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Southern KW, Solis-Moya A, Kurz D, Smith S. Macrolide antibiotics (including azithromycin) for cystic fibrosis. Cochrane Database Syst Rev 2024; 2:CD002203. [PMID: 38411248 PMCID: PMC10897949 DOI: 10.1002/14651858.cd002203.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Cystic fibrosis (CF) is a life-limiting genetic condition, affecting over 90,000 people worldwide. CF affects several organs in the body, but airway damage has the most profound impact on quality of life (QoL) and survival. Causes of lower airway infection in people with CF are, most notably, Staphylococcus aureus in the early course of the disease and Pseudomonas aeruginosa at a later stage. Macrolide antibiotics, e.g. azithromycin and clarithromycin, are usually taken orally, have a broad spectrum of action against gram-positive (e.g. S aureus) and some gram-negative bacteria (e.g. Haemophilus influenzae), and may have a modifying role in diseases involving airway infection and inflammation such as CF. They are well-tolerated and relatively inexpensive, but widespread use has resulted in the emergence of resistant bacteria. This is an updated review. OBJECTIVES To assess the potential effects of macrolide antibiotics on clinical status in terms of benefit and harm in people with CF. If benefit was demonstrated, we aimed to assess the optimal type, dose and duration of macrolide therapy. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals, and abstract books of conference proceedings. We last searched the Group's Cystic Fibrosis Trials Register on 2 November 2022. We last searched the trial registries WHO ICTRP and clinicaltrials.gov on 9 November 2022. We contacted investigators known to work in the field, previous authors and pharmaceutical companies manufacturing macrolide antibiotics for unpublished or follow-up data, where possible. SELECTION CRITERIA We included randomised controlled trials of macrolide antibiotics in adults and children with CF. We compared them to: placebo; another class of antibiotic; another macrolide antibiotic; or the same macrolide antibiotic at a different dose or type of administration. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed risk of bias. We assessed the certainty of evidence using GRADE. MAIN RESULTS We included 14 studies (1467 participants) lasting 28 days to 36 months. All the studies assessed azithromycin: 11 compared oral azithromycin to placebo (1167 participants); one compared a high dose to a low dose (47 participants); one compared nebulised to oral azithromycin (45 participants); and one looked at weekly versus daily dose (208 participants). Oral azithromycin versus placebo There is a slight improvement in forced expiratory volume (FEV1 % predicted) in one second in the azithromycin group at up to six months compared to placebo (mean difference (MD) 3.97, 95% confidence interval (CI) 1.74 to 6.19; high-certainty evidence), although there is probably no difference at three months, (MD 2.70%, 95% CI -0.12 to 5.52), or 12 months (MD -0.13, 95% CI -4.96 to 4.70). Participants in the azithromycin group are probably at a decreased risk of pulmonary exacerbation with a longer time to exacerbation (hazard ratio (HR) 0.61, 95% CI 0.50 to 0.75; moderate-certainty evidence). Mild side effects were common, but there was no difference between groups (moderate-certainty evidence). There is no difference in hospital admissions at six months (odds ratio (OR) 0.61, 95% CI 0.36 to 1.04; high-certainty evidence), or in new acquisition of P aeruginosa at 12 months (HR 1.00, 95% CI 0.64 to 1.55; moderate-certainty evidence). High-dose versus low-dose azithromycin We are uncertain whether there is any difference in FEV1 % predicted at six months between the two groups (no data available) or in the rate of exacerbations per child per month (MD -0.05 (95% CI -0.20 to 0.10)); very low-certainty evidence for both outcomes. Only children were included in the study and the study did not report on any of our other clinically important outcomes. Nebulised azithromycin versus oral azithromycin We were unable to include any of the data into our analyses and have reported findings directly from the paper; we graded all evidence as being of very low certainty. The authors reported that there was a greater mean change in FEV1 % predicted at one month in the nebulised azithromycin group (P < 0.001). We are uncertain whether there was a change in P aeruginosa count. Weekly azithromycin versus daily azithromycin There is probably a lower mean change in FEV1 % predicted at six months in the weekly group compared to the daily group (MD -0.70, 95% CI -0.95 to -0.45) and probably also a longer period of time until first exacerbation in the weekly group (MD 17.30 days, 95% CI 4.32 days to 30.28 days). Gastrointestinal side effects are probably more common in the weekly group and there is likely no difference in admissions to hospital or QoL. We graded all evidence as moderate certainty. AUTHORS' CONCLUSIONS Azithromycin therapy is associated with a small but consistent improvement in respiratory function, a decreased risk of exacerbation and longer time to exacerbation at six months; but evidence for treatment efficacy beyond six months remains limited. Azithromycin appears to have a good safety profile (although a weekly dose was associated with more gastrointestinal side effects, which makes it less acceptable for long-term therapy), with a relatively minimal treatment burden for people with CF, and it is inexpensive. A wider concern may be the emergence of macrolide resistance reported in the most recent study which, combined with the lack of long-term data, means we do not feel that the current evidence is strong enough to support azithromycin therapy for all people with CF. Future research should report over longer time frames using validated tools and consistent reporting, to allow for easier synthesis of data. In particular, future trials should report important adverse events such as hearing impairment or liver disease. More data on the effects of azithromycin given in different ways and reporting on our primary outcomes would benefit decision-making on whether and how to give macrolide antibiotics. Finally, it is important to assess azithromycin therapy for people with CF who are established on the relatively new cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies which correct the underlying molecular defect associated with CF (none of the trials included in the review are relevant to this population).
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Affiliation(s)
- Kevin W Southern
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Arturo Solis-Moya
- Servicio de Neumología, Hospital Nacional de Niños, San José, Costa Rica
| | | | - Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
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Fawcett LK, Wakefield CE, Sivam S, Middleton PG, Wark P, Widger J, Jaffe A, Waters SA. Avatar acceptability: views from the Australian Cystic Fibrosis community on the use of personalised organoid technology to guide treatment decisions. ERJ Open Res 2021; 7:00448-2020. [PMID: 33532470 PMCID: PMC7836586 DOI: 10.1183/23120541.00448-2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/18/2020] [Indexed: 12/22/2022] Open
Abstract
Background Patient-oriented research approaches that reflect the needs and priorities of those most affected by health research outcomes improves translation of research findings into practice. Targeted therapies for cystic fibrosis (CF) are now a viable treatment option for some eligible individuals despite the heterogeneous patient-specific therapeutic response. This has necessitated development of a clinical tool that predicts treatment response for individual patients. Patient-derived mini-organs (organoids) have been at the forefront of this development. However, little is known about their acceptability in CF patients and members of the public. Methods We used a cross-sectional observational design to conduct an online survey in people with CF, their carers and community comparisons. Acceptability was examined in five domains: 1) willingness to use organoids, 2) perceived advantages and disadvantages of organoids, 3) acceptable out-of-pocket costs, 4) turnaround time and 5) source of tissue. Results In total, 188 participants completed the questionnaire, including adults with CF and parents of children with CF (90 (48%)), and adults without CF and parents of children without CF (98 (52%)). Use of organoids to guide treatment decisions in CF was acceptable to 86 (95%) CF participants and 98 (100%) community participants. The most important advantage was that organoids may improve treatment selection, improving the patient's quality of life and life expectancy. The most important disadvantage was that the organoid recommended treatment might be unavailable or too expensive. Conclusions These findings indicate acceptance of patient-derived organoids as a tool to predict treatment response by the majority of people surveyed. This may indicate successful future implementation into healthcare systems. The perspective regarding clinical use of patient-derived organoid models to enable cystic fibrosis personalised therapeutic decision-making of 188 participating adults surveyedhttps://bit.ly/30nWDJ7
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Affiliation(s)
- Laura K Fawcett
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Molecular and Integrative Cystic Fibrosis Research Centre, University of New South Wales, Sydney and Sydney Children's Hospital, Sydney, NSW, Australia.,Dept of Respiratory Medicine, Sydney Children's Hospital, Sydney, NSW, Australia
| | - Claire E Wakefield
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Kids Cancer Centre, Sydney Children's Hospital, Sydney, NSW, Australia
| | - Sheila Sivam
- Dept of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Peter G Middleton
- Cystic Fibrosis Unit, Dept of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, NSW, Australia
| | - Peter Wark
- Centre for Healthy Lungs, University of Newcastle, Newcastle, NSW, Australia
| | - John Widger
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Molecular and Integrative Cystic Fibrosis Research Centre, University of New South Wales, Sydney and Sydney Children's Hospital, Sydney, NSW, Australia.,Dept of Respiratory Medicine, Sydney Children's Hospital, Sydney, NSW, Australia
| | - Adam Jaffe
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Molecular and Integrative Cystic Fibrosis Research Centre, University of New South Wales, Sydney and Sydney Children's Hospital, Sydney, NSW, Australia.,Dept of Respiratory Medicine, Sydney Children's Hospital, Sydney, NSW, Australia
| | - Shafagh A Waters
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Molecular and Integrative Cystic Fibrosis Research Centre, University of New South Wales, Sydney and Sydney Children's Hospital, Sydney, NSW, Australia.,Dept of Respiratory Medicine, Sydney Children's Hospital, Sydney, NSW, Australia
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Reynaud Q, Bricca R, Cavalli Z, Nove-Josserand R, Durupt S, Reix P, Burgel PR, Durieu I. Risk factors for nontuberculous mycobacterial isolation in patients with cystic fibrosis: A meta-analysis. Pediatr Pulmonol 2020; 55:2653-2661. [PMID: 32603551 DOI: 10.1002/ppul.24913] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND To better understand the mechanisms of infection with nontuberculous mycobacteria (NTM) in patients with cystic fibrosis (CF), we explore different risk factors associated with NTM positivity in a meta-analysis. METHODS Studies published before 31 July 2019 were selected from MEDLINE. Combined odds ratios (ORs) were calculated by pooling the ORs of each study. The weighted mean difference (WMD) was used for continuous numerical measurements. Summary data were pooled using fixed- or random-effects models according to the presence of heterogeneity (P < .1 or I2 > 50%). RESULTS Nineteen studies with a total of 23 418 patients, of whom 1421 (6%) were diagnosed as NTM positive, were included. Older age was significantly associated with NTM positivity (WMD = 2.12, 95% confidence interval [CI]: 1.11-3.13; P < .01, fixed-effects model). The OR for Staphylococcus aureus colonization was 1.66 (95% CI: 1.21-2.26; P = .001) in 11 studies (8091 patients), the OR for Aspergillus fumigatus colonization was 3.59 (95% CI: 3.05-4.23; P < .001) in 11 studies (20 480 patients), and the OR for Stenotrophomonas maltophilia colonization was 3.41 (95% CI: 2.66-4.39; P < .01) in seven studies (14 935 patients). Oral corticosteroids were significantly associated with NTM positivity (OR = 1.98, 95% CI: 1.24-3.16; P < .01, 6 studies, 1936 patients). No other factor showed a significant association. CONCLUSION Older age, S. aureus, S. maltophilia, and A. fumigatus chronic colonization, and oral corticosteroids were significantly associated with an increased risk of NTM positivity. CF patients with more severe conditions should be closely monitored for NTM.
