Antibiotic therapy for stable non-CF bronchiectasis in adults - A systematic review

Advancing the pipeline of cystic fibrosis clinical trials: a new roadmap with a global trial network perspective

The growing use of modulator therapies aimed at restoring cystic fibrosis transmembrane conductance regulator (CFTR) protein function in people with cystic fibrosis has fundamentally altered clinical trial strategies needed to advance new therapeutics across an orphan disease population that is now divided by CFTR modulator eligibility. The development of a robust pipeline of nucleic acid-based therapies (NABTs)-initially directed towards the estimated 10% of the cystic fibrosis population who are genetically ineligible for, or intolerant of, CFTR modulators-is dependent on the optimisation of restricted trial participant resources across multiple development programmes, a challenge that will preclude the use of gold standard placebo-controlled trials. Advancement of a full pipeline of symptomatic therapies across the entire cystic fibrosis population will be challenged by smaller effect sizes and uncertainty regarding their clinical importance in a growing modulator-treated population with more mild and stable pulmonary disease. In this Series paper, we aim to lay the foundation for clinical trial strategy and community partnership that must deviate from established and familiar precedent to advance the future pipeline of cystic fibrosis therapeutics.

Inhaled Antibiotics in Non-cystic Fibrosis Bronchiectasis (NCFB): A Systematic Review of Efficacy and Limitations in Adult Patients

Non-cystic fibrosis bronchiectasis has recently been under the spotlight due to a better detection rate with advanced imaging techniques. Recurrent infections in such patients are the main cause of their deterioration. This invariably leads to a catastrophic wheel of decline in lung function, reinfection, and repeated hospital consultations. The main goal of their management is based on the principles of prevention and vigorous treatment of recurrent infections. This review aimed to gather recent therapeutic options for inhaled antibacterial use in such patients and compare them for their properties of safety and efficacy. Studies done in the last 10 years on adult patients were gathered using the Medical Subject Headings (MeSH) strategy and later sorted using the inclusion/exclusion criteria. Research engines used include Google Scholar, PubMed, and the Saudi Digital Library. Out of the 31,739 articles identified initially, 1362 were screened. The final eight selected papers were assessed for quality by using the quality assessment checklist, the Cochrane bias assessment tool, the Scale for the Assessment of Narrative Review Articles (SANRA) tools and cross-examined by co-authors. We concluded that the use of inhaled antibiotics as an adjuvant and follow-up treatment option is associated with better short and long-term prognoses in patients. They lead to lesser systemic side effects than the oral and intravenous varieties available on the market. However, the establishment of a hierarchy among the subgroups remains a grey area that needs further research.

Inhaled Corticosteroid Therapy in Bronchiectasis is Associated with All-Cause Mortality: A Prospective Cohort Study

Background and Objective

Prescribing inhaled corticosteroids (ICS) for bronchiectasis (BE) in the absence of obstructive lung disease is controversial. Studies investigating ICS therapy and impact on morbidity and mortality in BE are sparse.

Methods

This study comprises all patients with BE managed at respiratory outpatient clinics at two university hospitals in the Capital Region of Denmark 2014-2015. Baseline data were obtained from patient medical records, and patients were followed until April 2020.

Results

Out of 264 patients, 122 (46%) were prescribed ICS with no demographic differences between users/non-users of ICS. Among patients prescribed ICS, 21% did not have a concomitant diagnosis of asthma or COPD. Patients prescribed ICS had lower lung function (median FEV1 65.2 vs 80.9%pred, p<0.001) and a higher symptom burden in terms of cough (p 0.028), sputum production (p <0.001) and dyspnea (p <0.001). Pseudomonas-positive sputum cultures were more common in ICS-treated patients (6.5 vs 20%, p 0.010), as were previous severe exacerbations (41% vs 21%, p <0.001). In terms of mortality, high-dose ICS use was associated with increased mortality in multivariable Cox regression adjusted for age, sex, FEV1 and concomitant asthma/COPD (HR 4.93 [95% CI 1.73-14.0], p 0.003).

Conclusion

In this cohort, close to one out of five patients with BE were prescribed ICS despite having no concomitant diagnosis of asthma or COPD. Overall, ICS treatment was associated with higher morbidity and mortality, though causation is difficult to establish.

