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Schwarz C, Bend J, Hebestreit H, Hogardt M, Hügel C, Illing S, Mainz JG, Rietschel E, Schmidt S, Schulte-Hubbert B, Sitter H, Wielpütz MO, Hammermann J, Baumann I, Brunsmann F, Dieninghoff D, Eber E, Ellemunter H, Eschenhagen P, Evers C, Gruber S, Koitschev A, Ley-Zaporozhan J, Düesberg U, Mentzel HJ, Nüßlein T, Ringshausen FC, Sedlacek L, Smaczny C, Sommerburg O, Sutharsan S, Vonberg RP, Weber AK, Zerlik J. [CF Lung Disease - a German S3 Guideline: Pseudomonas aeruginosa]. Pneumologie 2024; 78:367-399. [PMID: 38350639 DOI: 10.1055/a-2182-1907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
Cystic Fibrosis (CF) is the most common autosomal recessive genetic multisystemic disease. In Germany, it affects at least 8000 people. The disease is caused by mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene leading to dysfunction of CFTR, a transmembrane chloride channel. This defect causes insufficient hydration of the airway epithelial lining fluid which leads to reduction of the mucociliary clearance.Even if highly effective, CFTR modulator therapy has been available for some years and people with CF are getting much older than before, recurrent and chronic infections of the airways as well as pulmonary exacerbations still occur. In adult CF life, Pseudomonas aeruginosa (PA) is the most relevant pathogen in colonisation and chronic infection of the lung, leading to further loss of lung function. There are many possibilities to treat PA-infection.This is a S3-clinical guideline which implements a definition for chronic PA-infection and demonstrates evidence-based diagnostic methods and medical treatment in order to give guidance for individual treatment options.
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Affiliation(s)
- Carsten Schwarz
- Klinikum Westbrandenburg GmbH, Standort Potsdam, Deutschland
| | - Jutta Bend
- Mukoviszidose Institut gGmbH, Bonn, Deutschland
| | | | - Michael Hogardt
- Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Frankfurt, Deutschland
| | - Christian Hügel
- Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Deutschland
| | | | - Jochen G Mainz
- Klinikum Westbrandenburg, Standort Brandenburg an der Havel, Universitätsklinikum der Medizinischen Hochschule Brandenburg (MHB), Brandenburg an der Havel, Deutschland
| | - Ernst Rietschel
- Medizinische Fakultät der Universität zu Köln, Mukoviszidose-Zentrum, Klinik und Poliklinik für Kinder- und Jugendmedizin, Köln, Deutschland
| | - Sebastian Schmidt
- Ernst-Moritz-Arndt Universität Greifswald, Kinderpoliklinik, Allgemeine Pädiatrie, Greifswald, Deutschland
| | | | - Helmut Sitter
- Philipps-Universität Marburg, Institut für theoretische Medizin, Marburg, Deutschland
| | - Marc Oliver Wielpütz
- Universitätsklinikum Heidelberg, Klinik für Diagnostische und Interventionelle Radiologie, Heidelberg, Deutschland
| | - Jutta Hammermann
- Universitäts-Mukoviszidose-Zentrum "Christiane Herzog", Dresden, Deutschland
| | - Ingo Baumann
- Universität Heidelberg, Hals-Nasen-Ohrenklinik, Heidelberg, Deutschland
| | - Frank Brunsmann
- Allianz Chronischer Seltener Erkrankungen (ACHSE) e. V., Deutschland (Patient*innenvertreter)
| | | | - Ernst Eber
- Medizinische Universität Graz, Univ. Klinik für Kinder- und Jugendheilkunde, Klinische Abteilung für Pädiatrische Pulmonologie und Allergologie, Graz, Österreich
| | - Helmut Ellemunter
- Tirolkliniken GmbH, Department für Kinderheilkunde, Pädiatrie III, Innsbruck, Österreich
| | | | | | - Saskia Gruber
- Medizinische Universität Wien, Universitätsklinik für Kinder- und Jugendheilkunde, Wien, Österreich
| | - Assen Koitschev
- Klinikum Stuttgart - Standort Olgahospital, Klinik für Hals-Nasen-Ohrenkrankheiten, Stuttgart, Deutschland
| | - Julia Ley-Zaporozhan
- Klinik und Poliklinik für Radiologie, Kinderradiologie, LMU München, Deutschland
| | | | - Hans-Joachim Mentzel
- Universitätsklinikum Jena, Sektion Kinderradiologie, Institut für Diagnostische und Interventionelle Radiologie, Jena, Deutschland
| | - Thomas Nüßlein
- Gemeinschaftsklinikum Mittelrhein, Klinik für Kinder- und Jugendmedizin Koblenz und Mayen, Koblenz, Deutschland
| | - Felix C Ringshausen
- Medizinische Hochschule Hannover, Klinik für Pneumologie und Infektiologie und Deutsches Zentrum für Lungenforschung (DZL), Hannover, Deutschland
| | - Ludwig Sedlacek
- Medizinische Hochschule Hannover, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Hannover, Deutschland
| | - Christina Smaczny
- Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Deutschland
| | - Olaf Sommerburg
- Universitätsklinikum Heidelberg, Sektion Pädiatrische Pneumologie, Allergologie und Mukoviszidose-Zentrum, Heidelberg, Deutschland
| | | | - Ralf-Peter Vonberg
- Medizinische Hochschule Hannover, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Hannover, Deutschland
| | | | - Jovita Zerlik
- Altonaer Kinderkrankenhaus gGmbH, Abteilung Physiotherapie, Hamburg, Deutschland
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Terlizzi V, Farrell PM. Update on advances in cystic fibrosis towards a cure and implications for primary care clinicians. Curr Probl Pediatr Adolesc Health Care 2024; 54:101637. [PMID: 38811287 DOI: 10.1016/j.cppeds.2024.101637] [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: 05/31/2024]
Abstract
During the past quarter century, the diagnosis and treatment of cystic fibrosis (CF) have been transformed by molecular sciences that initiated a new era with discovery of the cystic fibrosis transmembrane conductance regulator (CFTR) gene. The knowledge gained from that breakthrough has had dramatic clinical impact. Although once a diagnostic dilemma with long delays, preventable deaths, and irreversible pathology, CF can now be routinely diagnosed shortly after birth through newborn screening programs. This strategy of pre-symptomatic identification has eliminated the common diagnostic "odyssey" that was a failure of the healthcare delivery system causing psychologically traumatic experiences for parents. Therapeutic advances of many kinds have culminated in CFTR modulator treatment that can reduce the effects of or even correct the molecular defect in the chloride channel -the basic cause of CF. This astonishing advance has transformed CF care as described fully herein. Despite this impressive progress, there are challenges and controversies in the delivery of care. Issues include how best to achieve high sensitivity newborn screening with acceptable specificity; what course of action is appropriate for children who are identified through the unavoidable incidental findings of screening tests (CFSPID/CRMS cases and heterozygote carriers); how best to ensure genetic counseling; when to initiate the very expensive but life-saving CFTR modulator drugs; how to identify new CFTR modulator drugs for patients with non-responsive CFTR variants; how to adjust other therapeutic modalities; and how to best partner with primary care clinicians. Progress always brings new challenges, and this has been evident worldwide for CF. Consequently, this article summarizes the major advances of recent years along with controversies and describes their implications with an international perspective.
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Affiliation(s)
- Vito Terlizzi
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Viale Gaetano Pieraccini 24, Florence, Italy
| | - Philip M Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Clinical Sciences Center (K4/948), 600 Highland Avenue, Madison, WI 53792, USA.
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Chen Q, Cai P, Chang THW, Burgener E, Kratochvil MJ, Gupta A, Hargill A, Secor PR, Nielsen JE, Barron AE, Milla C, Heilshorn SC, Spakowitz A, Bollyky PL. Pf bacteriophages hinder sputum antibiotic diffusion via electrostatic binding. SCIENCE ADVANCES 2024; 10:eadl5576. [PMID: 38820163 PMCID: PMC11141622 DOI: 10.1126/sciadv.adl5576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 04/30/2024] [Indexed: 06/02/2024]
Abstract
Despite great progress in the field, chronic Pseudomonas aeruginosa (Pa) infections remain a major cause of mortality in patients with cystic fibrosis (pwCF), necessitating treatment with antibiotics. Pf is a filamentous bacteriophage produced by Pa and acts as a structural element in Pa biofilms. Pf presence has been associated with antibiotic resistance and poor outcomes in pwCF, although the underlying mechanisms are unclear. We have investigated how Pf and sputum biopolymers impede antibiotic diffusion using pwCF sputum and fluorescent recovery after photobleaching. We demonstrate that tobramycin interacts with Pf and sputum polymers through electrostatic interactions. We also developed a set of mathematical models to analyze the complex observations. Our analysis suggests that Pf in sputum reduces the diffusion of charged antibiotics due to a greater binding constant associated with organized liquid crystalline structures formed between Pf and sputum polymers. This study provides insights into antibiotic tolerance mechanisms in chronic Pa infections and may offer potential strategies for novel therapeutic approaches.
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Affiliation(s)
- Qingquan Chen
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
| | - Pam Cai
- Department of Chemical Engineering, Stanford University, Stanford, CA, 94305, USA
| | - Tony Hong Wei Chang
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
| | - Elizabeth Burgener
- Center for Excellence in Pulmonary Biology, Department of Pediatrics, Stanford University, Stanford, CA 94305, USA
- Children’s Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA
| | - Michael J. Kratochvil
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
- Department of Materials Science and Engineering, Stanford University, 476 Lomita Mall, Stanford, CA 94305, USA
| | - Aditi Gupta
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
| | - Aviv Hargill
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
| | - Patrick R. Secor
- Division of Biological Sciences, University of Montana, Missoula, MT 59812, USA
| | - Josefine Eilsø Nielsen
- Department of Bioengineering, School of Medicine & School of Engineering, Stanford University, Stanford, CA 94305, USA
- Department of Science and Environment, Roskilde University, 4000 Roskilde, Denmark
| | - Annelise E. Barron
- Department of Bioengineering, School of Medicine & School of Engineering, Stanford University, Stanford, CA 94305, USA
| | - Carlos Milla
- Center for Excellence in Pulmonary Biology, Department of Pediatrics, Stanford University, Stanford, CA 94305, USA
| | - Sarah C. Heilshorn
- Department of Materials Science and Engineering, Stanford University, 476 Lomita Mall, Stanford, CA 94305, USA
| | - Andy Spakowitz
- Department of Chemical Engineering, Stanford University, Stanford, CA, 94305, USA
- Department of Materials Science and Engineering, Stanford University, 476 Lomita Mall, Stanford, CA 94305, USA
| | - Paul L. Bollyky
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
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Pessoa E, Ferreira M, Baixinho CL. Telerehabilitation in Children and Adolescents with Cystic Fibrosis: A Scoping Review. Healthcare (Basel) 2024; 12:971. [PMID: 38786383 PMCID: PMC11121520 DOI: 10.3390/healthcare12100971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 04/26/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Abstract
Cystic fibrosis requires regular monitoring and intervention by healthcare teams; despite that, adherence to therapeutic measures is less than desired. The evolution of technology has allowed much of the care provided in person to be replaced by a telehealth delivery model, but studies on telerehabilitation are scarce and dispersed. This scoping review aimed to identify which domains of rehabilitation intervention are mediated by information and communication technologies and how they are developed in the provision of care to children and adolescents with cystic fibrosis. The data collection was conducted in February and June 2023, following the three steps recommended by the JBI for this type of review: (1) the search was conducted in MEDLINE, CINAHL, Scopus, JBI, and Web of Science; (2) the bibliographic references obtained from the included articles were analysed; and (3) the grey literature was checked. The eligibility criteria were children and adolescents and rehabilitation interventions mediated by information and communication technologies. The five studies included in this review were subjected to analysis, and a narrative synthesis of the results was carried out. The interventions identified included physical exercise programs (60%), management of the therapeutic regimen (40%), and symptom control (40%). The information and communication technologies were web-based platforms, video games, and telephones. The use of telerehabilitation included face-to-face meetings to ensure participants performed the exercises correctly, monitor their response to exercise, and teach them how to avoid risky situations during home workouts. In all studies, exercise sessions were supervised by the participants' parents or caregivers.
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Affiliation(s)
- Ezequiel Pessoa
- Nursing School of Lisbon, 1600-190 Lisbon, Portugal;
- Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), Nursing School of Lisbon, 1600-190 Lisbon, Portugal;
| | - Mara Ferreira
- Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), Nursing School of Lisbon, 1600-190 Lisbon, Portugal;
- Centro Hospitalar Universitário Lisboa Norte, 1649-035 Lisbon, Portugal
| | - Cristina Lavareda Baixinho
- Nursing School of Lisbon, 1600-190 Lisbon, Portugal;
- Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), Nursing School of Lisbon, 1600-190 Lisbon, Portugal;
- Center for Innovative Care and Health Technology (ciTechcare), 2410-541 Leiria, Portugal
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Burgel PR, Ballmann M, Drevinek P, Heijerman H, Jung A, Mainz JG, Peckham D, Plant BJ, Schwarz C, Taccetti G, Smyth A. Considerations for the use of inhaled antibiotics for Pseudomonas aeruginosa in people with cystic fibrosis receiving CFTR modulator therapy. BMJ Open Respir Res 2024; 11:e002049. [PMID: 38702073 PMCID: PMC11086488 DOI: 10.1136/bmjresp-2023-002049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 04/11/2024] [Indexed: 05/06/2024] Open
Abstract
The major cause of mortality in people with cystic fibrosis (pwCF) is progressive lung disease characterised by acute and chronic infections, the accumulation of mucus, airway inflammation, structural damage and pulmonary exacerbations. The prevalence of Pseudomonas aeruginosa rises rapidly in the teenage years, and this organism is the most common cause of chronic lung infection in adults with cystic fibrosis (CF). It is associated with an accelerated decline in lung function and premature death. New P. aeruginosa infections are treated with antibiotics to eradicate the organism, while chronic infections require long-term inhaled antibiotic therapy. The prevalence of P. aeruginosa infections has decreased in CF registries since the introduction of CF transmembrane conductance regulator modulators (CFTRm), but clinical observations suggest that chronic P. aeruginosa infections usually persist in patients receiving CFTRm. This indicates that pwCF may still need inhaled antibiotics in the CFTRm era to maintain long-term control of P. aeruginosa infections. Here, we provide an overview of the changing perceptions of P. aeruginosa infection management, including considerations on detection and treatment, the therapy burden associated with inhaled antibiotics and the potential effects of CFTRm on the lung microbiome. We conclude that updated guidance is required on the diagnosis and management of P. aeruginosa infection. In particular, we highlight a need for prospective studies to evaluate the consequences of stopping inhaled antibiotic therapy in pwCF who have chronic P. aeruginosa infection and are receiving CFTRm. This will help inform new guidelines on the use of antibiotics alongside CFTRm.
