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Cordeiro R, Choi H, Haworth CS, Chalmers JD. The Efficacy and Safety of Inhaled Antibiotics for the Treatment of Bronchiectasis in Adults: Updated Systematic Review and Meta-Analysis. Chest 2024; 166:61-80. [PMID: 38309462 PMCID: PMC11251083 DOI: 10.1016/j.chest.2024.01.045] [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: 07/10/2023] [Revised: 12/15/2023] [Accepted: 01/21/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Inhaled antibiotics are recommended conditionally by international bronchiectasis guidelines for the treatment of patients with bronchiectasis, but results of individual studies are inconsistent. A previous meta-analysis demonstrated promising results regarding the efficacy and safety of inhaled antibiotics in bronchiectasis. Subsequent publications have supplemented the existing body of evidence further in this area. RESEARCH QUESTION To what extent do inhaled antibiotics demonstrate both efficacy and safety as a treatment option for adults with bronchiectasis? STUDY DESIGN AND METHODS Systematic review and meta-analysis of randomized controlled trials of inhaled antibiotics in adult patients with bronchiectasis. We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials.gov for eligible studies. Studies were included if they enrolled adults with bronchiectasis diagnosed by CT imaging and had a treatment duration of at least 4 weeks. The primary end point was exacerbation frequency, with additional key efficacy end points including severe exacerbations, bacterial load, symptoms, quality of life, and FEV1. Data were pooled through random-effects meta-analysis. RESULTS Twenty studies involving 3,468 patients were included. Inhaled antibiotics were associated with reduced number of patients with exacerbations (risk ratio, 0.85; 95% CI, 0.75-0.96), a slight reduction in exacerbation frequency (rate ratio [RR], 0.78; 95% CI, 0.68-0.91), a probable reduction in the frequency of severe exacerbations (RR, 0.48; 95% CI, 0.31-0.74), and a likely slight increase in time to first exacerbation (hazard ratio, 0.80; 95% CI, 0.68-0.94). Inhaled antibiotics likely lead to a slight increase in the Quality of Life Questionnaire-Bronchiectasis respiratory symptom score (mean difference, 2.51; 95% CI, 0.44-4.31) and may reduce scores on the St. George Respiratory Questionnaire (mean difference, -3.13; 95% CI, -5.93 to -0.32). Bacterial load consistently was reduced, but FEV1 was not changed with treatment. Evidence suggests little to no difference in adverse effects between groups (OR, 0.99; 95% CI, 0.75-1.30). Antibiotic-resistant organisms likely were increased by treatment. INTERPRETATION In this systematic review and meta-analysis, inhaled antibiotics resulted in a slight reduction in exacerbations, a probable reduction in severe exacerbations, and a likely slight improvement in symptoms and quality of life in adults with bronchiectasis. TRIAL REGISTRY International Prospective Register of Systematic Reviews; No.: CRD42023384694; URL: https://www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Ricardo Cordeiro
- Department of Pulmonology, Centro Hospitalar do Oeste, Torres Vedras, Portugal
| | - Hayoung Choi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Charles S Haworth
- Cambridge Centre for Lung Infection, Royal Papworth Hospital NHS Foundation Trust, University of Cambridge, Cambridge, England; Department of Medicine, University of Cambridge, Cambridge, England
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland.
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Choi H, McShane PJ, Aliberti S, Chalmers JD. Bronchiectasis management in adults: state of the art and future directions. Eur Respir J 2024; 63:2400518. [PMID: 38782469 PMCID: PMC11211698 DOI: 10.1183/13993003.00518-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
Formerly regarded as a rare disease, bronchiectasis is increasingly recognised. A renewed interest in this disease has led to significant progress in bronchiectasis research. Randomised clinical trials (RCTs) have demonstrated the benefits of airway clearance techniques, inhaled antibiotics and long-term macrolide therapy in bronchiectasis patients. However, the heterogeneity of bronchiectasis remains one of the most challenging aspects of management. Phenotypes and endotypes of bronchiectasis have been identified to help find "treatable traits" and partially overcome disease complexity. The goals of therapy for bronchiectasis are to reduce the symptom burden, improve quality of life, reduce exacerbations and prevent disease progression. We review the pharmacological and non-pharmacological treatments that can improve mucociliary clearance, reduce airway inflammation and tackle airway infection, the key pathophysiological features of bronchiectasis. There are also promising treatments in development for the management of bronchiectasis, including novel anti-inflammatory therapies. This review provides a critical update on the management of bronchiectasis focusing on treatable traits and recent RCTs.
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Affiliation(s)
- Hayoung Choi
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Pamela J McShane
- Division of Pulmonary and Critical Care, University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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3
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Panthi VK, Fairfull-Smith KE, Islam N. Ciprofloxacin-Loaded Inhalable Formulations against Lower Respiratory Tract Infections: Challenges, Recent Advances, and Future Perspectives. Pharmaceutics 2024; 16:648. [PMID: 38794310 PMCID: PMC11125790 DOI: 10.3390/pharmaceutics16050648] [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: 03/06/2024] [Revised: 04/29/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024] Open
Abstract
Inhaled ciprofloxacin (CFX) has been investigated as a treatment for lower respiratory tract infections (LRTIs) associated with cystic fibrosis (CF), chronic obstructive pulmonary disease (COPD), and bronchiectasis. The challenges in CFX effectiveness for LRTI treatment include poor aqueous solubility and therapy resistance. CFX dry powder for inhalation (DPI) formulations were well-tolerated, showing a remarkable decline in overall bacterial burden compared to a placebo in bronchiectasis patients. Recent research using an inhalable powder combining Pseudomonas phage PEV20 with CFX exhibited a substantial reduction in bacterial density in mouse lungs infected with clinical P. aeruginosa strains and reduced inflammation. Currently, studies suggest that elevated biosynthesis of fatty acids could serve as a potential biomarker for detecting CFX resistance in LRTIs. Furthermore, inhaled CFX has successfully addressed various challenges associated with traditional CFX, including the incapacity to eliminate the pathogen, the recurrence of colonization, and the development of resistance. However, further exploration is needed to address three key unresolved issues: identifying the right patient group, determining the optimal treatment duration, and accurately assessing the risk of antibiotic resistance, with additional multicenter randomized controlled trials suggested to tackle these challenges. Importantly, future investigations will focus on the effectiveness of CFX DPI in bronchiectasis and COPD, aiming to differentiate prognoses between these two conditions. This review underscores the importance of CFX inhalable formulations against LRTIs in preclinical and clinical sectors, their challenges, recent advancements, and future perspectives.
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Affiliation(s)
- Vijay Kumar Panthi
- Pharmacy Discipline, School of Clinical Sciences, Queensland University of Technology (QUT), Brisbane, QLD 4001, Australia;
| | - Kathryn E. Fairfull-Smith
- School of Chemistry and Physics, Faculty of Science, Queensland University of Technology (QUT), Brisbane, QLD 4001, Australia;
- Centre for Materials Science, Queensland University of Technology (QUT), Brisbane, QLD 4001, Australia
| | - Nazrul Islam
- Pharmacy Discipline, School of Clinical Sciences, Queensland University of Technology (QUT), Brisbane, QLD 4001, Australia;
- Centre for Materials Science, Queensland University of Technology (QUT), Brisbane, QLD 4001, Australia
- Centre for Immunology and Infection Control (CIIC), Queensland University of Technology (QUT), Brisbane, QLD 4001, Australia
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Floroiu A, Loretz B, Krämer J, Lehr CM. Drug solubility in biorelevant media in the context of an inhalation-based biopharmaceutics classification system (iBCS). Eur J Pharm Biopharm 2024; 197:114206. [PMID: 38316234 DOI: 10.1016/j.ejpb.2024.114206] [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: 07/03/2023] [Revised: 12/01/2023] [Accepted: 01/30/2024] [Indexed: 02/07/2024]
Abstract
An inhalation-based Biopharmaceutics Classification System for pulmonary drugs (iBCS) holds the perspective to allow for scientifically sound prediction of differences in the in vivo performance of orally inhaled drug products (OIDPs). A set of nine drug substances were selected, that are administered via both the oral and pulmonary routes. Their solubility was determined in media representative for the oral (Fasted State Simulated Intestinal Fluid (FaSSIF)) and pulmonary (Alveofact medium and Simulated Lung Fluid (SLF)) routes of administration to confirm the need for a novel approach for inhaled drugs. The complexity of these media was then stepwise reduced with the purpose of understanding the contribution of their components to the solubilizing capacity of the media. A second reason for varying the complexity was to identify a medium that would allow robust but accurate dissolution testing. Hence, Hank's balanced salt solution (HBSS) as a medium used in many in vitro biological tests, non-buffered saline solution, and water were included. For some drug substances (salbutamol sulfate, tobramycin, isoniazid, and tiotropium bromide), no significant differences were observed between the solubility in the media used. For other drugs, however, we observed either just small (rifampicin, budesonide, salmeterol) or unexpectedly large differences (beclomethasone dipropionate). Based on the minimum theoretical solubility required for their common pulmonary dose in 10 ml of lung lining fluid, drug solubility was classified as either high or low. Two high solubility and two low solubility compounds were then selected for refined solubility testing in pulmonary relevant media by varying their content of phospholipids, surfactant proteins and other proteins. The solubility of drug substances in simulated lung lining fluids was found to be dependent on the physicochemical properties of the drug substance and the composition of the media. While a pulmonary dissolution medium that would fit all drugs could not be established, our approach may provide guidance for finding the most suitable dissolution medium for a given drug substance and better designing in vitro tests for predicting the in vivo performance of inhalable drug products.
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Affiliation(s)
- Andreea Floroiu
- Department of Pharmacy, Saarland University, 66123 Saarbrücken, Germany; Eurofins PHAST Development GmbH & Co. KG, 78467 Konstanz, Germany.
| | - Brigitta Loretz
- Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research, Saarland University, Campus E8 1, 66123 Saarbrücken, Germany
| | | | - Claus-Michael Lehr
- Department of Pharmacy, Saarland University, 66123 Saarbrücken, Germany; Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research, Saarland University, Campus E8 1, 66123 Saarbrücken, Germany.