Inhaled antibiotics therapy for stable non-cystic fibrosis bronchiectasis: a meta-analysis

BACKGROUND

The optimum antibiotic therapy for non-cystic fibrosis bronchiectasis (NCFB) has yet to be determined. A meta-analysis was conducted to evaluate the efficacy and safety of inhaled antibiotics in adults with stable NCFB.

METHODS

PubMed, EMBASE, MEDLINE and the Cochrane Central Register of Controlled Trials were searched through November 2019.

RESULTS

A total of 16 randomized controlled trials (RCTs), recruiting 2748 NCFB patients, were finally included. Inhaled antibiotics treatment significantly reduced the sputum bacterial load [standard mean difference (SMD) = -0.74, 95% CI: -1.16-0.32, p < 0.001, I² = 68.1%], prolonged median time [hazard risk (HR) = 0.73, 95% confidence interval (CI): 0.57-0.93, p < 0.001, I² = 53.6%] and reduced frequency [incidence rate ratio (IRR) = 0.74, 95% CI 0.63-0.87, p < 0.001, I² = 20.5%] of exacerbations, with good tolerance. However, it failed to improve Pseudomonas aeruginosa eradication, [forced expiratory volume in 1 s (FEV1)] % predicted, quality of life questionnaire (QoL-B) and St. George's respiratory questionnaire (SGRQ) scores, and may induce higher risk of P. aeruginosa resistance. Subgroup analysis showed Ciprofloxacin was more effective than other antibiotics in reducing bacterial load (SMD = -1.35, 95% CI: -1.85-0.85, I² = 63.4%, p = 0.042).

CONCLUSION

Inhaled antibiotics therapy holds great promise for stable NCFB as it is effective in reducing sputum bacterial load and the risk of acute attack, delaying disease progression, and is well tolerated. Although this study brings some constructive ideas in the field of clinical medication, further clinical trials should be carried out, particularly in solving drug-resistance and improving health-related quality of life (HRQoL), which we believe will finally provide benefits for patients suffering from bronchiectasis. The reviews of this paper are available via the supplemental material section.

Results of Tobramycin Inhalation Therapy in Patients with Noncystic Fibrosis Bronchiectasis with Pseudomonas aeruginosa Colonization: Real Life Management

Background: Inhaled antibiotics for treating bronchiectasis have been investigated in the cystic fibrosis population since 1981 and long-term clinical benefits have been reported. However, studies on noncystic fibrosis bronchiectasis (NCFB) have only been performed more recently. Owing to limited evidence, inhaled antibiotics are not currently approved for treating NCFB by the U.S. Food and Drug Administration and the European Medicines Agency. The aim of this study was to evaluate the efficacy and safety of tobramycin inhalation therapy in patients with bronchiectasis with Pseudomonas aeruginosa (PA) colonization. Methods: In this retrospective cross-sectional study, NCFB patients who were Pseudomonas positive on three consecutive cultures 1 month apart and receiving tobramycin inhalation therapy were evaluated. Evaluation of the following parameters was done in this study: age, gender, smoking history, symptoms, pulmonary function test results, sputum culture results, tobramycin treatment duration, side effects of tobramycin and response evaluation, and hospital admissions before and after treatment. Treatment with 300 mg tobramycin through nebulizer twice daily for 28 days on-off cycles for a total of 6 months was considered to be one treatment period. The approvals for the study were received by the local ethics committee and institutional review board. Results: Of the 27 patients, 21 patients completed the first period, 7 patients completed the second period, 4 patients completed the third period, and 1 patient completed the fourth period. Sputum culture was negative in 10 (47.6%) of the 21 patients who completed the first period. Decreased sputum purulence and quantity, dyspnea, and cough were observed during treatment. The frequency of hospitalizations before treatment was 1.24 ± 1.36, whereas after treatment, it decreased to 0.52 ± 0.91, this difference was statistically significant (p = 0.019). The most common side effect was increased dyspnea after nebulization in five patients. Conclusion: Tobramycin inhalation appears to be a well-tolerated treatment in patients with PA colonization with bronchiectasis. This treatment may decrease the hospitalization rates and improve the symptoms.