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Affiliation(s)
- Pierre-Régis Burgel
- Université Paris Cité, Institut Cochin, Inserm U1016, Paris, France
- Respiratory Medicine and Cystic Fibrosis National Reference Center, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
- ERN-lung CF Network, Frankfurt, Germany
| | - Manfred Ballmann
- Kinder- und Jugendklinik der Universitätsmedizin Rostock, Rostock, Germany
| | - Pavel Drevinek
- Department of Medical Microbiology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Harry Heijerman
- Department of Pulmonology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Andreas Jung
- Division of Respiratory Medicine, University Children's Hospital, Zurich, Switzerland
| | - Jochen G Mainz
- Medizinische Hochschule Brandenburg (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Daniel Peckham
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Barry J Plant
- Cork Adult Cystic Fibrosis Centre, Cork University Hospital, University College, Cork, Republic of Ireland
| | - Carsten Schwarz
- HMU-Health and Medical University Potsdam, Internal Medicine and Pneumology, Clinic Westbrandenburg, Division of Cystic Fibrosis, CF Center Westbrandenburg, Campus Potsdam, Potsdam, Germany
| | - Giovanni Taccetti
- Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Centre, Department of Paediatric Medicine, Florence, Italy
| | - Alan Smyth
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
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Green DM, Lahiri T, Raraigh KS, Ruiz F, Spano J, Antos N, Bonitz L, Christon L, Gregoire-Bottex M, Hale JE, Langfelder-Schwind E, La Parra Perez Á, Maguiness K, Massie J, McElroy-Barker E, McGarry ME, Mercier A, Munck A, Oliver KE, Self S, Singh K, Smiley M, Snodgrass S, Tluczek A, Tuley P, Lomas P, Wong E, Hempstead SE, Faro A, Ren CL. Cystic Fibrosis Foundation Evidence-Based Guideline for the Management of CRMS/CFSPID. Pediatrics 2024; 153:e2023064657. [PMID: 38577740 DOI: 10.1542/peds.2023-064657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 04/06/2024] Open
Abstract
A multidisciplinary committee developed evidence-based guidelines for the management of cystic fibrosis transmembrane conductance regulator-related metabolic syndrome/cystic fibrosis screen-positive, inconclusive diagnosis (CRMS/CFSPID). A total of 24 patient, intervention, comparison, and outcome questions were generated based on surveys sent to people with CRMS/CFSPID and clinicians caring for these individuals, previous recommendations, and expert committee input. Four a priori working groups (genetic testing, monitoring, treatment, and psychosocial/communication issues) were used to provide structure to the committee. A systematic review of the evidence was conducted, and found numerous case series and cohort studies, but no randomized clinical trials. A total of 30 recommendations were graded using the US Preventive Services Task Force methodology. Recommendations that received ≥80% consensus among the entire committee were approved. The resulting recommendations were of moderate to low certainty for the majority of the statements because of the low quality of the evidence. Highlights of the recommendations include thorough evaluation with genetic sequencing, deletion/duplication analysis if <2 disease-causing variants were noted in newborn screening; repeat sweat testing until at least age 8 but limiting further laboratory testing, including microbiology, radiology, and pulmonary function testing; minimal use of medications, which when suggested, should lead to shared decision-making with families; and providing communication with emphasis on social determinants of health and shared decision-making to minimize barriers which may affect processing and understanding of this complex designation. Future research will be needed regarding medication use, antibiotic therapy, and the use of chest imaging for monitoring the development of lung disease.
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Affiliation(s)
- Deanna M Green
- Johns Hopkins All Children's Hospital, St Petersburg, Florida
| | - Thomas Lahiri
- University of Vermont Children's Hospital, Burlington, Vermont
| | - Karen S Raraigh
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Jacquelyn Spano
- Stanford University School of Medicine, Stanford, California
| | - Nicholas Antos
- Medical College of Wisconsin, Children's Wisconsin, Milwaukee, Wisconsin
| | - Lynn Bonitz
- Cohen Children's Medical Center of NY/Northwell Health, New Hyde Park, New York
| | - Lillian Christon
- Medical University of South Carolina, Charleston, South Carolina
| | - Myrtha Gregoire-Bottex
- Advanced Pediatric Pulmonology, Pllc, Miramar, Florida
- Memorial Health Network, Hollywood, Florida
| | - Jaime E Hale
- University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | | | - Álvaro La Parra Perez
- John B. Goddard School of Business and Economics, Weber State University, Ogden, Utah
| | - Karen Maguiness
- Riley Hospital for Children at IU Health, Indianapolis, Indiana
| | - John Massie
- University of Melbourne Murdoch Childrens Research Institute, Melbourne, Australia
| | | | - Meghan E McGarry
- University of California San Francisco, San Francisco, California
| | - Angelique Mercier
- Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Anne Munck
- Hospital Necker Enfants malades, AP-HP, Paris, France
| | | | - Staci Self
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Kathryn Singh
- University of California, Irvine, Orange, California Miller Children's and Women's Hospital, Long Beach, California
| | | | | | | | | | - Paula Lomas
- The Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Elise Wong
- The Cystic Fibrosis Foundation, Bethesda, Maryland
| | | | - Albert Faro
- The Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Clement L Ren
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Mahavy CE, Razanatseheno AJ, Mol A, Ngezahayo J, Duez P, El Jaziri M, Baucher M, Rasamiravaka T. Edible Medicinal Guava Fruit ( Psidium guajava L.) Are a Source of Anti-Biofilm Compounds against Pseudomonas aeruginosa. PLANTS (BASEL, SWITZERLAND) 2024; 13:1122. [PMID: 38674531 PMCID: PMC11054768 DOI: 10.3390/plants13081122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024]
Abstract
Psidium guajava is one of the most common edible medicinal plants frequently used in Malagasy traditional medicine to treat gastrointestinal infections. In order to evaluate their probable antibacterial activities, three organic extracts (successive extractions by hexane, dichloromethane, and ethanol) of ripe guava fruits were assessed for their bactericidal and anti-virulence properties against P. aeruginosa PAO1. Although these three extracts have shown no direct antibacterial activity (MIC of 1000 µg/mL) and, at the non-bactericidal concentration of 100 µg/mL, no impact on the production of major P. aeruginosa PAO1 virulence factors (pyocyanin and rhamnolipids), the hexane and dichloromethane extracts showed significant anti-biofilm properties and the dichloromethane extract disrupted the P. aeruginosa PAO1 swarming motility. Bioguided fractionation of the dichloromethane extract led to the isolation and identification of lycopene and β-sitosterol-β-D-glucoside as major anti-biofilm compounds. Interestingly, both compounds disrupt P. aeruginosa PAO1 biofilm formation and maintenance with IC50 of 1383 µM and 131 µM, respectively. More interestingly, both compounds displayed a synergistic effect with tobramycin with a two-fold increase in its effectiveness in killing biofilm-encapsulated P. aeruginosa PAO1. The present study validates the traditional uses of this edible medicinal plant, indicating the therapeutic effectiveness of guava fruits plausibly through the presence of these tri- and tetraterpenoids, which deserve to be tested against pathogens generally implicated in diarrhea.
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Affiliation(s)
- Christian Emmanuel Mahavy
- Laboratory of Biotechnology and Microbiology, University of Antananarivo, BP 906, Antananarivo 101, Madagascar
| | | | - Adeline Mol
- Laboratory of Plant Biotechnology, Université Libre de Bruxelles, B-1050 Brussels, Belgium
| | - Jeremie Ngezahayo
- Centre de Recherche en Sciences Naturelles et de l'Environnement (CRSNE), Université du Burundi, Bujumbura BP 2700, Burundi
| | - Pierre Duez
- Unit of Therapeutic Chemistry and Pharmacognosy, University of Mons, B-7000 Mons, Belgium
| | - Mondher El Jaziri
- Laboratory of Plant Biotechnology, Université Libre de Bruxelles, B-1050 Brussels, Belgium
| | - Marie Baucher
- Laboratory of Plant Biotechnology, Université Libre de Bruxelles, B-1050 Brussels, Belgium
| | - Tsiry Rasamiravaka
- Laboratory of Biotechnology and Microbiology, University of Antananarivo, BP 906, Antananarivo 101, Madagascar
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Schloss J, Coppolo DP, Suggett JA, Nagel MW, Mitchell JP. Interchanging Reusable and Disposable Nebulizers Used with Home-Based Compressors May Result in Inconsistent Dosing: A Laboratory Investigation with Device Combinations Supplied to the US Healthcare Environment. Pulm Ther 2024:10.1007/s41030-024-00256-0. [PMID: 38622443 DOI: 10.1007/s41030-024-00256-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 03/12/2024] [Indexed: 04/17/2024] Open
Abstract
INTRODUCTION Reusable nebulizer-compressor combinations deliver inhaled medications for patients with chronic lung diseases. On hospital discharge, the patient may take home the disposable nebulizer that was packaged and combine it with their home compressor. Though this practice may reduce waste, it can increase variability in medication delivery. Our study compared several reusable and disposable nebulizers packaged with compressor kits used in the US. We included a common disposable hospital nebulizer that may not be supplied with popular home kits but may be brought home after a hospitalization or emergency department visit. We focused on fine droplet mass < 4.7 μm aerodynamic diameter (FDM<4.7 μm), associated with medication delivery to the airways of the lungs. METHODS We evaluated the following nebulizer-compressor combinations (n = 5 replicates): 1. OMBRA® Table Top Compressor with MC 300® reusable and Airlife™ MistyMax™ 10® disposable nebulizer, 2. Sami-the-Seal® compressor with SideStream® reusable and disposable nebulizers and Airlife™ MistyMax 10™ disposable nebulizer, 3. VIOS® compressor with LC Sprint® reusable, and VixOne® and Airlife™ MistyMax™ disposable nebulizers, 4. Innospire® Elegance® compressor with SideStream® reusable and disposable nebulizers and Airlife™ MistyMax 10™ disposable nebulizer, 5. Willis-the-Whale® compressor with SideStream® reusable and disposable nebulizers and Airlife™ MistyMax 10™ disposable nebulizer, 6. Pari PRONEB® Max compressor with LC Sprint® reusable and Airlife™ MistyMax 10™ disposable nebulizer. We placed a 3-ml albuterol solution (0.833 mg/ml) in each nebulizer. A bacterial/viral filter was attached to the nebulizer mouthpiece to capture emitted medication, with the filter exit coupled to a simulator of a tidal breathing adult (rate = 10 cycles/min; Vt = 600 ml; I/E ratio = 1:2). The filter was replaced at 1-min intervals until onset of sputter. Droplet size distributions (n = 5 replicates/system) were determined in parallel by laser diffractometry. RESULTS Cumulative FDM<4.7 μm varied from 381 ± 33 μg for the best performing combination (Proneb/LC-Sprint) to 150 ± 21 μg for the system with the lowest output (VIOS®/MistyMax 10™). CONCLUSIONS Substituting one nebulizer for another can result in large differences in medication delivery to the lungs.
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Affiliation(s)
- Judy Schloss
- Monaghan Medical Corporation, Plattsburgh, NY, 12901, USA
| | | | | | - Mark W Nagel
- Trudell Medical International, London, ON, N5V 5G4, Canada
| | - Jolyon P Mitchell
- Jolyon Mitchell Inhaler Consulting Inc., 1154 St Anthony Road, London, ON, N6H 2R1, Canada.
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9
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Chen Q, Cai P, Chang THW, Burgener E, Kratochvil MJ, Gupta A, Hargil A, Secor PR, Nielsen JE, Barron AE, Milla C, Heilshorn SC, Spakowitz A, Bollyky PL. Pf bacteriophages hinder sputum antibiotic diffusion via electrostatic binding. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.03.10.584330. [PMID: 38496625 PMCID: PMC10942440 DOI: 10.1101/2024.03.10.584330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Despite great progress in the field, chronic Pseudomonas aeruginosa (Pa) infections remain a major cause of morbidity and mortality in patients with cystic fibrosis, necessitating treatment with inhaled antibiotics. Pf phage is a filamentous bacteriophage produced by Pa that has been reported to act as a structural element in Pa biofilms. Pf presence has been associated with resistance to antibiotics and poor outcomes in cystic fibrosis, though the underlying mechanisms are unclear. Here, we have investigated how Pf phages and sputum biopolymers impede antibiotic diffusion using human sputum samples and fluorescent recovery after photobleaching. We demonstrate that tobramycin interacts with Pf phages and sputum polymers through electrostatic interactions. We also developed a set of mathematical models to analyze the complex observations. Our analysis suggests that Pf phages in sputum reduce the diffusion of charged antibiotics due to a greater binding constant associated with organized liquid crystalline structures formed between Pf phages and sputum polymers. This study provides insights into antibiotic tolerance mechanisms in chronic Pa infections and may offer potential strategies for novel therapeutic approaches.
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Affiliation(s)
- Qingquan Chen
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305
| | - Pam Cai
- Department of Chemical Engineering, Stanford University, Stanford, CA, 94305
| | - Tony Hong Wei Chang
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305
| | - Elizabeth Burgener
- Center for Excellence in Pulmonary Biology, Department of Pediatrics, Stanford University, Stanford, CA 94305
- Children’s Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027
| | - Michael J. Kratochvil
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305
- Department of Materials Science and Engineering, Stanford University, 476 Lomita Mall, Stanford, CA 94305
| | - Aditi Gupta
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305
| | - Aviv Hargil
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305
| | - Patrick R. Secor
- Division of Biological Sciences, University of Montana, United States
| | - Josefine Eilsø Nielsen
- Department of Bioengineering, School of Medicine & School of Engineering, Stanford University, Stanford, CA 94305, United States
- Department of Science and Environment, Roskilde University, 4000 Roskilde, Denmark
| | - Annelise E. Barron
- Department of Bioengineering, School of Medicine & School of Engineering, Stanford University, Stanford, CA 94305, United States
| | - Carlos Milla
- Center for Excellence in Pulmonary Biology, Department of Pediatrics, Stanford University, Stanford, CA 94305
| | - Sarah C. Heilshorn
- Department of Materials Science and Engineering, Stanford University, 476 Lomita Mall, Stanford, CA 94305
| | - Andy Spakowitz
- Department of Chemical Engineering, Stanford University, Stanford, CA, 94305
- Department of Materials Science and Engineering, Stanford University, 476 Lomita Mall, Stanford, CA 94305
| | - Paul L. Bollyky
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305
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10
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Gramegna A, Aliberti S, Amorim A, Blasi F, Bourke S, Burgel PR, Diamantea F, Durieu I, Fila L, Moreno RMG, Messore B, Pokojová E, Taccetti G, Verhulst S, Dugac AV, Wege S, Duff A, Southern KW, Castellani C. Monitoring of ECFS quality standards for the clinical management of adults with cystic fibrosis. J Cyst Fibros 2024; 23:306-313. [PMID: 37949745 DOI: 10.1016/j.jcf.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 10/19/2023] [Accepted: 11/04/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Although cystic fibrosis (CF) standards of care have been produced and regularly updated, they are not specifically targeting at the adult population. The ECFS Standards of Care Project established an international task force of experts to identify quality standards for adults with CF and assess their adherence. METHODS This study was composed of two phases. In the first one, a task force of international experts derived from published guidelines and graded ten quality standards for adult CF care using a modified Delphi methodology. In the second phase, an international audit was conducted among adult CF centers to retrospectively validate the quality statements and monitor adherence. RESULTS The task force identified 10 quality standards specific to the care of adults with CF, mainly based on the 2018 ECFS standards of care. 14 adult CF centers participated in the audit, which showed that most quality standards for the management of CF in adults are met across Europe. Heterogeneity in adherence to standards was found across centers according to geographical setting and centers' characteristics. CONCLUSIONS The identification of quality standards is a valuable resource for the standardization and monitoring of care delivery across centers taking care of adults with CF.
