanding of droplet transmission of respiratory pathogens and can inform IP&C strategies for CF. These pathogens include severe acute respiratory syndrome coronavirus and the 2009 influenza A H1N1. Lessons learned about preventing transmission of methicillin-resistantStaphylococcus aureus(MRSA) and multidrug-resistant gram-negative pathogens in non-CF patient populations also can inform IP&C strategies for CF.
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11
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Devereux G, Fraser-Pitt D, Robertson J, Devlin E, Mercer D, O'Neil D. Cysteamine as a Future Intervention in Cystic Fibrosis Against Current and Emerging Pathogens: A Patient-based ex vivo Study Confirming its Antimicrobial and Mucoactive Potential in Sputum. EBioMedicine 2015; 2:1507-12. [PMID: 26629546 PMCID: PMC4634621 DOI: 10.1016/j.ebiom.2015.08.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/04/2015] [Accepted: 08/07/2015] [Indexed: 12/03/2022] Open
Abstract
Background Cysteamine has recently been shown to have in vitro properties potentially therapeutically beneficial in cystic fibrosis (CF). In this study we investigated the antimicrobial and mucolytic activity of cysteamine against the complex biologic matrix of CF sputum. Methods Sputum samples were obtained from 23 CF adults. Sputum polymicrobial content after in vitro exposure to cysteamine and standard CF antibiotics was assessed after a single exposure and after 14 days low-dose exposure. The effect of cysteamine on sputum spinnbarkeit was assessed. Findings Cysteamine reduced sputum polymicrobial burden by 3 · 18 (95% CI 2 · 30–4 · 07, p < 0.001) log10 units after 24 h incubation. Combined cysteamine and tobramycin reduced polymicrobial burden by a further 3 · 75 (95% CI 2 · 63–5 · 07, p < 0 · 001) log10 units above that seen with tobramycin. Repeated low dosing with cysteamine reduced sputum polymicrobial load from day 10 onwards (p = 0.032). Cysteamine reduced CF sputum viscoelasticity, sputum spinnbarkeit cysteamine 11.1 mm/s (95% CI 3.95–18.2) vs DNAse 1.69 mm/s (95% CI 0.73–2.65), p = 0.016. Cysteamine was active against Mycobacterium abscessus as a monotherapy and also potentiated the effects of amikacin and azithromycin. Conclusion Further investigation is required into the therapeutic potential of cysteamine in CF to treat emerging as well as established microbial pathogens and as a mucolytic agent. Cysteamine may have a role in treating cystic fibrosis. Cysteamine was added to sputum samples from 23 patients with cystic fibrosis. Cysteamine reduced microbial load and increased the effectiveness of tobramycin. Cysteamine greatly reduced the viscoelasticity of sputum. Cysteamine had activity against the emerging pathogen Mycobacterium abscessus.
Cystic fibrosis (CF) is a genetic disease that damages the lungs because the thick sticky mucus produced in CF airways becomes infected. There is a need to develop new treatments for CF lung infections. In this study we have taken sputum samples from 23 people with CF and shown that an investigational drug cysteamine reduces the number of bacteria in the sputum and also makes an antibiotic work better. Cysteamine also reduced sputum stickiness. These results suggest that cysteamine may have a role treating CF lung infections and further research is required to fully assess this.
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Affiliation(s)
- Graham Devereux
- Respiratory Group, University of Aberdeen, Aberdeen AB25 2ZG, UK
- Corresponding author at: Child Health, Royal Aberdeen Children's Hospital, Aberdeen AB25 2ZG, UK.Child HealthRoyal Aberdeen Children's HospitalAB25 2ZGAberdeenUK
| | | | - Jennifer Robertson
- NovaBiotics Ltd, Cruickshank Building, Craibstone, Aberdeen AB21 9TR, UK
| | - Edward Devlin
- Respiratory Group, University of Aberdeen, Aberdeen AB25 2ZG, UK
- NovaBiotics Ltd, Cruickshank Building, Craibstone, Aberdeen AB21 9TR, UK
| | - Derry Mercer
- NovaBiotics Ltd, Cruickshank Building, Craibstone, Aberdeen AB21 9TR, UK
| | - Deborah O'Neil
- NovaBiotics Ltd, Cruickshank Building, Craibstone, Aberdeen AB21 9TR, UK
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12
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Lynch JP, Sayah DM, Belperio JA, Weigt SS. Lung transplantation for cystic fibrosis: results, indications, complications, and controversies. Semin Respir Crit Care Med 2015; 36:299-320. [PMID: 25826595 DOI: 10.1055/s-0035-1547347] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Survival in patients with cystic fibrosis (CF) has improved dramatically over the past 30 to 40 years, with mean survival now approximately 40 years. Nonetheless, progressive respiratory insufficiency remains the major cause of mortality in CF patients, and lung transplantation (LT) is eventually required. Timing of listing for LT is critical, because up to 25 to 41% of CF patients have died while awaiting LT. Globally, approximately 16.4% of lung transplants are performed in adults with CF. Survival rates for LT recipients with CF are superior to other indications, yet LT is associated with substantial morbidity and mortality (∼50% at 5-year survival rates). Myriad complications of LT include allograft failure (acute or chronic), opportunistic infections, and complications of chronic immunosuppressive medications (including malignancy). Determining which patients are candidates for LT is difficult, and survival benefit remains uncertain. In this review, we discuss when LT should be considered, criteria for identifying candidates, contraindications to LT, results post-LT, and specific complications that may be associated with LT. Infectious complications that may complicate CF (particularly Burkholderia cepacia spp., opportunistic fungi, and nontuberculous mycobacteria) are discussed.
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Affiliation(s)
- Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David M Sayah
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - S Sam Weigt
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
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13
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Jain M, Saiman LM, Sabadosa K, LiPuma JJ. Point: does the risk of cross infection warrant exclusion of adults with cystic fibrosis from cystic fibrosis foundation events? Yes. Chest 2014; 145:678-680. [PMID: 24135971 DOI: 10.1378/chest.13-2404] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Manu Jain
- Department of Medicine and Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Lisa M Saiman
- Department of Pediatrics, Columbia University Medical Center, Department of Infection Prevention and Control, New York-Presbyterian Hospital, Lebanon, NH
| | - Kathy Sabadosa
- Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, New York, NY
| | - John J LiPuma
- The Department of Pediatrics and Communicable Disease, University of Michigan Medical School, Ann Arbor, MI
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14
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Hansen CR, Pressler T, Ridderberg W, Johansen HK, Skov M. Achromobacter species in cystic fibrosis: cross-infection caused by indirect patient-to-patient contact. J Cyst Fibros 2013; 12:609-15. [PMID: 23769270 DOI: 10.1016/j.jcf.2013.05.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 04/26/2013] [Accepted: 05/09/2013] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND METHODS Achromobacter species leads to chronic infection in an increasing number of CF patients. We report 2 cases of Achromobacter ruhlandii cross-infection between patients after well-described indirect contact. RESULTS Both cases were young, stable, CF patients without chronic infections and with normal FEV1, but experienced clinical deterioration after visits to the home of a CF patient with A. ruhlandii infection and after sharing facilities with an A. ruhlandii infected CF patient on a skiing vacation, respectively. Both cases became positive for A. ruhlandii in airway secretions and were colonized with A. ruhlandii in their sinuses. Aggressive, long-term antibiotic treatment led to clinical stability. One of the cases developed chronic A. ruhlandii infection. CONCLUSION A. species can cause cross-infection even after a short period of indirect contact between infected and non-infected CF patients. Patients should be followed closely for several months before the possibility of cross-infection is ruled out.
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Affiliation(s)
- C R Hansen
- Department of Pediatrics, Copenhagen CF Centre, University Hospital Rigshospitalet, Copenhagen, Denmark.