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Nakka S, Katari NK, Muchakayala SK, Jonnalagadda SB, Manabolu Surya SB. Synthesis and Trace-Level Quantification of Mutagenic and Cohort-of-Concern Ciprofloxacin Nitroso Drug Substance-Related Impurities (NDSRIs) and Other Nitroso Impurities Using UPLC-ESI-MS/MS-Method Optimization Using I-Optimal Mixture Design. ACS OMEGA 2024; 9:8773-8788. [PMID: 38434810 PMCID: PMC10905725 DOI: 10.1021/acsomega.3c05170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/06/2023] [Indexed: 03/05/2024]
Abstract
Globally, the pharmaceutical industry has been facing challenges from nitroso drug substance-related impurities (NDSRIs). In the current study, we synthesized and developed a rapid new UPLC-MS/MS method for the trace-level quantification of ciprofloxacin NDSRIs and a couple of N-nitroso impurities simultaneously. (Q)-SAR methodology was employed to assess and categorize the genotoxicity of all ciprofloxacin N-nitroso impurities. The projected results were positive, and the cohort of concern (CoC) for all three N-nitroso impurities indicates potential genotoxicity. AQbD-driven I-optimal mixture design was used to optimize the mixture of solvents in the method. The chromatographic resolution was accomplished using an Agilent Poroshell 120 Aq-C18 column (150 mm × 4.6 mm, 2.7 μm) in isocratic elution mode with 0.1% formic acid in a mixture of water, acetonitrile, and methanol in the ratio of 475:500:25 v/v/v at a flow rate of 0.5 mL/min. Quantification was carried out using triple quadrupole mass detection with electrospray ionization (ESI) in a multiple reaction monitoring technique. The finalized method was validated successfully, affording ICH guidelines. All N-nitroso impurities revealed excellent linearity over the concentration range of 0.00125-0.0250 ppm. The Pearson correlation coefficient of each N-nitroso impurity was >0.999. The method accuracy recoveries ranged from 93.98 to 108.08% for the aforementioned N-nitrosamine impurities. Furthermore, the method was effectively applied to quantify N-nitrosamine impurities simultaneously in commercially available formulated samples, with its efficiency recurring at trace levels. Thus, the current method is capable of determining the trace levels of three N-nitroso ciprofloxacin impurities simultaneously from the marketed tablet dosage forms for commercial release and stability testing.
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Affiliation(s)
- Srinivas Nakka
- Department
of Chemistry, School of Science, GITAM Deemed
to be University, Hyderabad 502329, India
| | - Naresh Kumar Katari
- Department
of Chemistry, School of Science, GITAM Deemed
to be University, Hyderabad 502329, India
- School
of Chemistry & Physics, College of Agriculture, Engineering &
Science, Westville Campus, University of
KwaZulu-Natal, P Bag X 54001, Durban 4000, South Africa
| | - Siva Krishna Muchakayala
- Department
of Chemistry, School of Science, GITAM Deemed
to be University, Hyderabad 502329, India
| | - Sreekantha Babu Jonnalagadda
- School
of Chemistry & Physics, College of Agriculture, Engineering &
Science, Westville Campus, University of
KwaZulu-Natal, P Bag X 54001, Durban 4000, South Africa
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Yong J, Shu H, Zhang X, Yang K, Luo G, Yu L, Li J, Huang H. Natural Products-Based Inhaled Formulations for Treating Pulmonary Diseases. Int J Nanomedicine 2024; 19:1723-1748. [PMID: 38414528 PMCID: PMC10898359 DOI: 10.2147/ijn.s451206] [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: 11/22/2023] [Accepted: 02/01/2024] [Indexed: 02/29/2024] Open
Abstract
Given the unique physiological and pathological characteristics of the lung, the direct, inhalable route is more conducive to pulmonary drug delivery and disease control than traditional systemic drug delivery, significantly circumventing drug loss, off-target effects, systemic and organ toxicity, etc., and is widely regarded as the preferred regimen for pulmonary drug delivery. However, very few lung diseases are currently treated with the preferred inhaled formulations, such as asthma, chronic obstructive pulmonary disease and pulmonary hypertension. And there is a lack of appropriate inhaled formulations for other critical lung diseases, such as lung cancer and pulmonary fibrosis, due to the fact that the physicochemical properties of the drugs and their pharmacokinetic profiles do not match the physiology of the lung, and conventional inhalation devices are unable to deliver them to the specific parts of the lung. Phytochemicals of natural origin, due to their wide availability and clear safety profile, hold great promise for the preparation of inhalable formulations to improve the current dilemma in the treatment of lung diseases. In particular, the preparation of inhalable formulations based on nano- and microparticulate carriers for drug delivery to deep lung tissues, which overcome the shortcomings of conventional inhalation therapies while targeting the drug activity directly to a specific part of the lung, may be the best approach to change the current dilemma of lung disease treatment. In this review, we discuss recent advances in nano- and micron-carrier-based inhalation formulations for the delivery of natural products for the treatment of pulmonary diseases, which may represent an opportunity for practical clinical translation of natural products.
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Affiliation(s)
- Jiangyan Yong
- Department of Clinical Laboratory, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, 610072, People’s Republic of China
| | - Hongli Shu
- Department of Clinical Laboratory, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, 610072, People’s Republic of China
| | - Xiao Zhang
- Department of Clinical Laboratory, Chengdu Children Special Hospital, Chengdu, Sichuan, 610031, People’s Republic of China
| | - Kun Yang
- Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, 611137, People’s Republic of China
| | - Guining Luo
- Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, 611137, People’s Republic of China
| | - Lu Yu
- Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, 611137, People’s Republic of China
| | - Jiaqi Li
- Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, 611137, People’s Republic of China
| | - Hong Huang
- Department of Clinical Laboratory, the People’s Hospital of Chongqing Liang Jiang New Area, Chongqing, 401121, People’s Republic of China
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Khadka P, Dummer J, Hill PC, Das SC. The quest to deliver high-dose rifampicin: can the inhaled approach help? Expert Opin Drug Deliv 2024; 21:31-44. [PMID: 38180078 DOI: 10.1080/17425247.2024.2301931] [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: 06/20/2023] [Accepted: 01/02/2024] [Indexed: 01/06/2024]
Abstract
INTRODUCTION Tuberculosis (TB) is a global health problem that poses a challenge to global treatment programs. Rifampicin is a potent and highly effective drug for TB treatment; however, higher oral doses than the standard dose (10 mg/kg/day) rifampicin may offer better efficacy in TB treatment. AREAS COVERED High oral dose rifampicin is not implemented in anti-TB regimens yet and requires about a 3-fold increase in dose for increased efficacy. We discuss inhaled delivery of rifampicin as an alternative or adjunct to oral high-dose rifampicin. Clinical results of safety, tolerability, and patient compliance with antibiotic dry powder inhalers are reviewed. EXPERT OPINION Clinical trials suggest that an approximately 3-fold increase in the standard oral dose of rifampicin may be required for better clinical outcomes. On the other hand, animal studies suggest that inhaled rifampicin can deliver a high concentration of the drug to the lungs and achieve approximately double the plasma concentration than that from oral rifampicin. Clinical trials on inhaled antibiotics suggest that dry powder inhalation is a patient-friendly and well-tolerated approach in treating respiratory infections compared to conventional treatments. Rifampicin, a well-known anti-TB drug given orally, is a good candidate for clinical development as a dry powder inhaler.
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Affiliation(s)
- Prakash Khadka
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Jack Dummer
- Department of Medicine, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Philip C Hill
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Shyamal C Das
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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de la Rosa-Carrillo D, Suárez-Cuartín G, Sibila O, Golpe R, Girón RM, Martínez-García MÁ. Efficacy and Safety of Dry Powder Antibiotics: A Narrative Review. J Clin Med 2023; 12:jcm12103577. [PMID: 37240682 DOI: 10.3390/jcm12103577] [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: 04/20/2023] [Revised: 05/10/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
The use of inhaled antibiotics was initially almost exclusively confined to patients with cystic fibrosis (CF). However, it has been extended in recent decades to patients with non-CF bronchiectasis or chronic obstructive pulmonary disease who present with chronic bronchial infection by potentially pathogenic microorganisms. Inhaled antibiotics reach high concentrations in the area of infection, which enhances their effect and enables their long-term administration to defeat the most resistant infections, while minimizing possible adverse effects. New formulations of inhaled dry powder antibiotics have been developed, providing, among other advantages, faster preparation and administration of the drug, as well as avoiding the requirement to clean nebulization equipment. In this review, we analyze the advantages and disadvantages of the different types of devices that allow the inhalation of antibiotics, especially dry powder inhalers. We describe their general characteristics, the different inhalers on the market and the proper way to use them. We analyze the factors that influence the way in which the dry powder drug reaches the lower airways, as well as aspects of microbiological effectiveness and risks of resistance development. We review the scientific evidence on the use of colistin and tobramycin with this type of device, both in patients with CF and with non-CF bronchiectasis. Finally, we discuss the literature on the development of new dry powder antibiotics.
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Affiliation(s)
| | | | - Oriol Sibila
- Respiratory Department, Hospital Clínic i Provincial, 08036 Barcelona, Spain
| | - Rafael Golpe
- Respiratory Department, Hospital Lucus Augusti, 27003 Lugo, Spain
| | - Rosa-María Girón
- Respiratory Department, Hospital de la Princesa, 28006 Madrid, Spain
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Zhang XX, Chen ZM, He ZF, Guan WJ. Advances in pharmacotherapy for bronchiectasis in adults. Expert Opin Pharmacother 2023; 24:1075-1089. [PMID: 37161410 DOI: 10.1080/14656566.2023.2210763] [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: 05/11/2023]
Abstract
INTRODUCTION Bronchiectasis has become a growing concern of chronic airway disease because of the enormous socioeconomic burden. Four cardinal interdependent components - impaired airway defense, recurrent airway infections, inflammatory response, and airway damage, in conjunction with the underlying etiology, have collectively played a role in modulating the vicious vortex of the pathogenesis and progression of bronchiectasis. Current pharmacotherapy aims to target at these aspects to break the vicious vortex. AREAS COVERED The authors retrieve and review, in MEDLINE, Web of Science and ClinicalTrials.gov registry, the studies about pharmacotherapy for bronchiectasis from these aspects: antibiotics, mucoactive medications, bronchodilators, anti-inflammatory drug, and etiological treatment. EXPERT OPINION Future drug development and clinical trials of bronchiectasis need to pay more attention to the different phenotypes or endotypes of bronchiectasis. There is a need for the development of novel inhaled antibiotics that could reduce bacterial loads, improve quality-of-life, and decrease exacerbation risks. More efforts are needed to explore the next-generation neutrophil-targeted therapeutic drugs that are expected to ameliorate respiratory symptom burden, reduce exacerbation risks, and hinder airway destruction in bronchiectasis.