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Affiliation(s)
- Andrea Gramegna
- Department of Pathophysiology and Transplantation, University of Milan, Milan 20122, Italy; Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan 20072, Italy; IRCCS Humanitas Research Hospital, Respiratory Unit, Via Manzoni 56, 20089 Rozzano, Milan, Italy.
| | - Adelina Amorim
- Adult Reference CF Center, Pulmonology Department, Faculty of Medicine, University of Porto, Portugal
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan 20122, Italy; Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Stephen Bourke
- Adult Cystic Fibrosis Center, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Pierre-Régis Burgel
- Department of Respiratory Medicine and French National Cystic Fibrosis Reference Center, Cochin Hospital, APHP, Paris France; Université Paris Cité and Inserm U1016, Institut Cochin, Paris, France; ERN-Lung Cystic Fibrosis Network, Frankfurt, Germany
| | | | - Isabelle Durieu
- ERN-Lung Cystic Fibrosis Network, Frankfurt, Germany; Cystic Fibrosis Adult Refence Center, Department of Internal Medicine, Groupe Hospitalier Sud, Hospices Civils de Lyon, 69495 Pierre Benite Cedex; INSERM U1290 RESHAPE Research in Health Care Performance, Lyon 1 Claude Bernard University, Lyon, France
| | - Libor Fila
- Cystic Fibrosis Centre, Department of Pneumology, University Hospital in Motol, Prague, Czech Republic
| | - Rosa María Girón Moreno
- Adult Reference CF Center, Pulmonology Department. Instituto de investigacion La Princesa. Calle Diego de Leon 62, Madrid 28006 Spain
| | - Barbara Messore
- Adult Cystic Fibrosis Center, Pulmonology Dept, AOU San Luigi Gonzaga, Orbassano, Turin, Italy
| | - Eva Pokojová
- ERN-Lung Cystic Fibrosis Network, Frankfurt, Germany; Department of Respiratory Diseases, University Hospital Brno, Jihlavska Str. 20, 62500 Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Giovanni Taccetti
- Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Centre, Department of Paediatric Medicine, 50139 Florence, Italy
| | - Stijn Verhulst
- Lab of Experimental Medicine and Pediatrics, University of Antwerp and department of Pediatrics, Antwerp University Hospital, Antwerp, Belgium
| | - Andrea Vukić Dugac
- Cystic Fibrosis Centre for Children and Adults, University Hospital Centre Zagreb, Croatia; School of Medicine, University of Zagreb, Croatia
| | - Sabine Wege
- Department of Pulmonology and Respiratory Medicine, Thoraxklinik at the University Hospital of Heidelberg, Röntgenstr. 1, 69126 Heidelberg, Germany
| | | | - Kevin W Southern
- Women and Children's Health, University of Liverpool, Liverpool, United Kingdom
| | - Carlo Castellani
- Cystic Fibrosis Center, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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11
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Shah KS, Saiman L, LiPuma JJ, Kosorok MR, Muhlebach MS. Association of Pseudomonas aeruginosa incident infections with adherence to cystic fibrosis foundation care guidelines. J Cyst Fibros 2024; 23:300-305. [PMID: 37953182 DOI: 10.1016/j.jcf.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/20/2023] [Accepted: 10/26/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Care guidelines for cystic fibrosis (CF) have been developed to enhance consistent care and to improve health outcomes. We determined if adherence to CF care guidelines predicted P. aeruginosa incidence rates (Pa-IR) at U.S. CF centers in 2018. METHODS This cross-sectional CF Foundation Patient Registry study included 82 adult and 132 pediatric centers. Adherence to 12 guidelines was defined categorically (guideline met) or as a continuous measure (proportion of patients being treated/evaluated per guideline). Association of adherence to individual guidelines with Pa-IR, accounted for center and patient characteristics relevant to Pa-IR and were modeled using random forests and weighted-least-squares (WLS) analyses. RESULTS The mean Pa-IR was 0.2 cases/patient-years at risk (SE 0.0074) for all centers combined. Guideline adherence was lowest for ≥4 bacterial cultures/year (54% of centers) and annual oral glucose tolerance test (OGTT) (48% of centers), and highest for annual non-tuberculous mycobacteria (NTM) sputum culture (98%). The mean number of guidelines met was 6.7 and higher for pediatric (7.3) than adult (5.6) centers, (p<0.001). The number of guidelines met correlated negatively with Pa-IR (β=-0.007, p = 0.043). Macrolide prescription and annual OGTT per guideline were associated with lower and higher Pa-IR, respectively. Centers with lower center-wide lung function, higher proportion of pwCF with low body-mass index, and location in the Southwest had higher Pa-IR. CONCLUSION Overall adherence to guidelines was high except for performing ≥4 bacterial cultures/year and OGTT. Higher Pa-IR was associated with center characteristics and lower guideline adherence. The lower Pa-IR with greater adherence to guidelines suggests that focusing on quality care can positively impact Pa-IR.
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Affiliation(s)
- Kushal S Shah
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, United States
| | - John J LiPuma
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI 48104, United States
| | - Michael R Kosorok
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Marianne S Muhlebach
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC 27599, United States; Marisco Lung Institute, University of North Carolina, Chapel Hill, NC 27599, United States.
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12
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Sawicki GS, Wicha WW, Hiley TS, Close NC, Gelone SP, Guico-Pabia CJ. Safety and Pharmacokinetics Following Oral or Intravenous Lefamulin in Adults With Cystic Fibrosis. Clin Ther 2024; 46:96-103. [PMID: 38195348 DOI: 10.1016/j.clinthera.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/27/2023] [Accepted: 12/03/2023] [Indexed: 01/11/2024]
Abstract
PURPOSE Methicillin-resistant Staphylococcus aureus infections are increasing in prevalence in patients with cystic fibrosis (CF) and are associated with worsening lung function and increased mortality. Lefamulin is a pleuromutilin antimicrobial approved to treat community-acquired bacterial pneumonia based on potent in vitro activity and clinical efficacy. This Phase I, open-label, randomized crossover study assessed the safety and pharmacokinetic profile of oral and intravenous (IV) lefamulin in adults with CF. METHODS The study comprised 2 dosing periods in which adults with CF (N = 13) received a single dose of lefamulin via a 150-mg IV infusion or 600-mg immediate-release orally administered tablet, separated by a 4- to 7-day washout period. Pharmacokinetic and safety parameters were assessed after lefamulin treatment. FINDINGS Single doses of lefamulin administered via oral tablet or IV infusion resulted in comparable drug exposure, and sputum analysis suggested rapid penetration of lefamulin into the lung. Comparison of the present results with those obtained from prior single-dose studies of healthy volunteers indicate no meaningful difference in the pharmacokinetic properties of lefamulin in patients with CF. Treatment-emergent adverse events were consistent with previous reports, and the majority were mild in severity. IMPLICATIONS These results show similar lefamulin pharmacokinetic and safety profiles between patients with CF and healthy volunteers receiving the same oral and IV doses, suggesting no need for lefamulin dose adjustment in patients with CF and indicating the potential of lefamulin as therapy for lung infections in patients with CF. CLINICALTRIALS gov identifier: NCT05225805.
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Affiliation(s)
| | | | - Tara S Hiley
- Nabriva Therapeutics US, Inc, Fort Washington, Pennsylvania, USA
| | | | - Steven P Gelone
- Nabriva Therapeutics US, Inc, Fort Washington, Pennsylvania, USA
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13
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Ghassani A, Triponney P, Bour M, Plésiat P, Jeannot K. Mutations in genes lpxL1, bamA, and pmrB impair the susceptibility of cystic fibrosis strains of Pseudomonas aeruginosa to murepavadin. Antimicrob Agents Chemother 2024; 68:e0129823. [PMID: 38092672 PMCID: PMC10790571 DOI: 10.1128/aac.01298-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/06/2023] [Indexed: 01/11/2024] Open
Abstract
Murepavadin is a peptidomimetic exhibiting specific inhibitory activity against Pseudomonas species. In the present study, its in vitro activity was assessed on 230 cystic fibrosis (CF) strains of Pseudomonas aeruginosa isolated from 12 French hospitals, in comparison with 12 other antipseudomonal antibiotics. Although murepavadin is still in preclinical stage of development, 9.1% (n = 21) of strains had a minimum inhibitory concentration (MIC) >4 mg/L, a level at least 128-fold higher than the modal MIC value of the whole collection (≤0.06 mg/L). Whole-genome sequencing of these 21 strains along with more susceptible isogenic counterparts coexisting in the same patients revealed diverse mutations in genes involved in the synthesis (lpxL1 and lpxL2) or transport of lipopolysaccharides (bamA, lptD, and msbA), or encoding histidine kinases of two-component systems (pmrB and cbrA). Allelic replacement experiments with wild-type reference strain PAO1 confirmed that alteration of genes lpxL1, bamA, and/or pmrB can decrease the murepavadin susceptibility from 8- to 32-fold. Furthermore, we found that specific amino acid substitutions in histidine kinase PmrB (G188D, Q105P, and D45E) reduce the susceptibility of P. aeruginosa to murepavadin, colistin, and tobramycin, three antibiotics used or intended to be used (murepavadin) in aerosols to treat colonized CF patients. Whether colistin or tobramycin may select mutants resistant to murepavadin or the opposite needs to be addressed by clinical studies.
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Affiliation(s)
- Aya Ghassani
- UMR6249 CNRS Chrono-environnement, Université de Franche-Comté, Besançon, France
| | - Pauline Triponney
- Laboratoire associé au Centre National de Référence de la résistance aux antibiotiques, Besançon, France
| | - Maxime Bour
- Laboratoire associé au Centre National de Référence de la résistance aux antibiotiques, Besançon, France
| | - Patrick Plésiat
- UMR6249 CNRS Chrono-environnement, Université de Franche-Comté, Besançon, France
| | - Katy Jeannot
- UMR6249 CNRS Chrono-environnement, Université de Franche-Comté, Besançon, France
- Laboratoire associé au Centre National de Référence de la résistance aux antibiotiques, Besançon, France
- Laboratoire de Bactériologie, Centre Hospitalier Universitaire Jean Minjoz, Besançon, France
| | - MucoMicrobes study GroupCardot-MartinEmilie1CattoirVincent2CrémetLise3Doléan-JordheimAnne4FerroniAgnès5GarnierFabien6Guet-RevilletHélène7GuillardThomas8Hery-ArnaudGeneviève9ImbertGuenièvre10MarianiPatricia11Centre Hospitalier Universitaire Foch, Paris, FranceCentre Hospitalier Universitaire de Rennes, Rennes, FranceCentre Hospitalier Universitaire de Nantes, Nantes, FranceHospices civils de Lyon, Lyon, FranceCentre Hospitalier Universitaire de Necker, Paris, FranceCentre Hospitalier Universitaire de Limoges, Limoges, FranceCentre Hospitalier Universitaire de Toulouse, Toulouse, FranceCentre Hospitalier Universitaire de Reims, Reims, FranceCentre Hospitalier Universitaire de Brest, Brest, FranceCentre Hospitalier de Toulon, Toulon, FranceCentre Hospitalier Universitaire Robert Debré, Paris, France
- UMR6249 CNRS Chrono-environnement, Université de Franche-Comté, Besançon, France
- Laboratoire associé au Centre National de Référence de la résistance aux antibiotiques, Besançon, France
- Laboratoire de Bactériologie, Centre Hospitalier Universitaire Jean Minjoz, Besançon, France
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14
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Manika K, Diamantea F, Tsakona A, Kakolyris A, Sopiadou A, Kotoulas SC, Sionidou M, Kirvasili SS, Hadji-Mitrova M, Papadaki E, Chrysochoou EA, Hatziagorou E. Use of cystic fibrosis inhaled medication before and after elexacaftor/tezacaftor/ivacaftor initiation. J Cyst Fibros 2024; 23:29-31. [PMID: 37169616 DOI: 10.1016/j.jcf.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/27/2023] [Accepted: 05/02/2023] [Indexed: 05/13/2023]
Abstract
Elexacator/tezacaftor/ivacaftor (ETI) has improved cystic fibrosis (CF) outcomes. A reduction in use of maintenance medication after its initiation has been reported. Seventy-one adult people with CF (PwCF) who are followed in three CF centers and completed one year of treatment with ETI were included in this study. Their use of inhaled dornase-α, colistin, tobramycin, aztreonam and levofloxacin during this period was compared with the corresponding use during one year without ETI, using the Medication Possession Ratio (MPR). MPR was significantly decreased after ETI initiation for dornase-α (67±35% vs 48±40%, p<0.001) and for all four inhaled antibiotics together (62±33% vs 41±37%, p<0.001). The findings of this multi-center, retrospective, study suggest that the initiation of ETI significantly leads to decrease in use of standard inhaled medication in PwCF. The significance of this finding in the course of the disease is yet to be investigated by larger prospective clinical trials.
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Affiliation(s)
- Katerina Manika
- Adult CF Unit, Pulmonary Department, Aristotle University of Thessaloniki, "G. Papanikolaou" Hospital, Leoforos Papanikolaou, Exochi, Thessaloniki 57010, Greece.
| | - Filia Diamantea
- Adult CF Unit, Sismanoglio Hospital, Sismanogliou 1, Marousi, Athens 15126, Greece
| | - Anna Tsakona
- Adult CF Unit, Pulmonary Department, Aristotle University of Thessaloniki, "G. Papanikolaou" Hospital, Leoforos Papanikolaou, Exochi, Thessaloniki 57010, Greece
| | - Alexandros Kakolyris
- Adult CF Unit, Sismanoglio Hospital, Sismanogliou 1, Marousi, Athens 15126, Greece
| | - Athina Sopiadou
- Cystic Fibrosis Unit, 3rd Paediatric Department, "Hippokration" Hospital, Aristotle University of Thessaloniki, Kostantinoupoleos 49, Thessaloniki 54642, Greece
| | - Serafeim-Chrysovalantis Kotoulas
- Adult CF Unit, Pulmonary Department, Aristotle University of Thessaloniki, "G. Papanikolaou" Hospital, Leoforos Papanikolaou, Exochi, Thessaloniki 57010, Greece
| | - Maria Sionidou
- Adult CF Unit, Pulmonary Department, Aristotle University of Thessaloniki, "G. Papanikolaou" Hospital, Leoforos Papanikolaou, Exochi, Thessaloniki 57010, Greece
| | - Sirmo-Stiliani Kirvasili
- Cystic Fibrosis Unit, 3rd Paediatric Department, "Hippokration" Hospital, Aristotle University of Thessaloniki, Kostantinoupoleos 49, Thessaloniki 54642, Greece
| | - Marija Hadji-Mitrova
- Adult CF Unit, Pulmonary Department, Aristotle University of Thessaloniki, "G. Papanikolaou" Hospital, Leoforos Papanikolaou, Exochi, Thessaloniki 57010, Greece
| | - Eleni Papadaki
- Adult CF Unit, Pulmonary Department, Aristotle University of Thessaloniki, "G. Papanikolaou" Hospital, Leoforos Papanikolaou, Exochi, Thessaloniki 57010, Greece
| | - Elisavet-Anna Chrysochoou
- Cystic Fibrosis Unit, 3rd Paediatric Department, "Hippokration" Hospital, Aristotle University of Thessaloniki, Kostantinoupoleos 49, Thessaloniki 54642, Greece
| | - Elpis Hatziagorou
- Cystic Fibrosis Unit, 3rd Paediatric Department, "Hippokration" Hospital, Aristotle University of Thessaloniki, Kostantinoupoleos 49, Thessaloniki 54642, Greece
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15
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Martiniano SL, Caceres SM, Poch K, Rysavy NM, Lovell VK, Armantrout E, Jones M, Anthony M, Keck A, Nichols DP, Vandalfsen JM, Sagel SD, Wagner B, Xie J, Weaver K, Heltshe SL, Daley CL, Davidson RM, Nick JA. Prospective evaluation of nontuberculous mycobacteria disease in cystic fibrosis: The design of the PREDICT study. J Cyst Fibros 2024; 23:50-57. [PMID: 37666709 PMCID: PMC10907544 DOI: 10.1016/j.jcf.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/07/2023] [Accepted: 08/25/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Nontuberculous mycobacteria (NTM) are an important cause of airway infections in people with cystic fibrosis (pwCF). Isolation of NTM from respiratory specimens of pwCF do not mandate treatment in the absence of clinical and radiologic features of NTM pulmonary disease (NTM-PD), as some pwCF clear the infection without treatment and others do not appear to progress to NTM-PD despite persistent infection. An evidence-based protocol to standardize diagnosis of NTM-PD is needed to systematically identify pwCF who may benefit from treatment. METHODS In this multicenter observational study, eligible pwCF who are 6 years of age and older and who have had a recent positive NTM culture are systematically evaluated for NTM-PD. Participants are identified based on positive NTM culture results obtained during routine clinical care and following enrollment are evaluated for NTM-PD and CF-related comorbidities. Participants are followed in PREDICT until they meet NTM-PD diagnostic criteria and are ready to initiate NTM treatment, or until study termination. Active participants who have not met these criteria are re-consented every 5 years to enable long-term participation. RESULTS The primary endpoint will summarize the proportion of participants who meet the NTM-PD diagnosis definition. The time from enrollment to NTM-PD diagnosis will be derived from Kaplan-Meier estimates. CONCLUSION A prospective protocol to identify NTM-PD in pwCF will test if this standardized approach defines a cohort with signs and symptoms associated with NTM-PD, to assist with clinical decision making and to build a framework for future therapeutic trials. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02073409.