Therapeutic Drug Monitoring of Inhaled Tobramycin in a Post-Hematopoietic Cell Transplant Patient With Bronchiolitis Obliterans and End-Stage Renal Disease

There are no widely accepted dose alterations for inhaled tobramycin in the setting of renal dysfunction, and serum concentrations are not typically monitored. Herein we describe a case report of a 16-year-old female with a history of 2 hematopoietic cell transplants and a kidney transplant who received inhaled tobramycin for chronic Pseudomonas aeruginosa management. The patient developed chronic kidney disease, and tobramycin concentrations were monitored. Initially she received a reduced dose of inhaled tobramycin, with repeated doses based on serum concentrations. The dose was increased, but serum concentrations obtained the following day remained higher than desired, leading to a suspicion of delayed systemic absorption. Tobramycin administration was changed from immediately prior to dialysis to the evening prior to the next day's dialysis session, and serum concentrations were consistently <1 mg/L postdialysis. In conclusion, systemic absorption of inhaled tobramycin in non-cystic fibrosis (CF) patients may differ compared to that observed in CF patients. Renal dysfunction may lead to systemic accumulation of inhaled tobramycin, and the timing of inhaled tobramycin administration with respect to dialysis has a potentially significant influence on drug clearance. Thus, monitoring may be required. Further cases are required to verify these observations.

Efficacy and safety of tobramycin inhalation powder in bronchiectasis patients with P. aeruginosa infection: Design of a dose-finding study (iBEST-1)

In patients with bronchiectasis (BE), infection with Pseudomonas aeruginosa (Pa) results in disease progression, frequent pulmonary exacerbations and lung function decline. However, at present, no inhaled antibiotics have been approved for the treatment of these patients. Tobramycin inhalation powder (TIP), approved for treatment of Pa infection in cystic fibrosis, could be a promising candidate. We aimed to assess effective and well-tolerated doses and regimens of TIP in BE patients with Pa infection. In this phase II, double-blind, placebo-controlled, randomised study, three different daily doses of TIP are administered either as continuous or cyclical regimens. The study protocol comprises 7-28 days of screening, 112 days of double-blind treatment and 56 days of follow-up. The plan was to enrol 180 patients (aged ≥18 years) with BE, documented Pa infection and a history of exacerbations. The primary outcome is change in sputum Pa density from baseline. Key secondary outcomes include number of pulmonary exacerbations, use of antipseudomonal antibiotics, serum and sputum tobramycin concentrations, quality of life and safety. Exploratory endpoints include lung clearance index, sputum inflammatory markers and microbiome analysis. As of October 2018, 107/180 patients were enrolled at 34 sites (six countries) following which recruitment was closed for administrative reasons unrelated to safety findings. Despite a reduced sample size from initially planned enrolment, the unique design may inform the benefit-risk profile of TIP in BE patients with chronic Pa infection. Moreover, several novel and exploratory endpoints (lung clearance index, inflammatory biomarkers, lung microbiome), will contribute to the advancement of research in this area.

Meta-analysis of macrolide maintenance therapy for prevention of disease exacerbations in patients with noncystic fibrosis bronchiectasis

BACKGROUND

Macrolide maintenance treatment remains controversial for patients with noncystic fibrosis (non-CF) bronchiectasis, we performed a meta-analysis to estimate the benefits and safety of macrolides therapy in adults and children with non-CF bronchiectasis.

METHODS

PubMed, Embase, the Cochrane Library, and Web of Science databases were searched for all the randomized controlled trials of macrolides for treating non-CF bronchiectasis. The primary outcome was improvement of bronchiectasis exacerbations. Secondary outcomes included adverse events and macrolide resistance.