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15
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Forier K, Messiaen AS, Raemdonck K, Deschout H, Rejman J, De Baets F, Nelis H, De Smedt SC, Demeester J, Coenye T, Braeckmans K. Transport of nanoparticles in cystic fibrosis sputum and bacterial biofilms by single-particle tracking microscopy. Nanomedicine (Lond) 2013; 8:935-49. [DOI: 10.2217/nnm.12.129] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Aim: The aim of this study was to evaluate the effect of the surface functionalization of model nanoparticles on their mobility in bacterial biofilms and cystic fibrosis sputum. Materials & methods: With single-particle tracking microscopy, the mobility of 0.1- and 0.2-µm fluorescent polyethylene glycol (PEG) modified, carboxylate- and N,N-dimethylethylenediamine-modified polystyrene nanospheres were evaluated in fresh cystic fibrosis sputum, as well as Burkholderia multivorans and Pseudomonas aeruginosa biofilms. Results: PEGylation increased the mobility of the particles in sputum and biofilms, while the charged nanospheres were strongly immobilized. However, the transport of the PEGylated nanoparticles was lower in sputum compared with biofilms. Furthermore, the particle transport showed heterogeneity in samples originating from different patients. Conclusion: This study’s data suggest that for future nanocarrier design it will be essential to combine PEGylation with a targeting moiety to ensure sufficient mobility in mucus and a better accumulation of the nanoparticles in the biofilm. Original submitted 14 February 2012; Revised submitted 24 July 2012; Published online 5 October 2012
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Affiliation(s)
- Katrien Forier
- Ghent University, Harelbekestraat 72, 9000 Ghent, Ghent, Belgium
- Center for Nano- and Biophotonics, Ghent University, Harelbekestraat 72, 9000 Ghent, Belgium
| | | | - Koen Raemdonck
- Ghent University, Harelbekestraat 72, 9000 Ghent, Ghent, Belgium
| | - Hendrik Deschout
- Ghent University, Harelbekestraat 72, 9000 Ghent, Ghent, Belgium
- Center for Nano- and Biophotonics, Ghent University, Harelbekestraat 72, 9000 Ghent, Belgium
| | - Joanna Rejman
- Ghent University, Harelbekestraat 72, 9000 Ghent, Ghent, Belgium
| | - Frans De Baets
- Department of Pediatrics, University Hospital of Ghent, De Pintelaan 185, 9000 Ghent, Ghent, Belgium
| | - Hans Nelis
- Ghent University, Harelbekestraat 72, 9000 Ghent, Ghent, Belgium
| | | | - Joseph Demeester
- Ghent University, Harelbekestraat 72, 9000 Ghent, Ghent, Belgium
| | - Tom Coenye
- Ghent University, Harelbekestraat 72, 9000 Ghent, Ghent, Belgium
| | - Kevin Braeckmans
- Ghent University, Harelbekestraat 72, 9000 Ghent, Ghent, Belgium
- Center for Nano- and Biophotonics, Ghent University, Harelbekestraat 72, 9000 Ghent, Belgium
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Ashish A, Shaw M, Winstanley C, Humphreys L, Walshaw MJ. Halting the spread of epidemic pseudomonas aeruginosa in an adult cystic fibrosis centre: a prospective cohort study. JRSM SHORT REPORTS 2013; 4:1. [PMID: 23413403 PMCID: PMC3572656 DOI: 10.1258/shorts.2012.012018] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objectives To assess if cohort segregation policies are effective in preventing cross-infection in cystic fibrosis (CF) clinics. Design A prospective cohort study. Setting A large adult CF centre in Northwest England. Participants All CF patients cared for at the Liverpool adult CF centre 2003–2009. Methods Regular sputum sampling with genotyping of pseudomonas aeruginosa (Psa) isolates led to a policy of inpatient and outpatient segregation by microbiological group. Main outcome measures Prevalence and cross-infection/super-infection rates of a transmissible Psa strain, i.e. the Liverpool epidemic strain (LES) in adult CF patients at the Liverpool adult CF centre from 2003 to 2009. Results There was a decline in the proportion of patients with LES (71–53%) and an increase in those with unique strains (23–31%) and without Psa infection (6–17%) from 2003 to 2009. There were two cases of LES super-infection and one case of new chronic Psa infection (with a unique strain). There were no cases of transmissible strain infection in patients previously uninfected by Psa. Conclusions Our segregation policy has halted the spread of the commonest highly transmissible strain in the UK (LES) in our clinic, without endangering patients who were not previously infected with Psa. It confirms that if genotypic surveillance is used, it is unnecessary to segregate patients infected with unique strains from those without Psa infection.
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Affiliation(s)
- Abdul Ashish
- Liverpool Heart and Chest Hospital , Liverpool L14 3PE , UK
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17
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Abstract
As a testimony to advances in patient care, more individuals with cystic fibrosis are surviving into their adult years than ever before. The clinical epidemiology of this complex multi-organ disease is evolving and has changed dramatically over the past two to three decades. This article discusses the emergence of chronic disease-related co-morbidities such as CF-related diabetes, chronic kidney disease, bone disease, arthropathy, and depression. It also provides an overview of the many challenges confronted by adult CF care providers.
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Affiliation(s)
- Bradley S Quon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington Medical Center, 1959 NE Pacific St., Campus Box 356522, Seattle, Washington, USA, 98195
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18
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Conway SP, Brownlee KG, Denton M, Peckham DG. Antibiotic Treatment of Multidrug-Resistant Organisms in Cystic Fibrosis. ACTA ACUST UNITED AC 2012; 2:321-32. [PMID: 14719998 DOI: 10.1007/bf03256660] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Respiratory tract infection with eventual respiratory failure is the major cause of morbidity and mortality in cystic fibrosis (CF). Infective exacerbations need to be treated promptly and effectively to minimize potentially accelerated attrition of lung function. The choice of antibiotic depends on in vitro sensitivity patterns. However, physicians treating patients with CF are increasingly faced with infection with multidrug-resistant isolates of Pseudomonas aeruginosa. In addition, innately resistant organisms such as Burkholderia cepacia complex, Stenotrophomonas maltophilia and Achromobacter (Alcaligenes) xylosoxidans are becoming more prevalent. Infection with methicillin-resistant Staphylococcus aureus (MRSA) is also a problem. These changing patterns probably result from greater patient longevity and increased antibiotic use for acute exacerbations and maintenance care. Multidrug-resistant P. aeruginosa infection may be treated successfully by using two antibiotics with different mechanisms of action. In practice antibiotic choices have usually been made on a best-guess basis, but recent research suggests that more directed therapy can be achieved through the application of multiple-combination bactericidal testing (MCBT). Aerosol delivery of tobramycin for inhalation solution achieves high endobronchial concentrations that may overcome bacterial resistance as defined by standard laboratory protocols. Resistance to colistin is rare and this antibiotic should be seen as a valuable second-line drug to be reserved for multidrug-resistant P. aeruginosa. The efficacy of new antibiotic groups such as the macrolides needs to be evaluated.CF units should adopt strict segregation policies to interrupt person-to-person spread of B. cepacia complex. Treatment of panresistant strains is difficult and often arbitrary. Combination antibiotic therapy is recommended, usually tobramycin and high-dose meropenem and/or ceftazidime, but the choice of treatment regimen should always be guided by the clinical response.The clinical significance of S. maltophilia, A. xylosoxidans and MRSA infection in CF lung disease remains uncertain. If patients show clinical decline and are chronically colonized/infected with either of the former two pathogens, treatment is recommended but efficacy data are lacking. There are defined microbiological reasons for attempting eradication of MRSA but there are no proven deleterious effects of this infection on lung function in patients with CF. Various treatment protocols exist but none has been subject to a randomized, controlled trial. Multidrug-resistant microorganisms are an important and growing issue in the care of patients with CF. Each patient infected with such strains should be assessed individually and antibiotic treatment planned according to in vitro sensitivity, patient drug tolerance, and results of in vitro studies which may direct the physician to antibiotic combinations most likely to succeed.