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Affiliation(s)
- Stacey L Martiniano
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA.
| | - Silvia M Caceres
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Katie Poch
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Noel M Rysavy
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Valerie K Lovell
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Emily Armantrout
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Marion Jones
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Margaret Anthony
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Allison Keck
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - David P Nichols
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Jill M Vandalfsen
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Scott D Sagel
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Brandie Wagner
- Department of Biostatistics and Informatics, Colorado School of Public Health University of Colorado Anschutz Medical Campus Aurora Colorado, USA
| | - Jing Xie
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Katie Weaver
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Sonya L Heltshe
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Charles L Daley
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA; Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Rebecca M Davidson
- Center for Genes, Environment, and Health, National Jewish Health, Denver, CO 80206, USA
| | - Jerry A Nick
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA; Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
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16
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Agoramurthi K, Berlinski A. Effect of Disinfection Method and Testing Methodology on the Performance of a Breath-Enhanced Jet Nebulizer. Pharmaceutics 2023; 16:16. [PMID: 38276494 PMCID: PMC10819286 DOI: 10.3390/pharmaceutics16010016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/18/2023] [Accepted: 11/29/2023] [Indexed: 01/27/2024] Open
Abstract
National guidelines for cystic fibrosis recommend cleaning and disinfecting nebulizers after each use. We tested two groups of five reusable breath-enhanced nebulizers after 0, 5, 10, 15, 20, 30, 60, 90, 120, 150, and 180 sterilization (baby bottle sterilizer) or cleaning cycles. The nebulizers were operated for 7 min (6 L/min) after loading albuterol (2.5 mg/3 mL), and they were evaluated with and without breathing simulation after cleaning/sterilization (0-180 and 0-60 cycles, respectively). Over the course of 180 cleaning/sterilization cycles, the mean (SD) solution output was 1.33 mL (0.12 mL)/1.29 mL (0.08 mL); the nebulizer mass remaining in the nebulizer was 61.5% (5.2%)/63% (4%); sputtering time was 4.7 min (0.8 min)/4.8 s (0.6 min); inspiratory filter was 19% (3%)/18.5% (2.4%); expiratory filter was 6.7% (1.1%)/6.7% (0.8%); and difference in drug output calculated using the solution output and nebulizer mass was 6.8% (4%)/5.2% (2.9%). Thermal disinfection with a baby-bottle sterilizer did not alter the performance of a reusable breath-enhanced nebulizer. The nebulizer test performed without breathing simulation underestimated its performance. The calculation of the drug output based on the solution output resulted in its overestimation.
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Affiliation(s)
- Kanjanamala Agoramurthi
- Pulmonary and Sleep Medicine Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
- Pediatric Aerosol Research Laboratory, Arkansas Children’s Research Institute, Little Rock, AR 72202, USA
| | - Ariel Berlinski
- Pulmonary and Sleep Medicine Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
- Pediatric Aerosol Research Laboratory, Arkansas Children’s Research Institute, Little Rock, AR 72202, USA
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17
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Hardman SJ, Shackley FM, Ugonna K, Darton TC, Rigby AS, Bogaert D, Binkowska JM, Condliffe AM. Seasonal Azithromycin Use in Paediatric Protracted Bacterial Bronchitis Does Not Promote Antimicrobial Resistance but Does Modulate the Nasopharyngeal Microbiome. Int J Mol Sci 2023; 24:16053. [PMID: 38003242 PMCID: PMC10671346 DOI: 10.3390/ijms242216053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 10/30/2023] [Accepted: 11/03/2023] [Indexed: 11/26/2023] Open
Abstract
Protracted bacterial bronchitis (PBB) causes chronic wet cough for which seasonal azithromycin is increasingly used to reduce exacerbations. We investigated the impact of seasonal azithromycin on antimicrobial resistance and the nasopharyngeal microbiome. In an observational cohort study, 50 children with PBB were enrolled over two consecutive winters; 25/50 at study entry were designated on clinical grounds to take azithromycin over the winter months and 25/50 were not. Serial nasopharyngeal swabs were collected during the study period (12-20 months) and cultured bacterial isolates were assessed for antimicrobial susceptibility. 16S rRNA-based sequencing was performed on a subset of samples. Irrespective of azithromycin usage, high levels of azithromycin resistance were found; 73% of bacteria from swabs in the azithromycin group vs. 69% in the comparison group. Resistance was predominantly driven by azithromycin-resistant S. pneumoniae, yet these isolates were mostly erythromycin susceptible. Analysis of 16S rRNA-based sequencing revealed a reduction in within-sample diversity in response to azithromycin, but only in samples of children actively taking azithromycin at the time of swab collection. Actively taking azithromycin at the time of swab collection significantly contributed to dissimilarity in bacterial community composition. The discrepancy between laboratory detection of azithromycin and erythromycin resistance in the S. pneumoniae isolates requires further investigation. Seasonal azithromycin for PBB did not promote antimicrobial resistance over the study period, but did perturb the microbiome.
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Affiliation(s)
- Simon J. Hardman
- Department of General Paediatrics, Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield S44 5BL, UK
| | - Fiona M. Shackley
- Department of Paediatric Immunology, Allergy and Infectious Diseases, Sheffield Children’s Hospital NHS Foundation Trust, Sheffield S10 2TH, UK;
| | - Kelechi Ugonna
- Department of Paediatric Respiratory Medicine, Sheffield Children’s Hospital NHS Foundation Trust, Sheffield S10 2TH, UK;
| | - Thomas C. Darton
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2RX, UK; (T.C.D.); (A.M.C.)
| | - Alan S. Rigby
- Hull York Medical School, University of Hull, Hull HU6 7RX, UK;
| | - Debby Bogaert
- Department of Paediatric Immunology and Infectious Diseases, Wilhelmina Children’s Hospital and University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh EH8 9YL, UK;
| | - Justyna M. Binkowska
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh EH8 9YL, UK;
| | - Alison M. Condliffe
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2RX, UK; (T.C.D.); (A.M.C.)
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18
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Fathi M, Moradi N, Yousefi N, Peiravian F, Shobeiri N. Evaluating the affordability of asthma, chronic obstructive pulmonary disease, and cystic fibrosis medicines in a middle-income country. BMC Pulm Med 2023; 23:429. [PMID: 37925396 PMCID: PMC10625700 DOI: 10.1186/s12890-023-02737-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 10/26/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND A heavy financial burden is imposed on patients suffering from chronic diseases due to medicine out-of-pocket payments. OBJECTIVES This study focuses on assessing the affordability of medications used for chronic respiratory diseases (CRDs) such as asthma, chronic obstructive pulmonary disease (COPD), and cystic fibrosis (CF) in Iran, specifically on the category R medicines listed in the 2017 Iran drug list (IDL) that are used for the treatment of these diseases, based on the anatomical therapeutic chemical (ATC) drug code. METHODS The affordability of medicines in mono and combination therapy approaches was assessed in CRDs using the World Health Organization/Health Action International (WHO/HAI) methodology. Accordingly, if out-of-pocket payment for 30-days of pharmacotherapy exceeds one day for the lowest-paid unskilled government worker (LPGW), it's considered non-affordable. RESULTS Based on the monotherapy approach, our finding demonstrates that all generic medicines of category R were affordable. However, branded drugs such as Symbicort®, Pulmicort Respules®, Flusalmex®, Seretide®, Fluticort Plus®, Seroflo®, and Salmeflo® cost between 1.2 and 2.5 days' wage of LPGW and considered unaffordable despite 70% insurance coverage. Moreover, based on the affordability ratio in the combination therapy approach, all medicines used in asthma, COPD, and CF patients with mild respiratory problems are affordable except omalizumab (inj), which is non-affordable due to its high price and no insurance coverage. CONCLUSION Results showed that the existing insurance coverage does not protect households from hardship, so more considerations are needed such as different insurance schedules and patient support programs.
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Affiliation(s)
- Mahdieh Fathi
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Najmeh Moradi
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nazila Yousefi
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzad Peiravian
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nikta Shobeiri
- Department of Pharmaceutical Control, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.
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19
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Wajda KE, Roesch EA, Gifford AH. Chronic daily respiratory care needs in people with cystic fibrosis treated with highly effective cystic fibrosis transmembrane conductance regulator modulators. Curr Opin Pulm Med 2023; 29:580-586. [PMID: 37611027 DOI: 10.1097/mcp.0000000000001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
PURPOSE OF REVIEW Cystic fibrosis is a genetic disease that increases risk of death from respiratory failure because of impairment in mucociliary clearance. Complex daily care regimens including medications and airway clearance techniques (ACTs) aim to preserve lung function and alleviate symptoms for people with cystic fibrosis (pwCF). The success of highly effective modulator therapy (HEMT) permits evaluation of treatment simplification. In this review, we evaluate adjustments made in daily respiratory care among pwCF taking HEMT and the feasibility of treatment simplification. RECENT FINDINGS Treatment simplification has been identified as a top priority among pwCF, with recent studies showing pwCF are willing to sacrifice mild to moderate amounts of lung function and longevity to reduce treatment burden. Retrospective studies have shown that patients taking HEMT with better baseline lung function have lower adherence to and prescription of inhaled medications. A randomized, controlled trial found that short-term discontinuation of dornase alfa or hypertonic saline was clinically noninferior to continuation of these medications. Major knowledge gaps remain about withdrawing ACTs. SUMMARY This review highlights trials evaluating the feasibility of treatment simplification among pwCF taking HEMT. More data is needed to evaluate approaches to simplification in this phenotypically diverse patient population.
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Affiliation(s)
- Katherine E Wajda
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University Hospitals Cleveland Medical Center
- Department of Pediatrics, Division of Pediatric Pulmonology, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Erica A Roesch
- Department of Pediatrics, Division of Pediatric Pulmonology, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Alex H Gifford
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University Hospitals Cleveland Medical Center
- Department of Pediatrics, Division of Pediatric Pulmonology, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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20
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Gipsman AI, Lapinel NC, Mayer OH. Airway clearance in patients with neuromuscular disease. Paediatr Respir Rev 2023; 47:33-40. [PMID: 36894356 PMCID: PMC10928549 DOI: 10.1016/j.prrv.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
Airway clearance is a critical component of both maintenance of respiratory health and management of acute respiratory illnesses. The process of effective airway clearance begins with the recognition of secretions in the airway and culminates in expectoration or swallowing. There are multiple points on this continuum at which neuromuscular disease causes impaired airway clearance. This can result in an otherwise mild upper respiratory illness progressing unabated from an easily managed condition to a severe, life-threatening lower respiratory illness requiring intensive therapy for patient recovery. Even during periods of relative health, airway protective mechanisms can be compromised, and patients may have difficulty managing average quantities of secretions. This review summarizes airway clearance physiology and pathophysiology, mechanical and pharmacologic treatment modalities, and provides a practical approach for managing secretions in patients with neuromuscular disease. Neuromuscular disease is an umbrella term used to describe disorders that involve dysfunction of peripheral nerves, the neuromuscular junction, or skeletal muscle. Although this paper specifically reviews airway clearance pertaining to those with neuromuscular diseases (e.g., muscular dystrophy, spinal muscular atrophy, myasthenia gravis), most of its content is relevant to the management of patients with central nervous system disorders such as chronic static encephalopathy caused by trauma, metabolic or genetic abnormalities, congenital infection, or neonatal hypoxic-ischemic injury.
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Affiliation(s)
| | | | - Oscar Henry Mayer
- Division of Pulmonary and Sleep Medicine, The Children's Hospital of Philadelphia, USA
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21
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Love AJ, Quon BS. Falling through the Cracks-The Impact of Care Gaps on Lung Function Loss in Cystic Fibrosis. Ann Am Thorac Soc 2023; 20:1235-1236. [PMID: 37655958 PMCID: PMC10502880 DOI: 10.1513/annalsats.202305-459ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Affiliation(s)
- Allison J Love
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | - Bradley S Quon
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
- Centre for Heart Lung Innovation, University of British Columbia and St. Paul's Hospital, Vancouver, British Columbia, Canada
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22
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Goldberg JF, Truby LK, Agbor-Enoh S, Jackson AM, deFilippi CR, Khush KK, Shah P. Selection and Interpretation of Molecular Diagnostics in Heart Transplantation. Circulation 2023; 148:679-694. [PMID: 37603604 PMCID: PMC10449361 DOI: 10.1161/circulationaha.123.062847] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
The number of heart transplants performed annually in the United States and worldwide continues to increase, but there has been little change in graft longevity and patient survival over the past 2 decades. The reference standard for diagnosis of acute cellular and antibody-mediated rejection includes histologic and immunofluorescence evaluation of endomyocardial biopsy samples, despite invasiveness and high interrater variability for grading histologic rejection. Circulating biomarkers and molecular diagnostics have shown substantial predictive value in rejection monitoring, and emerging data support their use in diagnosing other posttransplant complications. The use of genomic (cell-free DNA), transcriptomic (mRNA and microRNA profiling), and proteomic (protein expression quantitation) methodologies in diagnosis of these posttransplant outcomes has been evaluated with varying levels of evidence. In parallel, growing knowledge about the genetically mediated immune response leading to rejection (immunogenetics) has enhanced understanding of antibody-mediated rejection, associated graft dysfunction, and death. Antibodies to donor human leukocyte antigens and the technology available to evaluate these antibodies continues to evolve. This review aims to provide an overview of biomarker and immunologic tests used to diagnose posttransplant complications. This includes a discussion of pediatric heart transplantation and the disparate rates of rejection and death experienced by Black patients receiving a heart transplant. This review describes diagnostic modalities that are available and used after transplant and the landscape of future investigations needed to enhance patient outcomes after heart transplantation.
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Affiliation(s)
- Jason F Goldberg
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, VA (J.F.G., C.R.d., P.S.)
- Department of Pediatrics, Inova L.J. Murphy Children's Hospital, Falls Church, VA (J.F.G.)
| | - Lauren K Truby
- Department of Medicine, University of Texas Southwestern, Dallas (L.K.T.)
| | - Sean Agbor-Enoh
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD (S.A.-E.)
- Applied Precision Genomics, National Heart, Lung and Blood Institute, Bethesda, MD (S.A.-E.)
| | - Annette M Jackson
- Department of Surgery, Duke University School of Medicine, Durham, NC (A.M.J.)
| | - Christopher R deFilippi
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, VA (J.F.G., C.R.d., P.S.)
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, CA (K.K.K.)
| | - Palak Shah
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, VA (J.F.G., C.R.d., P.S.)
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23
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Escher A, Kieninger E, Groof SD, Savas ST, Schneiter M, Tschanz SA, Frenz M, Latzin P, Casaulta C, Müller L. In Vitro Effect of Combined Hypertonic Saline and Salbutamol on Ciliary Beating Frequency and Mucociliary Transport in Human Nasal Epithelial Cells of Healthy Volunteers and Patients with Cystic Fibrosis. J Aerosol Med Pulm Drug Deliv 2023; 36:171-180. [PMID: 37196208 DOI: 10.1089/jamp.2022.0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
Background: Inhalation of hypertonic saline (HS) is standard of care in patients with cystic fibrosis (CF). However, it is unclear if adding salbutamol has-besides bronchodilation-further benefits, for example, on the mucociliary clearance. We assessed this in vitro by measuring the ciliary beating frequency (CBF) and the mucociliary transport rate (MCT) in nasal epithelial cells (NECs) of healthy volunteers and patients with CF. Aims: To investigate the effect of HS, salbutamol, and its combination on (muco)ciliary activity of NECs in vitro, and to assess potential differences between healthy controls and patients with CF. Methods: NECs obtained from 10 healthy volunteers and 5 patients with CF were differentiated at the air-liquid interface and aerosolized with 0.9% isotonic saline ([IS] control), 6% HS, 0.06% salbutamol, or combined HS and salbutamol. CBF and MCT were monitored over 48-72 hours. Results: In NECs of healthy controls, the absolute CBF increase was comparable for all substances, but CBF dynamics were different: HS increased CBF slowly and its effect lasted for an extended period, salbutamol and IS increased CBF rapidly and the effect subsided similarly fast, and HS and salbutamol resulted in a rapid and long-lasting CBF increase. Results for CF cells were comparable, but less pronounced. Similar to CBF, MCT increased after the application of all the tested substances. Conclusion: CBF and MCT of NECs of healthy participants and CBF of patients with CF increased upon treatment with aerosolized IS, HS, salbutamol, or HS and salbutamol, showing a relevant effect for all tested substances. The difference in the CBF dynamics can be explained by the fact that the properties of the mucus are changed differently by different saline concentrations.