RESULTS

A total of 10 studies involving 602 patients were included in the analysis. Pooled results showed that macrolide therapy significantly reduced the number of patients who suffered from exacerbations (RR = 1.56, 95% CI = 1.14-2.14, P = .006, I = 72%), number of patients who experienced at least 3 exacerbations (RR = 0.55, 95% CI = 0.39-0.77, P = .0005, I = 40%), average exacerbations per patient during the observation time (SMD = -0.69, 95% CI = -1.06 to -0.32, P = .0002, I = 60%), and bronchiectasis exacerbation-related admissions (RR = 0.46, 95% CI = 0.23-0.96, P = .04, I = 0%). Specified subgroup analyses of the number of patients free from exacerbations were further performed; macrolide therapy showed a significant benefit in both children (RR 5.03, 95% CI 2.02-12.50, P = .0005, I = 45%) and adults (RR = 1.66, 95% CI = 1.37-2.02, P < .00001, I = 79%); azithromycin showed a significant reduction on the number of patients who suffered from exacerbations (RR = 2.25, 95% CI = 1.67-3.02, P < .00001, I = 0%), was different from erythromycin (RR = 1.33, 95% CI = 0.92-1.94, P = .13, I = 0%) and roxithromycin (RR = 1.14, 95% CI = 0.97-1.35, P = .11, I = 0%). The pooled results also showed no higher risk of adverse events (RR = 0.98, 95% CI = 0.85-1.13, P = .80, I = 8%), even a lower risk of severe adverse events (RR = 0.53, 95% CI = 0.33-0.85, P = .009, I = 0%). However, a higher risk of macrolide resistance (RR = 3.59, 95% CI 2.6-4.96, P < .00001, I = 0%) was observed.

CONCLUSION

For both children and adults with non-CF bronchiectasis, macrolide maintenance therapy can effectively reduce bronchiectasis exacerbations, especially for patients with more frequent exacerbations and needing hospital treatment. Azithromycin was more effective than other macrolides. Macrolide maintenance therapy did not increase the risk of adverse events, but may increase the risk of macrolide resistance.

Spotlight on inhaled ciprofloxacin and its potential in the treatment of non-cystic fibrosis bronchiectasis

Non-cystic fibrosis bronchiectasis (NCFB) is a severe chronic illness characterized by irreversible dilation of airways and thickening of bronchial walls, chronic inflammation, repeated infections, and progressive obstruction of the airways. In contrast to cystic fibrosis bronchiectasis (CFB), which is a well-defined genetic disorder, NCFB is a heterogeneous disease caused by many different medical entities. Inhaled antibiotics are effective for patients with CFB, but their efficacy in NCFB has not been proven. The main pathogens involved in the colonization of patients with bronchiectasis are Haemophilus influenza, Moraxella catarrhalis, Staphylococcus aureus, and Pseudomonas aeruginosa. The latter is associated with increased morbidity and mortality. In addition, in NCFB, P. aeruginosa strains are frequently more resistant than those in CFB. At present, there are no approved inhaled antibiotic therapies for NCFB patients. Inhaled ciprofloxacin has been under investigation in the last few years. In two phase II randomized, double-blind, placebo-controlled trials, the use of inhaled ciprofloxacin was significantly associated with reduction in sputum bacterial density and greater eradication rates. In four phase III randomized, double-blind, placebo-controlled trials, the results regarding the time of the first exacerbation and the rate of exacerbations were inconsistent. Specifically, ORBIT-4 and RESPIRE-1 trials showed clinical benefit (prolongation of the time of the first exacerbation and reduced rate of exacerbations in the treatment group compared to the placebo group), whereas the ORBIT-3 and RESPIRE-2 failed to achieve their primary endpoints. The RESPIRE-1 was the first trial that examined the 14-days on/off course separate from the standard 28-days on/off regimen, which is based on CFB protocol treatments. The current data on the efficacy of inhaled ciprofloxacin are encouraging, but further evaluation is needed to determine the appropriate target group and the ideal duration of treatment.

A new approach to the classification and management of airways diseases: identification of treatable traits

This review outlines a new, personalized approach for the classification and management of airway diseases. The current approach to airways disease is, we believe, no longer fit for purpose. It is impractical, overgeneralizes complex and heterogeneous conditions and results in management that is imprecise and outcomes that are worse than they could be. Importantly, the assumptions we make when applying a diagnostic label have impeded new drug discovery and will continue to do so unless we change our approach. This review suggests a new mechanism-based approach where the emphasis is on identification of key causal mechanisms and targeted intervention with treatment based on possession of the relevant mechanism rather than an arbitrary label. We highlight several treatable traits and suggest how they can be identified and managed in different healthcare settings.