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Affiliation(s)
- Quitterie Reynaud
- Centre de ressources et de compétences pour la mucoviscidose adulte, Service de médecine interne et vasculaire, Hospices Civils de Lyon, Lyon, France.,EA HESPER 7425, Université Claude Bernard Lyon 1, Lyon, France
| | - Romain Bricca
- Centre de ressources et de compétences pour la mucoviscidose adulte, Service de médecine interne et vasculaire, Hospices Civils de Lyon, Lyon, France
| | - Zoe Cavalli
- Centre de ressources et de compétences pour la mucoviscidose adulte, Service de médecine interne et vasculaire, Hospices Civils de Lyon, Lyon, France
| | - Raphaële Nove-Josserand
- Centre de ressources et de compétences pour la mucoviscidose adulte, Service de médecine interne et vasculaire, Hospices Civils de Lyon, Lyon, France
| | - Stéphane Durupt
- Centre de ressources et de compétences pour la mucoviscidose adulte, Service de médecine interne et vasculaire, Hospices Civils de Lyon, Lyon, France
| | - Philippe Reix
- UMR CNRS 5558, Equipe Evaluation et Modélisation des Effets Thérapeutiques, Laboratoire de Biométrie et Biologie Evolutive, Université de Lyon, Lyon, France.,Centre de ressources et de compétences pour la mucoviscidose pédiatrique, Service de pneumologie pédiatrique, Hospices Civils de Lyon, Lyon, France
| | - Pierre Régis Burgel
- Centre de Référence Maladies Rares Mucoviscidose de l'adulte. Site Coordonnateur National, Hôpital Cochin, APHP, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Isabelle Durieu
- Centre de ressources et de compétences pour la mucoviscidose adulte, Service de médecine interne et vasculaire, Hospices Civils de Lyon, Lyon, France.,EA HESPER 7425, Université Claude Bernard Lyon 1, Lyon, France
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4
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Zemanick ET, Polineni D. Unraveling the CFTR Function–Phenotype Connection for Precision Treatment in Cystic Fibrosis. Am J Respir Crit Care Med 2019; 199:1053-1054. [PMID: 30939246 PMCID: PMC6515879 DOI: 10.1164/rccm.201903-0696ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Edith T. Zemanick
- Department of PediatricsUniversity of Colorado Anschutz Medical CampusAurora, Coloradoand
| | - Deepika Polineni
- Department of Internal MedicineUniversity of Kansas School of MedicineKansas City, Kansas
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Abstract
Human deoxyribonuclease I (DNase I) is an endonuclease that catalyzes the hydrolysis of extracellular DNA and is just one of the numerous types of nucleases found in nature. The enzymatic mechanism for a single turnover is reasonably well understood based on biochemical and structural studies that are consistent with divalent metal ion dependent nonspecific nicking of a phosphodiester bond in one of the strands of double stranded DNA. Recombinant human DNase I (rhDNase I, rhDNase, Pulmozyme®, dornase alfa) has been expressed in mammalian cell culture in Chinese hamster ovary cells and developed clinically where it is aerosolized into the airways for treatment of pulmonary disease in patients with cystic fibrosis (CF). rhDNase I hydrolyzes the DNA in purulent sputum of CF patients and reduces sputum viscoelasticity. Reduction of high molecular weight DNA into smaller fragments by treatment with aerosolized rhDNase I has been proposed as the mechanism to reduce the mucus viscosity and improve mucus clearability from obstructed airways in patients. The improved clearance of the purulent mucus enhances pulmonary function and reduces recurrent exacerbations of respiratory symptoms. rhDNase I was approved for clinical use in 1993 and has been widely used as a safe and effective therapy for CF patients. The use of rhDNase I has also been investigated in other diseases where exogenous DNA has been implicated in the disease pathology.
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Bosch B, Bilton D, Sosnay P, Raraigh KS, Mak DYF, Ishiguro H, Gulmans V, Thomas M, Cuppens H, Amaral M, De Boeck K. Ethnicity impacts the cystic fibrosis diagnosis: A note of caution. J Cyst Fibros 2017; 16:488-491. [PMID: 28233695 DOI: 10.1016/j.jcf.2017.01.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 01/27/2017] [Accepted: 01/28/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The diagnosis of Cystic Fibrosis (CF) is by consensus based on the same parameters in all patients, yet the influence of ethnicity has only scarcely been studied. We aimed at elucidating the impact of Asian descent on the diagnosis of CF. METHODS We performed a retrospective analysis of the CFTR2 and UK CF databases for clinical phenotype, sweat chloride values and CFTR mutations and compared the diagnostic characteristics of Asian to non-Asian patients with CF. RESULTS Asian patients with CF do not have a worse clinical phenotype. The repeatedly reported lower FEV1 of Asian patients with CF is attributable to the influence of ethnicity on lung function in general. However, pancreatic sufficiency is more common in Asian patients with CF. The diagnosis of CF in people with Asian ancestry is heterogeneous as mean sweat chloride values are lower (92±26 versus 99±22mmol/L in controls) and 14% have sweat chloride values below 60mmol/L (versus 6% in non-Asians). Also, CFTR mutations differ from those in Caucasians: 55% of British Asian patients with CF do not have one mutation included in the routine newborn screening panel. CONCLUSIONS Bringing together the largest cohort of patients with CF and Asian ethnicity, we demonstrate that Asian roots impact on all three CF diagnostic pillars. These findings have implications for clinical practice in the increasingly ethnically diverse Western population.
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Affiliation(s)
- Barbara Bosch
- Pediatric Pulmonology, University Hospitals Leuven, Leuven, Belgium; Organ Systems, KU Leuven, Leuven, Belgium.
| | - Diana Bilton
- NIHR Specialist Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London, UK
| | - Patrick Sosnay
- Pulmonary & Critical Care Medicine, Johns Hopkins University, Baltimore, USA; McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, USA
| | - Karen S Raraigh
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, USA
| | | | - Hiroshi Ishiguro
- Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Vincent Gulmans
- Research Department, Dutch Cystic Fibrosis Foundation, Baarn, The Netherlands
| | - Muriel Thomas
- Belgium Cystic Fibrosis Registry (BMR-RBM), Scientific Institute of Public Health (WIV-ISP), Brussels, Belgium
| | - Harry Cuppens
- Pediatric Pulmonology, University Hospitals Leuven, Leuven, Belgium
| | - Margarida Amaral
- University of Lisboa, Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, Lisboa, Portugal
| | - Kris De Boeck
- Pediatric Pulmonology, University Hospitals Leuven, Leuven, Belgium
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Rowe SM. A little CFTR can change a lot: slowing cystic fibrosis progression. THE LANCET RESPIRATORY MEDICINE 2017; 5:86-87. [DOI: 10.1016/s2213-2600(16)30465-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 12/06/2016] [Indexed: 11/16/2022]
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Abstract
BACKGROUND Pseudomonas aeruginosa is the most common bacterial pathogen causing lung infections in people with cystic fibrosis and appropriate antibiotic therapy is vital. Antibiotics for pulmonary exacerbations are usually given intravenously, and for long-term treatment, via a nebuliser. Oral anti-pseudomonal antibiotics with the same efficacy and safety as intravenous or nebulised antibiotics would benefit people with cystic fibrosis due to ease of treatment and avoidance of hospitalisation. This is an update of a previous review. OBJECTIVES To determine the benefit or harm of oral anti-pseudomonal antibiotic therapy for people with cystic fibrosis, colonised with Pseudomonas aeruginosa, in the:1. treatment of a pulmonary exacerbation; and2. long-term treatment of chronic infection. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.We contacted pharmaceutical companies and checked reference lists of identified trials.Date of last search: 08 July 2016. SELECTION CRITERIA Randomised or quasi-randomised controlled trials comparing any dose of oral anti-pseudomonal antibiotics, to other combinations of inhaled, oral or intravenous antibiotics, or to placebo or usual treatment for pulmonary exacerbations and long-term treatment. DATA COLLECTION AND ANALYSIS Two authors independently selected the trials, extracted data and assessed quality. We contacted trial authors to obtain missing information. MAIN RESULTS We included three trials examining pulmonary exacerbations (171 participants) and two trials examining long-term therapy (85 participants). We regarded the most important outcomes as quality of life and lung function. The analysis did not identify any statistically significant difference between oral anti-pseudomonal antibiotics and other treatments for these outcome measures for either pulmonary exacerbations or long-term treatment. One of the included trials reported significantly better lung function when treating a pulmonary exacerbation with ciprofloxacin when compared with intravenous treatment; however, our analysis did not confirm this finding. We found no evidence of difference between oral anti-pseudomonal antibiotics and other treatments regarding adverse events or development of antibiotic resistance, but trials were not adequately powered to detect this. None of the studies had a low risk of bias from blinding which may have an impact particularly on subjective outcomes such as quality of life. The risk of bias for other criteria could not be clearly stated across the studies. AUTHORS' CONCLUSIONS We found no conclusive evidence that an oral anti-pseudomonal antibiotic regimen is more or less effective than an alternative treatment for either pulmonary exacerbations or long-term treatment of chronic infection with P. aeruginosa. Until results of adequately-powered future trials are available, treatment needs to be selected on a pragmatic basis, based upon any available non-randomised evidence, the clinical circumstances of the individual, the known effectiveness of drugs against local strains and upon individual preference.