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Affiliation(s)
- Anaïs Escher
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Elisabeth Kieninger
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Susan De Groof
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Sibel T Savas
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Martin Schneiter
- Institute of Applied Physics, University of Bern, Bern, Switzerland
- Institute of Anatomy, University of Bern, Bern, Switzerland
| | | | - Martin Frenz
- Institute of Applied Physics, University of Bern, Bern, Switzerland
| | - Philipp Latzin
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Carmen Casaulta
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Loretta Müller
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
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24
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Bentley S, Cheong J, Gudka N, Makhecha S, Hadjisymeou-Andreou S, Standing JF. Therapeutic drug monitoring-guided dosing for pediatric cystic fibrosis patients: recent advances and future outlooks. Expert Rev Clin Pharmacol 2023; 16:715-726. [PMID: 37470695 DOI: 10.1080/17512433.2023.2238597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Medicine use in children with cystic fibrosis (CF) is complicated by inconsistent pharmacokinetics at variance with the general population, a lack of research into this and its effects on clinical outcomes. In the absence of established dose regimens, therapeutic drug monitoring (TDM) is a clinically relevant tool to optimize drug exposure and maximize therapeutic effect by the bedside. In clinical practice though, use of this is variable and limited by a lack of expert recommendations. AREAS COVERED We aimed to review the use of TDM in children with CF to summarize recent developments, current recommendations, and opportunities for future directions. We searched PubMed for relevant publications using the broad search terms "cystic fibrosis" in combination with the specific terms "therapeutic drug monitoring (TDM)" and "children." Further searches were undertaken using the name of identified drugs combined with the term "TDM." EXPERT OPINION Further research into the use of Bayesian forecasting and the relationship between exposure and response is required to personalize dosing, with the opportunity for the development of expert recommendations in children with CF. Use of noninvasive methods of TDM has the potential to improve accessibility to TDM in this cohort.
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Affiliation(s)
- Siân Bentley
- Pharmacy Department, Royal Brompton Hospital, London, UK
| | - Jamie Cheong
- Pharmacy Department, Royal Brompton Hospital, London, UK
| | - Nikesh Gudka
- Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | - Joseph F Standing
- Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Infection, Immunity and Inflammation,great Ormond Street Institute of Child Health, University College London, London, UK
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25
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Abstract
Importance Cystic fibrosis, a genetic disorder defined by variants in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, affects more than 30 000 individuals in the US and approximately 89 000 worldwide. Absent or decreased function of the CFTR protein is associated with multiorgan dysfunction and shortened life expectancy. Observations CFTR is an anion channel in the apical membrane of epithelial cells. Loss of function leads to obstructed exocrine glands. Of people with cystic fibrosis in the US, approximately 85.5% have the gene variant F508del. Manifestations of cystic fibrosis in patients with the F508del gene variant begin in infancy with steatorrhea, poor weight gain, and respiratory symptoms (coughing, wheezing). As people with cystic fibrosis age, chronic respiratory bacterial infections cause loss of lung function and bronchiectasis. With the availability of universal newborn screening in multiple countries including the US, many people with cystic fibrosis are asymptomatic at diagnosis. With multidisciplinary care teams that included dietitians, respiratory therapists, and social workers, treatment of cystic fibrosis can slow disease progression. Median survival has improved from 36.3 years (95% CI, 35.1-37.9) in 2006 to 53.1 years (95% CI, 51.6-54.7) in 2021. Pulmonary therapies for patients with cystic fibrosis consist of mucolytics (eg, dornase alfa), anti-inflammatories (eg, azithromycin), and antibiotics (such as tobramycin delivered by a nebulizer). Four small molecular therapies, termed CFTR modulators, that facilitate CFTR production and/or function have received regulatory approval. Examples are ivacaftor and elexacaftor-tezacaftor-ivacaftor. For example, in patients with 1 F508del variant, the combination of ivacaftor, tezacaftor, and elexacaftor improved lung function from -0.2% in the placebo group to 13.6% (difference, 13.8%; 95% CI, 12.1%-15.4%) and decreased the annualized estimated rate of pulmonary exacerbations from 0.98 to 0.37 (rate ratio, 0.37; 95% CI, 0.25-0.55). Improved respiratory function and symptoms have lasted up to 144 weeks in postapproval observational studies. An additional 177 variants are eligible for treatment with the elexacaftor-tezacaftor-ivacaftor combination. Conclusion Cystic fibrosis affects approximately 89 000 people worldwide and is associated with a spectrum of disease related to exocrine dysfunction, including chronic respiratory bacterial infections and reduced life expectancy. First-line pulmonary therapies consist of mucolytics, anti-inflammatories, and antibiotics, and approximately 90% of people with cystic fibrosis who are 2 years or older may benefit from a combination of ivacaftor, tezacaftor, and elexacaftor.
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Affiliation(s)
- Thida Ong
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle
| | - Bonnie W Ramsey
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle
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26
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Han X, Li D, Reyes-Ortega F, Schneider-Futschik EK. Dry Powder Inhalation for Lung Delivery in Cystic Fibrosis. Pharmaceutics 2023; 15:pharmaceutics15051488. [PMID: 37242730 DOI: 10.3390/pharmaceutics15051488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/30/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
Pulmonary drug delivery has long been used for local and systemic administration of different medications used in acute and chronic respiratory diseases. Certain lung diseases, such as cystic fibrosis, rely heavily on chronic treatments, including targeted lung delivery. Pulmonary drug delivery possesses various physiological advantages compared to other delivery methods and is also convenient for the patient to use. However, the formulation of dry powder for pulmonary delivery proves challenging due to aerodynamic restrictions and the lower tolerance of the lung. The aim of this review is to provide an overview of the respiratory tract structure in patients with cystic fibrosis, including during acute and chronic lung infections and exacerbations. Furthermore, this review discusses the advantages of targeted lung delivery, including the physicochemical properties of dry powder and factors affecting clinical efficacy. Current inhalable drug treatments and drugs currently under development will also be discussed.
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Affiliation(s)
- Xiaoxuan Han
- Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Danni Li
- Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Felisa Reyes-Ortega
- Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Elena K Schneider-Futschik
- Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC 3010, Australia
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27
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McGarry LJ, Bhaiwala Z, Lopez A, Chandler C, Pelligra CG, Rubin JL, Liou TG. Calibration and validation of modeled 5-year survival predictions among people with cystic fibrosis treated with the cystic fibrosis transmembrane conductance regulator modulator ivacaftor using United States registry data. PLoS One 2023; 18:e0283479. [PMID: 37043485 PMCID: PMC10096446 DOI: 10.1371/journal.pone.0283479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 03/09/2023] [Indexed: 04/13/2023] Open
Abstract
OBJECTIVES Cystic fibrosis (CF) is a rare genetic disease characterized by life-shortening lung function decline. Ivacaftor, a CF transmembrane conductance regulator modulator (CFTRm), was approved in 2012 for people with CF with specific gene mutations. We used real-world evidence of 5-year mortality impacts of ivacaftor in a US registry population to validate a CF disease-progression model that estimates the impact of ivacaftor on survival. METHODS The model projects the impact of ivacaftor vs. standard care in people with CF aged ≥6 years with CFTR gating mutations by combining parametric equations fitted to historical registry survival data, with mortality hazards adjusted for fixed and time-varying person-level characteristics. Disease progression with standard care was derived from published registry studies and the expected impact of ivacaftor on clinical characteristics was derived from clinical trials. Individual-level baseline characteristics of the registry ivacaftor-treated population were entered into the model; 5-year model-projected mortality with credible intervals (CrIs) was compared with registry mortality to evaluate the model's validity. RESULTS Post-calibration 5-year mortality projections closely approximated registry mortality in populations treated with standard care (6.4% modeled [95% CrI: 5.3% to 7.6%] vs. 6.0% observed) and ivacaftor (3.4% modeled [95% CrI: 2.7% to 4.4%] vs. 3.1% observed). The model accurately predicted 5-year relative risk of mortality (0.53 modeled [0.47 to 0.60] vs. 0.51 observed) in people treated with ivacaftor vs. standard care. CONCLUSIONS Modeled 5-year survival projections for people with CF initiating ivacaftor vs. standard care align closely with real-world registry data. Findings support the validity of modeling CF to predict long-term survival and estimate clinical and economic outcomes of CFTRm.
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Affiliation(s)
- Lisa J. McGarry
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America
| | - Zahra Bhaiwala
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America
| | - Andrea Lopez
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America
| | | | | | - Jaime L. Rubin
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America
| | - Theodore G. Liou
- Adult CF Center, University of Utah, Salt Lake City, UT, United States of America
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28
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Rehman T, Welsh MJ. Inflammation as a Regulator of the Airway Surface Liquid pH in Cystic Fibrosis. Cells 2023; 12:1104. [PMID: 37190013 PMCID: PMC10137218 DOI: 10.3390/cells12081104] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 05/17/2023] Open
Abstract
The airway surface liquid (ASL) is a thin sheet of fluid that covers the luminal aspect of the airway epithelium. The ASL is a site of several first-line host defenses, and its composition is a key factor that determines respiratory fitness. Specifically, the acid-base balance of ASL has a major influence on the vital respiratory defense processes of mucociliary clearance and antimicrobial peptide activity against inhaled pathogens. In the inherited disorder cystic fibrosis (CF), loss of cystic fibrosis transmembrane conductance regulator (CFTR) anion channel function reduces HCO3- secretion, lowers the pH of ASL (pHASL), and impairs host defenses. These abnormalities initiate a pathologic process whose hallmarks are chronic infection, inflammation, mucus obstruction, and bronchiectasis. Inflammation is particularly relevant as it develops early in CF and persists despite highly effective CFTR modulator therapy. Recent studies show that inflammation may alter HCO3- and H+ secretion across the airway epithelia and thus regulate pHASL. Moreover, inflammation may enhance the restoration of CFTR channel function in CF epithelia exposed to clinically approved modulators. This review focuses on the complex relationships between acid-base secretion, airway inflammation, pHASL regulation, and therapeutic responses to CFTR modulators. These factors have important implications for defining optimal ways of tackling CF airway inflammation in the post-modulator era.
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Affiliation(s)
- Tayyab Rehman
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Michael J. Welsh
- Departments of Internal Medicine and Molecular Physiology and Biophysics, Pappajohn Biomedical Institute, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
- Howard Hughes Medical Institute, University of Iowa, Iowa City, IA 52242, USA
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Vaillancourt M, Galdino ACM, Limsuwannarot SP, Celedonio D, Dimitrova E, Broerman M, Bresee C, Doi Y, Lee JS, Parks WC, Jorth P. A compensatory RNase E variation increases Iron Piracy and Virulence in multidrug-resistant Pseudomonas aeruginosa during Macrophage infection. PLoS Pathog 2023; 19:e1010942. [PMID: 37027441 PMCID: PMC10115287 DOI: 10.1371/journal.ppat.1010942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 04/19/2023] [Accepted: 03/24/2023] [Indexed: 04/08/2023] Open
Abstract
During chronic cystic fibrosis (CF) infections, evolved Pseudomonas aeruginosa antibiotic resistance is linked to increased pulmonary exacerbations, decreased lung function, and hospitalizations. However, the virulence mechanisms underlying worse outcomes caused by antibiotic resistant infections are poorly understood. Here, we investigated evolved aztreonam resistant P. aeruginosa virulence mechanisms. Using a macrophage infection model combined with genomic and transcriptomic analyses, we show that a compensatory mutation in the rne gene, encoding RNase E, increased pyoverdine and pyochelin siderophore gene expression, causing macrophage ferroptosis and lysis. We show that iron-bound pyochelin was sufficient to cause macrophage ferroptosis and lysis, however, apo-pyochelin, iron-bound pyoverdine, or apo-pyoverdine were insufficient to kill macrophages. Macrophage killing could be eliminated by treatment with the iron mimetic gallium. RNase E variants were abundant in clinical isolates, and CF sputum gene expression data show that clinical isolates phenocopied RNase E variant functions during macrophage infection. Together these data show how P. aeruginosa RNase E variants can cause host damage via increased siderophore production and host cell ferroptosis but may also be targets for gallium precision therapy.
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Affiliation(s)
- Mylene Vaillancourt
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Anna Clara Milesi Galdino
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Sam P. Limsuwannarot
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Diana Celedonio
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Elizabeth Dimitrova
- Women’s Guild Lung Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Matthew Broerman
- Acute Lung Injury Center of Excellence, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine; Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Catherine Bresee
- Biostatistics Core, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Yohei Doi
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Janet S. Lee
- Acute Lung Injury Center of Excellence, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine; Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - William C. Parks
- Women’s Guild Lung Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Peter Jorth
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
- Women’s Guild Lung Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
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Møller R, Pressler T, Qvist T. Antimicrobial Strategies for Cystic Fibrosis. Semin Respir Crit Care Med 2023; 44:297-306. [PMID: 36535665 DOI: 10.1055/s-0042-1758733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Lung infection is the leading cause of death in cystic fibrosis (CF), and antimicrobial therapies are the backbone of infection management. While many different strategies may be applied, rigorous microbiological surveillance, intensive eradication therapy, and long-term maintenance therapy based on inhaled antibiotics may be considered the main strategy for infection control in individuals with CF. While most of the existing evidence is based on infection with Pseudomonas aeruginosa, other important pathogens causing lung inflammation and deterioration exist and should be treated despite the evidence gap. In this chapter, we describe the approaches to the antimicrobial treatment of the most important pathogens in CF and the evidence behind.
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Affiliation(s)
- Rikke Møller
- Department of Infectious Diseases, Cystic Fibrosis Center Copenhagen, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Tacjana Pressler
- Department of Infectious Diseases, Cystic Fibrosis Center Copenhagen, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Tavs Qvist
- Department of Infectious Diseases, Cystic Fibrosis Center Copenhagen, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
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Thornton CS, Parkins MD. Microbial Epidemiology of the Cystic Fibrosis Airways: Past, Present, and Future. Semin Respir Crit Care Med 2023; 44:269-286. [PMID: 36623820 DOI: 10.1055/s-0042-1758732] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Progressive obstructive lung disease secondary to chronic airway infection, coupled with impaired host immunity, is the leading cause of morbidity and mortality in cystic fibrosis (CF). Classical pathogens found in the airways of persons with CF (pwCF) include Pseudomonas aeruginosa, Staphylococcus aureus, the Burkholderia cepacia complex, Achromobacter species, and Haemophilus influenzae. While traditional respiratory-tract surveillance culturing has focused on this limited range of pathogens, the use of both comprehensive culture and culture-independent molecular approaches have demonstrated complex highly personalized microbial communities. Loss of bacterial community diversity and richness, counteracted with relative increases in dominant taxa by traditional CF pathogens such as Burkholderia or Pseudomonas, have long been considered the hallmark of disease progression. Acquisition of these classic pathogens is viewed as a harbinger of advanced disease and postulated to be driven in part by recurrent and frequent antibiotic exposure driven by frequent acute pulmonary exacerbations. Recently, CF transmembrane conductance regulator (CFTR) modulators, small molecules designed to potentiate or restore diminished protein levels/function, have been successfully developed and have profoundly influenced disease course. Despite the multitude of clinical benefits, structural lung damage and consequent chronic airway infection persist in pwCF. In this article, we review the microbial epidemiology of pwCF, focus on our evolving understanding of these infections in the era of modulators, and identify future challenges in infection surveillance and clinical management.