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Affiliation(s)
- S P Conway
- Paediatric and Adult Regional Cystic Fibrosis Centres, St James' and Seacroft University Hospitals, Leeds, UK.
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19
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Hauser AR, Jain M, Bar-Meir M, McColley SA. Clinical significance of microbial infection and adaptation in cystic fibrosis. Clin Microbiol Rev 2011; 24:29-70. [PMID: 21233507 PMCID: PMC3021203 DOI: 10.1128/cmr.00036-10] [Citation(s) in RCA: 287] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A select group of microorganisms inhabit the airways of individuals with cystic fibrosis. Once established within the pulmonary environment in these patients, many of these microbes adapt by altering aspects of their structure and physiology. Some of these microbes and adaptations are associated with more rapid deterioration in lung function and overall clinical status, whereas others appear to have little effect. Here we review current evidence supporting or refuting a role for the different microbes and their adaptations in contributing to poor clinical outcomes in cystic fibrosis.
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Affiliation(s)
- Alan R Hauser
- Department of Microbiology/Immunology, Northwestern University, 303 E. Chicago Ave., Searle 6-495, Chicago, IL 60611, USA.
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20
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Abstract
Infection of the airways remains the primary cause of morbidity and mortality in persons with cystic fibrosis (CF). This review describes salient features of the epidemiologies of microbial species that are involved in respiratory tract infection in CF. The apparently expanding spectrum of species causing infection in CF and recent changes in the incidences and prevalences of infection due to specific bacterial, fungal, and viral species are described. The challenges inherent in tracking and interpreting rates of infection in this patient population are discussed.
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21
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Hansen C, Pressler T, Nielsen K, Jensen P, Bjarnsholt T, Høiby N. Inflammation in Achromobacter xylosoxidans infected cystic fibrosis patients. J Cyst Fibros 2010; 9:51-8. [DOI: 10.1016/j.jcf.2009.10.005] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2009] [Revised: 10/26/2009] [Accepted: 10/27/2009] [Indexed: 11/26/2022]
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22
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Simmonds NJ, Gyi KM. Cystic fibrosis, a Burkholderia cenocepacia chest wall abscess and rapid clinical deterioration. J R Soc Med 2008; 101 Suppl 1:S46-50. [PMID: 18607020 DOI: 10.1258/jrsm.2008.s18011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- N J Simmonds
- Department of Cystic Fibrosis, Royal Brompton Hospital Sydney Street, London SW3 6NP, UK.
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Courtney JM, Bradley J, Mccaughan J, O'Connor TM, Shortt C, Bredin CP, Bradbury I, Elborn JS. Predictors of mortality in adults with cystic fibrosis. Pediatr Pulmonol 2007; 42:525-32. [PMID: 17469153 DOI: 10.1002/ppul.20619] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Assessment of prognostic indicators in patients with cystic fibrosis (CF) is important. The study's aim was to assess the relative contribution of gender, genetics and microbiology on survival in adults with CF. Adult patients were studied from 1995 to 2005 and data collected included FEV(1) (%predicted), body mass index (BMI), genetics, and microbiology. Data was available on 183 patients in 1995. Forty-five patients died in the subsequent 10 years. Patients who died during the study had lower mean (SD) FEV(1) %predicted in 1995 when compared to those remaining alive, 41.5 (15.2)% versus 69.8 (23.2)% predicted, respectively, P<0.001 and they had lower mean (SD) BMI in 1995, 19.2 (3.3) kg/m(2) in comparison to those remaining alive, 20.7 (3.4) kg/m(2), P=0.008. The proportion of patients infected with Pseudomonas aeruginosa and Burkholderia cepacia complex was higher in the group who died during the study compared to those remaining alive, odds ratio 20.9 P<0.0001 and 7.1 P<0.0001, respectively. The presence of the Delta F508 homozygous mutation did not alter survival, P=0.3. Patients infected with either P.aeruginosa or B.cepacia complex had reduced survival compared to those without infection, P=0.01 and P<0.0001, respectively. FEV(1)% (P<0.0001), infection with P.aeruginosa (P=0.005) or B.cepacia complex (P=0.03) were the only significant predictors of mortality. This study demonstrates adults who died were more likely to have worse lung function and be infected with either P.aeruginosa or B.cepacia complex. FEV(1)% and infection with P.aeruginosa or B.cepacia complex were the most significant predictors of survival in adults with CF.
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Affiliation(s)
- J M Courtney
- Adult Cystic Fibrosis Unit, Belfast City Hospital, Belfast, Northern Ireland, Ireland.
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24
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Cheung KJ, Li G, Urban TA, Goldberg JB, Griffith A, Lu F, Burns JL. Pilus-mediated epithelial cell death in response to infection with Burkholderia cenocepacia. Microbes Infect 2007; 9:829-37. [PMID: 17537663 DOI: 10.1016/j.micinf.2007.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2006] [Revised: 01/09/2007] [Accepted: 03/01/2007] [Indexed: 11/20/2022]
Abstract
Burkholderia cenocepacia is an opportunistic pathogen that can cause serious infections in cystic fibrosis (CF) patients. The ET12 lineage appears particularly virulent in CF; however, its pathogenesis is poorly understood and may be associated with host response. To help characterize this response, the ability of B. cenocepacia to induce cytotoxicity and apoptosis in an epithelial cell model was examined. Upon infection with B. cenocepacia strain K56-2, A549 human lung epithelial cells underwent significant cell death; propidium iodine staining and DNA fragmentation assays suggested apoptosis. Initiation of cell death was independent of the type III secretion system, biofilm formation, and secreted bacterial cytotoxins. However, the frequency of cell death was lower in cells infected with a non-piliated mutant, K56-2 cblA::Tp. Furthermore, purified cbl pili were found to directly induce cytotoxicity in A549 cells and activate caspase-9, -8, -7, and -3, the major cysteine proteinases involved in apoptosis. It appears that B. cenocepacia cbl pili, which are a distinctive feature of the ET12 lineage, act as an initiator of cytotoxicity and apoptosis. Understanding the role of cbl pili in the pathogenesis of B. cenocepacia infections offers the potential for decreasing the virulence of these potentially life-threatening organisms in CF patients.