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Affiliation(s)
- Tracey Remmington
- University of LiverpoolDepartment of Women's and Children's HealthAlder Hey Children's NHS Foundation TrustEaton RoadLiverpoolUKL12 2AP
| | - Nikki Jahnke
- University of LiverpoolDepartment of Women's and Children's HealthAlder Hey Children's NHS Foundation TrustEaton RoadLiverpoolUKL12 2AP
| | - Christian Harkensee
- Newcastle General HospitalPaediatricsWestgate RoadNewcastle upon TyneTyne and WearUK
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Cousin M, Molinari N, Foulongne V, Caimmi D, Vachier I, Abely M, Chiron R. Rhinovirus-associated pulmonary exacerbations show a lack of FEV1 improvement in children with cystic fibrosis. Influenza Other Respir Viruses 2016; 10:109-12. [PMID: 26493783 PMCID: PMC4746558 DOI: 10.1111/irv.12353] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Respiratory viral infections lead to bronchial inflammation in patients with cystic fibrosis, especially during pulmonary exacerbations. The aim of this study was to determine the impact of viral-associated pulmonary exacerbations in children with cystic fibrosis and failure to improve forced expiratory volume in 1 s (FEV1 ) after an appropriate treatment. METHODS We lead a pilot study from January 2009 until March 2013. Children with a diagnosis of cystic fibrosis were longitudinally evaluated three times: at baseline (Visit 1), at the diagnosis of pulmonary exacerbation (Visit 2), and after exacerbation treatment (Visit 3). Nasal and bronchial samples were analyzed at each visit with multiplex viral respiratory PCR panel (qualitative detection of 16 viruses). Pulmonary function tests were recorded at each visit, in order to highlight a possible failure to improve them after treatment. Lack of improvement was defined by an increase in FEV1 less than 5% between Visit 2 and Visit 3. RESULTS Eighteen children were analyzed in the study. 10 patients failed to improve by more than 5% their FEV1 between Visit 2 and Visit 3. Rhinovirus infection at Visit 2 or Visit 3 was the only risk factor significantly associated with such a failure (OR, 12; 95% CI, 1·3-111·3), P = 0·03. CONCLUSIONS Rhinovirus infection seems to play a role in the FEV1 recovery after pulmonary exacerbation treatment in children with cystic fibrosis. Such an association needs to be confirmed by a large-scale study because this finding may have important implications for pulmonary exacerbation management.
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Affiliation(s)
- Mathias Cousin
- Centre de Ressources et de Compétences pour la Mucoviscidose, Hôpital Arnaud de Villeneuve, Centre Hospitalier Régional Universitaire de Montpellier, Montpellier, France.,Centre Hospitalier Régional Universitaire de Montpellier, Université de Montpellier, Montpellier, France
| | - Nicolas Molinari
- Centre Hospitalier Régional Universitaire de Montpellier, Université de Montpellier, Montpellier, France.,Département de Statistiques, U1046 INSERM, UMR9214 CNRS, Centre Hospitalier Régional Universitaire de Montpellier, Montpellier, France
| | - Vincent Foulongne
- Centre Hospitalier Régional Universitaire de Montpellier, Université de Montpellier, Montpellier, France.,Laboratoire de virologie, Centre Hospitalier Régional Universitaire de Montpellier, Montpellier, France.,INSERM, U1058, Centre Hospitalier Régional Universitaire de Montpellier, Montpellier, France
| | - Davide Caimmi
- Centre de Ressources et de Compétences pour la Mucoviscidose, Hôpital Arnaud de Villeneuve, Centre Hospitalier Régional Universitaire de Montpellier, Montpellier, France
| | - Isabelle Vachier
- Centre de Ressources et de Compétences pour la Mucoviscidose, Hôpital Arnaud de Villeneuve, Centre Hospitalier Régional Universitaire de Montpellier, Montpellier, France
| | - Michel Abely
- Centre de Ressources et de Compétences pour la Mucoviscidose, American Memorial Hospital, Reims Cedex, France
| | - Raphael Chiron
- Centre de Ressources et de Compétences pour la Mucoviscidose, Hôpital Arnaud de Villeneuve, Centre Hospitalier Régional Universitaire de Montpellier, Montpellier, France
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Chopra R, Paul L, Manickam R, Aronow WS, Maguire GP. Efficacy and adverse effects of drugs used to treat adult cystic fibrosis. Expert Opin Drug Saf 2015; 14:401-11. [PMID: 25604518 DOI: 10.1517/14740338.2015.994503] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Cystic fibrosis (CF) is an autosomal recessive disease and is the most commonly seen monogenetic disease in Caucasians. The disease has various manifestations resulting from the abnormal thick secretions, most common being chronic lung infection and airway obstruction. Many new promising drugs have appeared on the horizon over the years. This review here is an attempt to bring together the various treatments being used to prolong and enhance the quality of life of CF patients. AREAS COVERED A literature review of published as well as ongoing clinical trials, meta-analysis and systematic reviews regarding the drugs used in CF management was carried out using PubMed and Ovid databases. EXPERT OPINION New concepts have been formed and some positive results in this direction have already led to the approval of cystic fibrosis transmembrane conductance regulator potentiator drug. Gene therapy and stem cell therapy are under development. The current therapies such as dornase alfa and pancreatic enzymes targeting the symptoms continue to evolve as they play an important complementary role. Development of new simple and cost-effective markers, which help assess the efficacy and safety of these constantly emerging new drugs, is also being investigated.
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Affiliation(s)
- Ravi Chopra
- New York Medical College/Westchester Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine , 100 Woods Road, Valhalla, NY 10595 , USA +1 914 493 7518 ; +1 914 493 8130 ;
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11
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Azithromycin may antagonize inhaled tobramycin when targeting Pseudomonas aeruginosa in cystic fibrosis. Ann Am Thorac Soc 2014; 11:342-50. [PMID: 24476418 DOI: 10.1513/annalsats.201310-352oc] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Recent studies of inhaled tobramycin in subjects with cystic fibrosis (CF) find less clinical improvement than previously observed. Nonhuman data suggest that in some strains of Pseudomonas aeruginosa, azithromycin can antagonize tobramycin. OBJECTIVES We tested the hypothesis that concomitant azithromycin use correlates with less improvement in key outcome measures in subjects receiving inhaled tobramycin while not affecting those receiving a comparative, nonaminoglycoside inhaled antibiotic. METHODS We studied a cohort of 263 subjects with CF enrolled in a recent clinical trial comparing inhaled tobramycin with aztreonam lysine. We performed a secondary analysis to examine key clinical and microbiologic outcomes based on concomitant, chronic azithromycin use at enrollment. MEASUREMENTS AND MAIN RESULTS The cohort randomized to inhaled tobramycin and reporting azithromycin use showed a significant decrease in the percent predicted FEV1 after one and three courses of inhaled tobramycin when compared with those not reporting azithromycin use (28 d: -0.51 vs. 3.43%, P < 0.01; 140 d: -1.87 vs. 6.07%, P < 0.01). Combined azithromycin and inhaled tobramycin use was also associated with earlier need for additional antibiotics, lesser improvement in disease-related quality of life, and a trend toward less reduction in sputum P. aeruginosa density. Subjects randomized to inhaled aztreonam lysine had significantly greater improvement in these outcome measures, which were unaffected by concomitant azithromycin use. Outcomes in those not using azithromycin who received inhaled tobramycin were not significantly different from subjects receiving aztreonam lysine. Azithromycin also antagonized tobramycin but not aztreonam lysine in 40% of P. aeruginosa clinical isolates tested in vitro. CONCLUSIONS Oral azithromycin may antagonize the therapeutic benefits of inhaled tobramycin in subjects with CF with P. aeruginosa airway infection.
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Haworth CS, Bilton D, Elborn JS. Long-term macrolide maintenance therapy in non-CF bronchiectasis: evidence and questions. Respir Med 2014; 108:1397-408. [PMID: 25301290 DOI: 10.1016/j.rmed.2014.09.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 08/19/2014] [Accepted: 09/07/2014] [Indexed: 12/14/2022]
Abstract
Macrolide antibiotics have anti-inflammatory and immunomodulatory properties in addition to antibacterial activity. Until recently, only a small number of studies evaluating macrolides in patients with non-cystic fibrosis (CF) bronchiectasis had been published. These were open-label, uncontrolled, short-duration studies that included small numbers of patients. However, these studies suggested that macrolides can reduce exacerbation frequency, reduce sputum volume, and improve lung function in patients with non-CF bronchiectasis. Three recently published randomised, double-blind, placebo-controlled studies showed that macrolides (azithromycin or erythromycin) taken for between 6 and 12 months led to significant reductions in exacerbation rate and reduced the decline in lung function. In all studies, macrolides were generally well tolerated. The advantages of macrolide maintenance therapy need to be balanced against the risks, which include emergence of bacterial resistance, cardiotoxicity and ototoxicity. In addition, a key need is the consistent definition of endpoints for studies in non-CF bronchiectasis, particularly the definition of exacerbation, to allow systematic data analysis. Existing studies on the use of low-dose macrolides in non-CF bronchiectasis are encouraging, but further studies are needed to define the optimal agent, dose, duration for treatment, and the patients likely to benefit and long-term safety.
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Affiliation(s)
- Charles S Haworth
- Cambridge Centre for Lung Infection, Papworth Hospital, Cambridge, CB23 3RE, UK.
| | - Diana Bilton
- Department of Respiratory Medicine, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
| | - J Stuart Elborn
- Centre for Infection and Immunity, Queen's University of Belfast, 97 Lisburn Road, Belfast, BT9 7BC, Northern Ireland, UK
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Abstract
PURPOSE OF REVIEW Severe asthma is a heterogeneous syndrome, encompassing several distinct clinical phenotypes. Different molecular and cellular pathways or endotypes determine the type of underlying airway inflammation in patients with severe asthma, which can be categorized as eosinophilic asthma (allergic and nonallergic) or noneosinophilic asthma (neutrophilic and paucigranulocytic). In this review, we discuss the potential role of macrolides in the treatment of severe asthma in adults. RECENT FINDINGS Maintenance treatment with low-dose macrolides such as erythromycin and azithromycin provides clinical benefit in several chronic neutrophilic airway diseases, including cystic fibrosis (CF), non-CF bronchiectasis and exacerbation-prone chronic obstructive pulmonary disease. Although several short-term studies of macrolides in mild-to-moderate asthma have failed to improve lung function, the AzIthromycin in Severe Asthma trial has demonstrated a significant reduction in the rate of exacerbations in patients with exacerbation-prone noneosinophilic severe asthma. As chronic macrolide use is associated with the risks of population antimicrobial resistance, this add-on treatment should be restricted to severe asthma patients at greatest unmet need despite optimal asthma management. SUMMARY Further clinical, translational and basic research is needed to better phenotype patients with severe asthma, to determine the risk-benefit ratio of macrolide maintenance treatment in neutrophilic severe asthma and to elucidate the principal mechanisms of action of macrolides.