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Affiliation(s)
- Christina S Thornton
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Michael D Parkins
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Alberta, Canada
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Mayer-Hamblett N, Ratjen F, Russell R, Donaldson SH, Riekert KA, Sawicki GS, Odem-Davis K, Young JK, Rosenbluth D, Taylor-Cousar JL, Goss CH, Retsch-Bogart G, Clancy JP, Genatossio A, O'Sullivan BP, Berlinski A, Millard SL, Omlor G, Wyatt CA, Moffett K, Nichols DP, Gifford AH, Kloster M, Weaver K, Chapdu C, Xie J, Skalland M, Romasco M, Heltshe S, Simon N, VanDalfsen J, Mead A, Buckingham R, Seidel K, Midamba N, Couture L, Case BZ, Au W, Rockers E, Cooke D, Olander A, Bondick I, Johnson M, VanHousen L, Nicholson B, Omlor G, Parrish M, Roberts D, Head J, Carey J, Caverly L, Dangerfield J, Linnemann R, Fullmer J, Roman C, Mogayzel P, Reyes D, Harmala A, Lysinger J, Bergeron J, Virella-Lowell I, Brown P, Godusevic L, Casey A, Paquette L, Lahiri T, Sweet J, Donaldson S, Harris J, Parnell S, Szentpetery S, Froh D, Tharrington E, Jain M, Nelson R, Kadon S, McPhail G, McBennett K, Rone T, Dasenbrook E, Weaver D, Johnson T, McCoy K, Jain R, Mcleod M, Klosterman M, Sharma P, Jones A, Mueller G, Janney R, Taylor-Cousar J, Cross M, Hoppe J, Cahill J, Mukadam Z, Finto J, Schultz K, Villalta SD, Smith A, Millard S, Symington T, Graff G, Kitch D, Sanders D, Thompson M, Pena T, Teresi M, Gafford J, Schaeffer D, Mermis J, Scott L, Escobar H, Williams K, Dorman D, O'Sullivan B, Bethay R, Danov Z, Berlinski A, Turbeville K, Johannes J, Rodriguez A, Marra B, Zanni R, Morton R, Simeon T, Braun A, Dondlinger N, Biller J, Hubertz E, Antos N, Roth L, Billings J, Larson C, Balaji P, McNamara J, Clark T, Moffett K, Griffith R, Martinez N, Hussain S, Malveaux H, Egan M, Guzman C, DeCelie-Germana J, Galvin S, Savant A, Falgout N, Walker P, Demarco T, DiMango E, Ycaza M, Ballo J, Tirakitsoontorn P, Layish D, Serr D, Livingston F, Wooldridge S, Milla C, Spano J, Davis R, Elidemir O, Chittivelu S, Scott A, Alam S, Dorgan D, Butoryak M, Weiner D, Renna H, Wyatt C, Klein B, Stone A, Lessard M, Schechter MS, Johnson B, Scofield S, Liou T, Vroom J, Akong K, Gil M, Betancourt L, Singer J, Ly N, Moreno C, Aitken M, Gambol T, Genatossio A, Gibson R, Lambert A, Milton J, Rosenbluth D, Smith S, Green D, Hodge D, Fortner C, Forell M, Karlnoski R, Patel K, Daines C, Ryan E, Amaro-Galvez R, Dohanich E, Lennox A, Messer Z, Hanes H, Powell K, Polineni D. Discontinuation versus continuation of hypertonic saline or dornase alfa in modulator treated people with cystic fibrosis (SIMPLIFY): results from two parallel, multicentre, open-label, randomised, controlled, non-inferiority trials. THE LANCET. RESPIRATORY MEDICINE 2023; 11:329-340. [PMID: 36343646 PMCID: PMC10065895 DOI: 10.1016/s2213-2600(22)00434-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Reducing treatment burden is a priority for people with cystic fibrosis, whose health has benefited from using new modulators that substantially increase CFTR protein function. The SIMPLIFY study aimed to assess the effects of discontinuing nebulised hypertonic saline or dornase alfa in individuals using the CFTR modulator elexacaftor plus tezacaftor plus ivacaftor (ETI). METHODS The SIMPLIFY study included two parallel, multicentre, open-label, randomised, controlled, non-inferiority trials at 80 participating clinics across the USA in the Cystic Fibrosis Therapeutics Development Network. We included individuals with cystic fibrosis aged 12-17 years with percent predicted FEV1 (ppFEV1) of 70% or more, or those aged 18 years or older with ppFEV1 of 60% or more, if they had been taking ETI and either (or both) mucoactive therapies (≥3% hypertonic saline or dornase alfa) for at least 90 days before screening. Participants on both hypertonic saline and dornase alfa were randomly assigned to one of the two trials, and those on a single therapy were assigned to the applicable trial. All participants were then randomly assigned 1:1 to continue or discontinue therapy for 6 weeks using permuted blocks of varying size, stratified by baseline ppFEV1 (week 0; ≥90% or <90%), single or concurrent use of hypertonic saline and dornase alfa, previous SIMPLIFY study participation (yes or no), and age (≥18 or <18 years). For participants randomly assigned to continue their therapy during a given trial, this therapy was instructed to be taken at least once daily according to each participant's pre-existing, clinically prescribed regimen. Hypertonic saline concentration was required to be at least 3%. The primary objective for each trial was to determine whether discontinuing was non-inferior to continuing, measured by the 6-week change in ppFEV1 in the per-protocol population. We established a non-inferiority margin of -3% for the difference between groups in the 6-week change in ppFEV1. Safety outcomes were analysed in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT04378153. FINDINGS From Aug 25, 2020, to May 25, 2022, a total of 672 unique participants were screened for eligibility for one or both trials, resulting in 847 total random assignments across both trials with 594 unique participants. 370 participants were randomly assigned in the hypertonic saline trial and 477 in the dornase alfa trial. Participants across both trials had an average ppFEV1 of 96·9%. Discontinuing treatment was non-inferior to continuing treatment with respect to the absolute 6-week change in ppFEV1 in both the hypertonic saline trial (-0·19% [95% CI -0·85 to 0·48] in the discontinuation group [n=133] vs 0·14% [-0·51 to 0·78] in the continuation group [n=140]; between-group difference -0·32% [-1·25 to 0·60]) and dornase alfa trial (0·18% [-0·38 to 0·74] in the discontinuation group [n=199] vs -0·16% [-0·73 to 0·41] in the continuation group [n=193]; between-group difference 0·35% [-0·45 to 1·14]), with consistent results in the intention-to-treat populations. In the hypertonic saline trial, 64 (35%) of 184 in the discontinuation group versus 44 (24%) of 186 participants in the continuation group and, in the dornase alfa trial, 89 (37%) of 240 in the discontinuation group versus 55 (23%) of 237 in the continuation group had at least one adverse event. INTERPRETATION In individuals with cystic fibrosis on ETI with relatively well preserved pulmonary function, discontinuing daily hypertonic saline or dornase alfa for 6 weeks did not result in clinically meaningful differences in pulmonary function when compared with continuing treatment.
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Anderson JD, Davis BH, Giang G, Jones A, Lee CR, Parker K, Searcy H, Benner K, Limdi N, Guimbellot JS. Pharmacogenetic actionability and medication prescribing in people with cystic fibrosis. Clin Transl Sci 2023; 16:662-672. [PMID: 36760155 PMCID: PMC10087076 DOI: 10.1111/cts.13479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 02/11/2023] Open
Abstract
Although major advancements have been made in the therapeutics for people with cystic fibrosis (PwCF), many still require the use of multiple medications to manage acute exacerbations of disease and maintain health. Iterative trial and error processes of pharmacotherapeutic management can be optimized by assessing and incorporating pharmacogenetics. For 82 PwCF, we reviewed 2 years of medication use and response history and interrogated metabolizer status for common pharmacogenes, revealing 3336 medication exposure events (MEEs) to 286 unique medications. As expected, the more frequent MEEs were those commonly used to treat cystic fibrosis (CF), such as antibiotics and respiratory medications. Antibiotics also comprised 56.7% of the undesirable drug responses. The impact of gene variants on drug responses was assessed using Pharmacogenomics Knowledgebase (PharmGKB) and Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines. Thirty-three (11.5%) medications have strong evidence of genetic influence on response as evidenced by gene-based dosing guidelines. 110 (38.5%) unique medications had at least one association with a very important pharmacogene, whereas 143 (50%) were associated with at least one clinical or variant annotation. Over 97% of participants had at least one actionable genotype. Eleven (13.4%) patients with an actionable genotype, taking the impacted medication, had an undesirable drug response described in the CPIC guidelines that could potentially have been mitigated with a priori knowledge of the genotype. PwCF take many medications for disease management, with frequent dose changes to elicit a desired clinical effect. As CF care evolves, implementing pharmacogenetics testing can improve efficiency and safety of prescribing practices using precision selection and dosing at medication initiation.
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Affiliation(s)
- Justin D. Anderson
- Gregory Fleming James Cystic Fibrosis Research CenterUniversity of Alabama at Birmingham (UAB)BirminghamAlabamaUSA
- Division of Pulmonary and Sleep Medicine, Department of PediatricsUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Brittney H. Davis
- Department of Neurology, School of MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Gracie Giang
- McWhorter School of PharmacySamford UniversityBirminghamAlabamaUSA
| | - April Jones
- McWhorter School of PharmacySamford UniversityBirminghamAlabamaUSA
| | - Cameron R. Lee
- McWhorter School of PharmacySamford UniversityBirminghamAlabamaUSA
| | - Kennedy Parker
- Gregory Fleming James Cystic Fibrosis Research CenterUniversity of Alabama at Birmingham (UAB)BirminghamAlabamaUSA
- Division of Pulmonary and Sleep Medicine, Department of PediatricsUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Heather Searcy
- Division of Pulmonary and Sleep Medicine, Department of PediatricsUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Kim Benner
- McWhorter School of PharmacySamford UniversityBirminghamAlabamaUSA
| | - Nita A. Limdi
- Department of Neurology, School of MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Jennifer S. Guimbellot
- Gregory Fleming James Cystic Fibrosis Research CenterUniversity of Alabama at Birmingham (UAB)BirminghamAlabamaUSA
- Division of Pulmonary and Sleep Medicine, Department of PediatricsUniversity of Alabama at BirminghamBirminghamAlabamaUSA
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Naehrig S, Schulte-Hubbert B, Hafkemeyer S, Hammermann J, Dumke M, Sieber S. Chronic inhaled antibiotic therapy in people with cystic fibrosis with Pseudomonas aeruginosa infection in Germany. Pulm Pharmacol Ther 2023; 80:102214. [PMID: 37003541 DOI: 10.1016/j.pupt.2023.102214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/16/2023] [Accepted: 03/26/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Several clinical guidelines recommend chronic inhaled therapy for pwCF (people with cystic fibrosis) and chronic Pseudomonas aeruginosa infection of the lungs. METHODS To demonstrate what kind of therapy regimens are used in Germany, we retrospectively analysed chronic inhaled antibiotic therapy within the cohort of the German CF Registry in 2020. For comparison we also analysed the use of inhaled antibiotics in pwCF with intermittent Pseudomonas or without Pseudomonas infection. RESULTS A total of 1960 pwCF had chronic P. aeruginosa infection and were retrospectively evaluated. Almost 90% (n = 1751) received at least one inhaled antibiotic. The most commonly used inhaled antibiotic was colistin solution for inhalation (55.2%), followed by aztreonam solution for inhalation (32.6%) and tobramycin solution for Inhalation (30%). Almost 56% of adults and 44% of children alternated two antibiotics for inhalation. In children, alternating colistin + tobramycin was the most often used regimen. In adults, only 23% used colistin + tobramycin; there was a wide range of treatment regimens among adults using two inhaled antibiotics alternately. 2456 pwCF had no Pseudomonas infection, but almost 24% had a chronic inhaled antibiotic therapy, while 56% of 361 pwCF and intermittent chronic Pseudomonas infection had a chronic inhaled antibiotic therapy. CONCLUSION In all three groups the most commonly used inhaled antibiotic was colistin solution for inhalation. Almost 56% of adults and 44% of children with chronic Pseudomonas infection alternated two antibiotics for inhalation. It will be interesting to see how the introduction of the highly effective modulator elexacaftor/tezacaftor/ivacaftor will change the use of inhaled antibiotics.
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Affiliation(s)
- S Naehrig
- University Hospital of the Ludwig Maximilians University Munich (LMU), Department of Internal Medicine V, Cystic Fibrosis Center for Adults, Munich, Germany.
| | - B Schulte-Hubbert
- Division of Pulmonology, Medical Department I, Cystic Fibrosis Center, University Hospital Carl Gustav Carus, Technische Universität, Dresden, Germany
| | - S Hafkemeyer
- Mukoviszidose Institut gGmbH (MI), Bonn, Germany
| | - J Hammermann
- Children's Hospital, Cystic Fibrosis Center, University Hospital Carl Gustav Carus, Technische Universität, Dresden, Germany
| | - M Dumke
- STAT-UP Statistical Consulting & Services, Munich, Germany
| | - S Sieber
- STAT-UP Statistical Consulting & Services, Munich, Germany
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Flume PA, Basavaraj A, Garcia B, Winthrop K, Di Mango E, Daley CL, Philley JV, Henkle E, O'Donnell AE, Metersky M. Towards development of evidence to inform recommendations for the evaluation and management of bronchiectasis. Respir Med 2023; 211:107217. [PMID: 36931575 DOI: 10.1016/j.rmed.2023.107217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 02/17/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023]
Abstract
Bronchiectasis (BE) is a chronic condition characterized by airway dilation as a consequence of a variety of pathogenic processes. It is often associated with persistent airway infection and an inflammatory response resulting in cough productive of purulent sputum, which has an adverse impact on quality of life. The prevalence of BE is increasing worldwide. Treatment guidelines exist for managing BE, but they are generally informed by a paucity of high-quality evidence. This review presents the findings of a scientific advisory board of experts held in the United States in November 2020. The main focus of the meeting was to identify unmet needs in BE and propose ways to identify research priorities for the management of BE, with a view to developing evidence-based treatment recommendations. Key issues identified include diagnosis, patient evaluation, promoting airway clearance and appropriate use of antimicrobials. Unmet needs include effective pharmacological agents to promote airway clearance and reduce inflammation, control of chronic infection, clinical endpoints to be used in the design of BE clinical trials, and more accurate classification of patients using phenotypes and endotypes to better guide treatment decisions and improve outcomes.
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Affiliation(s)
- Patrick A Flume
- Department of Medicine and Pediatrics, Medical University of South Carolina, 96 Jonathan Lucas Street, Room 816-CSB, Charleston, SC, USA.
| | - Ashwin Basavaraj
- Division of Pulmonary, Critical Care and Sleep Medicine, New York University Grossman School of Medicine, 462 First Avenue, Administration Building OBV, A601, New York, NY, 10016, USA.
| | - Bryan Garcia
- University of Alabama at Birmingham, 1900 University Blvd, THT Suite 541A, Birmingham, AL, 35233, USA.
| | - Kevin Winthrop
- Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, 97239, Portland, OR, USA.
| | - Emily Di Mango
- Department of Medicine, Columbia University Irving Medical Center, 622 West 168th Street, New York, NY, 10032, USA.
| | - Charles L Daley
- Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO, 80206, USA.
| | - Julie V Philley
- Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center at Tyler, 11937 US Hwy 271, 75708, Tyler, USA.
| | - Emily Henkle
- Oregon Health and Science University, OHSU-PSU School of Public Health, 3181 SW Sam Jackson Park Rd, Mailcode VPT, Portland, OR, 97239, USA.
| | - Anne E O'Donnell
- Division of Pulmonary, Critical Care and Sleep Medicine, Georgetown University Medical Center, Washington, DC, USA.
| | - Mark Metersky
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT, 06030-1321, USA.
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Ribeiro CMP, Higgs MG, Muhlebach MS, Wolfgang MC, Borgatti M, Lampronti I, Cabrini G. Revisiting Host-Pathogen Interactions in Cystic Fibrosis Lungs in the Era of CFTR Modulators. Int J Mol Sci 2023; 24:ijms24055010. [PMID: 36902441 PMCID: PMC10003689 DOI: 10.3390/ijms24055010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/25/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Cystic fibrosis transmembrane conductance regulator (CFTR) modulators, a new series of therapeutics that correct and potentiate some classes of mutations of the CFTR, have provided a great therapeutic advantage to people with cystic fibrosis (pwCF). The main hindrances of the present CFTR modulators are related to their limitations in reducing chronic lung bacterial infection and inflammation, the main causes of pulmonary tissue damage and progressive respiratory insufficiency, particularly in adults with CF. Here, the most debated issues of the pulmonary bacterial infection and inflammatory processes in pwCF are revisited. Special attention is given to the mechanisms favoring the bacterial infection of pwCF, the progressive adaptation of Pseudomonas aeruginosa and its interplay with Staphylococcus aureus, the cross-talk among bacteria, the bronchial epithelial cells and the phagocytes of the host immune defenses. The most recent findings of the effect of CFTR modulators on bacterial infection and the inflammatory process are also presented to provide critical hints towards the identification of relevant therapeutic targets to overcome the respiratory pathology of pwCF.