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Affiliation(s)
- K-John Cheung
- Division of Infectious Diseases, Immunology and Rheumatology, Children's Hospital and Regional Medical Center, 307 Westlake Avenue N., Seattle, WA 98109, USA
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Downey DG, Martin SL, Dempster M, Moore JE, Keogan MT, Starcher B, Edgar J, Bilton D, Elborn JS. The relationship of clinical and inflammatory markers to outcome in stable patients with cystic fibrosis. Pediatr Pulmonol 2007; 42:216-20. [PMID: 17238189 DOI: 10.1002/ppul.20553] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Decreased survival in patients with cystic fibrosis has been related to FEV1, BMI, and infection with Burkholderia cepacia complex (BCC). We have assessed the relationship of blood, sputum, and urine inflammatory markers to lung function, BMI, colonization with B cenocepacia (Bc), and patient survival. Thirty-nine stable cystic fibrosis (CF) patients (10 with Bc) were enrolled in a study to determine the effect of alpha-1-antitrypsin on airways inflammation. Pre-treatment measurements were used in this study. Demographics, sputum microbiology, heart rate, oxygen saturation, lung function were recorded. Blood samples were obtained for white blood count (WBC), C-Reactive Protein (CRP), and plasma neutrophil elastase/AAT complexes (pNEC). Neutrophil elastase (NE), neutrophil elastase/AAT complexes (sNEC), interleukin-8 (IL-8), TNF-receptor 1 (sTNFr), and myeloperoxidase (MPO) were measured in sputum and urinary desmosine concentration determined. Patients with Bc had significantly higher levels of pNEC, 332 +/- 91.4 ng/ml (mean +/- SEM) versus 106 +/- 18.2 ng/ml (P = 0.0005) and sNEC, 369 +/- 76.6 ng/ml versus 197 +/- 36.0 ng/ml compared to those who were not. Five deaths were reported at the end of 1 year, (four with Bc) (P = 0.011). Patients who subsequently died had significantly lower lung function FEV1, 1.2 +/- 0.2 L versus 2.0 +/- 0.1 L (P = 0.03) and FVC, 2 +/- 0.3 L versus 3.1 +/- 0.2 L (P = 0.01), compared to those that survived. There was significantly higher NE activity, 3.6 +/- 1.6 U/ml versus 1.5 +/- 0.6 U/ml (P = 0.03), pNEC, 274 +/- 99 ng/ml versus 142 +/- 30 ng/ml (P = 0.05), MPO, 163 +/- 62 mcg/ml versus 54 +/- 6.9 mcg/ml (P = 0.03), and urinary desmosines 108 +/- 19.9 pM/mg creatinine versus 51.1 +/- 3.3 pM/mg creatinine (P = 0.001), in those patients who subsequently died compared to those that survived. These data suggest there is increased neutrophil degranulation in patients infected with Bc and these patients have a poor outcome.
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Affiliation(s)
- Damian G Downey
- Adult Cystic Fibrosis Centre, Belfast City Hospital and Queens University, Belfast, Northern Ireland
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26
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Bamford S, Ryley H, Jackson SK. Highly purified lipopolysaccharides from Burkholderia cepacia complex clinical isolates induce inflammatory cytokine responses via TLR4-mediated MAPK signalling pathways and activation of NFkappaB. Cell Microbiol 2006; 9:532-43. [PMID: 17002785 DOI: 10.1111/j.1462-5822.2006.00808.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In cystic fibrosis (CF), bacteria of the Burkholderia cepacia complex (Bcc) can induce a fulminant inflammation with pneumonitis and sepsis. Lipopolysaccharide (LPS) may be an important virulence factor associated with this decline but little is known about the molecular pathogenesis of Bcc LPS. In this study we have investigated the inflammatory response to highly purified LPS from different Bcc clinical isolates and the cellular signalling pathways employed. The inflammatory response (TNFalpha, IL-6) was measured in human MonoMac 6 monocytes and inhibition experiments were used to investigate the Toll-like receptors and associated adaptor molecules and pathways utilized. LPS from all clinical Bcc isolates induced significant pro-inflammatory cytokines and utilized TLR4 and CD14 to mediate activation of mitogen-activated protein kinase pathways, IkappaB-alpha degradation and NFkappaB activation. However, LPS from different clinical isolates of the same clonal strain of Burkholderia cenocepacia were found to induce a varied inflammatory response. LPS from clinical isolates of Burkholderia multivorans was found to activate the inflammatory response via MyD88-independent pathways. This study suggests that LPS alone from clinical isolates of Bcc is an important virulence factor in CF and utilizes TLR4-mediated signalling pathways to induce a significant inflammatory response.
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Affiliation(s)
- Sarah Bamford
- Department of Medical Microbiology, School of Medicine, Cardiff University, Cardiff, UK
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27
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Vonberg RP, Häußler S, Vandamme P, Steinmetz I. Identification of Burkholderia cepacia complex pathogens by rapid-cycle PCR with fluorescent hybridization probes. J Med Microbiol 2006; 55:721-727. [PMID: 16687590 DOI: 10.1099/jmm.0.46457-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Members of the Burkholderia cepacia complex are important bacterial pathogens in cystic fibrosis (CF) patients. The B. cepacia complex currently consists of nine genetic subgroups (genomovars) of different epidemiological relevance and possibly of different pathogenic potential in humans. In this study, a new approach was developed for the rapid identification of B. cepacia genomovar I, Burkholderia multivorans (genomovar II), Burkholderia cenocepacia (lineage III-A and III-B), Burkholderia stabilis (genomovar IV) and Burkholderia vietnamiensis (genomovar V), which cause the large majority of infections in CF patients. The method was based on the detection of differences in the recA gene sequence by using rapid-cycle PCR and genomovar-specific fluorescence resonance energy transfer (FRET) probes. The genomovar status of all 39 B. cepacia complex strains tested (genomovars I–V) was identified by melting-curve analysis. Each FRET probe produced a specific fluorescence signal only with the respective genomovar, and not with other B. cepacia complex strains and Burkholderia spp. The identification system was easy to handle and revealed B. cepacia complex genomovar I–V status from culture isolates within about 1 h.
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Affiliation(s)
- Ralf-Peter Vonberg
- Institute of Medical Microbiology and Hospital Epidemiology, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Susanne Häußler
- Department of Cell Biology, German Research Center for Biotechnology, Braunschweig, Germany
- Institute of Medical Microbiology and Hospital Epidemiology, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Peter Vandamme
- Laboratorium voor Mikrobiologie, Universiteit Gent, Belgium
| | - Ivo Steinmetz
- Friedrich Loeffler Institute of Medical Microbiology, Ernst Moritz Arndt University Greifswald, Germany
- Institute of Medical Microbiology and Hospital Epidemiology, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
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Taccetti G, Costantini D, Furnari ML. Clinical follow-up of 122 Italian cystic fibrosis patients with B. cepacia complex colonisation. J Cyst Fibros 2005; 4:145-6; author reply 147. [PMID: 15978538 DOI: 10.1016/j.jcf.2004.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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McManus TE, McDowell A, Moore JE, Elborn SJ. Organisms isolated from adults with cystic fibrosis. Ann Clin Microbiol Antimicrob 2004; 3:26. [PMID: 15601468 PMCID: PMC544565 DOI: 10.1186/1476-0711-3-26] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2004] [Accepted: 12/15/2004] [Indexed: 11/18/2022] Open
Abstract
Background Patients with cystic fibrosis [CF] have frequent pulmonary exacerbations associated with the isolation of bacterial organisms from sputum samples. It is not clear however, if there are differences in the types of additional organisms isolated from patients who are infected with Burkholderia cepacia complex [BCC] or Pseudomonas aerugionsa [PA] in comparison to those who are not infected with either of these organisms [NI]. Methods Adult patients attending the regional CF unit were followed over a two year period and patients were assigned to three groups depending on whether they were known to be chronically infected with BCC, PA or NI. We compared the numbers and types of organisms which were isolated in each of these groups. Results Information was available on a total of 79 patients; BCC 23, PA 30 and NI 26. Total numbers of organisms isolated, expressed as median and IQR for each group, [P = 0.045] and numbers of co-infecting organisms [P = 0.003] were significantly higher in the BCC group compared to PA, and in the PA group [P < 0.001, p = 0.007 respectively] compared to NI patients. The pattern of co-infecting organisms was similar in all three groups. Conclusions Total numbers of organisms isolated and numbers of co-infecting organisms were significantly higher in the BCC group compared to PA, and in the PA group compared to NI patients. Types of co-infecting organisms are similar in all groups of patients.