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Affiliation(s)
- Xiao-Xian Zhang
- Guangzhou Institute of Respiratory Health, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhao-Ming Chen
- Guangzhou Institute of Respiratory Health, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhen-Feng He
- Guangzhou Institute of Respiratory Health, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wei-Jie Guan
- Guangzhou Institute of Respiratory Health, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Thoracic Surgery, Guangzhou Institute for Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Department of Respiratory Centre, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
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Riveiro V, Casal A, Álvarez‐Dobaño JM, Lourido T, Suárez‐Artime P, Rodríguez‐García C, Ferreiro L, Toubes ME, Valdés L. Response to inhaled ceftazidime in patients with non-cystic fibrosis bronchiectasis and chronic bronchial infection unrelated to Pseudomonas aeruginosa. THE CLINICAL RESPIRATORY JOURNAL 2022; 16:768-773. [PMID: 36017771 PMCID: PMC9629990 DOI: 10.1111/crj.13534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/04/2022] [Accepted: 08/16/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Inhaled antibiotics reduce the frequency of exacerbations. The objective was to assess the efficacy of inhaled ceftazidime in patients with non-cystic fibrosis bronchiectasis (NCFB) and concomitant chronic bronchial infection (CBI) caused by potentially pathogenic microorganisms (PPM) other than Pseudomonas aeruginosa (PA). MATERIAL AND METHOD Quasi-experimental study in 21 patients with exacerbations who developed CBI by a PPM other than PA. RESULTS Bacterial infection was resolved in 85.7% patients. Rehospitalizations, length of hospital stay, moderate exacerbations and blood levels of CRP decreased significantly. In addition, SGRQ questionnaire also decreased more than 4 points in 57.1% of the patients. CONCLUSION The results suggest that inhaled ceftazidime in NCFB unrelated to PA is a plausible alternative to the standard therapies used in clinical practice.
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Affiliation(s)
- Vanessa Riveiro
- Pulmonology DepartmentUniversity Clinical Hospital of SantiagoSantiago de CompostelaSpain
| | - Ana Casal
- Pulmonology DepartmentUniversity Clinical Hospital of SantiagoSantiago de CompostelaSpain
| | - José M. Álvarez‐Dobaño
- Pulmonology DepartmentUniversity Clinical Hospital of SantiagoSantiago de CompostelaSpain
- Interdisciplinary Research Group in PulmonologyHealth Research Institute of Santiago de Compostela (IDIS)Santiago de CompostelaSpain
| | - Tamara Lourido
- Pulmonology DepartmentUniversity Clinical Hospital of SantiagoSantiago de CompostelaSpain
| | - Pedro Suárez‐Artime
- Pharmacy DepartmentUniversity Clinical Hospital of SantiagoSantiago de CompostelaSpain
| | | | - Lucía Ferreiro
- Pulmonology DepartmentUniversity Clinical Hospital of SantiagoSantiago de CompostelaSpain
- Interdisciplinary Research Group in PulmonologyHealth Research Institute of Santiago de Compostela (IDIS)Santiago de CompostelaSpain
| | - María E. Toubes
- Pulmonology DepartmentUniversity Clinical Hospital of SantiagoSantiago de CompostelaSpain
| | - Luis Valdés
- Pulmonology DepartmentUniversity Clinical Hospital of SantiagoSantiago de CompostelaSpain
- Interdisciplinary Research Group in PulmonologyHealth Research Institute of Santiago de Compostela (IDIS)Santiago de CompostelaSpain
- University of Santiago de CompostelaSantiago de CompostelaSpain
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11
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Muacevic A, Adler JR. Inhaled Antibiotics in Non-cystic Fibrosis Bronchiectasis (NCFB): A Systematic Review of Efficacy and Limitations in Adult Patients. Cureus 2022; 14:e30660. [PMID: 36439573 PMCID: PMC9685586 DOI: 10.7759/cureus.30660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/24/2022] [Indexed: 12/01/2022] Open
Abstract
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.
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Katiyar SK, Gaur SN, Solanki RN, Sarangdhar N, Suri JC, Kumar R, Khilnani GC, Chaudhary D, Singla R, Koul PA, Mahashur AA, Ghoshal AG, Behera D, Christopher DJ, Talwar D, Ganguly D, Paramesh H, Gupta KB, Kumar T M, Motiani PD, Shankar PS, Chawla R, Guleria R, Jindal SK, Luhadia SK, Arora VK, Vijayan VK, Faye A, Jindal A, Murar AK, Jaiswal A, M A, Janmeja AK, Prajapat B, Ravindran C, Bhattacharyya D, D'Souza G, Sehgal IS, Samaria JK, Sarma J, Singh L, Sen MK, Bainara MK, Gupta M, Awad NT, Mishra N, Shah NN, Jain N, Mohapatra PR, Mrigpuri P, Tiwari P, Narasimhan R, Kumar RV, Prasad R, Swarnakar R, Chawla RK, Kumar R, Chakrabarti S, Katiyar S, Mittal S, Spalgais S, Saha S, Kant S, Singh VK, Hadda V, Kumar V, Singh V, Chopra V, B V. Indian Guidelines on Nebulization Therapy. Indian J Tuberc 2022; 69 Suppl 1:S1-S191. [PMID: 36372542 DOI: 10.1016/j.ijtb.2022.06.004] [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: 05/07/2022] [Revised: 06/03/2022] [Accepted: 06/09/2022] [Indexed: 06/16/2023]
Abstract
Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.
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Affiliation(s)
- S K Katiyar
- Department of Tuberculosis & Respiratory Diseases, G.S.V.M. Medical College & C.S.J.M. University, Kanpur, Uttar Pradesh, India.
| | - S N Gaur
- Vallabhbhai Patel Chest Institute, University of Delhi, Respiratory Medicine, School of Medical Sciences and Research, Sharda University, Greater NOIDA, Uttar Pradesh, India
| | - R N Solanki
- Department of Tuberculosis & Chest Diseases, B. J. Medical College, Ahmedabad, Gujarat, India
| | - Nikhil Sarangdhar
- Department of Pulmonary Medicine, D. Y. Patil School of Medicine, Navi Mumbai, Maharashtra, India
| | - J C Suri
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Raj Kumar
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, National Centre of Allergy, Asthma & Immunology; University of Delhi, Delhi, India
| | - G C Khilnani
- PSRI Institute of Pulmonary, Critical Care, & Sleep Medicine, PSRI Hospital, Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Dhruva Chaudhary
- Department of Pulmonary & Critical Care Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Rupak Singla
- Department of Tuberculosis & Respiratory Diseases, National Institute of Tuberculosis & Respiratory Diseases (formerly L.R.S. Institute), Delhi, India
| | - Parvaiz A Koul
- Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India
| | - Ashok A Mahashur
- Department of Respiratory Medicine, P. D. Hinduja Hospital, Mumbai, Maharashtra, India
| | - A G Ghoshal
- National Allergy Asthma Bronchitis Institute, Kolkata, West Bengal, India
| | - D Behera
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - D J Christopher
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Deepak Talwar
- Metro Centre for Respiratory Diseases, Noida, Uttar Pradesh, India
| | | | - H Paramesh
- Paediatric Pulmonologist & Environmentalist, Lakeside Hospital & Education Trust, Bengaluru, Karnataka, India
| | - K B Gupta
- Department of Tuberculosis & Respiratory Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences Rohtak, Haryana, India
| | - Mohan Kumar T
- Department of Pulmonary, Critical Care & Sleep Medicine, One Care Medical Centre, Coimbatore, Tamil Nadu, India
| | - P D Motiani
- Department of Pulmonary Diseases, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
| | - P S Shankar
- SCEO, KBN Hospital, Kalaburagi, Karnataka, India
| | - Rajesh Chawla
- Respiratory and Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India
| | - Randeep Guleria
- All India Institute of Medical Sciences, Department of Pulmonary Medicine & Sleep Disorders, AIIMS, New Delhi, India
| | - S K Jindal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S K Luhadia
- Department of Tuberculosis and Respiratory Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | - V K Arora
- Indian Journal of Tuberculosis, Santosh University, NCR Delhi, National Institute of TB & Respiratory Diseases Delhi, India; JIPMER, Puducherry, India
| | - V K Vijayan
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, University of Delhi, Delhi, India
| | - Abhishek Faye
- Centre for Lung and Sleep Disorders, Nagpur, Maharashtra, India
| | | | - Amit K Murar
- Respiratory Medicine, Cronus Multi-Specialty Hospital, New Delhi, India
| | - Anand Jaiswal
- Respiratory & Sleep Medicine, Medanta Medicity, Gurugram, Haryana, India
| | - Arunachalam M
- All India Institute of Medical Sciences, New Delhi, India
| | - A K Janmeja
- Department of Respiratory Medicine, Government Medical College, Chandigarh, India
| | - Brijesh Prajapat
- Pulmonary and Critical Care Medicine, Yashoda Hospital and Research Centre, Ghaziabad, Uttar Pradesh, India
| | - C Ravindran
- Department of TB & Chest, Government Medical College, Kozhikode, Kerala, India
| | - Debajyoti Bhattacharyya
- Department of Pulmonary Medicine, Institute of Liver and Biliary Sciences, Army Hospital (Research & Referral), New Delhi, India
| | | | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - J K Samaria
- Centre for Research and Treatment of Allergy, Asthma & Bronchitis, Department of Chest Diseases, IMS, BHU, Varanasi, Uttar Pradesh, India
| | - Jogesh Sarma
- Department of Pulmonary Medicine, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Lalit Singh
- Department of Respiratory Medicine, SRMS Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
| | - M K Sen
- Department of Respiratory Medicine, ESIC Medical College, NIT Faridabad, Haryana, India; Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Mahendra K Bainara
- Department of Pulmonary Medicine, R.N.T. Medical College, Udaipur, Rajasthan, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi PostGraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Nilkanth T Awad
- Department of Pulmonary Medicine, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Narayan Mishra
- Department of Pulmonary Medicine, M.K.C.G. Medical College, Berhampur, Orissa, India
| | - Naveed N Shah
- Department of Pulmonary Medicine, Chest Diseases Hospital, Government Medical College, Srinagar, Jammu & Kashmir, India
| | - Neetu Jain
- Department of Pulmonary, Critical Care & Sleep Medicine, PSRI, New Delhi, India
| | - Prasanta R Mohapatra
- Department of Pulmonary Medicine & Critical Care, All India Institute of Medical Sciences, Bhubaneswar, Orissa, India
| | - Parul Mrigpuri
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Pawan Tiwari
- School of Excellence in Pulmonary Medicine, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - R Narasimhan
- Department of EBUS and Bronchial Thermoplasty Services at Apollo Hospitals, Chennai, Tamil Nadu, India
| | - R Vijai Kumar
- Department of Pulmonary Medicine, MediCiti Medical College, Hyderabad, Telangana, India
| | - Rajendra Prasad
- Vallabhbhai Patel Chest Institute, University of Delhi and U.P. Rural Institute of Medical Sciences & Research, Safai, Uttar Pradesh, India
| | - Rajesh Swarnakar
- Department of Respiratory, Critical Care, Sleep Medicine and Interventional Pulmonology, Getwell Hospital & Research Institute, Nagpur, Maharashtra, India
| | - Rakesh K Chawla
- Department of, Respiratory Medicine, Critical Care, Sleep & Interventional Pulmonology, Saroj Super Speciality Hospital, Jaipur Golden Hospital, Rajiv Gandhi Cancer Hospital, Delhi, India
| | - Rohit Kumar
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - S Chakrabarti
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | | | - Saurabh Mittal