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Practice Guidelines, Clinical Trials, and Unexpected Results in Cystic Fibrosis. Ann Am Thorac Soc 2014; 11:402-3. [DOI: 10.1513/annalsats.201401-023ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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15
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Corvol H, Taytard J, Thouvenin G, Périsson C, Nathan N, Clement A. [Why use long-term macrolide therapy in pediatric pulmonology?]. Arch Pediatr 2014; 21:314-21. [PMID: 24503457 DOI: 10.1016/j.arcped.2013.12.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 10/31/2013] [Accepted: 12/11/2013] [Indexed: 12/16/2022]
Abstract
Macrolides are well-known antibiotics exerting antimicrobial as well as anti-inflammatory and immunomodulatory effects. Since the observation of a dramatic improvement in lung disease and survival in patients with diffuse panbronchiolitis, macrolides have been used over the long term in several chronic respiratory diseases. This review describes the results of trials that have evaluated long-term macrolides in the treatment of cystic fibrosis, non-cystic fibrosis bronchiectasis, and asthma, particularly focusing on the impact on children. It also provides new insights on the potential effects of macrolides on diffuse parenchymal lung diseases.
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Affiliation(s)
- H Corvol
- Service de pneumologie pédiatrique, hôpital Trousseau, AP-HP, centre de ressources et de compétences pour la mucoviscidose, centre de référence des maladies respiratoires rares, université Pierre-et-Marie-Curie-Paris 6, unité Inserm U938, 26, avenue du Dr-Netter, 75012 Paris, France.
| | - J Taytard
- Service de pneumologie pédiatrique, hôpital Trousseau, AP-HP, centre de ressources et de compétences pour la mucoviscidose, centre de référence des maladies respiratoires rares, université Pierre-et-Marie-Curie-Paris 6, unité Inserm U938, 26, avenue du Dr-Netter, 75012 Paris, France
| | - G Thouvenin
- Service de pneumologie pédiatrique, hôpital Trousseau, AP-HP, centre de ressources et de compétences pour la mucoviscidose, centre de référence des maladies respiratoires rares, université Pierre-et-Marie-Curie-Paris 6, unité Inserm U938, 26, avenue du Dr-Netter, 75012 Paris, France
| | - C Périsson
- Service de pneumologie pédiatrique, hôpital Trousseau, AP-HP, centre de ressources et de compétences pour la mucoviscidose, centre de référence des maladies respiratoires rares, université Pierre-et-Marie-Curie-Paris 6, unité Inserm U938, 26, avenue du Dr-Netter, 75012 Paris, France
| | - N Nathan
- Service de pneumologie pédiatrique, hôpital Trousseau, AP-HP, centre de ressources et de compétences pour la mucoviscidose, centre de référence des maladies respiratoires rares, université Pierre-et-Marie-Curie-Paris 6, unité Inserm U938, 26, avenue du Dr-Netter, 75012 Paris, France
| | - A Clement
- Service de pneumologie pédiatrique, hôpital Trousseau, AP-HP, centre de ressources et de compétences pour la mucoviscidose, centre de référence des maladies respiratoires rares, université Pierre-et-Marie-Curie-Paris 6, unité Inserm U938, 26, avenue du Dr-Netter, 75012 Paris, France
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Abstract
BACKGROUND Pseudomonas aeruginosa is the most common bacterial pathogen causing lung infections in people with CF and appropriate antibiotic therapy is vital. Antibiotics for pulmonary exacerbations are usually given intravenously, and for long-term treatment, via a nebuliser. Oral anti-pseudomonal antibiotics with the same efficacy and safety as intravenous or nebulised antibiotics would benefit people with CF due to ease of treatment and avoidance of hospitalisation. OBJECTIVES To determine the benefit or harm of oral anti-pseudomonal antibiotic therapy for people with CF, colonised with Pseudomonas aeruginosa, in the:1. treatment of a pulmonary exacerbation; and 2. long-term treatment of chronic infection. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.We contacted pharmaceutical companies and checked reference lists of identified trials.Date of last search: 28 June 2013. SELECTION CRITERIA Randomised or quasi-randomised controlled trials comparing any dose of oral anti-pseudomonal antibiotics, to other combinations of inhaled, oral or intravenous antibiotics, or to placebo or usual treatment for pulmonary exacerbations and long-term treatment. DATA COLLECTION AND ANALYSIS Two authors independently selected the trials, extracted data and assessed quality. We contacted trial authors to obtain missing information. MAIN RESULTS We included three trials examining pulmonary exacerbations (171 participants) and two trials examining long-term therapy (85 participants). We regarded the most important outcomes as quality of life and lung function. The analysis did not identify any statistically significant difference between oral anti-pseudomonal antibiotics and other treatments for these outcome measures for either pulmonary exacerbations or long-term treatment. One of the included trials reported significantly better lung function when treating a pulmonary exacerbation with ciprofloxacin when compared with intravenous treatment; however, our analysis did not confirm this finding. We found no evidence of difference between oral anti-pseudomonal antibiotics and other treatments regarding adverse events or development of antibiotic resistance, but trials were not adequately powered to detect this. None of the studies had a low risk of bias from blinding which may have an impact particularly on subjective outcomes such as quality of life. The risk of bias for other criteria could not be clearly stated across the studies. AUTHORS' CONCLUSIONS We found no conclusive evidence that an oral anti-pseudomonal antibiotic regimen is more or less effective than an alternative treatment for either pulmonary exacerbations or long-term treatment of chronic infection with P. aeruginosa. Until results of adequately-powered future trials are available, treatment needs to be selected on a pragmatic basis, based upon any available non-RCT evidence, the clinical circumstances of the individual, the known effectiveness of drugs against local strains and upon individual preference.
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Affiliation(s)
- Tracey Remmington
- Department of Women's and Children's Health, University of Liverpool, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, UK, L12 2AP
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17
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Cory TJ, Birket SE, Murphy BS, Hayes D, Anstead MI, Kanga JF, Kuhn RJ, Bush HM, Feola DJ. Impact of azithromycin treatment on macrophage gene expression in subjects with cystic fibrosis. J Cyst Fibros 2013; 13:164-71. [PMID: 24018177 DOI: 10.1016/j.jcf.2013.08.007] [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: 05/10/2013] [Revised: 06/21/2013] [Accepted: 08/13/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Azithromycin treatment improves clinical parameters in patients with CF, and alters macrophage activation from a pro-inflammatory (M1) phenotype to a pro-fibrotic, alternatively activated (M2) phenotype. The transcriptional profile of cells from patients receiving azithromycin is unknown. METHODS Gene expression in association with macrophage polarization, inflammation, and tissue remodeling was assessed from sputum samples collected from patients with CF. Transcriptional profiles and clinical characteristics, including azithromycin therapy, were compared. RESULTS Expression of NOS2 and TNFα was decreased in subjects receiving azithromycin, whereas expression of M2-associated genes was unaffected. Principal component analysis revealed gene expression profiles consistent with M1- (MMP9, NOS2, and TLR4) or M2-polarization (CCL18, fibronectin, and MR1) in select subject groups. These expression signatures did not significantly correlate with clinical characteristics. CONCLUSIONS Pro-inflammatory gene expression was low in subjects receiving AZM. Genes were stratified into groupings characteristic of M1- or M2-polarization, suggesting that overall polarization status is distinct among patient groups.
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Affiliation(s)
- Theodore J Cory
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, 789 S. Limestone, Lexington, KY 40536, United States; Department of Pharmacy Practice, University of Nebraska College of Pharmacy, 986000 Nebraska Medical Center, Omaha, NE 68198, United States
| | - Susan E Birket
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, 789 S. Limestone, Lexington, KY 40536, United States; Department of Medicine, University of Alabama at Birmingham, 1918 University Blvd., Birmingham, AL 35294, United States
| | - Brian S Murphy
- Department of Internal Medicine, University of Kentucky College of Medicine, 138 Leader Avenue, Lexington, KY 40506, United States
| | - Don Hayes
- Section of Pulmonary Medicine, Department of Pediatrics, The Ohio State University, Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH 43205, United States
| | - Michael I Anstead
- Department of Pediatrics, University of Kentucky, 138 Leader Avenue, Lexington, KY 40506, United States
| | - Jamshed F Kanga
- Department of Pediatrics, University of Kentucky, 138 Leader Avenue, Lexington, KY 40506, United States
| | - Robert J Kuhn
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, 789 S. Limestone, Lexington, KY 40536, United States
| | - Heather M Bush
- Department of Biostatistics, University of Kentucky College of Medicine, 725 Rose Street, Lexington, KY 40536, United States
| | - David J Feola
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, 789 S. Limestone, Lexington, KY 40536, United States.
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18
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Zobell JT, Young DC, Waters CD, Ampofo K, Stockmann C, Sherwin CMT, Spigarelli MG. Optimization of anti-pseudomonal antibiotics for cystic fibrosis pulmonary exacerbations: VI. Executive summary. Pediatr Pulmonol 2013; 48:525-37. [PMID: 23359557 DOI: 10.1002/ppul.22757] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 12/28/2012] [Indexed: 11/07/2022]
Abstract
Acute pulmonary exacerbations (APE) are well-described complications of cystic fibrosis (CF) and are associated with progressive morbidity and mortality. Despite aggressive management with two or more intravenous anti-pseudomonal agents, approximately 25% of exacerbations will result in a loss of lung function. The aim of this review is to provide an overview of the classes of intravenous anti-pseudomonal antibiotics, the findings of anti-pseudomonal antibiotic utilization surveys, the current antibiotic dosing recommendations from the U.S. and Europe, and the pharmacokinetic (PK) and pharmacodynamic (PD) differences between CF and non-CF individuals. Anti-pseudomonal antibiotic classes include beta-lactams, aminoglycosides, fluoroquinolones, and colistimethate sodium. Recent surveys of antibiotic utilization in CF Foundation-accredited care centers have shown that a large number of centers are not following recommended dosing strategies despite published recommendations in the U.S. and Europe. The recommended doses for anti-pseudomonal antibiotics may be higher than FDA-approved doses due to PK and PD differences. As a large portion of CF patients will not regain their lung function following an APE, it seems possible that currently available anti-pseudomonal agents are being used sub-optimally. As new anti-pseudomonal agents are not currently available, we suggest the need to optimize antibiotic dosing and dosing regimens used to treat pulmonary exacerbations in an effort to improve outcomes for CF patients infected with Pseudomonas aeruginosa.