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Affiliation(s)
- Carla M. P. Ribeiro
- Marsico Lung Institute/Cystic Fibrosis Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Cell Biology and Physiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Correspondence: (C.M.P.R.); (G.C.)
| | - Matthew G. Higgs
- Marsico Lung Institute/Cystic Fibrosis Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Microbiology and Immunology, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Marianne S. Muhlebach
- Marsico Lung Institute/Cystic Fibrosis Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Matthew C. Wolfgang
- Marsico Lung Institute/Cystic Fibrosis Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Microbiology and Immunology, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Monica Borgatti
- Department of Life Sciences and Biotechnology, University of Ferrara, 44121 Ferrara, Italy
- Innthera4CF, Center on Innovative Therapies for Cystic Fibrosis, University of Ferrara, 44121 Ferrara, Italy
| | - Ilaria Lampronti
- Department of Life Sciences and Biotechnology, University of Ferrara, 44121 Ferrara, Italy
- Innthera4CF, Center on Innovative Therapies for Cystic Fibrosis, University of Ferrara, 44121 Ferrara, Italy
| | - Giulio Cabrini
- Department of Life Sciences and Biotechnology, University of Ferrara, 44121 Ferrara, Italy
- Innthera4CF, Center on Innovative Therapies for Cystic Fibrosis, University of Ferrara, 44121 Ferrara, Italy
- Correspondence: (C.M.P.R.); (G.C.)
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Lima EMF, Almeida FAD, Sircili MP, Bueris V, Pinto UM. N-acetylcysteine (NAC) attenuates quorum sensing regulated phenotypes in Pseudomonas aeruginosa PAO1. Heliyon 2023; 9:e14152. [PMID: 36923901 PMCID: PMC10009464 DOI: 10.1016/j.heliyon.2023.e14152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 02/22/2023] [Accepted: 02/22/2023] [Indexed: 03/05/2023] Open
Abstract
The expression of many virulence genes in bacteria is regulated by quorum sensing (QS), and the inhibition of this mechanism has been intensely investigated. N-acetylcysteine (NAC) has good antibacterial activity and is able to interfere with biofilm-related respiratory infections, but little is known whether this compound has an effect on bacterial QS communication. This work aimed to evaluate the potential of NAC as a QS inhibitor (QSI) in Pseudomonas aeruginosa PAO1 through in silico and in vitro analyses, as well as in combination with the antibiotic tobramycin. Initially, a molecular docking analysis was performed between the QS regulatory proteins, LasR and RhlR, of P. aeruginosa with NAC, 3-oxo-C12-HSL, C4-HSL, and furanone C30. The NAC sub-inhibitory concentration was determined by growth curves. Then, we performed in vitro tests using the QS reporter strains P. aeruginosa lasB-gfp and rhlA-gfp, as well as the expression of QS-related phenotypes. Finally, the synergistic effect of NAC with the antibiotic tobramycin was calculated by fractional inhibitory concentrations index (FICi) and investigated against bacterial growth, pigment production, and biofilm formation. In the molecular docking study, NAC bound to LasR and RhlR proteins in a similar manner to the AHL cognate, suggesting that it may be able to bind to QS receptor proteins in vivo. In the biosensor assay, the GFP signal was turned down in the presence of NAC at 1000, 500, 250, and 125 μM for lasB-gfp and rhlA-gfp (p < 0.05), suggesting a QS inhibitory effect. Pyocyanin and rhamnolipids decreased (p < 0.05) up to 34 and 37%, respectively, in the presence of NAC at 125 μM. Swarming and swimming motilities were inhibited (p < 0.05) by NAC at 250 to 10000 μM. Additionally, 2500 and 10000 μM of NAC reduced biofilm formation. NAC-tobramycin combination showed synergistic effect with FICi of 0.8, and the best combination was 2500-1.07 μM, inhibiting biofilm formation up to 60%, besides reducing pyocyanin and pyoverdine production. Confocal microscopy images revealed a stronger, dense, and compact biofilm of P. aeruginosa PAO1 control, while the biofilm treated with NAC-tobramycin became thinner and more dispersed. Overall, NAC at low concentrations showed promising anti-QS properties against P. aeruginosa PAO1, adding to its already known effect as an antibacterial and antibiofilm agent.
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Affiliation(s)
- Emília Maria França Lima
- Food Research Center, Department of Food and Experimental Nutrition, Faculty of Pharmaceutical Sciences, University of Sao Paulo (USP), São Paulo, SP, Brazil
| | - Felipe Alves de Almeida
- Instituto de Laticínios Cândido Tostes (ILCT), Empresa de Pesquisa Agropecuária de Minas Gerais (EPAMIG), Juiz de Fora, MG, Brazil
| | | | - Vanessa Bueris
- Microbiology Department, Institute of Biomedical Science, University of São Paulo (USP), São Paulo, SP, Brazil
| | - Uelinton Manoel Pinto
- Food Research Center, Department of Food and Experimental Nutrition, Faculty of Pharmaceutical Sciences, University of Sao Paulo (USP), São Paulo, SP, Brazil
- Corresponding author.
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Wood M, Babowicz F, Kennedy AG, Antell M, Gilhooly E, Tompkins BJ, Reddy SS. Incidence of transaminitis in adults with cystic fibrosis taking elexacaftor/tezacaftor/ivacaftor. J Am Pharm Assoc (2003) 2023; 63:920-924. [PMID: 36872183 DOI: 10.1016/j.japh.2023.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 02/07/2023] [Accepted: 02/14/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) transmembrane conductance regulator modulators are a cornerstone of CF treatment. However, many patients develop CF liver disease (CFLD) over time, and previous data indicate a risk for transaminase elevation with modulator use. Elexacaftor/tezacaftor/ivacaftor is a commonly prescribed modulator with broad efficacy among CF genomic profiles. Theoretically, elexacaftor/tezacaftor/ivacaftor drug-induced liver injury could exacerbate and further worsen CFLD, but holding modulators can cause a decline in clinical status. OBJECTIVES This study was designed to determine the real-world incidence of transaminase elevations in adult patients with CF taking elexacaftor/tezacaftor/ivacaftor. METHODS This exploratory, retrospective descriptive study included all adults with CF-prescribed elexacaftor/tezacaftor/ivacaftor at our institution's outpatient CF clinic. We explored transaminase elevations in 2 separate outcomes: incidence of transaminase elevations of more than 3 times the upper limit of normal (ULN), and transaminase elevations of 25% or more above baseline. RESULTS 83 patients were prescribed elexacaftor/tezacaftor/ivacaftor. Nine patients (11%) experienced an elevation of more than 3 times ULN and 62 (75%) experienced an elevation of 25% or more above baseline. The median days to transaminase elevation were 108 and 135 days, respectively. Therapy was not discontinued due to transaminase elevations in any of the patients. CONCLUSION Transaminase elevations among adults taking elexacaftor/tezacaftor/ivacaftor were common but did not result in discontinuation of therapy. Pharmacists should be reassured of the liver safety profile of this important medication for patients with CF.
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Party P, Klement ML, Szabó-Révész P, Ambrus R. Preparation and Characterization of Ibuprofen Containing Nano-Embedded-Microparticles for Pulmonary Delivery. Pharmaceutics 2023; 15:pharmaceutics15020545. [PMID: 36839867 PMCID: PMC9966045 DOI: 10.3390/pharmaceutics15020545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 02/10/2023] Open
Abstract
A fatal hereditary condition, cystic fibrosis (CF) causes severe lung problems. Ibuprofen (IBU), a non-steroidal anti-inflammatory drug, slows the progression of disease without causing significant side effects. Considering the poor water-solubility of the drug, IBU nanoparticles are beneficial for local pulmonary administration. We aimed to formulate a carrier-free dry powder inhaler containing nanosized IBU. We combined high-performance ultra-sonication and nano spray-drying. IBU was dissolved in ethyl acetate; after that, it was sonicated into a polyvinyl alcohol solution, where it precipitated as nanoparticles. Mannitol and leucine were added when producing dry particles using nano-spray drying. The following investigations were implemented: dynamic light scattering, laser diffraction, surface tension measurement, scanning electron microscopy, X-ray powder diffraction, differential scanning calorimetry, Fourier-transform infrared spectroscopy, in vitro dissolution test, and in vitro aerodynamic assessment (Andersen Cascade Impactor). The particle diameter of the IBU was in the nano range. The spray-dried particles showed a spherical morphology. The drug release was rapid in artificial lung media. The products represented large fine particle fractions and proper aerodynamic diameters. We successfully created an inhalable powder, containing nano-sized IBU. Along with the exceptional aerodynamic performance, the ideal particle size, shape, and drug-release profile might offer a ground-breaking local therapy for CF.
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Schultheis JM, Durham ME, Kram SJ, Kuhrt M, Gilstrap DL, Parish A, Green CL, Kram BL. Incidence and associated risk factors for systemic drug levels with inhaled aminoglycoside therapy. J Antimicrob Chemother 2023; 78:450-456. [PMID: 36512376 PMCID: PMC10169422 DOI: 10.1093/jac/dkac412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 11/11/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To characterize the incidence of and risk factors for a detectable drug level (DDL) in patients that received inhaled aminoglycoside therapy. METHODS This retrospective, single-centre study included adult patients who received at least one dose of an inhaled aminoglycoside with a drug level during inpatient hospitalization. Patients were excluded if they received an aminoglycoside intravenously within 7 days or if the drug level was not drawn within 4 h of the next dose. A repeated measures logistic regression model evaluated the association between potential risk factors and a DDL. RESULTS Among 286 drug levels, 88 (30.8%) drug levels were detectable. In multivariable analysis, cystic fibrosis (CF) (OR: 3.03; 95% CI: 1.10-8.35), chronic kidney disease (CKD) (OR: 4.25; 95% CI: 1.84-9.83), lung transplant recipient (OR: 3.08; 95% CI: 1.09-8.73), mechanical ventilation (OR: 2.99; 95% CI: 1.25-7.15) and tobramycin (OR: 5.26; 95% CI: 2.35-11.78) were associated with higher odds of a DDL. Among those with a DDL, inhaled aminoglycoside type and drug level concentration were not associated with acute kidney injury (P = 0.161). CONCLUSIONS Among 286 drug levels identified among inpatients receiving inhaled aminoglycoside therapy, 88 (30.8%) unique drug levels were detectable. Based on the results of this study, periodic trough concentrations should be considered for patients receiving inhaled aminoglycoside therapy with CF, CKD, lung transplantation, mechanical ventilation or tobramycin.
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Affiliation(s)
| | - Mary E Durham
- Department of Pharmacy, Premier Inc., Charlotte, NC, USA
| | - Shawn J Kram
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
| | - Michelle Kuhrt
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
| | - Daniel L Gilstrap
- Department of Pulmonary, Allergy, and Critical Care Medicine, Duke University Hospital, Durham, NC, USA
| | - Alice Parish
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Cynthia L Green
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Bridgette L Kram
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
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AtbFinder Diagnostic Test System Improves Optimal Selection of Antibiotic Therapy in Persons with Cystic Fibrosis. J Clin Microbiol 2023; 61:e0155822. [PMID: 36602344 PMCID: PMC9879114 DOI: 10.1128/jcm.01558-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Cystic fibrosis (CF) is characterized by mutations of CFTR that lead to increased viscous secretions, bacterial colonization, and recurrent infections. Chronic Pseudomonas aeruginosa infection in persons with CF is associated with progressive and accelerated lung function decline despite aggressive antibiotic treatment. We report the management of respiratory infections in persons with CF with antibiotic therapy that was based on the recommendations of AtbFinder, a novel, rapid, culture-based diagnostic test system that employs a novel paradigm of antibiotic selection. AtbFinder mimics bacterial interactions with antibiotics at concentrations that can be achieved in affected tissues or organs and models conditions of interbacterial interactions within polymicrobial biofilms. This open-label, single-arm, investigator-initiated clinical study was designed to identify the efficacy of antibiotics selected using AtbFinder in persons with CF. Microbiological and clinical parameters were assessed following the change of antibiotic therapy to antibiotics selected with AtbFinder between January 2016 and December 2018 and retrospectively compared with clinical data collected between January 2013 and December 2015. We enrolled 35 persons with CF (33 with chronic P. aeruginosa colonization). Antibiotics selected using AtbFinder resulted in clearance of P. aeruginosa in 81.8% of subsequent cultures, decreased pulmonary exacerbations from 1.21 per patient per annum to 0, and an increase in predicted percent predicted forced expiratory volume in 1 s up to 28.4% from baseline. The number of systemic antibiotic courses used in patients after switching to the AtbFinder-selected therapy was reduced from 355 to 178. These findings describe the superiority of antibiotic regimens selected with AtbFinder compared with routine antimicrobial susceptibility testing.
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Systemic Corticosteroids in the Management of Pediatric Cystic Fibrosis Pulmonary Exacerbations. Ann Am Thorac Soc 2023; 20:75-82. [PMID: 36044723 DOI: 10.1513/annalsats.202203-201oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Rationale: Pulmonary exacerbation (PEx) events contribute to lung function decline in people with cystic fibrosis (CF). CF Foundation PEx guidelines note that a short course of systemic corticosteroids may offer benefit without contributing to long-term adverse effects. However, insufficient evidence exists to recommend systemic corticosteroids for PEx treatment. Objectives: To determine if systemic corticosteroids for the treatment of in-hospital pediatric PEx are associated with improved clinical outcomes compared with treatment without systemic corticosteroids. Methods: We conducted a retrospective cohort study using the CF Foundation Patient Registry-Pediatric Health Information System linked database. People with CF were included if hospitalized for a PEx between 2006 and 2018 and were 6-21 years of age. Time to next PEx was assessed by Cox proportional hazards regression. Lung function outcomes were assessed by linear mixed-effect modeling and generalized estimating equations. To address confounding by indication, inverse probability treatment weighting was used. Results: A total of 3,471 people with CF contributed 9,787 PEx for analysis. Systemic corticosteroids were used in 15% of all PEx. In our primary analysis, systemic corticosteroids were not associated with better pre- to post-PEx percent predicted forced expiratory volume in 1 second responses (mean difference, -0.36; 95% confidence interval [CI], -1.14, 0.42; P = 0.4) or a higher odds of returning to lung function baseline (odds ratio, 0.97; 95% CI, 0.84-1.12; P = 0.7) but were associated with a reduced chance of future PEx requiring intravenous antibiotics (hazard ratio, 0.91; 95% CI, 0.85-0.96; P = 0.002). When restricting the analysis to one PEx per person, lung function outcomes remained no different among PEx treated with or without systemic corticosteroids, but, in contrast to our primary analysis, the use of systemic corticosteroids was no longer associated with a reduced chance of having a future PEx requiring intravenous antibiotics (hazard ratio, 0.96; 95% CI, 0.86, 1.07; P = 0.42). Conclusions: Systemic corticosteroid treatment for in-hospital pediatric PEx was not associated with improved lung function outcomes. Prospective trials are needed to better evaluate the risks and benefits of systemic corticosteroid use for PEx treatment in children with CF.