- Department of Pulmonary, Critical Care & Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sonam Spalgais
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | | | - Surya Kant
- Department of Respiratory (Pulmonary) Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - V K Singh
- Centre for Visceral Mechanisms, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Vijay Hadda
- Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Kumar
- All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Virendra Singh
- Mahavir Jaipuria Rajasthan Hospital, Jaipur, Rajasthan, India
| | - Vishal Chopra
- Department of Chest & Tuberculosis, Government Medical College, Patiala, Punjab, India
| | - Visweswaran B
- Interventional Pulmonology, Yashoda Hospitals, Hyderabad, Telangana, India
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Chang RYK, Li M, Chow MY, Ke WR, Tai W, Chan HK. A dual action of D-amino acids on anti-biofilm activity and moisture-protection of inhalable ciprofloxacin powders. Eur J Pharm Biopharm 2022; 173:132-140. [DOI: 10.1016/j.ejpb.2022.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 02/16/2022] [Accepted: 03/08/2022] [Indexed: 01/03/2023]
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Brennan M, McDonnell MJ, Harrison MJ, Duignan N, O’Regan A, Murphy DM, Ward C, Rutherford RM. Antimicrobial therapies for prevention of recurrent acute exacerbations of COPD (AECOPD): beyond the guidelines. Respir Res 2022; 23:58. [PMID: 35287677 PMCID: PMC8919139 DOI: 10.1186/s12931-022-01947-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 02/04/2022] [Indexed: 12/19/2022] Open
Abstract
Background Unfortunately, many COPD patients continue to exacerbate despite good adherence to GOLD Class D recommended therapy. Acute exacerbations lead to an increase in symptoms, decline in lung function and increased mortality rate. The purpose of this review is to do a literature search for any prophylactic anti-microbial treatment trials in GOLD class D patients who ‘failed’ recommended therapy and discuss the role of COPD phenotypes, lung and gut microbiota and co-morbidities in developing a tailored approach to anti-microbial therapies for high frequency exacerbators. Main text There is a paucity of large, well-conducted studies in the published literature to date. Factors such as single-centre, study design, lack of well-defined controls, insufficient patient numbers enrolled and short follow-up periods were significant limiting factors in numerous studies. One placebo-controlled study involving more than 1000 patients, who had 2 or more moderate exacerbations in the previous year, demonstrated a non-significant reduction in exacerbations of 19% with 5 day course of moxifloxacillin repeated at 8 week intervals. In Pseudomonas aeruginosa (Pa) colonised COPD patients, inhaled antimicrobial therapy using tobramycin, colistin and gentamicin resulted in significant reductions in exacerbation frequency. Viruses were found to frequently cause acute exacerbations in COPD (AECOPD), either as the primary infecting agent or as a co-factor. However, other, than the influenza vaccination, there were no trials of anti-viral therapies that resulted in a positive effect on reducing AECOPD. Identifying clinical phenotypes and co-existing conditions that impact on exacerbation frequency and severity is essential to provide individualised treatment with targeted therapies. The role of the lung and gut microbiome is increasingly recognised and identification of pathogenic bacteria will likely play an important role in personalised antimicrobial therapies. Conclusion Antimicrobial therapeutic options in patients who continue to exacerbate despite adherence to guidelines-directed therapy are limited. Phenotyping patients, identification of co-existing conditions and assessment of the microbiome is key to individualising antimicrobial therapy. Given the impact of viruses on AECOPD, anti-viral therapeutic agents and targeted anti-viral vaccinations should be the focus of future research studies.
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Safety and Efficacy of Devices Delivering Inhaled Antibiotics among Adults with Non-Cystic Fibrosis Bronchiectasis: A Systematic Review and a Network Meta-Analysis. Antibiotics (Basel) 2022; 11:antibiotics11020275. [PMID: 35203878 PMCID: PMC8868526 DOI: 10.3390/antibiotics11020275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/09/2022] [Accepted: 02/16/2022] [Indexed: 12/29/2022] Open
Abstract
It remains unknown whether the type of aerosol generating device is affecting efficacy and safety among non-cystic fibrosis bronchiectasis (NCFB) adults. The proposal of this network meta-analysis (NMA) is to evaluate effectiveness and safety of inhaled antibiotics administered via dry powder inhaler (DPI) and via nebulizers (SVN) among adult patients with NCFB. Inclusion criteria were randomized-controlled trials, adults (≥18 years) with NCFB, and inhaled antibiotics administered via DPI as intervention. Search strategy was performed in PubMed, Web of Science, and Cochrane Library from 2000 to 2019. Sixteen trials (2870 patients) were included. Three trials (all ciprofloxacin) used DPIs and thirteen used SVN (three ciprofloxacin). Both DPI and SVN devices achieved similar safety outcomes (adverse events, antibiotic discontinuation, severe adverse events, and bronchospasm). Administration of ciprofloxacin via DPI significantly improved time to first exacerbation (87 days, 95% CI 34.3–139.7) and quality of life (MD −7.52; 95% CI −13.06 to −1.98) when compared with via SVN. No other significant differences were documented in clinical efficacy (at least one exacerbation, FEV1% predicted) and microbiologic response (bacterial eradication, emergence of new potential pathogens, and emergence of antimicrobial resistance) when comparing devices. Our NMA documented that time to first exacerbation and quality of life, were more favorable for DPIs. Decisions on the choice of devices should incorporate these findings plus other criteria, such as simplicity, costs or maintenance requirements.
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Livnat G, Yaari N, Stein N, Bentur L, Hanna M, Harel M, Adir Y, Shteinberg M. 4-week daily airway clearance using oscillating positive-end expiratory pressure versus autogenic drainage in bronchiectasis patients: a randomised controlled trial. ERJ Open Res 2021; 7:00426-2021. [PMID: 34760994 PMCID: PMC8573225 DOI: 10.1183/23120541.00426-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 08/25/2021] [Indexed: 12/03/2022] Open
Abstract
Background Airway clearance is a fundamental component of bronchiectasis care. Lung clearance index (LCI) is a measurement of ventilation inhomogeneity. Its responsiveness to long-term airway clearance is unknown. We aimed to compare two methods of daily airway clearance over 4 weeks: autogenic drainage (AD) and oscillating positive airway pressure (oPEP), and to determine effects of airway clearance on LCI and clinical outcomes. Methods Adults with bronchiectasis naive to airway clearance were randomised to daily airway clearance with either AD or oPEP. Difference in LCI as primary outcome, spirometry, sputum volume and purulence, and quality of life were at randomisation and after 4 weeks of airway clearance. Results 51 patients (32 women and 19 men, mean age 66.2±12.8 years) were randomised and 49 completed the study (25 AD and 24 oPEP). The LCI and forced expiratory volume in 1 s did not change between visits between groups (difference between groups 0.02), nor between visits in either group. Sputum quantity decreased in 12 out of 24 (50%) of the oPEP group, and in six out of 25 (24%) of the AD group (p=0.044). The “treatment burden” worsened or was unchanged in 70% of participants randomised to AD and 55% randomised to oPEP (p=0.038). Conclusion Sputum quantity decreased in more participants randomised to oPEP group after 1 month of daily airway clearance, with a better treatment burden. The effects of 4 weeks of airway clearance on LCI were not significant in either treatment group. People with bronchiectasis were randomised to 4 weeks of two methods of daily airway clearance, autogenic drainage (AD) and oscillating PEP (oPEP). Sputum volume decreased in more people randomised to oPEP than AD. LCI did not change in either group.https://bit.ly/3gNj2bi
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Affiliation(s)
- Galit Livnat
- Pediatric Pulmonology, Carmel Medical Center, Haifa, Israel.,Cystic Fibrosis Center, Carmel Medical Center, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Naama Yaari
- Dept of Physical Therapy, Carmel Medical Center, Haifa, Israel
| | - Nili Stein
- Dept of Community Medicine and Epidemiology, Carmel Medical Center, Haifa, Israel
| | - Lea Bentur
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Pediatric Pulmonology and CF Center, The Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Moneera Hanna
- Pediatric Pulmonology and CF Center, The Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Maya Harel
- Pulmonology Institute, Carmel Medical Center, Haifa, Israel
| | - Yochai Adir
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Pulmonology Institute, Carmel Medical Center, Haifa, Israel
| | - Michal Shteinberg
- Cystic Fibrosis Center, Carmel Medical Center, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Pulmonology Institute, Carmel Medical Center, Haifa, Israel
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Tejada S, Campogiani L, Solé-Lleonart C, Gómez A, Gallego M, Vendrell M, Soriano JB, Rello J. Inhaled antibiotics for treatment of adults with non-cystic fibrosis bronchiectasis: A systematic review and meta-analysis. Eur J Intern Med 2021; 90:77-88. [PMID: 33947626 DOI: 10.1016/j.ejim.2021.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 02/26/2021] [Accepted: 04/12/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Inhaled antibiotics (IA) in non-cystic fibrosis bronchiectasis (NCFB) are recommended by some clinical practice guidelines for prevention or treatment of NCFB exacerbations. METHODS We performed a systematic review and meta-analysis to evaluate the efficacy and safety of IA use for treatment of adults with NCFB and Pseudomonas aeruginosa chronic bronchial infection. The search was performed in the Cochrane Library, PubMed, and Web of Science databases from 2000 to 2019. Studies of IA for treatment of stable or exacerbated NCFB adults (≥18 years) with P. aeruginosa infection were considered eligible. PROSPERO Registration number: CRD42019136154. RESULTS Twelve trials (2476 participants) were included. IA therapy increased P. aeruginosa eradication from sputum in patients with exacerbations (OR: 3.19, 95%CI: 1.70-5.99) with similar effects on stable patients (OR: 7.22, 95%CI: 2.81-18.59), and a trend to reduced emergence of new respiratory pathogens (OR: 0.58, 95%CI: 0.28-1.18). IA achieved significant reduced exacerbation rates (RR: 0.90; 95%CI: 0.82-0.98) in stable patients, with a number needed to treat (NNT) of 59, but no significant changes in FEV1, mortality, hospitalizations or quality of life were identified. In stable patients, IA use increased antimicrobial resistance (RR: 2.10, 95%CI: 1.35-3.27) at the end of therapy, with a number needed to treat of 6. CONCLUSIONS IA therapy achieved a statistically significant eradication of P. aeruginosa from sputum, with a 10% reduction of exacerbations in stable patients. This effect has to be balanced with significant increases in antimicrobial resistance. Our meta-analysis failed to show a significant benefit in terms of patient-centered outcomes.