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Affiliation(s)
- Jeffery T Zobell
- Department of Pharmacy, Intermountain Primary Children's Medical Center, Salt Lake City, Utah, USA.
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19
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Nichols DP, Caceres S, Caverly L, Fratelli C, Kim SH, Malcolm K, Poch KR, Saavedra M, Solomon G, Taylor-Cousar J, Moskowitz S, Nick JA. Effects of azithromycin in Pseudomonas aeruginosa burn wound infection. J Surg Res 2013; 183:767-76. [PMID: 23478086 DOI: 10.1016/j.jss.2013.02.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 01/29/2013] [Accepted: 02/01/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cutaneous thermal injuries (i.e., burns) remain a common form of debilitating trauma, and outcomes are often worsened by wound infection with environmental bacteria, chiefly Pseudomonas aeruginosa. MATERIALS AND METHODS We tested the effects of early administration of a single dose of azithromycin, with or without subsequent antipseudomonal antibiotics, in a mouse model of standardized thermal injury infected with P aeruginosa via both wound site and systemic infection. We also tested the antimicrobial effects of these antibiotics alone or combined in comparative biofilm and planktonic cultures in vitro. RESULTS In our model, early azithromycin administration significantly reduced wound and systemic infection without altering wound site or circulating neutrophil activity. The antimicrobial effect of azithromycin was additive with ciprofloxacin but significantly reduced the antimicrobial effect of tobramycin. This pattern was reproduced in biofilm cultures and not observed in planktonic cultures of P aeruginosa. CONCLUSION These data suggest that early administration of azithromycin following burn-related trauma and infection may reduce P aeruginosa infection and potential interactions with other antibiotics should be considered when designing future studies.
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Affiliation(s)
- David P Nichols
- Pulmonary Medicine Division, Department of Pediatrics, National Jewish Health, Denver, CO 80206, USA.
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20
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A retrospective analysis of the impact of azithromycin maintenance therapy on adults attending a UK cystic fibrosis clinic. J Cyst Fibros 2013; 12:49-53. [DOI: 10.1016/j.jcf.2012.05.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 05/29/2012] [Accepted: 05/30/2012] [Indexed: 11/22/2022]
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21
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Abstract
BACKGROUND Macrolide antibiotics may have a modifying role in diseases which involve airway infection and inflammation, like cystic fibrosis. OBJECTIVES To test the hypotheses that, in people with cystic fibrosis, macrolide antibiotics: 1. improve clinical status compared to placebo or another antibiotic; 2. do not have unacceptable adverse effects. If benefit was demonstrated, we aimed to assess the optimal type, dose and duration of macrolide therapy. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings.We contacted investigators known to work in the field, previous authors and pharmaceutical companies manufacturing macrolide antibiotics for unpublished or follow-up data (May 2010).Latest search of the Group's Cystic Fibrosis Trials Register: 29 February 2012. SELECTION CRITERIA Randomised controlled trials of macrolide antibiotics compared to: placebo; another class of antibiotic; another macrolide antibiotic; or the same macrolide antibiotic at a different dose. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed risk of bias. Seven groups were contacted and provided additional data which were incorporated into the review. MAIN RESULTS Ten of 31 studies identified were included (959 patients). Five studies with a low risk of bias examined azithromycin versus placebo and demonstrated consistent improvement in forced expiratory volume in one second over six months (mean difference at six months 3.97% (95% confidence interval 1.74% to 6.19%; n = 549, from four studies)). Patients treated with azithromycin were approximately twice as likely to be free of pulmonary exacerbation at six months, odds ratio 1.96 (95% confidence interval 1.15 to 3.33). With respect to secondary outcomes, there was a significant reduction in need for oral antibiotics and greater weight gain in those taking azithromycin. Adverse events were uncommon and not obviously associated with azithromycin, although a once-weekly high dose regimen was associated with more frequent gastrointestinal adverse events. Treatment with azithromycin was associated with reduced identification of Staphylococcus aureus on respiratory culture, but also a significant increase in macrolide resistance. AUTHORS' CONCLUSIONS This review provides evidence of improved respiratory function after six months of azithromycin. Data beyond six months were less clear, although reduction in pulmonary exacerbation was sustained. Treatment appeared safe over a six-month period; however, emergence of macrolide resistance was a concern. A multi-centre trial examining long-term effects of this antibiotic treatment is needed, especially for infants recognised through newborn screening.
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Affiliation(s)
- Kevin W Southern
- Institute of ChildHealth, University of Liverpool, Liverpool, UK.
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22
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Wilms EB, Touw DJ, Heijerman HGM, van der Ent CK. Azithromycin maintenance therapy in patients with cystic fibrosis: a dose advice based on a review of pharmacokinetics, efficacy, and side effects. Pediatr Pulmonol 2012; 47:658-65. [PMID: 22684985 DOI: 10.1002/ppul.21620] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 10/27/2011] [Indexed: 01/31/2023]
Abstract
Azithromycin maintenance therapy results in improvement of respiratory function in patients with cystic fibrosis (CF). In azithromycin maintenance therapy, several dosing schemes are applied. In this review, we combine current knowledge about azithromycin pharmacokinetics with the dosing schedules used in clinical trials in order to come to a dosing advise which could be generally applicable. We used data from a recently updated Cochrane meta analysis (2011), the reports of clinical trials and pharmacokinetic studies. Based on these data, it was concluded that a dose level of 22-30 mg/kg/week is the lowest dose level with proven efficacy. Due to the extended half-life in patients with CF, the weekly dose of azithromycin can be divided in one to seven dosing moments, depending on patient preference and gastro-intestinal tolerance. No important side effects or interactions with other CF-related drugs have been documented so far.
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Affiliation(s)
- Erik B Wilms
- Central Hospital Pharmacy, The Hague, The Netherlands.
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Han MK, Huang YJ, Lipuma JJ, Boushey HA, Boucher RC, Cookson WO, Curtis JL, Erb-Downward J, Lynch SV, Sethi S, Toews GB, Young VB, Wolfgang MC, Huffnagle GB, Martinez FJ. Significance of the microbiome in obstructive lung disease. Thorax 2012; 67:456-63. [PMID: 22318161 PMCID: PMC3578398 DOI: 10.1136/thoraxjnl-2011-201183] [Citation(s) in RCA: 165] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The composition of the lung microbiome contributes to both health and disease, including obstructive lung disease. Because it has been estimated that over 70% of the bacterial species on body surfaces cannot be cultured by currently available techniques, traditional culture techniques are no longer the gold standard for microbial investigation. Advanced techniques that identify bacterial sequences, including the 16S ribosomal RNA gene, have provided new insights into the depth and breadth of microbiota present both in the diseased and normal lung. In asthma, the composition of the microbiome of the lung and gut during early childhood development may play a key role in the development of asthma, while specific airway microbiota are associated with chronic asthma in adults. Early bacterial stimulation appears to reduce asthma susceptibility by helping the immune system develop lifelong tolerance to innocuous antigens. By contrast, perturbations in the microbiome from antibiotic use may increase the risk for asthma development. In chronic obstructive pulmonary disease, bacterial colonisation has been associated with a chronic bronchitic phenotype, increased risk of exacerbations, and accelerated loss of lung function. In cystic fibrosis, studies utilising culture-independent methods have identified associations between decreased bacterial community diversity and reduced lung function; colonisation with Pseudomonas aeruginosa has been associated with the presence of certain CFTR mutations. Genomic analysis of the lung microbiome is a young field, but has the potential to define the relationship between lung microbiome composition and disease course. Whether we can manipulate bacterial communities to improve clinical outcomes remains to be seen.
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Affiliation(s)
- Meilan K Han
- Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, 3916 Taubman Center, Box 5360, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5360, USA.
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Abstract
BACKGROUND Macrolide antibiotics may have a modifying role in diseases which involve airway infection and inflammation, like cystic fibrosis. OBJECTIVES To test the hypotheses that, in people with cystic fibrosis, macrolide antibiotics: 1. improve clinical status compared to placebo or another antibiotic; 2. do not have unacceptable adverse effects. If benefit was demonstrated, we aimed to assess the optimal type, dose and duration of macrolide therapy. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings.We contacted investigators known to work in the field, previous authors and pharmaceutical companies manufacturing macrolide antibiotics for unpublished or follow-up data (May 2010).Latest search of the Group's Cystic Fibrosis Trials Register: 09 February 2011. SELECTION CRITERIA Randomised controlled trials of macrolide antibiotics compared to: placebo; another class of antibiotic; another macrolide antibiotic; or the same macrolide antibiotic at a different dose. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed risk of bias. Seven groups were contacted and provided additional data which were incorporated into the review. MAIN RESULTS Ten of 31 studies identified were included (959 patients). Five studies with a low risk of bias examined azithromycin versus placebo and demonstrated consistent improvement in forced expiratory volume in one second over six months (mean difference at six months 3.97% (95% confidence interval 1.74% to 6.19%; n = 549, from four studies)). Patients treated with azithromycin were approximately twice as likely to be free of pulmonary exacerbation at six months, odds ratio 1.96 (95% confidence interval 1.15 to 3.33). With respect to secondary outcomes, there was a significant reduction in need for oral antibiotics and greater weight gain in those taking azithromycin. Adverse events were uncommon and not obviously associated with azithromycin, although a once-weekly high dose regimen was associated with more frequent gastrointestinal adverse events. Treatment with azithromycin was associated with reduced identification of Staphylococcus aureus on respiratory culture, but also a significant increase in macrolide resistance. AUTHORS' CONCLUSIONS This review provides evidence of improved respiratory function after six months of azithromycin. Data beyond six months were less clear, although reduction in pulmonary exacerbation was sustained. Treatment appeared safe over a six-month period; however, emergence of macrolide resistance was a concern. A multi-centre trial examining long-term effects of this antibiotic treatment is needed, especially for infants recognised through newborn screening.