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Affiliation(s)
- Terence E McManus
- Regional Adult Cystic Fibrosis Center, Belfast City Hospital, Belfast, Northern Ireland, BT9 7AB, UK
| | - Andrew McDowell
- Department of Bacteriology, Belfast City Hospital, Belfast, Northern Ireland, BT9 7AB, UK
| | - John E Moore
- Department of Bacteriology, Belfast City Hospital, Belfast, Northern Ireland, BT9 7AB, UK
| | - Stuart J Elborn
- Regional Adult Cystic Fibrosis Center, Belfast City Hospital, Belfast, Northern Ireland, BT9 7AB, UK
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Jones AM, Dodd ME, Govan JRW, Barcus V, Doherty CJ, Morris J, Webb AK. Burkholderia cenocepacia and Burkholderia multivorans: influence on survival in cystic fibrosis. Thorax 2004; 59:948-51. [PMID: 15516469 PMCID: PMC1746874 DOI: 10.1136/thx.2003.017210] [Citation(s) in RCA: 176] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Burkholderia cepacia infection has been associated with a poor prognosis for patients with cystic fibrosis (CF). It is now recognised that organisms classified as B cepacia comprise a number of distinct genomic species each known as a genomovar of the B cepacia complex (BCC). The outcome of infection for CF patients with individual genomovars is unknown. The clinical outcome of infection with the two most commonly isolated genomovars (B cenocepacia and B multivorans) was studied at a specialist CF centre between 1982 and 2003. METHODS The numbers of patients who progressed from initial to chronic infection were assessed. Control groups were created by matching patients with chronic BCC infection by percentage forced expiratory volume in 1 second with patients with Pseudomonas aeruginosa infection. Outcome measures were survival time, deaths from "cepacia syndrome", rate of decline in spirometry and body mass index (BMI), and treatment requirements. RESULTS Forty nine patients had an initial infection with either B multivorans (n = 16) or B cenocepacia (n = 33); 8/16 and 31/33, respectively, developed chronic infection (p<0.001). Deaths from "cepacia syndrome" occurred in both BCC groups. Patients with B cenocepacia infection had a shorter survival than patients with P aeruginosa infection (p = 0.01). There was no difference in survival between CF patients infected with B multivorans and P aeruginosa. There were no observed differences in changes in spirometry and BMI or treatment requirements between the BCC groups and respective controls. CONCLUSION In CF, the genomovar status of BCC may influence both the likelihood of progression from initial to chronic infection and the overall survival of the patients.
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Affiliation(s)
- A M Jones
- Manchester Adult Cystic Fibrosis Centre, South Manchester University Hospitals NHS Trust, Wythenshawe Hospital, Manchester M23 9LT, UK.
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Taylor PC, McLaws ML, De Borde M, Pritchard R. Isolation and identification of Burkholderia cepacia by participants in an external Quality Assurance Program (QAP) between 1994 and 1999. Pathology 2004; 36:352-7. [PMID: 15370136 DOI: 10.1080/00313020410001721636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
AIM External quality assurance programs (QAPs) provide an opportunity to benchmark laboratory performance according to the profile of specimens received. Participant confidentiality is maintained within each group of laboratories whose performance is measured using similar, repetitive exercises. Isolation and identification of Burkholderia cepacia from simulated cystic fibrosis (CF) sputa was a clinically relevant exercise that provided a model for this analytical approach. METHODS Between 1994 and 1999, six Royal College of Pathologists of Australasia (RCPA) Microbiology QAPs included four simulated CF sputa and two panels of oxidative Gram-negative bacilli. Laboratories were grouped according to experience with CF sputa disclosed by two questionnaires. Data were analysed by laboratory group for ability to isolate and identify B. cepacia. RESULTS Three laboratory groups annually received >100 CF sputa (CF>100), 100 CF sputa or fewer, or did not regularly receive CF sputa. CF>100 laboratories inoculated more isolation media, were more likely to use selective media and were less likely to misidentify B. cepacia than the other groups. Improved performance by CF>100 laboratories was marked after the first exercise and remained at a high level compared with the other two groups. This trend in performance was also apparent for Pseudomonas aeruginosa although the numbers of errors were less than for B. cepacia. CONCLUSIONS These exercises demonstrated consistently improved performance only among CF>100 laboratories. The future criteria for laboratory accreditation may include performance as well as participation in QAPs, placing additional burdens on organisers and participants.
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Affiliation(s)
- Peter C Taylor
- Department of Microbiology, South Eastern Area Laboratory Service, The Prince of Wales Hospital, Randwick, NSW 2031, Australia.
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De Soyza A, Ellis CD, Khan CMA, Corris PA, Demarco de Hormaeche R. Burkholderia cenocepaciaLipopolysaccharide, Lipid A, and Proinflammatory Activity. Am J Respir Crit Care Med 2004; 170:70-7. [PMID: 15044201 DOI: 10.1164/rccm.200304-592oc] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Organisms from the Burkholderia cepacia complex are important pathogens in cystic fibrosis and are associated with increased rates of sepsis and death. These organisms comprise nine closely related species known as genomovars. B. cenocepacia (genomovar III) is the most prevalent and appears the most virulent. We investigated the biological activity of a reference panel of strains using whole-cell lysates to induce septic-shock related cytokines from differentiated human monocytic cells. We found varying biological activity within and between genomovars, with B. cenocepacia strains possessing the greatest cytokine induction activity. This activity was CD-14 dependent, suggesting that LPS was responsible for the cytokine induction. Cytokine induction was not simply related to the expression of rough or smooth LPS. We purified LPS from two strains, B. cenocepacia LMG 12614 and B. multivorans LMG 14273, each possessing rough LPS. Divergence in biological activity of the two genomovars was preserved when human monocytic cells were stimulated with purified LPS. Lipid A purified from LMG 14273 and LMG 12614 were analyzed by matrix-assisted laser desorption ionization/time of flight mass spectrometry. Lipid A from the less effective cytokine inducer LMG 14273 was found to be missing a beta-hydroxymyristate (3-OH C14:0) relative to the lipid A of B. cenocepacia LMG 12614.
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Affiliation(s)
- Anthony De Soyza
- Transplantation and Immunobiology group, The Freeman Hospital, High Heaton, Newcastle-upon-Tyne NE7 7DN, United Kingdom.
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Affiliation(s)
- A De Soyza
- Transplantation and Immunobiology Group, Freeman Hospital, University of Newcastle, Newcastle-upon-Tyne, UK.
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Jackson R, Pencharz PB. Transition of care between paediatric and adult gastroenterology. Cystic fibrosis. Best Pract Res Clin Gastroenterol 2003; 17:213-35. [PMID: 12676116 DOI: 10.1016/s1521-6918(02)00150-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Advancement in treatment has resulted in a dramatic increase in life expectancy of patients with cystic fibrosis (CF) to well beyond 30 years of age in most centres. What was once a fatal genetic disease in childhood now sees over a third of its CF populations in adult clinics. The improved survival is multifactorial, but most attribute the reasons to more aggressive nutritional care along with better management of the gastrointestinal and pulmonary systems. Many of the nutritional and GI issues of paediatric patients remain similar when they become adults, except that there is the added psychosocial stress associated with this transition. This chapter aims to highlight the gastrointestinal and nutritional issues manifesting at the different stages of life from infancy to adulthood, and the recommended management.