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Affiliation(s)
- Sofia Tejada
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain.
| | - Laura Campogiani
- Clinical Infectious Diseases, Department of System Medicine, Tor Vergata University, Rome, Italy
| | | | - Aroa Gómez
- Department of Donor & Transplant Coordination, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Miguel Gallego
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Respiratory Department, Parc Taulí University Hospital, Barcelona, Spain
| | - Monserrat Vendrell
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain; Respiratory Department, Dr. Josep Trueta University Hospital, Girona, Spain; Insitut d'Investigació Biomèdica de Girona (IDIBGI), Universitat de Girona, Girona, Spain
| | - Joan B Soriano
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Hospital Universitario La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Jordi Rello
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain; Clinical Research in the ICU, Anesthesia Department, CHU Nimes, Universite de Nimes-Montpellier, France
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Suarez-Cuartin G, Hernandez-Argudo M, Perea L, Sibila O. Long-Term Antibiotics in Bronchiectasis. Semin Respir Crit Care Med 2021; 42:606-615. [PMID: 34261184 DOI: 10.1055/s-0041-1730945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A significant proportion of bronchiectasis patients are chronically infected by potentially pathogenic microorganisms which may lead to frequent exacerbations and worse clinical outcomes. Current bronchiectasis guidelines recommend long-term inhaled antibiotics and/or oral macrolides as a part of patient management. In recent years, an increasing amount of evidence assessing the impact of these treatments on patient outcomes has been collected. Inhaled antibiotics have demonstrated significant improvements in sputum bacterial load, but their impact on patient quality of life, lung function, and exacerbation rate has not been consistent across trials. In this regard, recent post hoc analyses of inhaled antibiotics trials in bronchiectasis patients have shown that sputum bacterial load may be a key biomarker to predict treatment response in these patients. Oral macrolides, on the other hand, have proven to reduce exacerbation frequency and improve quality of life, but potential drug-related adverse effects and the increase in bacterial resistance are relevant. This review aims to summarize current important evidence for long-term antibiotic treatment in bronchiectasis patients.
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Affiliation(s)
- Guillermo Suarez-Cuartin
- Department of Respiratory Medicine, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Marta Hernandez-Argudo
- Department of Respiratory Medicine, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Lidia Perea
- Department of Respiratory Medicine, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERES, Barcelona, Spain
| | - Oriol Sibila
- Department of Respiratory Medicine, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERES, Barcelona, Spain
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19
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Ding L, Wang J, Cai S, Smyth H, Cui Z. Pulmonary biofilm-based chronic infections and inhaled treatment strategies. Int J Pharm 2021; 604:120768. [PMID: 34089796 DOI: 10.1016/j.ijpharm.2021.120768] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/20/2021] [Accepted: 05/31/2021] [Indexed: 12/12/2022]
Abstract
Certain pulmonary diseases, such as cystic fibrosis (CF), non-CF bronchiectasis, chronic obstructive pulmonary disease, and ventilator-associated pneumonia, are usually accompanied by respiratory tract infections due to the physiological alteration of the lung immunological defenses. Recurrent infections may lead to chronic infection through the formation of biofilms. Chronic biofilm-based infections are challenging to treat using antimicrobial agents. Therefore, effective ways to eradicate biofilms and thus relieve respiratory tract infection require the development of efficacious agents for biofilm destruction, the design of delivery carriers with biofilm-targeting and/or penetrating abilities for these agents, and the direct delivery of them into the lung. This review provides an in-depth description of biofilm-based infections caused by pulmonary diseases and focuses on current existing agents that are administered by inhalation into the lung to treat biofilm, which include i) inhalable antimicrobial agents and their combinations, ii) non-antimicrobial adjuvants such as matrix-targeting enzymes, mannitol, glutathione, cyclosporin A, and iii) liposomal formulations of anti-biofilm agents. Finally, novel agents that have shown promise against pulmonary biofilms as well as traditional and new devices for pulmonary delivery of anti-biofilm agents into the lung are also discussed.
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Affiliation(s)
- Li Ding
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
| | - Jieliang Wang
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
| | - Shihao Cai
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
| | - Hugh Smyth
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA.
| | - Zhengrong Cui
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA.
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Xu MJ, Dai B. Inhaled antibiotics therapy for stable non-cystic fibrosis bronchiectasis: a meta-analysis. Ther Adv Respir Dis 2021; 14:1753466620936866. [PMID: 32615859 PMCID: PMC7336831 DOI: 10.1177/1753466620936866] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
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.
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Affiliation(s)
- Meng-Jiao Xu
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital, China Medical University, Shenyang, China
| | - Bing Dai
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital, China Medical University, Shenyang, 110001, China
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21
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McLeese RH, Spinou A, Alfahl Z, Tsagris M, Stuart Elborn J, Chalmers JD, De Soyza A, Loebinger MR, Birring SS, Fragkos KC, Wilson R, O'Neill K, Bradley JM. Psychometrics of HRQoL questionnaires in bronchiectasis: A systematic review and meta-analysis. Eur Respir J 2021; 58:13993003.00025-2021. [PMID: 33888521 PMCID: PMC8581652 DOI: 10.1183/13993003.00025-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 04/02/2021] [Indexed: 11/21/2022]
Abstract
Introduction Understanding the psychometric properties of health-related quality of life (HRQoL) questionnaires can help inform selection in clinical trials. Our objective was to assess the psychometric properties of HRQoL questionnaires in bronchiectasis using a systematic review and meta-analysis of the literature. Methods A literature search was conducted. HRQoL questionnaires were assessed for psychometric properties (reliability, validity, minimal clinically important difference (MCID) and floor/ceiling effects). Meta-analyses assessed the associations of HRQoL with clinical measures and responsiveness of HRQoL in clinical trials. Results 166 studies and 12 HRQoL questionnaires were included. The Bronchiectasis Health Questionnaire (BHQ), Leicester Cough Questionnaire (LCQ), Chronic Obstructive Pulmonary Disease (COPD) Assessment Test (CAT) and Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) had good internal consistency in all domains reported (Cronbach's α≥0.7) across all studies, and the Quality of Life-Bronchiectasis (QOL-B), St George's Respiratory Questionnaire (SGRQ), Chronic Respiratory Disease Questionnaire (CRDQ) and Seattle Obstructive Lung Disease Questionnaire (SOLQ) had good internal consistency in all domains in the majority of (but not all) studies. BHQ, SGRQ, LCQ and CAT had good test–retest reliability in all domains reported (intraclass correlation coefficient ≥0.7) across all studies, and QOL-B, CRDQ and SOLQ had good test–retest reliability in all domains in the majority of (but not all) studies. HRQoL questionnaires were able to discriminate between demographics, important markers of clinical status, disease severity, exacerbations and bacteriology. For HRQoL responsiveness, there was a difference between the treatment and placebo effect. Conclusions SGRQ was the most widely used HRQoL questionnaire in bronchiectasis studies and it had good psychometric properties; however, good psychometric data are emerging on the bronchiectasis-specific HRQoL questionnaires QOL-B and BHQ. Future studies should focus on the medium- to long-term test–retest reliability, responsiveness and MCID in these HRQoL questionnaires which show potential in bronchiectasis. The psychometric properties of health-related quality of life questionnaires should inform the selection of patient-reported outcomes in bronchiectasis clinical trialshttps://bit.ly/3wQuSrm
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Affiliation(s)
- Rebecca H McLeese
- The Wellcome Trust-Wolfson Northern Ireland Clinical Research Facility, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Arietta Spinou
- Population Health Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Zina Alfahl
- The Wellcome Trust-Wolfson Northern Ireland Clinical Research Facility, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.,School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Michail Tsagris
- Department of Economics, University of Crete, Rethymnon, Greece
| | - J Stuart Elborn
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Dundee, UK
| | - Anthony De Soyza
- Respiratory Department, Institute of Cellular Medicine, Newcastle University and Freeman Hospital, Sir William Leech Research Centre, Newcastle upon Tyne, UK
| | | | - Surinder S Birring
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | | | - Robert Wilson
- Host Defence Unit, Royal Brompton Hospital, London, UK
| | - Katherine O'Neill
- The Wellcome Trust-Wolfson Northern Ireland Clinical Research Facility, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.,Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.,Co-senior authors
| | - Judy M Bradley
- The Wellcome Trust-Wolfson Northern Ireland Clinical Research Facility, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK .,Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.,Co-senior authors
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22
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Xu Y, Thakur A, Zhang Y, Foged C. Inhaled RNA Therapeutics for Obstructive Airway Diseases: Recent Advances and Future Prospects. Pharmaceutics 2021; 13:pharmaceutics13020177. [PMID: 33525500 PMCID: PMC7912103 DOI: 10.3390/pharmaceutics13020177] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 02/06/2023] Open
Abstract
Obstructive airway diseases, e.g., chronic obstructive pulmonary disease (COPD) and asthma, represent leading causes of morbidity and mortality worldwide. However, the efficacy of currently available inhaled therapeutics is not sufficient for arresting disease progression and decreasing mortality, hence providing an urgent need for development of novel therapeutics. Local delivery to the airways via inhalation is promising for novel drugs, because it allows for delivery directly to the target site of action and minimizes systemic drug exposure. In addition, novel drug modalities like RNA therapeutics provide entirely new opportunities for highly specific treatment of airway diseases. Here, we review state of the art of conventional inhaled drugs used for the treatment of COPD and asthma with focus on quality attributes of inhaled medicines, and we outline the therapeutic potential and safety of novel drugs. Subsequently, we present recent advances in manufacturing of thermostable solid dosage forms for pulmonary administration, important quality attributes of inhalable dry powder formulations, and obstacles for the translation of inhalable solid dosage forms to the clinic. Delivery challenges for inhaled RNA therapeutics and delivery technologies used to overcome them are also discussed. Finally, we present future prospects of novel inhaled RNA-based therapeutics for treatment of obstructive airways diseases, and highlight major knowledge gaps, which require further investigation to advance RNA-based medicine towards the bedside.
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Affiliation(s)
- You Xu
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark; (Y.X.); (A.T.); (Y.Z.)
| | - Aneesh Thakur
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark; (Y.X.); (A.T.); (Y.Z.)
| | - Yibang Zhang
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark; (Y.X.); (A.T.); (Y.Z.)
- Department of Pharmaceutics, School of Pharmacy, Jiangsu University, Zhenjiang 212013, China
| | - Camilla Foged
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark; (Y.X.); (A.T.); (Y.Z.)