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Affiliation(s)
- Kevin W Southern
- Institute of Child Health, University of Liverpool, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, Merseyside, UK, L12 2AP
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Zarogoulidis P, Papanas N, Kioumis I, Chatzaki E, Maltezos E, Zarogoulidis K. Macrolides: from in vitro anti-inflammatory and immunomodulatory properties to clinical practice in respiratory diseases. Eur J Clin Pharmacol 2011; 68:479-503. [PMID: 22105373 DOI: 10.1007/s00228-011-1161-x] [Citation(s) in RCA: 187] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 10/25/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Macrolides have long been recognised to exert immunomodulary and anti-inflammatory actions. They are able to suppress the "cytokine storm" of inflammation and to confer an additional clinical benefit through their immunomodulatory properties. METHODS A search of electronic journal articles was performed using combinations of the following keywords: macrolides, COPD, asthma, bronchitis, bronchiolitis obliterans, cystic fibrosis, immunomodulation, anti-inflammatory effect, diabetes, side effects and systemic diseases. RESULTS Macrolide effects are time- and dose-dependent, and the mechanisms underlying these effects remain incompletely understood. Both in vitro and in vivo studies have provided ample evidence of their immunomodulary and anti-inflammatory actions. Importantly, this class of antibiotics is efficacious with respect to controlling exacerbations of underlying respiratory problems, such as cystic fibrosis, asthma, bronchiectasis, panbrochiolitis and cryptogenic organising pneumonia. Macrolides have also been reported to reduce airway hyper-responsiveness and improve pulmonary function. CONCLUSION This review provides an overview on the properties of macrolides (erythromycin, clarithromycin, roxithromycin, azithromycin), their efficacy in various respiratory diseases and their adverse effects.
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Affiliation(s)
- P Zarogoulidis
- Pulmonary Department, G. Papanikolaou Hospital, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece.
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Eakin MN, Bilderback A, Boyle MP, Mogayzel PJ, Riekert KA. Longitudinal association between medication adherence and lung health in people with cystic fibrosis. J Cyst Fibros 2011; 10:258-64. [PMID: 21458391 DOI: 10.1016/j.jcf.2011.03.005] [Citation(s) in RCA: 160] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 03/04/2011] [Accepted: 03/05/2011] [Indexed: 11/15/2022]
Abstract
BACKGROUND This study examined the relationship of medication adherence to frequency of pulmonary exacerbation and rate of decline in FEV(1)% predicted (FEV(1)). METHODS 95 CF patients aged 6 years or older and prescribed a pulmonary medication, were enrolled in a longitudinal retrospective review of medication adherence and health outcomes (the occurrence and frequency of intravenous (IV) antibiotic treatments and FEV(1)) over 12-months. Pharmacy refill records were used to calculate a medication possession ratio (MPR). RESULTS Composite MPR predicted the occurrence of at least one pulmonary exacerbation requiring a course of IV antibiotics (IRR=2.34, p=0.05), but not the frequency of exacerbations, after controlling for gender, baseline FEV(1,) and regimen complexity. Composite MPR predicted baseline FEV(1) (estimate=29.81, p=.007), but not decline in FEV(1). CONCLUSIONS These results demonstrate a significant relation between medication adherence and IV antibiotics in CF patients, highlighting the importance of addressing adherence during clinic visits to improve health outcomes.
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Affiliation(s)
- Michelle N Eakin
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21224, USA.
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Cai Y, Chai D, Wang R, Bai N, Liang BB, Liu Y. Effectiveness and safety of macrolides in cystic fibrosis patients: a meta-analysis and systematic review. J Antimicrob Chemother 2011; 66:968-78. [DOI: 10.1093/jac/dkr040] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Sibley CD, Grinwis ME, Rabin HR, Surette MG. Azithromycin paradox in the treatment of cystic fibrosis airway disease. Future Microbiol 2010; 5:1315-9. [DOI: 10.2217/fmb.10.99] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Evaluation of: Saiman L, Anstead M, Mayer-Hamblett N et al.: Effect of azithromycin on pulmonary function in patients with cystic fibrosis uninfected with Pseudomonas aeruginosa: a randomized controlled trial. JAMA 303(17), 1707–1715 (2010). Chronic airway infection and inflammation are hallmarks of cystic fibrosis (CF). Disease progression can be described as chronic inflammation punctuated by acute exacerbations with overt immunological responses. Macrolide antibiotics, which have both immunomodulatory and antibacterial activities, have been shown to be beneficial in the management of CF airway disease, although the mechanism of action is unknown. It is also unclear whether all patients, particularly those not colonized with Pseudomonas aeruginosa, benefit from this treatment. In this article, Saiman et al. examine the effects of azithromycin on lung function in pediatric and adolescent CF patients who are not colonized with P. aeruginosa. The data indicate beneficial effects of azithromycin treatment and suggest the mechanisms of action of azithromycin is at least partially independent of P. aeruginosa.
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Affiliation(s)
- Christopher D Sibley
- Department of Microbiology & Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Margot E Grinwis
- Department of Microbiology & Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Harvey R Rabin
- Department of Microbiology & Infectious Diseases, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
- Department of Medicine & Adult Cystic Fibrosis Clinic, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Michael G Surette
- Department of Biochemistry & Molecular Biology, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
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Abstract
Interest in azithromycin in the management of patients with cystic fibrosis has grown over the last decade. Uniquely this drug has both antibacterial and immune modulating effects which appear to be the reason for its clinical benefit as proven in several well designed clinical studies. In this review we discuss the proposed mechanisms of action of azithromycin and review the evidence for its clinical effectiveness and safety in cystic fibrosis.
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Affiliation(s)
- Abdullah A Yousef
- Department of Respiratory Medicine, Sydney Children's Hospital, High Street, Randwick 2031, University of New South Wales, Randwick, Sydney, Australia.
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Murphy DM, Forrest IA, Curran D, Ward C. Macrolide antibiotics and the airway: antibiotic or non-antibiotic effects? Expert Opin Investig Drugs 2010; 19:401-14. [DOI: 10.1517/13543781003636480] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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31
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Kabra S, Pawaiya R, Lodha R, Kapil A, Kabra M, Vani AS, Agarwal G, Shastri S. Long-term daily high and low doses of azithromycin in children with cystic fibrosis: A randomized controlled trial. J Cyst Fibros 2010; 9:17-23. [DOI: 10.1016/j.jcf.2009.09.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Revised: 08/30/2009] [Accepted: 09/10/2009] [Indexed: 10/20/2022]
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Measuring and improving respiratory outcomes in cystic fibrosis lung disease: opportunities and challenges to therapy. J Cyst Fibros 2009; 9:1-16. [PMID: 19833563 DOI: 10.1016/j.jcf.2009.09.003] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Revised: 07/20/2009] [Accepted: 09/22/2009] [Indexed: 12/22/2022]
Abstract
Cystic fibrosis (CF) is a life-shortening disease with significant morbidity. Despite overall improvements in survival, patients with CF experience frequent pulmonary exacerbations and declining lung function, which often accelerates during adolescence. New treatments target steps in the pathogenesis of lung disease, such as the basic defect in CF (CF Transmembrane Conductance Regulator [CFTR]), pulmonary infections, inflammation, and mucociliary clearance. These treatments offer hope but also present challenges to patients, clinicians, and researchers. Comprehensive assessment of efficacy is critical to identify potentially beneficial treatments. Lung function and pulmonary exacerbation are the most commonly used outcome measures in CF clinical research. Other outcome measures under investigation include measures of CFTR function; biomarkers of infection, inflammation, lung injury and repair; and patient-reported outcomes. Molecular diagnostics may help elucidate the complex CF airway microbiome. As new treatments are developed for patients with CF, efforts should be made to balance treatment burden with quality of life. This review highlights emerging treatments, obstacles to optimizing outcomes, and key future directions for research.
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Oliynyk I, Varelogianni G, Schalling M, Asplund MS, Roomans GM, Johannesson M. Azithromycin increases chloride efflux from cystic fibrosis airway epithelial cells. Exp Lung Res 2009; 35:210-21. [PMID: 19337904 DOI: 10.1080/01902140802534967] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
It was investigated whether azithromycin (AZM) stimulates chloride (Cl-) efflux from cystic fibrosis (CF) and non-CF airway epithelial cells, possibly secondary to up-regulation of the multidrug resistance protein (MDR). CF and non-CF human airway epithelial cell lines (CFBE and 16HBE) were treated with 0.4, 4, and 40 microg/mL AZM for 4 days. Cl- efflux was explored in the presence or absence of specific inhibitors of CFTR and alternative Cl- channels. Six CF patients received AZM (500 mg daily) for 6 months. The percentage of predicted forced vital capacity (FVC%), forced expiratory volume (FEV1%), and the number of acute exacerbations were compared before and after treatment. Nasal biopsies were taken before and after treatment, and mRNA expression of MDR and CFTR was determined by in situ hybridization. A significant dose-dependent increase of Cl- efflux from CFBE cells (but not from 16HBE cells) was observed after AZM treatment. A CFTR inhibitor significantly reduced AZM-stimulated Cl- efflux from CFBE cells. A significant improvement in FEV1%, and fewer exacerbations were observed. AZM treatment did not affect mRNA expression of MDR and CFTR. The stimulation of Cl- efflux could be part of the explanation for the clinical improvement seen among the patients.
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Affiliation(s)
- Igor Oliynyk
- Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden.