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Affiliation(s)
- Reuben Jackson
- Department of Paediatrics, Division of GI/Nutrition, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ont., Canada M5G 1X8
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Vermis K, Coenye T, Mahenthiralingam E, Nelis HJ, Vandamme P. Evaluation of species-specific recA-based PCR tests for genomovar level identification within the Burkholderia cepacia complex. J Med Microbiol 2002; 51:937-940. [PMID: 12448677 DOI: 10.1099/0022-1317-51-11-937] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The Burkholderia cepacia complex presently comprises nine genomovars: B. cepacia (genomovar I), B. multivorans (genomovar II), B. cepacia genomovar III, B. stabilis (genomovar IV), B. vietnamiensis (genomovar V), B. cepacia genomovar VI, B. ambifaria (genomovar VII), B. anthina (genomovar VIII) and B. pyrrocinia (genomovar IX). Strains of each genomovar can colonise the respiratory tract of cystic fibrosis (CF) patients. However, the majority of infections in CF patients are caused by B. multivorans and B. cepacia genomovar III isolates. Accurate genomovar-level identification is best achieved through a polyphasic approach combining phenotypic and genotypic analyses. In the present study, the sensitivity and specificity of recA-based genomovar specific primer pairs were evaluated with a collection of 508 B. cepacia complex isolates representing all nine genomovars. The assays for the identification of B. multivorans (sensitivity and specificity, 100%), B. cepacia genomovar III (sensitivity, 92%; specificity, 100%), and B. ambifaria (sensitivity and specificity, 100%) were the most efficient. However, the B. cepacia genomovar I assay lacked sensitivity (72%) and cross-reacted with all B. pyrrocinia isolates examined. Several new recA RFLP types were also revealed within the B. cepacia complex. One of these profiles was shared by a clinical and an environmental B. cepacia-like isolate and by the B. ubonensis type strain. The latter organism is a recently described soil bacterium. Its relationship to the various B. cepacia complex genomovars needs further study.
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Affiliation(s)
| | - Tom Coenye
- Laboratory of Pharmaceutical Microbiology and *Laboratory of Microbiology, Ghent University, Ghent, Belgium and ‡Cardiff School of Biosciences, Cardiff University, Cardiff
| | - Eshwar Mahenthiralingam
- Laboratory of Pharmaceutical Microbiology and *Laboratory of Microbiology, Ghent University, Ghent, Belgium and ‡Cardiff School of Biosciences, Cardiff University, Cardiff
| | | | - Peter Vandamme
- Laboratory of Pharmaceutical Microbiology and *Laboratory of Microbiology, Ghent University, Ghent, Belgium and ‡Cardiff School of Biosciences, Cardiff University, Cardiff
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Vermis K, Vandekerckhove C, Nelis HJ, Vandamme PAR. Evaluation of restriction fragment length polymorphism analysis of 16S rDNA as a tool for genomovar characterisation within the Burkholderia cepacia complex. FEMS Microbiol Lett 2002; 214:1-5. [PMID: 12204364 DOI: 10.1111/j.1574-6968.2002.tb11316.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
A total of 154 Burkholderia cepacia complex strains, isolated from cystic fibrosis and non-cystic fibrosis patients and the environment, representing all nine genomovars and a putative tenth, were analysed by 16S rDNA-restriction fragment length polymorphism using the restriction enzymes AluI, CfoI and DdeI. Examining this diverse strain collection resulted in very diverse restriction patterns. Only B. cepacia genomovar VI could be identified unambiguously. The same restriction patterns were observed for B. cepacia genomovars I and III and approximately half of the Burkholderia ambifaria, B. anthina and B. pyrrocinia strains. Burkholderia vietnamiensis and B. ubonensis, a putative tenth B. cepacia complex genomovar, shared identical restriction profiles. The majority of Burkholderia multivorans and B. stabilis isolates generated a unique restriction pattern, but two strains of each showed divergent restriction profiles which were also observed in other genomovars.
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Affiliation(s)
- Karen Vermis
- Laboratory for Pharmaceutical Microbiology, Faculty of Pharmaceutical Sciences, Ghent University, Belgium
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Cantón R, Girón R, Martínez-Martínez L, Oliver A, Solé A, Valdezate S, Máiz L. [Multiresistant pathogens in cystic fibrosis]. Arch Bronconeumol 2002; 38:376-85. [PMID: 12199920 DOI: 10.1016/s0300-2896(02)75243-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- R Cantón
- Servicio de Microbiología, Hospital Ramón y Cajal, Madrid, Spain.
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Ledson MJ, Gallagher MJ, Robinson M, Cowperthwaite C, Williets T, Hart CA, Walshaw MJ. A randomized double-blinded placebo-controlled crossover trial of nebulized taurolidine in adult cystic fibrosis patients infected with Burkholderia cepacia. JOURNAL OF AEROSOL MEDICINE : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR AEROSOLS IN MEDICINE 2002; 15:51-7. [PMID: 12006145 DOI: 10.1089/08942680252908575] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Burkholderia cepacia is an aggressive pathogen that colonizes cystic fibrosis (CF) patients, causing greatly increased morbidity and mortality. It is resistant to most antibiotics, but sensitive in vitro to a novel agent, taurolidine. This has not previously been used against B. cepacia, nor given in nebulized form. We assessed the effect of nebulized taurolidine on United Kingdom epidemic (ET12) B. cepacia infection in 20 adult CF patients attending our regional adult cystic fibrosis outpatient clinic using a prospective, randomized, double-blinded placebo-controlled crossover trial. Nebulized taurolidine (4 mL 2% solution) or saline (4 mL 0.9% solution) was given twice daily. Each arm lasted 4 weeks, with a 2-week intervening washout period. Sputum B. cepacia colony counts (primary outcome measure), spirometry, and symptoms (secondary outcome measures) were assessed. Eighteen patients completed the study. There was no change in B. cepacia colony counts or spirometry, nor symptom scores. We conclude that, although taurolidine is well tolerated in nebulized form, in this study it had no in vivo anti-B. cepacia activity.
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Affiliation(s)
- Martin J Ledson
- Regional Adult Cystic Fibrosis Unit, Liverpool University, Liverpool, United Kingdom
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Ledson MJ, Gallagher MJ, Jackson M, Hart CA, Walshaw MJ. Outcome of Burkholderia cepacia colonisation in an adult cystic fibrosis centre. Thorax 2002; 57:142-5. [PMID: 11828044 PMCID: PMC1746259 DOI: 10.1136/thorax.57.2.142] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Colonisation with Burkholderia cepacia is a poor prognostic indicator in subjects with cystic fibrosis (CF), but outcome prediction is impossible since patients are colonised by different strains with differing pathogenicity. The clinical course of a large cohort of CF patients colonised with UK epidemic (ET12) B cepacia was followed for 5 years and compared with that of the remaining patients in the clinic. METHODS Pulmonary function, nutritional state, and lung pathogen colonisation were recorded for 5 years before December 1997 or death for all 107 patients who had attended the Liverpool adult CF clinic since 1993. For each patient a time line from study entry to date of death or 1997 was constructed. In 1993 potential risk factors including age and sex were subjected to Cox proportional hazards analysis using the end point of mortality as the outcome variable. The analysis was supplemented by time varying covariables that described the change in FEV(1), BMI, and colonisation status across time, and the excess risk associated with B cepacia colonisation was calculated. Subsequently, in those patients who died between 1993 and 1997, predictive factors for death were compared within groups using complete 5 year data. RESULTS Thirty seven patients had been colonised by epidemic B cepacia and these patients had four times the mortality of the remainder (p<0.01). In 1993 univariate predictors of mortality were age (alive 19.6 (0.64) v dead 23.8 (1.44); p<0.005) and baseline FEV(1) (alive 68.6 (2.5)% predicted v dead 43.2 (4.8)%; p<0.001) with a trend for BMI (p=0.07). However, following time varying covariate Cox proportional hazards analysis, only lower FEV(1) (hazards ratio 1.1, 95% confidence limits 1.06 to 1.14; p<0.001) and colonisation with B cepacia (hazards ratio 7.92, confidence limits 2.65 to 23.69; p<0.001) were identified as significant factors for death. Surviving B cepacia patients had similar initial lung function to the remaining surviving patients but had an accelerated loss of lung function over the study period (colonised -1.9% predicted per year v non-colonised -0.3% predicted per year; p<0.05). Deceased patients colonised with B cepacia had better spirometric results than the remaining deceased patients 5 years before death (p<0.05) but lost lung function at a greater rate than non-colonised patients (colonised -6.2% predicted per year v non-colonised -1.9% predicted per year; p<0.05). CONCLUSIONS This study confirms the excess mortality associated with epidemic B cepacia colonisation and shows that those with poor spirometric values are at the greatest risk.