- Correspondence: ; Tel.: +45-3533-6402
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23
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Wang S, Zhang A, Yao X. Meta-analysis of efficacy and safety of inhaled ciprofloxacin in non-cystic fibrosis bronchiectasis patients. Intern Med J 2021; 51:1505-1512. [PMID: 33469994 DOI: 10.1111/imj.15210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 12/12/2020] [Accepted: 01/13/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND No antibiotic therapies have been approved for reducing exacerbations and preventing disease progression in non-cystic fibrosis bronchiectasis (NCFB) patients. Several recent clinical studies have investigated the feasibility of inhaled ciprofloxacin in NCFB, whereas the results were controversial. AIM No antibiotic therapies have been approved for reducing exacerbations and preventing disease progression in non-cystic fibrosis bronchiectasis (NCFB) patients. Several recent clinical studies have investigated the feasibility of inhaled ciprofloxacin in NCFB, whereas the results were controversial. We conducted the present meta-analysis to comprehensively evaluate the feasibility of inhalation of ciprofloxacin in NCFB. METHODS Electrical databases Medline and Cochrane library were retrieved from inception through December 2019. Randomised controlled trials (RCT) comparing inhaled ciprofloxacin and placebo were selected. The primary outcomes were time to first exacerbation, frequency of exacerbations and the change in sputum Pseudomonas aeruginosa density. RESULTS A total of five articles involving six RCT was finally included in the analysis. The time to first exacerbation was significantly prolonged by inhaled ciprofloxacin (hazard ratio: 0.72, 95% confidence interval (CI): 0.63-0.82), with low heterogeneity (I2 = 23%). Inhalation of ciprofloxacin significantly reduced frequency of exacerbations (risk ratio: 0.70, 95% CI: 0.61-0.79) and decreased density of sputum P. aeruginosa (weighted mean difference: -2.11 log10 CFU/g, 95% CI: -2.96 to -1.27 log10 CFU/g) compared with placebo. No significant between-group differences in mortality, adverse events and discontinuation rate were observed. Further indirect treatment comparison showed no differences between the two types of inhaled ciprofloxacin in all outcomes of interest. CONCLUSIONS Ciprofloxacin inhalation treatment significantly prolonged the time to first exacerbation, reduced the frequency of exacerbations and decreased sputum P. aeruginosa density and was well tolerated. Ciprofloxacin inhalation is promising in the treatment of NCFB.
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Affiliation(s)
- Sumei Wang
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Department of Respiratory and Critical Medicine, Jiangyan TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Taizhou, China
| | - Aiping Zhang
- Department of Respiratory and Critical Medicine, Jiangyan TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Taizhou, China
| | - Xin Yao
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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24
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Garcia-Clemente M, de la Rosa D, Máiz L, Girón R, Blanco M, Olveira C, Canton R, Martinez-García MA. Impact of Pseudomonas aeruginosa Infection on Patients with Chronic Inflammatory Airway Diseases. J Clin Med 2020; 9:jcm9123800. [PMID: 33255354 PMCID: PMC7760986 DOI: 10.3390/jcm9123800] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/20/2020] [Accepted: 11/22/2020] [Indexed: 12/12/2022] Open
Abstract
Pseudomonas aeruginosa (P. aeruginosa) is a ubiquitous and opportunistic microorganism and is considered one of the most significant pathogens that produce chronic colonization and infection of the lower respiratory tract, especially in people with chronic inflammatory airway diseases such as asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), and bronchiectasis. From a microbiological viewpoint, the presence and persistence of P. aeruginosa over time are characterized by adaptation within the host that precludes any rapid, devastating injury to the host. Moreover, this microorganism usually develops antibiotic resistance, which is accelerated in chronic infections especially in those situations where the frequent use of antimicrobials facilitates the selection of “hypermutator P. aeruginosa strain”. This phenomenon has been observed in people with bronchiectasis, CF, and the “exacerbator” COPD phenotype. From a clinical point of view, a chronic bronchial infection of P. aeruginosa has been related to more severity and poor prognosis in people with CF, bronchiectasis, and probably in COPD, but little is known on the effect of this microorganism infection in people with asthma. The relationship between the impact and treatment of P. aeruginosa infection in people with airway diseases emerges as an important future challenge and it is the most important objective of this review.
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Affiliation(s)
- Marta Garcia-Clemente
- Pneumology Department, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain;
| | - David de la Rosa
- Pneumology Department, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain;
| | - Luis Máiz
- Servicio de Neumología, Unidad de Fibrosis Quística, Bronquiectasias e Infección Bronquial Crónica, Hospital Ramón y Cajal, 28034 Madrid, Spain;
| | - Rosa Girón
- Pneumology Department, Hospital Univesitario la Princesa, 28006 Madrid, Spain;
| | - Marina Blanco
- Servicio de Neumología, Hospital Universitario A Coruña, 15006 A Coruña, Spain;
| | - Casilda Olveira
- Servicio de Neumología, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga, 29010 Málaga, Spain;
| | - Rafael Canton
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain;
| | - Miguel Angel Martinez-García
- Pneumology Department, Universitary and Polytechnic La Fe Hospital, 46012 Valencia, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28034 Madrid, Spain
- Correspondence: ; Tel.: +34-609865934
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25
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Di Pasquale M, Aliberti S, Mantero M, Gramegna A, Blasi F. Pharmacotherapeutic management of bronchial infections in adults: non-cystic fibrosis bronchiectasis and chronic obstructive pulmonary disease. Expert Opin Pharmacother 2020; 21:1975-1990. [PMID: 32808825 DOI: 10.1080/14656566.2020.1793958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Effective management of both acute and chronic bronchial infections is mandatory due to their high frequency rate, the relevant morbidity and mortality and the significant burden to health care systems, especially with the aging of population. Bacteria are the main causative pathogens, followed by viruses, and less commonly by fungi. The clinical evaluation of new therapeutic associations is mandatory to cope with the increases in resistance, in association with better infection control and antimicrobial policies. AREAS COVERED The authors searched Medline for any article published in English language up until March 1, 2020 that concerns the treatment of acute exacerbations and chronic infections in chronic obstructive respiratory disease and bronchiectasis. EXPERT OPINION As acute exacerbations are a main common and detrimental event in patients with COPD and bronchiectasis, effective antimicrobial therapies and regimens should be optimized. The development of new molecules or combination regimens is vital to patients with severe and/or difficult-to-treat infections. Moreover, chronic infection control is mandatory in these patients to their improve quality of life, respiratory function and prognosis as well as for reducing health care costs.
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Affiliation(s)
- Marta Di Pasquale
- Department of Pathophysiology and Transplantation, University of Milan, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy
| | - Stefano Aliberti
- Department of Pathophysiology and Transplantation, University of Milan, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy
| | - Marco Mantero
- Department of Pathophysiology and Transplantation, University of Milan, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, University of Milan, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy
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26
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Inhaled Dry Powder Antibiotics in Patients with Non-Cystic Fibrosis Bronchiectasis: Efficacy and Safety in a Real-Life Study. J Clin Med 2020; 9:jcm9072317. [PMID: 32708262 PMCID: PMC7408283 DOI: 10.3390/jcm9072317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Nebulised antibiotics are habitually used in patients with bronchiectasis, but the use of dry powder inhaled antibiotics (DPIA) in these patients is extremely limited. This study seeks to analyse the efficacy and safety of DPIA in bronchiectasis patients. MATERIAL AND METHODS Multi-centre study of historic cohorts. All the hospital centres in Spain were contacted in order to collect data on patients with a diagnosis of bronchiectasis who had taken at least one dose of DPIA. Its efficacy was analysed in clinical, functional and microbiological terms by comparing the year before and the year after the prescription of DPIA. Adverse effects and variables associated with these effects, or any need to withdraw the drug, were also analysed. RESULTS 164 patients from 33 Spanish centres were included; 86% and 14% of these were treated with dry powder colistin and tobramycin, respectively. Chronic bronchial infection by Pseudomonas aeruginosa was present in 86% of these patients, and DPIA significantly reduced the number of exacerbations, the quantity and purulence of sputum and the isolation of pathogenic microorganisms. The most common adverse effect was cough (40%), particularly in cases of Chronic Obstructive Pulmonary Disease (COPD) and a previous cough and in those patients who had difficulties in handling the device. These factors were associated with a higher level of withdrawal of the treatment. There were no serious adverse effects. CONCLUSIONS Our study suggests that DPIA are clinically efficacious and safe for treating bronchiectasis patients. Cough was shown to be the most common side-effect and reason for withdrawal of the treatment.
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Máiz Carro L, Blanco-Aparicio M. Nuevos antibióticos inhalados y formas de administración. OPEN RESPIRATORY ARCHIVES 2020. [DOI: 10.1016/j.opresp.2020.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Brillault J, Tewes F. Control of the Lung Residence Time of Highly Permeable Molecules after Nebulization: Example of the Fluoroquinolones. Pharmaceutics 2020; 12:pharmaceutics12040387. [PMID: 32340298 PMCID: PMC7238242 DOI: 10.3390/pharmaceutics12040387] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/05/2020] [Accepted: 04/07/2020] [Indexed: 12/29/2022] Open
Abstract
Pulmonary drug delivery is a promising strategy to treat lung infectious disease as it allows for a high local drug concentration and low systemic side effects. This is particularly true for low-permeability drugs, such as tobramycin or colistin, that penetrate the lung at a low rate after systemic administration and greatly benefit from lung administration in terms of the local drug concentration. However, for relatively high-permeable drugs, such as fluoroquinolones (FQs), the rate of absorption is so high that the pulmonary administration has no therapeutic advantage compared to systemic or oral administration. Formulation strategies have thus been developed to decrease the absorption rate and increase FQs’ residence time in the lung after inhalation. In the present review, some of these strategies, which generally consist of either decreasing the lung epithelium permeability or decreasing the release rate of FQs into the epithelial lining fluid after lung deposition, are presented in regards to their clinical aspects.
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Affiliation(s)
- Julien Brillault
- INSERM U-1070, Pôle Biologie Santé, 86000 Poitiers, France
- UFR Médecine-Pharmacie, Université de Poitiers, 86073 Poitiers, France
- Correspondence: (J.B.); (F.T.)
| | - Frédéric Tewes
- INSERM U-1070, Pôle Biologie Santé, 86000 Poitiers, France
- UFR Médecine-Pharmacie, Université de Poitiers, 86073 Poitiers, France
- Correspondence: (J.B.); (F.T.)
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29
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Lim JU, Hong SW, Ko JH. Efficacy of inhaled ciprofloxacin agents for the treatment of bronchiectasis: a systematic review and meta-analysis of randomized controlled trials. Ther Adv Respir Dis 2020; 13:1753466619875930. [PMID: 31538535 PMCID: PMC6755641 DOI: 10.1177/1753466619875930] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: The efficacy of inhaled ciprofloxacin agents in the treatment of patients
with bronchiectasis is controversial. The objective of the study was to
review systematically the efficacy of inhaled ciprofloxacin agents in
patients with bronchiectasis. Methods: We searched PubMed, EMBASE, and Cochrane Library databases for randomized
controlled trials (RCTs) evaluating inhaled ciprofloxacin agents among
patients with bronchiectasis. Data were pooled using a meta-analysis
technique. Results: Two phase II and four phase III RCTs were included with a total of 1685
patients. Treatment durations of phase III studies were 48 weeks, while
those of phase II studies were shorter. Pooled analysis of overall studies
exhibited a statistically significant benefit of inhaled ciprofloxacin
agents in three exacerbation outcome measures, including time to first
exacerbation (hazard ratio 0.74, 95% confidence interval [CI] 0.63–0.86,
I2 23%), exacerbation frequency (risk ratio
[RR] 0.73, 95% CI 0.61–0.86, I2 42%), and
exacerbation proportion (RR 0.85, 95% CI 0.76–0.96,
I2 25%) without significant heterogeneity.