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Florescu DF, Murphy PJ, Kalil AC. Effects of prolonged use of azithromycin in patients with cystic fibrosis: a meta-analysis. Pulm Pharmacol Ther 2009; 22:467-72. [PMID: 19328860 DOI: 10.1016/j.pupt.2009.03.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Accepted: 03/12/2009] [Indexed: 10/21/2022]
Abstract
Azithromycin has been studied as potential therapeutic anti-inflammatory agent for cystic fibrosis (CF) patients. Azithromycin (AZM) has been used as an immunomodulating agent, based on few small studies. Considering the cost and potential side effects of long-term azithromycin therapy, it is important to identify the group of patients that would benefit the most. Weighted mean difference was used for pulmonary function tests, and risk ratios for all other variables. The random-effects model was applied for all reports. Combining four studies (N=368), azithromycin showed increase in FEV(1) (3.53%, 95% CI 0.00, 7.07, p=0.05; I(2)=38%) and FVC (4.24%, 95% CI 2.02, 6.45, p=0.0002; I(2)=0%). When trials were analyzed by baseline Pseudomonas sputum colonization, the heterogeneity decreased (I(2)=0%), FEV(1) significantly increased to 4.66% (95% CI 1.18, 8.15, p=0.009), and FVC increased to 4.64% (95% CI 2.11, 7.17, p=0.0003). The GI side effects were 72% higher with azithromycin use (RR 1.72, 95% CI 1.33, 2.21, p=0.00003), the main side effects being nausea (RR 2.04, 95% CI 1.19, 3.45, p=0.009), and diarrhea (RR 2.12, 95% CI 1.10, 4.08, p=0.02). Azithromycin improves lung function of CF patients, especially in the subgroup colonized with Pseudomonas. However, nausea and diarrhea are significantly more frequent with azythromycin.
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Affiliation(s)
- D F Florescu
- Infectious Diseases Section, University of Nebraska Medical Center, Omaha 68198-5400, NE, USA.
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35
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Bergamini G, Cigana C, Sorio C, Della Peruta M, Pompella A, Corti A, Huaux FA, Leal T, Assael BM, Melotti P. Effects of azithromycin on glutathione S-transferases in cystic fibrosis airway cells. Am J Respir Cell Mol Biol 2008; 41:199-206. [PMID: 19097986 DOI: 10.1165/rcmb.2008-0013oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Anti-inflammatory properties of azithromycin (AZM) have been proposed as possible mechanisms of clinical beneficial effects in patients with cystic fibrosis (CF). Altered glutathione (GSH) transport in cystic fibrosis transmembrane regulator protein (CFTR)-deficient cells leads to the occurrence of oxidative stress that finally induces glutathione S-transferase (GST) activity. The present investigation was aimed to verify the effects of AZM on GST activity and expression in CF airway cells in vitro and in vivo. AZM exposure significantly decreased GSTT1 and GSTM1 mRNA and protein expression in IB3-1, restoring the levels to those observed in non-CF C38 cells, which also express lower levels of gamma-glutamyltransferase (GGT) activity than IB3-1. In another CF cell line, 2CFSMEo-, AZM produced 45% reduction in GSTT1 and GSTM1 mRNA levels. AZM reduced GST activity by approximately 25% and 40% in IB3-1 and 2CFSMEo- cells, respectively. GSTP1 was similarly expressed in all CF and non-CF cells and was unaffected by AZM. The anti-inflammatory cytokine IL-10 down-modulated GST activity at similar levels, supporting a link between GST inhibition and anti-inflammatory properties of AZM. In bronchoalveolar lavage fluid of CF mice homozygous for the F508 del mutation, GSTM1 protein levels were undetectable after AZM treatment. The association between increased GST expression and activity, together with its reversal by AZM treatment in vitro and in vivo, suggest novel antioxidant properties for this drug. The issue whether decreased GST activity may directly concur to anti-inflammatory properties of AZM or is rather a marker of the oxidative status of CF cells will require additional studies.
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Affiliation(s)
- Gabriella Bergamini
- Cystic Fibrosis Center-Azienda Ospedaliera di Verona, Piazzale Stefani 1, 37126 Verona, Italy
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Banner KH, De Jonge H, Elborn S, Growcott E, Gulbins E, Konstan M, Moss R, Poll C, Randell SH, Rossi AG, Thomas L, Waltz D. Highlights of a workshop to discuss targeting inflammation in cystic fibrosis. J Cyst Fibros 2008; 8:1-8. [PMID: 19022708 DOI: 10.1016/j.jcf.2008.10.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Revised: 10/08/2008] [Accepted: 10/09/2008] [Indexed: 12/17/2022]
Abstract
A workshop to discuss anti-inflammatory approaches in the treatment of CF was held at Novartis Institutes for Biomedical Research (NIBR, Horsham, UK) in March 2008. Key opinion leaders in the field (Hugo De Jonge, Stuart Elborn, Erich Gulbins, Mike Konstan, Rick Moss, Scott Randell and Adriano Rossi), and NIBR scientists were brought together to collectively address three main aims: (i) to identify anti-inflammatory targets in CF, (ii) to evaluate the pros and cons of targeting specific cell types and (iii) to discuss model systems to profile potential therapeutic agents. The highlights of the workshop are captured in this review.
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Affiliation(s)
- Katharine H Banner
- Novartis Institutes for Biomedical Research, Wimblehurst Road, Horsham, West Sussex, RH12 5AB, UK.
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38
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Kremer TM, Zwerdling RG, Michelson PH, O'Sullivan P. Intensive care management of the patient with cystic fibrosis. J Intensive Care Med 2008; 23:159-77. [PMID: 18443012 DOI: 10.1177/0885066608315679] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cystic fibrosis was previously thought to be a disease of childhood. With a better understanding of this condition along with improvements in therapy, patients with cystic fibrosis are now living well into adulthood. The aim of this article is to familiarize the intensive care unit physician with cystic fibrosis care, to discuss complications associated with cystic fibrosis specifically related to the intensive care unit, and to detail the current recommendations for the clinical management of the patient with cystic fibrosis. With advancing disease, the most severely affected organs are the lungs. Obstruction, infection, and inflammation contribute to the decline of pulmonary function, ultimately leading to death. Some patients may be eligible for lung transplantation, but choosing wisely will affect posttransplant survival. Because other organs are affected by the genetic defect and associated treatments, serious complications related to the liver, pancreas, intestines, and kidneys must be considered by the intensivist faced with a patient with cystic fibrosis. As practitioners, the fact that not all patients will survive and help our patients and families gracefully through the end-of-life process should be accepted.
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Affiliation(s)
- Ted M Kremer
- Department of Pediatrics, University of Massachusetts Medical Center, Worcester, Massachusetts 01655, USA.
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39
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Goss CH, Mayer-Hamblett N, Williams J, Ramsey BW. The Cystic Fibrosis Foundation Therapeutics Development Network: A National Effort by the Cystic Fibrosis Foundation to Build a Clinical Trials Network. CHILDRENS HEALTH CARE 2008. [DOI: 10.1080/02739610701766859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Martinez FJ, Curtis JL, Albert R. Role of macrolide therapy in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2008; 3:331-50. [PMID: 18990961 PMCID: PMC2629987 DOI: 10.2147/copd.s681] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of death and disability worldwide. The Global Burden of Disease study has concluded that COPD will become the third leading cause of death worldwide by 2020, and will increase its ranking of disability-adjusted life years lost from 12th to 5th. Acute exacerbations of COPD (AECOPD) are associated with impaired quality of life and pulmonary function. More frequent or severe AECOPDs have been associated with especially markedly impaired quality of life and a greater longitudinal loss of pulmonary function. COPD and AECOPDs are characterized by an augmented inflammatory response. Macrolide antibiotics are macrocyclical lactones that provide adequate coverage for the most frequently identified pathogens in AECOPD and have been generally included in published guidelines for AECOPD management. In addition, they exert broad-ranging, immunomodulatory effects both in vitro and in vivo, as well as diverse actions that suppress microbial virulence factors. Macrolide antibiotics have been used to successfully treat a number of chronic, inflammatory lung disorders including diffuse panbronchiolitis, asthma, noncystic fibrosis associated bronchiectasis, and cystic fibrosis. Data in COPD patients have been limited and contradictory but the majority hint to a potential clinical and biological effect. Additional, prospective, controlled data are required to define any potential treatment effect, the nature of this effect, and the role of bronchiectasis, baseline colonization, and other cormorbidities.
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Affiliation(s)
- Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI 48109-0360, USA.
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42
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Abstract
In summary, there is a significant interplay between the pulmonary manifestations and nutritional status of CF patients. The advances in CF clinical care in the past 2 decades are mainly attributed to anti-infective therapy as well as aggressive nutritional management. Currently, there are multiple therapeutic agents that are in clinical trial that target either the underlying CFTR defect or the downstream effects of CFTR. The broad spectrum of therapeutic agents being studied as well as the advances in therapies that target the underlying CFTR defect are exciting, making it likely that at least one of the treatments will make a major difference in how we will treat CF in the future.
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Affiliation(s)
- Reshma Amin
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
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43
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Abély M. Traitement de l'inflammation bronchique dans la mucoviscidose. Arch Pediatr 2007; 14:1350-5. [PMID: 17702549 DOI: 10.1016/j.arcped.2007.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2007] [Accepted: 06/27/2007] [Indexed: 11/19/2022]
Abstract
Cystic fibrosis airway inflammation is characterized by neutrophilic efflux and high levels of proinflammatory cytokines such as IL-8 and IL-6. Inhaled corticosteroids are widely used despite lack of evidence of efficacity. Despite evidence of efficacity of ibuprofen, many clinicians have chosen not to use this therapy because of concerns regarding potential side effects. Azithromycin has antiinflammatory properties and is effective in cystic fibrosis (CF) patients. Deoxyribonuclease (rhDNase) has been shown to improve lung function in patients with cystic fibrosis and may also have a positive effect on inflammation. Other antiinflammatory drugs are in the process of validation.
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Affiliation(s)
- M Abély
- Service de pédiatrie A, centre de ressources et de compétences pour la mucoviscidose, American Memorial Hospital, CHU de Reims, 47, rue Cognacq-Jay, 51092 Reims cedex, France.