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Affiliation(s)
- M J Ledson
- Regional Adult Cystic Fibrosis Unit, The Cardiothoracic Centre, Liverpool L14 3PE, UK
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Affiliation(s)
- R Hamutcu
- Division of Pediatric Pulmonology, Children's Hospital Los Angeles, Los Angeles, California 90027, USA
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Abstract
Previous studies have indicated that pulmonary infection with Burkholderia cepacia is associated with poor clinical outcome after lung transplantation in cystic fibrosis (CF). Many treatment centers consider B. cepacia infection an absolute contraindication to lung transplantation. However, the B. cepacia complex actually consists of several closely related bacterial species. Although each of these has been isolated from CF sputum culture, certain species are much more frequently recovered than others, and it is not yet clear whether all species have the same potential for virulence in CF. Additional study is needed to better define the relative risks associated with each species of the B. cepacia complex.
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Affiliation(s)
- J J LiPuma
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan 48109-0646, USA.
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Sajjan U, Thanassoulis G, Cherapanov V, Lu A, Sjolin C, Steer B, Wu YJ, Rotstein OD, Kent G, McKerlie C, Forstner J, Downey GP. Enhanced susceptibility to pulmonary infection with Burkholderia cepacia in Cftr(-/-) mice. Infect Immun 2001; 69:5138-50. [PMID: 11447196 PMCID: PMC98610 DOI: 10.1128/iai.69.8.5138-5150.2001] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Progressive pulmonary infection is the dominant clinical feature of cystic fibrosis (CF), but the molecular basis for this susceptibility remains incompletely understood. To study this problem, we developed a model of chronic pneumonia by repeated instillation of a clinical isolate of Burkholderia cepacia (genomovar III, ET12 strain), an opportunistic gram-negative bacterium, from a case of CF into the lungs of Cftr (m1unc-/-) (Cftr(-/-)) and congenic Cftr(+/+) controls. Nine days after the last instillation, the CF transmembrane regulator knockout mice showed persistence of viable bacteria with chronic severe bronchopneumonia while wild-type mice remained healthy. The histopathological changes in the lungs of the susceptible Cftr(-/-) mice were characterized by infiltration of a mixed inflammatory-cell population into the peribronchiolar and perivascular spaces, Clara cell hyperplasia, mucus hypersecretion in airways, and exudation into alveolar airspaces by a mixed population of macrophages and neutrophils. An increased proportion of neutrophils was observed in bronchoalveolar lavage fluid from the Cftr(-/-) mice, which, despite an increased bacterial load, demonstrated minimal evidence of activation. Alveolar macrophages from Cftr(-/-) mice also demonstrated suboptimal activation. These observations suggest that the pulmonary host defenses are compromised in lungs from animals with CF, as manifested by increased susceptibility to bacterial infection and lung injury. This murine model of chronic pneumonia thus reflects, in part, the situation in human patients and may help elucidate the mechanisms leading to defective host defense in CF.
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Affiliation(s)
- U Sajjan
- Research Institute, The Hospital for Sick Children, Toronto, Ontario M5G 1X8
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Jones AM, Dodd ME, Webb AK. Burkholderia cepacia: current clinical issues, environmental controversies and ethical dilemmas. Eur Respir J 2001; 17:295-301. [PMID: 11334134 DOI: 10.1183/09031936.01.17202950] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Burkholderia cepacia is a plant phytogen and is known as a hardy and versatile organism. Over the past two decades it has emerged as a pathogen in the cystic fibrosis (CF) community, with devastating effects. Pulmonary colonisation can lead to an accelerated decline in lung function. In some cases, it causes a rapid and progressive pneumonic illness termed "cepacia syndrome", which is untreatable and fatal. B. cepacia is inherently resistant to multiple antibiotics and highly transmissible and virulent strains have been identified. CF patients colonised with the organism have to be segregated from their peers to try to prevent cross-infection. However, the pathogenicity of B. cepacia is not limited to CF. Other groups, such as individuals with chronic granulomatous disease and immunocompromised patients are vulnerable and it has caused disease in healthy individuals. However, the agricultural and petrochemical industries are attempting to exploit properties of B. cepacia for use as a biopesticide and biodegradation agent. This article provides an up to date review of clinically based literature on the Burkholderia cepacia complex, highlighting clinical management issues for both cystic fibrosis and non-cystic fibrosis patients. The article also addresses the potential conflict between medicine and agriculture on plans to reintroduce strains of Burkholderia cepacia back into the environment.
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Affiliation(s)
- A M Jones
- Manchester Adult Cystic Fibrosis Unit, Wythenshawe Hospital, UK
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McCloskey M, McCaughan J, Redmond AO, Elborn JS. Clinical outcome after acquisition of Burkholderia cepacia in patients with cystic fibrosis. Ir J Med Sci 2001; 170:28-31. [PMID: 11440408 DOI: 10.1007/bf03167716] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Respiratory disease is the major cause of morbidity and mortality in cystic fibrosis (CF). The significance of Burkholderia cepacia (B. cepacia) in the pathogenesis of lung disease in CF is debated, but its exact role remains unclear. AIM To assess the impact of respiratory tract colonisation with B. cepacia in patients with CF by measuring changes in pulmonary function and body mass index (BMI). METHODS Three groups of patients were defined based on sputum culture isolates: Group 1 were B. cepacia and Pseudomonas aeruginosa (P. aeruginosa) positive patients; Group 2 were P. aeruginosa positive; and Group 3 were colonised with neither organism. Forced expiratory volume (FEV) and BMI were measured annually from 1987 to 1995 and the year of acquisition of P. aeruginosa or B. cepacia was recorded. RESULTS The mean annual decrease in FEV1 was significantly different in all three groups: Group 1, -5.4 (5.1)%; Group 2, -3.9 (6.5)%; and Group 3, -1.6 (1.0)%, (p<0.05). The mean percentage decrease in FEV1 of a sub-group of Group 1 patients where the B. cepacia acquisition date was known was 6.1% per year versus 1.55% in Group 2 patients (p<0.05). CONCLUSIONS Acquisition of B. cepacia may be a cause of, rather than a marker for, a decrease in pulmonary function.
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Affiliation(s)
- M McCloskey
- Adult Cystic Fibrosis Unit, Belfast City Hospital, Northern Ireland
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Banerjee D, Stableforth D. The treatment of respiratory pseudomonas infection in cystic fibrosis: what drug and which way? Drugs 2000; 60:1053-64. [PMID: 11129122 DOI: 10.2165/00003495-200060050-00006] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Pseudomonas aeruginosa is a non-capsulate and non-sporing gram-negative bacillus that most commonly affects the lower respiratory system in humans. Burkholderia (previously Pseudomonas) cepacia has emerged as an important respiratory pathogen in patients with cystic fibrosis (CF). The ability of P. aeruginosa to persist and multiply in moist environments and equipment, such as humidifiers in hospital wards, bathrooms, sinks and kitchens, maybe of importance in cross-infection. P. aeruginosa infections of the lower respiratory tract can range in severity from colonisation (without an immunological response) to a severe necrotising bronchopneumonia. Infection is seen in patients with CF and other chronic lung diseases such as non-CF bronchiectasis. In patients with CF, once P. aeruginosa is established in the airways it is almost impossible to eradicate, but prior to this, aggressive treatment can delay the development of chronic infection. 30 to 40% of the present paediatric population with CF will have chronic pseudomonal infection. B. cepacia has a particular predisposition to infect patients with CF and may be distinguished from P. aeruginosa by accelerated lung disease in about one- third of patients. Overwhelming septicaemia and necrotising pneumonia are well described (cepacia syndrome); events that are rare with P. aeruginosa. With the propensity for social cross-infection, segregation policies have been accepted as means of controlling outbreaks. A number of antipseudomonal agents are available. The most commonly used are the extended-spectrum penicillins, aminoglycosides, cephalosporins, fluoroquinolones, polymixins and the monobactams. An aminoglycoside with a beta-lactam penicillin is usually considered to be the first line treatment. No trial has shown any significant clinical advantage of any particular combination regimen over another. The emergence of resistance continues to be a concern. Pipericillin, piperacillin/tazobactam and meropenem have good but equivalent antibacterial activity against P. aeruginosa. However, B. cepacia is characterised by in vitro resistance to colistin (colomycin), aminoglycosides and ciprofloxacin but better susceptibility to ceftazidime. Nebulised delivery of antipseudomonal antibiotics is thought to prevent recurrent exacerbations, reduce antibiotic usage and maintain lung function, particularly in patients with CF. Colistin, tobramycin and gentamicin are currently the most commonly prescribed nebulised antibiotics. Much effort is directed at treating chronic P. aeruginosa infection but as chronic infection is seldom if ever eradicated when first established, prevention is preferable. Early intensive treatment for P. aeruginosa infection is advocated in order to maintain pulmonary function and postpone the onset of chronic P. aeruginosa infection.