Outcomes evaluating pulmonary function, quality of life, and adverse events
were not significantly different between the two groups. Although
eradication of respiratory pathogens was more frequently observed, the
emergence of ciprofloxacin resistance was also significantly higher in the
ciprofloxacin group. Conclusions: A meta-analysis of RCTs of inhaled ciprofloxacin agents showed clinical
benefit in terms of pulmonary exacerbations in patients with bronchiectasis.
Since a significant increase of resistance was also noticed, clinical trials
with a longer study period are required for a conclusive assessment. The reviews of this paper are available via the supplemental material
section.
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Affiliation(s)
- Jeong Uk Lim
- Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Republic of Korea, Department of Internal Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung Wook Hong
- Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Republic of Korea, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae-Hoon Ko
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea
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30
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Karampitsakos T, Papaioannou O, Kaponi M, Kozanidou A, Hillas G, Stavropoulou E, Bouros D, Dimakou K. Low penetrance of antibiotics in the epithelial lining fluid. The role of inhaled antibiotics in patients with bronchiectasis. Pulm Pharmacol Ther 2019; 60:101885. [PMID: 31891761 DOI: 10.1016/j.pupt.2019.101885] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 12/25/2019] [Indexed: 12/16/2022]
Abstract
Plasma drug concentrations, spectrum of antibacterial activity and minimum inhibitory concentration (MIC) had been widely considered as markers of the efficacy of antibiotics. Nonetheless, in several cases, antibiotics characterized by all these features were ineffective for the treatment of respiratory tract infections. A typical paradigm represented the case of patients with bronchiectasis who do not always benefit from antibiotics and thus experiencing increased sputum production, worse quality of life, more rapid forced expiratory volume in the first second (FEV1) decline, more frequent exacerbations and increased mortality rates, especially those with Pseudomonas aeruginosa (P. aeruginosa) chronic infection. Subsequently, penetrance of antibiotics in the epithelial lining fluid has gradually emerged as another key factor for the outcome of antibiotic treatment. Given that a plethora of antibiotics presented with poor or intermediate penetrance in the epithelial lining fluid, inhaled antibiotics targeting directly the site of infection emerged as a new option for patients with respiratory disorders including patients with bronchiectasis. This review article intends to summarize the current state of knowledge for the penetrance of antibiotics in the epithelial lining fluid and present results from clinical trials of inhaled antibiotics in patients with bronchiectasis of etiology other than cystic fibrosis.
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Affiliation(s)
| | - Ourania Papaioannou
- 5th Department of Pneumonology, Hospital for Thoracic Diseases, "Sotiria", Athens, Greece
| | - Maria Kaponi
- 5th Department of Pneumonology, Hospital for Thoracic Diseases, "Sotiria", Athens, Greece
| | - Andreana Kozanidou
- Department of Internal Medicine, Hippokrateion Hospital, Thessaloniki, Greece
| | - Georgios Hillas
- 5th Department of Pneumonology, Hospital for Thoracic Diseases, "Sotiria", Athens, Greece
| | - Elisavet Stavropoulou
- Service de Médecine Interne, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Demosthenes Bouros
- First Academic Department of Pneumonology, Hospital for Thoracic Diseases, "Sotiria", Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Katerina Dimakou
- 5th Department of Pneumonology, Hospital for Thoracic Diseases, "Sotiria", Athens, Greece.
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Weers J. Comparison of Phospholipid-Based Particles for Sustained Release of Ciprofloxacin Following Pulmonary Administration to Bronchiectasis Patients. Pulm Ther 2019; 5:127-150. [PMID: 32026415 PMCID: PMC6967322 DOI: 10.1007/s41030-019-00104-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Indexed: 02/06/2023] Open
Abstract
The rapid clearance of ciprofloxacin hydrochloride from the lungs following administration as an aerosol leads to poor efficacy in the treatment of pulmonary infections. The development of formulations capable of sustaining ciprofloxacin concentrations in the lungs has the potential to significantly improve antibacterial activity. The present review compares two approaches for sustaining levels of ciprofloxacin in the lungs, a liposomal formulation where ciprofloxacin is encapsulated in small unilamellar vesicles, and a dry powder formulation of the practically insoluble zwitterionic form of the drug. These two formulations recently completed large multicenter, phase 3 clinical studies in bronchiectasis patients. As such, they present a unique opportunity to examine the chemistry, manufacturing, and control of the dosage forms in addition to their tolerability and efficacy in more than 1000 bronchiectasis patients. Both formulations were generally well tolerated with most adverse events found to be mild to moderate in intensity. While the formulations were effective in reducing and/or eradicating infections, this did not lead to reductions in pulmonary exacerbations, the primary endpoint. The failures speak more to the heterogeneous nature of the disease and the difficulty in identifying bronchiectasis patients likely to exacerbate, rather than an inherent limitation of the formulations. While the formulations are similar in many respects, they also present some interesting differences. This review explores the implications of these differences on the treatment of respiratory infections.
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Affiliation(s)
- Jeffry Weers
- Respira Therapeutics, Inc., Burlingame, CA, USA.
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Loebinger MR, Polverino E, Blasi F, Elborn SJ, Chalmers JD, Tiddens HA, Goossens H, Tunney M, Zhou W, Angyalosi G, Hill AT, Haworth CS. Efficacy and safety of tobramycin inhalation powder in bronchiectasis patients with P. aeruginosa infection: Design of a dose-finding study (iBEST-1). Pulm Pharmacol Ther 2019; 58:101834. [PMID: 31433997 DOI: 10.1016/j.pupt.2019.101834] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/17/2019] [Indexed: 01/26/2023]
Abstract
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.
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Affiliation(s)
- Michael R Loebinger
- Host Defence Unit, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom; Imperial College London, London, United Kingdom.
| | - Eva Polverino
- Respiratory Disease Department, Vall d' Hebron University Hospital - VHIR, CIBER, Barcelona, Spain
| | - Francesco Blasi
- Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Stuart J Elborn
- Halo Research Group, Centre for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom; Imperial College and Royal Brompton Hospital and Harefield NHS Foundation Trust, London, United Kingdom
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom
| | - Harm Awm Tiddens
- Department of Paediatric Pulmonology and Allergology, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Herman Goossens
- Department of Clinical Microbiology, University Hospital Antwerp, Antwerp, Belgium
| | - Michael Tunney
- Halo Research Group, School of Pharmacy, Queen's University Belfast, Belfast, United Kingdom
| | | | | | - Adam T Hill
- Respiratory Medicine, Royal Infirmary of Edinburgh, and University of Edinburgh, Edinburgh, United Kingdom
| | - Charles S Haworth
- Cambridge Centre for Lung Infection, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
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Gregson EC. Which antibiotics should be used to treat children with an acute exacerbation of bronchiectasis and as long-term prevention of exacerbations? Arch Dis Child 2019; 104:1013-1016. [PMID: 31326917 DOI: 10.1136/archdischild-2019-317562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/06/2019] [Accepted: 07/08/2019] [Indexed: 11/03/2022]
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Laska IF, Crichton ML, Shoemark A, Chalmers JD. The efficacy and safety of inhaled antibiotics for the treatment of bronchiectasis in adults: a systematic review and meta-analysis. THE LANCET RESPIRATORY MEDICINE 2019; 7:855-869. [PMID: 31405826 DOI: 10.1016/s2213-2600(19)30185-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/24/2019] [Accepted: 04/24/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Although use of inhaled antibiotics is the standard of care in cystic fibrosis, there is insufficient evidence to support use of inhaled antibiotics in patients with bronchiectasis not due to cystic fibrosis. We aimed to assess the efficacy and safety of inhaled antibiotics for the long-term treatment of adults with bronchiectasis and chronic respiratory tract infections. METHODS We did a systematic review and meta-analysis of all randomised controlled trials of inhaled-antibiotic use in adult patients with bronchiectasis and chronic respiratory tract infections. Eligible publications were identified by searching MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials.gov. Randomised controlled trials of inhaled antibiotics were included if the patients were adults with stable bronchiectasis diagnosed by CT or bronchography, the trials had treatment a duration of at least 4 weeks, and their outcomes met at least one of the endpoints of interest. Studies in cystic fibrosis were excluded. Efficacy endpoints assessed were bacterial load, bacterial eradication from sputum, frequency of exacerbations, time to first exacerbation, proportion of patients with at least one exacerbation, frequency of severe exacerbations, quality of life, change in FEV1, 6-min walk distance, mortality, adherence to treatment, and sputum volume; safety endpoints were adverse events and bacterial resistance in sputum. Each study was independently reviewed for methodological quality using the Cochrane risk of bias tool. Random-effects meta-analysis was used to pool individual studies. Heterogeneity was assessed using I2. The review is registered on PROSPERO, number CRD42019122892. FINDINGS 16 trials (n=2597 patients) were included for analysis. The mean reduction of colony forming units per g of sputum with inhaled antibiotics was -2·32 log units (95% CI -3·20 to -1·45; p<0·0001). Bacterial eradication was increased with inhaled antibiotic therapy (odds ratio [OR] 3·36, 1·63 to 6·91; p=0·0010). Inhaled antibiotics significantly reduced exacerbation frequency (rate ratio 0·81, 0·67 to 0·97; p=0·020). Time to first exacerbation was significantly prolonged with inhaled antibiotics (hazard ratio 0·83, 0·69 to 0·99; p=0·028). The proportion of patients with at least one exacerbation decreased (risk ratio 0·85, 0·74 to 0·97; p=0·015). There was a significant reduction in the frequency of severe exacerbations (rate ratio 0·43, 0·24 to 0·78; p=0·0050). The scores for neither the Quality of Life Bronchiectasis questionnaire nor St George's Respiratory Questionnaire improved above the minimal clinically important difference. The relative change in FEV1 was a deterioration of 0·87% predicted value (-2·00 to 0·26%; p=0·13). Other efficacy endpoints were reported in only few studies or had few events. There was no difference in treatment-emergent adverse effects (OR 0·97, 0·67 to 1·40; p=0·85) or bronchospasm (0·99, 0·66 to 1·48; p=0·95). Emergence of bacterial resistance was evident at the end of the treatment period (risk ratio 1·91, 1·46 to 2·49; p<0·0001). INTERPRETATION Inhaled antibiotics are well tolerated, reduce bacterial load, and achieve a small but statistically significant reduction in exacerbation frequency without clinically significant improvements in quality of life in patients with bronchiectasis and chronic respiratory tract infections. FUNDING British Lung Foundation through the GSK/British Lung Foundation Chair of Respiratory Research and European Respiratory Society through the EMBARC2 consortium. EMBARC2 is supported by project partners Chiesi, Grifols, Insmed, Novartis, and Zambon.