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Subinhibitory concentrations of azithromycin decrease nontypeable Haemophilus influenzae biofilm formation and Diminish established biofilms. Antimicrob Agents Chemother 2007; 52:137-45. [PMID: 17954687 DOI: 10.1128/aac.00607-07] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Nontypeable Haemophilus influenzae (NTHi) commonly causes otitis media, chronic bronchitis in emphysema, and early airway infections in cystic fibrosis. Long-term, low-dose azithromycin has been shown to improve clinical outcomes in chronic lung diseases, although the mechanism of action remains unclear. The inhibition of bacterial biofilms by azithromycin has been postulated to be one mechanism mediating these effects. We hypothesized that subinhibitory concentrations of azithromycin would affect NTHi biofilm formation. Laboratory strains of NTHi expressing green fluorescent protein and azithromycin-resistant clinical isolates were grown in flow-cell and static-culture biofilm models. Using a range of concentrations of azithromycin and gentamicin, we measured the degree to which these antibiotics inhibited biofilm formation and persistence. Large biofilms formed over 2 to 4 days in a flow cell, displaying complex structures, including towers and channels. Subinhibitory concentrations of azithromycin significantly decreased biomass and maximal thickness in both forming and established NTHi biofilms. In contrast, subinhibitory concentrations of gentamicin had no effect on biofilm formation. Furthermore, established NTHi biofilms became resistant to gentamicin at concentrations far above the MIC. Biofilm formation of highly resistant clinical NTHi isolates (azithromycin MIC of > 64 microg/ml) was similarly decreased at subinhibitory azithromycin concentrations. Clinically obtainable azithromycin concentrations inhibited biofilms in all but the most highly resistant isolates. These data show that subinhibitory concentrations of azithromycin have antibiofilm properties, provide mechanistic insights, and supply an additional rationale for the use of azithromycin in chronic biofilm infections involving H. influenzae.
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Bell SC, Robinson PJ. Exacerbations in cystic fibrosis: 2 . prevention. Thorax 2007; 62:723-32. [PMID: 17687099 PMCID: PMC2117269 DOI: 10.1136/thx.2006.060897] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2006] [Accepted: 01/31/2007] [Indexed: 01/12/2023]
Abstract
The life span of people with cystic fibrosis (CF) has increased dramatically over the past 50 years. Many factors have contributed to this improvement. Respiratory exacerbations of CF lung disease are associated with the need for hospitalisation and antibiotic treatment, reduction in the quality of life, fragmented sleep and mortality. A number of preventive treatment strategies have been developed to reduce the frequency and severity of respiratory exacerbations in CF including mucolytic agents, physiotherapy and exercise, antibiotics, nutritional strategies, anti-inflammatory treatments and vaccinations against common respiratory pathogens. The evidence for each of these treatments and their potential impact is discussed.
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Affiliation(s)
- Scott C Bell
- Adult Cystic Fibrosis Centre, The Prince Charles Hospital, Rode Road, Chermside, Brisbane 4032, Australia.
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46
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Abstract
Cystic fibrosis (CF) results in chronic pulmonary disease in the majority of patients resulting from the production of viscous secretions and impairment of mucociliary clearance due to alterations in airway surface liquid. Chronic infection results, and the combination of tissue damage by pathogenic organisms and a robust host inflammatory response leads to the development of bronchiectasis and progressive lung disease. Macrolide antibiotics have demonstrated efficacy in diffuse panbronchiolitis, a disease that shares many similarities to CF, and this has generated interest in the use of these agents in patients who have CF. The authors review the data that demonstrate clinical benefits of long-term azithromycin administration in patients who have CF and discuss potential host- and pathogen-related explanations for the positive therapeutic effect.
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Affiliation(s)
- John R McArdle
- Adult Cystic Fibrosis Program, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA.
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47
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Abstract
BACKGROUND Pseudomonas aeruginosa is the most common bacterial pathogen causing infection in the lungs of people with CF and appropriate antibiotic therapy is vital. Antibiotics for exacerbations are usually given intravenously, and for long-term treatment, via a nebuliser. Oral anti-pseudomonal antibiotics with the same efficacy and safety as intravenous or nebulised antibiotics would benefit the quality of life of people with CF due to ease of treatment and avoidance of hospitalisation. OBJECTIVES To determine the benefit or harm of oral anti-pseudomonal antibiotic therapy for people with CF, colonised with Pseudomonas aeruginosa, in the: (1) treatment of an exacerbation of respiratory tract infection; and (2) long-term treatment in chronic infection. SEARCH STRATEGY We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We contacted pharmaceutical companies for information on relevant trials and checked reference lists of identified trials. Most recent search: March 2007. SELECTION CRITERIA Randomised or quasi-randomised controlled trials comparing any dose of oral anti-pseudomonal antibiotics, with other combinations of inhaled, oral or intravenous antibiotics, or with placebo or usual treatment for exacerbations and long-term treatment. DATA COLLECTION AND ANALYSIS Two authors independently selected the trials, extracted data and assessed quality. We contacted trialists to obtain missing information. MAIN RESULTS We included four trials examining exacerbations (197 participants) and two trials examining long-term therapy (85 participants). We regarded the most important outcomes as quality of life and lung function. In our analysis, we were unable to identify any statistically significant difference between oral anti-pseudomonal antibiotics and other treatments for these outcome measures for either exacerbations or long-term treatment. One of the included trials reported significantly better lung function when treating an exacerbation with ciprofloxacin when compared with intravenous treatment; however, our analysis did not confirm this finding. We found no evidence of difference between oral anti-pseudomonal antibiotics and other treatments regarding adverse events or development of antibiotic resistance, but trials were not adequately powered to detect this. AUTHORS' CONCLUSIONS We found no conclusive evidence that an oral anti-pseudomonal antibiotic regimen is more or less effective than an alternative treatment for either exacerbations or long-term treatment of chronic infection with P. aeruginosa. Until results of adequately-powered future trials are available, treatment needs to be selected on a pragmatic basis, based upon known effectiveness against local strains and upon individual preference.
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Affiliation(s)
- T Remmington
- University of Liverpool, Institute of Child Health, Alder Hey Children's Hospital, Eaton Road, Liverpool, UK, L12 2AP.
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48
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Sharma S, Jaffe A, Dixon G. Immunomodulatory effects of macrolide antibiotics in respiratory disease: therapeutic implications for asthma and cystic fibrosis. Paediatr Drugs 2007; 9:107-18. [PMID: 17407366 DOI: 10.2165/00148581-200709020-00004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The macrolide antibiotics are a family of related 14- or 15-membered lactone ring antibiotics. There has been recent interest in the beneficial effects of these drugs as immune modulators in respiratory conditions in children. Cystic fibrosis (CF) and asthma, both of which occur in childhood, have an underlying inflammatory component and are associated with significant morbidity. The pathogenesis of both conditions is poorly understood but several molecular mechanisms have been suggested. In CF, these mechanisms broadly involve altered chloride transport and alteration of the airway surface liquid with disordered neutrophilic inflammation. There is much evidence for a proinflammatory propensity in CF immune effector and epithelial cells and many studies indicate that macrolides modulate these inflammatory processes. Recent studies have confirmed a clinical improvement in CF following treatment with macrolides, but the exact mechanisms by which they work are unknown. Asthma is likely to represent several different phenotypes but in all of these, airway obstruction, bronchial hyperresponsiveness, and inflammation are central processes. Results from trials using macrolides have suggested an improvement in clinical outcome. The putative mechanisms of macrolide immunomodulatory action include improvement of the primary defense mechanisms, inhibition of the bacteria-epithelial cell interaction, modulation of the signaling pathway and chemokine release, and direct neutrophil effects. Putative mechanisms of phenotypic modulation have also been proposed involving interactions with nitric oxide, endothelin-1, and bronchoconstriction, endothelial growth factors and airway remodeling, and bioactive phospholipids in both CF and asthma. Further characterization of these effects and development of targeted designer drugs will further expand our therapeutic repertoire and lead to improved quality and quantity of life for patients with CF and asthma.
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49
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Nguyen D, Emond MJ, Mayer-Hamblett N, Saiman L, Marshall BC, Burns JL. Clinical response to azithromycin in cystic fibrosis correlates with in vitro effects on Pseudomonas aeruginosa phenotypes. Pediatr Pulmonol 2007; 42:533-41. [PMID: 17469154 DOI: 10.1002/ppul.20620] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A 6-month clinical trial of azithromycin (AZM) in American cystic fibrosis (CF) patients with chronic Pseudomonas aeruginosa infection showed clinical improvement without significant reduction in bacterial density. Sub-inhibitory AZM has been hypothesized to affect P. aeruginosa virulence, partly contributing to the mechanism of action of AZM. To correlate bacterial phenotypes of P. aeruginosa isolates with clinical response to AZM in CF patients. Pre-treatment P. aeruginosa isolates from subjects randomized to AZM in the US trial were characterized for bacterial phenotypes: AZM minimal inhibitory concentration (MIC), mucoidy, and baseline and AZM effects on twitching and swimming motility, and production of pyocyanin, protease and phospholipase C (PLC). Initial analyses of a subset of subjects identified phenotypes most strongly associated with FEV(1) response and pulmonary exacerbation. These phenotypes were subsequently characterized and tested in isolates from subjects of the complete AZM cohort. Exploratory analyses of the initial subset suggested that the MIC and in vitro change in PLC and swimming motility with AZM were the strongest candidates among the bacterial phenotypes. When tested, only the change in PLC was significantly correlated with the change in FEV(1) (P=0.05), and occurrence and time to pulmonary exacerbation (both P=0.02). In the complete cohort, change in PLC continued to show significant correlation with FEV(1) response (P=0.006), but not exacerbation. The in vitro effect of AZM on PLC correlates with FEV(1) response to AZM. This suggests that AZM anti-virulence effects may be predictive of clinical response and play a role in the mechanism of action of AZM in CF patients.
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Affiliation(s)
- Dao Nguyen
- Children's Hospital and Regional Medical Center, Seattle, Washington, USA
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Döring G, Elborn JS, Johannesson M, de Jonge H, Griese M, Smyth A, Heijerman H. Clinical trials in cystic fibrosis. J Cyst Fibros 2007; 6:85-99. [PMID: 17350898 DOI: 10.1016/j.jcf.2007.02.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2007] [Accepted: 02/07/2007] [Indexed: 12/20/2022]
Abstract
In patients with cystic fibrosis (CF), clinical trials are of paramount importance. Here, the current status of drug development in CF is discussed and future directions highlighted. Methods for pre-clinical testing of drugs with potential activity in CF patients including relevant animal models are described. Study design options for phase II and phase III studies involving CF patients are provided, including required patient numbers, safety issues and surrogate end point parameters for drugs, tested for different disease manifestations. Finally, regulatory issues for licensing new therapies for CF patients are discussed, including new directives of the European Union and the structure of a European clinical trial network for clinical studies involving CF patients is proposed.
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