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Affiliation(s)
- D Banerjee
- Department of Respiratory Medicine, Birmingham Heartlands Hospital, Bordesley Green East, England
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Beringer PM, Appleman MD. Unusual respiratory bacterial flora in cystic fibrosis: microbiologic and clinical features. Curr Opin Pulm Med 2000; 6:545-50. [PMID: 11100967 DOI: 10.1097/00063198-200011000-00015] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pulmonary infections continue to be a significant source of morbidity and mortality among patients with cystic fibrosis. Although our understanding of the pathogenesis and clinical consequences of pulmonary infections with Pseudomonas aeruginosa has increased greatly in recent years, very little is known about potentially emerging pathogens such as Burkholderia cepacia complex, Stenotrophomonas maltophilia, Alcaligenes xylosoxidans, and methicillin-resistant Staphylococcus aureus. In this review, the authors discuss methods for appropriate identification of these "unusual" organisms and their epidemiologic and clinical features. Multicenter surveillance studies are needed to more clearly establish the pathogenicity of these organisms.
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Affiliation(s)
- P M Beringer
- Department of Pharmacy, School of Pharmacy, University of Southern California, Los Angeles, USA.
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Hendry J, Nixon L, Dodd M, Elborn JS, Govan J, Shale DJ, Webb AK. Pulmonary function, serum markers of inflammation, and IgG antibodies to core lipopolysaccharide of Burkholderia cepacia in adults with cystic fibrosis, following colonization with Burkholderia cepacia. Pediatr Pulmonol 2000; 29:8-10. [PMID: 10613780 DOI: 10.1002/(sici)1099-0496(200001)29:1<8::aid-ppul2>3.0.co;2-s] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Eight patients with cystic fibrosis [CF] colonized with Pseudomonas aeruginosa (P. aeruginosa) had serial lung function, peripheral blood inflammatory markers, and serum IgG antibodies to Burkholderia cepacia (B. cepacia) lipopolysaccharide measured in the months preceding and following colonisation with B. cepacia. One patient experienced a fall in FEV(1) from 33% to 19% of predicted values, coinciding with the first sputum isolation of B. cepacia, and he died 12 weeks later. He had a rise in inflammatory markers preterminally, and this change was refractory to antibiotic therapy. There was no significant fall in FEV(1) % of predicted values in the remaining seven patients, and no significant changes in their serum markers of inflammation following colonization with B. cepacia over a median (range) period of 10.9 (7.3-12.0) months.
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Affiliation(s)
- J Hendry
- Bradbury Cystic Fibrosis Unit, Wythenshawe Hospital, Manchester, UK.
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Frangolias DD, Mahenthiralingam E, Rae S, Raboud JM, Davidson AG, Wittmann R, Wilcox PG. Burkholderia cepacia in cystic fibrosis. Variable disease course. Am J Respir Crit Care Med 1999; 160:1572-7. [PMID: 10556123 DOI: 10.1164/ajrccm.160.5.9805046] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Variable clinical course has been reported with the acquisition of Burkholderia cepacia in patients who have cystic fibrosis (CF). We hypothesized that the perceived worsening with B. cepacia may reflect the underlying severity of pulmonary disease at the time of acquisition. To test this hypothesis, we matched CF patients colonized with B. cepacia with CF patients not colonized with the organism. Two-year pre- and postacquisition data and long-term data were compared. Patients were matched for gender, age (+/- 1 yr), height (+/- 5 cm), weight (+/- 8 kg), percent predicted forced expiratory volume in one second (% pred FEV(1)) (+/- 10%), and pancreatic sufficiency status. Differences in rates of change pre- and postacquisition for FEV(1), FVC, weight, and frequency of intravenous courses were compared within pairs with the Wilcoxon signed rank test. Two-year and long-term survival was compared within pairs with the McNemar test. No significant differences were observed in mean annual rates of change in weight (0.33 and -0.28 kg/yr), % pred FEV(1) (-0.36 and -1.74%/yr), and percent predicted forced vital capacity (% pred FVC) (-3.80 and -2.32%/yr) between B. cepacia and control pairs in 2-yr and long-term postacquisition interval, respectively. Similar rates of change were noted for pre- to postacquisition intervals within pairs for weight (0.17 kg/yr), % pred FEV(1) (-0.16%/yr), % pred FVC (5.02 %/yr). There was a significantly higher rate of intravenous antibiotic courses in B. cepacia cases in the 2-yr and long-term postacquisition interval. Higher mortality was observed in the B. cepacia cases in the long term (p < 0.05). We conclude that colonization with B. cepacia does not necessarily adversely affect pulmonary status, but is associated with reduced long term survival. Whereas previous associations may be attributed to a propensity to colonize those who had more advanced disease, specific strain types of B. cepacia may have enhanced pathogenicity.
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Affiliation(s)
- D D Frangolias
- Pulmonary Research Laboratory, Division of Infectious and Immunological Diseases, Department of Pediatrics, Canadian HIV Trials Network, British Columbia, Vancouver
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Shreve MR, Butler S, Kaplowitz HJ, Rabin HR, Stokes D, Light M, Regelmann WE. Impact of microbiology practice on cumulative prevalence of respiratory tract bacteria in patients with cystic fibrosis. J Clin Microbiol 1999; 37:753-7. [PMID: 9986845 PMCID: PMC84543 DOI: 10.1128/jcm.37.3.753-757.1999] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Investigators participating in the Epidemiologic Study of Cystic Fibrosis project began to collect microbiological, pulmonary, and nutritional data on cystic fibrosis (CF) patients at 180 North American sites in 1994. Part of this study was a survey undertaken in August 1995 to determine microbiology laboratory practices with regard to pulmonary specimens from CF patients. The survey included a section on test ordering, completed by a site clinician, and a section on test performance and reporting, completed by each site's clinical microbiology laboratory staff. Seventy-nine percent of the surveys were returned. There was intersite consistency of microbiology laboratory practices in most cases. The majority of sites follow most of the CF Foundation consensus conference recommendations. There were differences in the frequency at which specimens for culture were obtained, in the use of selective media for Staphylococcus aureus and Haemophilus influenzae, and in the use of a prolonged incubation for Burkholderia cepacia. These variations in practice contribute to prevalence differences among sites and may result in differences in clinical care.
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Affiliation(s)
- M R Shreve
- University of Minnesota School of Medicine, Minneapolis, Minnesota, USA.
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Affiliation(s)
- A E Frost
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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