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Athanazio RA, Tanni SE, Ferreira J, Dalcin PDTR, Fuccio MBD, Esposito C, Canan MGM, Coelho LS, Firmida MDC, Almeida MBD, Marostica PJC, Monte LDFV, Souza EL, Pinto LA, Rached SZ, Oliveira VSBD, Riedi CA, Silva Filho LVRFD. Brazilian guidelines for the pharmacological treatment of the pulmonary symptoms of cystic fibrosis. Official document of the Sociedade Brasileira de Pneumologia e Tisiologia (SBPT, Brazilian Thoracic Association). J Bras Pneumol 2023; 49:e20230040. [PMID: 37194817 DOI: 10.36416/1806-3756/e20230040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 03/31/2023] [Indexed: 05/18/2023] Open
Abstract
Cystic fibrosis (CF) is a genetic disease that results in dysfunction of the CF transmembrane conductance regulator (CFTR) protein, which is a chloride and bicarbonate channel expressed in the apical portion of epithelial cells of various organs. Dysfunction of that protein results in diverse clinical manifestations, primarily involving the respiratory and gastrointestinal systems, impairing quality of life and reducing life expectancy. Although CF is still an incurable pathology, the therapeutic and prognostic perspectives are now totally different and much more favorable. The purpose of these guidelines is to define evidence-based recommendations regarding the use of pharmacological agents in the treatment of the pulmonary symptoms of CF in Brazil. Questions in the Patients of interest, Intervention to be studied, Comparison of interventions, and Outcome of interest (PICO) format were employed to address aspects related to the use of modulators of this protein (ivacaftor, lumacaftor+ivacaftor, and tezacaftor+ivacaftor), use of dornase alfa, eradication therapy and chronic suppression of Pseudomonas aeruginosa, and eradication of methicillin-resistant Staphylococcus aureus and Burkholderia cepacia complex. To formulate the PICO questions, a group of Brazilian specialists was assembled and a systematic review was carried out on the themes, with meta-analysis when applicable. The results obtained were analyzed in terms of the strength of the evidence compiled, the recommendations being devised by employing the GRADE approach. We believe that these guidelines represent a major advance to be incorporated into the approach to patients with CF, mainly aiming to favor the management of the disease, and could become an auxiliary tool in the definition of public policies related to CF.
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Affiliation(s)
- Rodrigo Abensur Athanazio
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Suzana Erico Tanni
- . Faculdade de Medicina de Botucatu, Universidade Estadual Paulista Julio de Mesquita Filho - UNESP - Botucatu (SP) Brasil
| | - Juliana Ferreira
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Paulo de Tarso Roth Dalcin
- . Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
- . Serviço de Pneumologia, Hospital de Clínicas de Porto Alegre - HCPA - Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | - Marcelo B de Fuccio
- . Hospital Júlia Kubitschek, Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | | | | | - Liana Sousa Coelho
- . Faculdade de Medicina de Botucatu, Universidade Estadual Paulista Julio de Mesquita Filho - UNESP - Botucatu (SP) Brasil
| | | | - Marina Buarque de Almeida
- . Unidade de Pneumologia, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Paulo José Cauduro Marostica
- . Unidade de Pneumologia Infantil, Hospital de Clínicas de Porto Alegre - HCPA - Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | | | - Edna Lúcia Souza
- . Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador (BA) Brasil
| | | | - Samia Zahi Rached
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Verônica Stasiak Bednarczuk de Oliveira
- . Hospital de Clínicas, Universidade Federal do Paraná, Curitiba (PR) Brasil
- . Unidos Pela Vida - Instituto Brasileiro de Atenção à Fibrose Cística, Curitiba (PR) Brasil
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Orenti A, Mei-Zahav M, Boracchi P, Lindblad A, Shteinberg M. Prevalence, trends and outcomes of long-term inhaled antibiotic treatment in people with cystic fibrosis without chronic Pseudomonas aeruginosa infection - A European cystic fibrosis patient registry data analysis. J Cyst Fibros 2023; 22:103-111. [PMID: 36045028 DOI: 10.1016/j.jcf.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 08/11/2022] [Accepted: 08/13/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Long-term treatment with inhaled antibiotics is recommended for people with cystic fibrosis (pwCF) chronically infected with Pseudomonas aeruginosa (PA). However, pwCF without chronic PA infection are also commonly treated with inhaled antibiotics. Using data from the European Cystic Fibrosis Patient Registry (ECFSPR) we aimed to determine the prevalence and factors associated with inhaled antibiotic treatment in pwCF without chronic PA infection, and long-term outcomes with inhaled antibiotics use. METHODS The ECFSPR was searched for pwCF 6 years of age and older who were not chronically infected with PA at baseline. Factors associated with inhaled antibiotic use were first assessed through a logistic regression. From this model a propensity score was computed for each individual, providing the likelihood of being treated with inhaled antibiotics. Long-term outcomes with and without inhaled antibiotics were assessed separately for propensity scores tertiles. RESULTS 7210 pwCF without chronic PA infection at baseline were included, with 2722 (37.75%) receiving long-term treatment with inhaled antibiotics. Treatment with inhaled antibiotics was more prevalent with severe genotype, diabetes, pancreatic insufficiency, and past infection with chronic PA (OR 3.8, 95% CI, 2.88-5.04). Treatment with inhaled antibiotics was not associated with a reduced risk for acquisition of PA or other resistant pathogens, or with improved lung function decline, mortality, or transplantation. CONCLUSIONS Many pwCF without chronic PA infection are receiving long-term treatment with inhaled antibiotics despite lack of support from clinical trials or practice guidelines. We did not observe improve outcomes with inhaled antibiotics. Our findings suggest controlled studies evaluating specific inhaled antibiotic regimens targeting specific pathogens or indications be performed to determine their effect.
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Affiliation(s)
- Annalisa Orenti
- Department of Clinical Sciences and Community Health, Laboratory of Medical Statistics, Biometry and Epidemiology "G. A. Maccacaro", University of Milan, Milan, Italy
| | - Meir Mei-Zahav
- Pulmonary Institute, Schneider Children's Medical Center of Israel, Sackler School of Medicine, Tel Aviv University, Petach Tikva, Tel Aviv, Israel
| | - Patrizia Boracchi
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
| | - Anders Lindblad
- Department of pediatrics, Queen Silvia Childrens Hospital, Gothenburg, Sweden
| | - Michal Shteinberg
- The B. Rappaport Faculty of Medicine, Pulmonology Institute and CF Center, Carmel Medical Center, The Technion-Israel Institute of Technology, 7 Michal St., Haifa 34362, Israel.
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Law JP, Wood AJ, Friman VP. The Effects of Antibiotic Combination Treatments on Pseudomonas aeruginosa Tolerance Evolution and Coexistence with Stenotrophomonas maltophilia. Microbiol Spectr 2022; 10:e0184222. [PMID: 36453898 PMCID: PMC9769631 DOI: 10.1128/spectrum.01842-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 11/09/2022] [Indexed: 12/03/2022] Open
Abstract
The Pseudomonas aeruginosa bacterium is a common pathogen of cystic fibrosis (CF) patients due to its ability to evolve resistance to antibiotics during treatments. While P. aeruginosa resistance evolution is well-characterized in monocultures, it is less well-understood in polymicrobial CF infections. Here, we investigated how exposure to ciprofloxacin, colistin, or tobramycin antibiotics, administered at sub-minimum inhibitory concentration (MIC) doses, both alone and in combination, shaped the tolerance evolution of P. aeruginosa (PAO1 lab and clinical CF LESB58 strains) in the absence and presence of a commonly co-occurring species, Stenotrophomonas maltophilia. The increases in antibiotic tolerances were primarily driven by the presence of that antibiotic in the treatment. We observed a reciprocal cross-tolerance between ciprofloxacin and tobramycin, and, when combined, the selected antibiotics increased the MICs for all of the antibiotics. Though the presence of S. maltophilia did not affect the tolerance or the MIC evolution, it drove P. aeruginosa into extinction more frequently in the presence of tobramycin due to its relatively greater innate tobramycin tolerance. In contrast, P. aeruginosa dominated and drove S. maltophilia extinct in most other treatments. Together, our findings suggest that besides driving high-level antibiotic tolerance evolution, sub-MIC antibiotic exposure can alter competitive bacterial interactions, leading to target pathogen extinctions in multispecies communities. IMPORTANCE Cystic fibrosis (CF) is a genetic condition that results in thick mucus secretions in the lungs that are susceptible to chronic bacterial infections. The bacterial pathogen Pseudomonas aeruginosa is often associated with morbidity in CF and is difficult to treat due to its high resistance to antibiotics. The resistance evolution of Pseudomonas aeruginosa is poorly understood in polymicrobial infections that are typical of CF. To study this, we exposed P. aeruginosa to sublethal concentrations of ciprofloxacin, colistin, or tobramycin antibiotics in the absence and presence of a commonly co-occurring CF species, Stenotrophomonas maltophilia. We found that low-level antibiotic concentrations selected for high-level antibiotic resistance. While P. aeruginosa dominated in most antibiotic treatments, S. maltophilia drove it into extinction in the presence of tobramycin due to an innately higher tobramycin resistance. Our findings suggest that, besides driving high-level antibiotic tolerance evolution, sublethal antibiotic exposure can magnify competition in bacterial communities, which can lead to target pathogen extinctions in multispecies communities.
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Affiliation(s)
- Jack P. Law
- Department of Biology, University of York, York, United Kingdom
| | - A. Jamie Wood
- Department of Biology, University of York, York, United Kingdom
- Department of Mathematics, University of York, York, United Kingdom
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Inflammation and Infection in Cystic Fibrosis: Update for the Clinician. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121898. [PMID: 36553341 PMCID: PMC9777099 DOI: 10.3390/children9121898] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/09/2022]
Abstract
Inflammation and infection play an important role in the pathophysiology of cystic fibrosis, and they are significant causes of morbidity and mortality in CF. The presence of thick mucus in the CF airways predisposes to local hypoxia and promotes infection and inflammation. A vicious cycle of airway obstruction, inflammation, and infection is of critical importance for the progression of the disease, and new data elucidate the different factors that influence it. Recent research has been focused on improving infection and inflammation in addition to correcting the basic gene defect. This review aims to summarize important advances in infection and inflammation as well as the effect of new treatments modulating the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) protein. New approaches to target infection and inflammation are being studied, including gallium, nitric oxide, and phage therapy for infection, along with retinoids and neutrophil elastase inhibitors for inflammation.
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Collaco JM, Albon D, Ostrenga JS, Flume P, Schechter MS, Cromwell EA. Factors associated with receiving CF care and use of telehealth in 2020 among persons with Cystic Fibrosis in the United States. J Cyst Fibros 2022:S1569-1993(22)01424-2. [DOI: 10.1016/j.jcf.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/08/2022] [Accepted: 12/06/2022] [Indexed: 12/15/2022]
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Sunman B, Yalcin E, Ozsezen B, Tural DA, Buyuksahin HN, Guzelkas I, Emiralioglu N, Dogru D, Özçelik U, Şener B, Kiper N. Association between early chronic methicillin-susceptible Staphylococcus aureus colonization and lung function in children with cystic fibrosis. Pediatr Pulmonol 2022; 57:2963-2970. [PMID: 35962540 DOI: 10.1002/ppul.26114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 07/22/2022] [Accepted: 08/11/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Our aim was to determine whether early chronic methicillin-susceptible Staphylococcus aureus (MSSA) colonization in children with cystic fibrosis (CF) is associated at 8 years of age with poorer lung function, poorer nutritional status, and increased exacerbation frequency. METHODS In this retrospective cohort study, a total of 52 children with chronic MSSA colonization were included. Of them, 26 were chronically colonized with MSSA before the age of 4 years (early onset), and 26 were chronically colonized from 4 years to 6 years of age (late-onset). At the age of 8 years, lung function, body mass index (BMI) as an indicator of nutritional status and frequency of pulmonary exacerbations were compared between two groups. RESULTS At 8 years of age, BMI was similar between the early-onset and late-onset groups (15.0 [min-max: 12.9-26.8] vs. 15.7 (min-max: 13.0-24.9), p = 0.327]. Percentage of forced expiratory volume in 1 s (FEV1) and forced expiratory flow between 25% and 75% of vital capacity (FEF25-75) in 8-year-old children were significantly lower in the early onset group compared to the late-onset group (98 [min-max: 44-139] vs. 106.5 [min-max: 82-131], p = 0.047; 84.9 ± 25.5 vs. -102.3 ± 26.3, respectively; p = 0.019], although the percentage of forced vital capacity did not differ significantly between two groups (93.5 [min-max: 45-131] vs. 103 [min-max: 84-119], respectively; p = 0.092). Exacerbation frequency between the ages of 6 and 8 years in the early onset group was higher compared to the late-onset group according to the Poisson regression model [1 (min-max:0-10) vs 0 (min-max:0-4), respectively; p = 0.044]. CONCLUSIONS Early chronic MSSA colonization is associated with poorer lung function and frequent exacerbations in children with CF. However, further studies are needed to reveal the cause-and-effect relationship between early chronic MSSA colonization and pulmonary outcome.
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Affiliation(s)
- Birce Sunman
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Ebru Yalcin
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Beste Ozsezen
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Dilber A Tural
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Halime N Buyuksahin
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Ismail Guzelkas
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Nagehan Emiralioglu
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Deniz Dogru
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Uğur Özçelik
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Burçin Şener
- Department of Medical Microbiology, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Nural Kiper
- Department of Pediatric Pulmonology, Hacettepe University Faculty of Medicine, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
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49
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Goltermann L, Andersen KL, Johansen HK, Molin S, La Rosa R. Macrolide therapy in Pseudomonas aeruginosa infections causes uL4 ribosomal protein mutations leading to high-level resistance. Clin Microbiol Infect 2022; 28:1594-1601. [PMID: 35988850 DOI: 10.1016/j.cmi.2022.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/05/2022] [Accepted: 08/06/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Pseudomonas aeruginosa colonizes the cystic fibrosis (CF) airways causing chronic bacterial lung infections. CF patients are routinely treated with macrolides, however, P. aeruginosa is considered insusceptible as consequence of inadequate susceptibility testing leaving resistance mechanism completely overlooked. Here, we investigated a new mechanism of macrolide resistance caused by ribosomal protein mutations. METHODS Investigating a longitudinal collection of 529 isolates from CF patients and analysing 5758 protein sequences from different sources, mutations in P. aeruginosa's ribosomal proteins connected to macrolide resistance were identified. Using a modified susceptibility testing protocol, isolates harbouring a mutated uL4 ribosomal protein were tested for resistance against macrolide antibiotics and macrolide-induced quorum sensing modulation. Proteome and ribosome profiling were applied to assess the impact of the mutations on the bacterial physiology. RESULTS Five uL4 mutations were identified in isolates from different CF patients. Most mapped to the conserved loop region of uL4 and resulted in increased macrolide tolerance (>10-fold relative to wt strains). Greater concentrations (>10-fold) of macrolide antibiotic were needed to inhibit the growth, reduce swimming motility, and induce redox sensitivity of the uL4 mutants. 16 proteins involved in ribosome adaptation displayed altered expression possibly to compensate for the uL4 mutations, which changed the ribosome stoichiometry without negatively affecting bacterial physiology. CONCLUSIONS Macrolide antibiotics should, therefore, be considered as active antimicrobial agents against P. aeruginosa and resistance development should be contemplated when patients are treated with prolonged courses of macrolides. Importantly, improved macrolide susceptibility testing is necessary for the detection of resistant bacteria.
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Affiliation(s)
- Lise Goltermann
- The Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark.
| | | | - Helle Krogh Johansen
- The Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark; Department of Clinical Microbiology 9301, Rigshospitalet, 2100, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Søren Molin
- The Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark
| | - Ruggero La Rosa
- The Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark.
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50
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DeFilippo EMM, Talwalkar JS, Harris ZM, Butcher J, Nasr SZ. Transitions of Care in Cystic Fibrosis. Clin Chest Med 2022; 43:757-771. [PMID: 36344079 DOI: 10.1016/j.ccm.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The development of formal transition models emerged to reduce variability in care, including cystic fibrosis (CF) responsibility, independence, self-care, and education (RISE), which provides a standardized transition program, including knowledge assessments, self-management checklists, and milestones for people with CF. Despite these interventions, the current landscape of health care transition (HCT) remains suboptimal, and additional focused attention on HCT is necessary. Standardization of assessment tools to gauge the efficacy of transfer from pediatric to adult care is a high priority. Such tools should incorporate both clinical and patient-centered outcomes to provide a comprehensive picture of progress and deficiencies of the HCT process.
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Affiliation(s)
| | - Jaideep S Talwalkar
- Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT, USA; Yale Adult Cystic Fibrosis Program, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Zachary M Harris
- Yale Adult Cystic Fibrosis Program, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jennifer Butcher
- Department of Pediatrics, Division of Pediatric Psychology, Mott Children's Hospital, University of Michigan Health, Ann Arbor, MI, USA
| | - Samya Z Nasr
- Department of Pediatrics, Division of Pediatric Pulmonology, Mott Children's Hospital, University of Michigan Health, 1500 E. Medical Center Dr., Ann Arbor, MI 48109-5212, USA.
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