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Affiliation(s)
- Irena F Laska
- Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, UK
| | - Megan L Crichton
- Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, UK
| | - Amelia Shoemark
- Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, UK
| | - James D Chalmers
- Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, UK; Ninewells Hospital and Medical School, University of Dundee, Dundee, UK.
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Ling J, Mangal S, Park H, Wang S, Cavallaro A, Zhou QT. Simultaneous Particle Size Reduction and Homogeneous Mixing to Produce Combinational Powder Formulations for Inhalation by the Single-Step Co-Jet Milling. J Pharm Sci 2019; 108:3146-3151. [PMID: 31112716 DOI: 10.1016/j.xphs.2019.05.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/17/2019] [Accepted: 05/07/2019] [Indexed: 01/12/2023]
Abstract
Homogeneous mixing of 2 cohesive jet-milled drug powders is a challenge for pharmaceutical manufacturing on account of their cohesive nature resulting in the formation of strong and random agglomerates. In this study, colistin and ciprofloxacin were co-jet milled to develop combinational antibiotic dry powder formulations for inhalation. The properties of particle size, morphology, content uniformity, and in vitro aerosolization were evaluated. The distribution of 2 drugs in the co-jet milled powders was assessed using time-of-flight-secondary ion mass spectrometry. The co-jet milled powders demonstrated an acceptable content uniformity indicating homogeneity. In general, time-of-flight-secondary ion mass spectrometry images showed relatively homogeneous distributions of ciprofloxacin and colistin in the co-milled formulations. Importantly, the 2 drugs generally had the similar fine particle fraction and deposition behavior in each combinational formulation supporting that the particle mixtures were relatively homogenous and could maximize the antimicrobial synergy. In conclusion, co-jet milling could be a viable technique to produce the combination powders for inhalation.
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Affiliation(s)
- Junhong Ling
- School of Food and Pharmacy, Zhejiang Ocean University, Zhuoshan 316022, China; Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana 47907
| | - Sharad Mangal
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana 47907
| | - Heejun Park
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana 47907
| | - Shaoning Wang
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana 47907; Department of Medicinal Chemistry, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, 103 Wenhua Road, Shenyang 110016, China
| | - Alex Cavallaro
- Future Industries Institute, University of South Australia, Mawson Lakes, South Australia 5095, Australia
| | - Qi Tony Zhou
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana 47907.
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Hill AT, Sullivan AL, Chalmers JD, De Soyza A, Elborn SJ, Floto AR, Grillo L, Gruffydd-Jones K, Harvey A, Haworth CS, Hiscocks E, Hurst JR, Johnson C, Kelleher PW, Bedi P, Payne K, Saleh H, Screaton NJ, Smith M, Tunney M, Whitters D, Wilson R, Loebinger MR. British Thoracic Society Guideline for bronchiectasis in adults. Thorax 2019; 74:1-69. [PMID: 30545985 DOI: 10.1136/thoraxjnl-2018-212463] [Citation(s) in RCA: 233] [Impact Index Per Article: 46.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Adam T Hill
- Respiratory Medicine, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Anita L Sullivan
- Department of Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust (Queen Elizabeth Hospital), Birmingham, UK
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital, Dundee, UK
| | - Anthony De Soyza
- Institute of Cellular Medicine, NIHR Biomedical Research Centre for Aging and Freeman Hospital Adult Bronchiectasis service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Stuart J Elborn
- Royal Brompton Hospital and Imperial College London, and Queens University Belfast
| | - Andres R Floto
- Department of Medicine, University of Cambridge, Cambridge UK.,Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge UK
| | | | | | - Alex Harvey
- Department of Clinical Sciences, Brunel University London, London, UK
| | - Charles S Haworth
- Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge UK
| | | | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | | | - Peter W Kelleher
- Centre for Immunology and Vaccinology, Chelsea &Westminster Hospital Campus, Department of Medicine, Imperial College London.,Host Defence Unit, Department of Respiratory Medicine, Royal Brompton Hospital and Harefield NHS Foundation Trust, London.,Chest & Allergy Clinic St Mary's Hospital, Imperial College Healthcare NHS Trust
| | - Pallavi Bedi
- University of Edinburgh MRC Centre for Inflammation Research, Edinburgh, UK
| | | | | | | | - Maeve Smith
- University of Alberta, Edmonton, Alberta, Canada
| | - Michael Tunney
- School of Pharmacy, Queens University Belfast, Belfast, UK
| | | | - Robert Wilson
- Host Defence Unit, Department of Respiratory Medicine, Royal Brompton Hospital and Harefield NHS Foundation Trust, London
| | - Michael R Loebinger
- Host Defence Unit, Department of Respiratory Medicine, Royal Brompton Hospital and Harefield NHS Foundation Trust, London
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Safety and efficacy of the human neutrophil elastase inhibitor BAY 85-8501 for the treatment of non-cystic fibrosis bronchiectasis: A randomized controlled trial. Pulm Pharmacol Ther 2019; 56:86-93. [PMID: 30917927 DOI: 10.1016/j.pupt.2019.03.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/14/2019] [Accepted: 03/21/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND There are only limited treatment options for patients with non-cystic fibrosis bronchiectasis (non-CF BE). Human neutrophil elastase (HNE) is a mediator of tissue destruction in non-CF BE. BAY 85-8501, a selective and reversible HNE inhibitor, could represent a new treatment option for this disease. METHODS This was a phase 2a, randomized, placebo-controlled, double-blind, parallel-group study. The primary objective was to assess the safety and tolerability of 1 mg BAY 85-8501 once daily (OD) for 28 days compared with placebo in patients with non-CF BE. Secondary objectives were to investigate the effects of 4 weeks of treatment with BAY 85-8501 on health-related quality of life, pulmonary function, and inflammatory and tissue damage biomarkers in sputum, blood and/or urine, and to evaluate the pharmacokinetics of BAY 85-8501. RESULTS Overall, 94 patients (mean age, 66 years; 53% male) were randomized (n = 47 per group), and 82 completed the study (BAY 85-8501, n = 37; placebo, n = 45). Treatment-emergent adverse events (TEAEs) occurred in 31 patients (66%) taking BAY 85-8501 and in 36 patients (77%) taking placebo, and were mostly mild or moderate. The serious TEAEs (BAY 85-8501, n = 3; placebo, n = 1) were not considered to be study-drug related. There were no changes in pulmonary function parameters from baseline to end of treatment, and health-related quality of life did not improve in any group. HNE activity in blood after zymosan challenge decreased significantly with BAY 85-8501 treatment (P = 0.0250 versus placebo). There were no significant differences in other biomarkers between treatment groups, with the exception of a small increase in interleukin-8 levels in sputum in the BAY 85-8501 group. Trough plasma concentrations of BAY 85-8501 plateaued after 2 weeks. CONCLUSIONS 1 mg BAY 85-8501 OD had a favourable safety and tolerability profile when administered for 28 days to patients with non-CF BE. Further studies with a longer treatment duration are needed to evaluate the potential clinical efficacy in this study population.
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Crichton ML, Aliberti S, Chalmers JD. A systematic review of pharmacotherapeutic clinical trial end-points for bronchiectasis in adults. Eur Respir Rev 2019; 28:28/151/180108. [PMID: 30872400 PMCID: PMC9488648 DOI: 10.1183/16000617.0108-2018] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 01/23/2019] [Indexed: 12/25/2022] Open
Abstract
Bronchiectasis is an increasing clinical problem, but multiple recent clinical trials have failed to reach their primary end-point. Difficulties in achieving “positive” bronchiectasis trials is reflected in a lack of agreement from trialists and regulators on what are the optimal end-points. To evaluate the use of end-points in bronchiectasis trials, we conducted a systematic review of published bronchiectasis trials from 2008 to 2018 and extracted end-points used, definitions, methods of analysis and responsiveness. Our analysis shows that quality of life and exacerbation end-points are most frequently used. Trials using exacerbation end-points have been characterised by varying definitions, multiple methods of analysis and durations of follow-up. There are multiple quality of life tools for bronchiectasis (Quality of Life – Bronchiectasis questionnaire, St George's Respiratory Questionnaire, etc.). The majority of studies measure lung function (e.g. forced expiratory volume in 1 s), but this is shown to be nonresponsive to the majority of interventions. Microbiology end-points frequently show statistically significant differences in phase 2 antibiotic studies but their correlation with clinical end-points is unknown. This systematic review demonstrates a need for guidance to standardise definitions and design features to improve reproducibility and increase the likelihood of demonstrating statistically significant benefits with new therapies. There is an urgent need to standardise clinical trial end-points in bronchiectasis. This systematic review shows the diversity of end-points used in bronchiectasis and suggests approaches that may improve the success rate and reproducibility of trials.http://ow.ly/d4HR30nvvS3
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Affiliation(s)
| | - Stefano Aliberti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
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Lamy B, Serrano DR, O’Connell P, Couet W, Marchand S, Healy AM, Tewes F. Use of leucine to improve aerodynamic properties of ciprofloxacin-loaded maltose microparticles for inhalation. ACTA ACUST UNITED AC 2019. [DOI: 10.34154/2019-ejpr.01(01).pp-02-11/euraass] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ciprofloxacin (CIP) apparent permeability and absorption rate across the pulmonary epithelium can be controlled by its complexation with copper (II) ion. The aim of the current study was to formulate CIP-Cu-loaded microparticles comprising three main excipients, calcium carbonate, maltose and L-leucine, and to process by spray drying so as to generate particles with suitable aerodynamic properties for pulmonary delivery using a dry powder inhaler. Different maltose:calcium carbonate ratios were used to prepare microparticles, and the role of the excipients on the particles’ physicochemical properties, stability, and aerosolization characteristics were investigated. All the formulations without L-leucine were fully X-ray amorphous. In the presence of L-leucine, diffraction peaks of low intensity were observed, which were attributed to the crystallization of the L-leucine at the particle surfaces. The addition of L-leucine modified the particle morphology and reduced the median geometric and aerodynamic diameters to 3.2 and 3.4 µm, respectively. The fine particle fraction of powder emitted from a Handihaler® device was increased up to 65.4%, predicting high total lung deposition. Stability studies showed that the powder X-ray diffraction pattern did not change over 21 months of storage in desiccated conditions, suggesting a good physical stability of the optimized formulation comprised of CIP-Cu, maltose and L-Leucine.
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Affiliation(s)
- Barbara Lamy
- INSERM, U1070, UFR de Médecine Pharmacie, Université de Poitiers, 1 rue Georges Bonnet, TSA 51106, 86073 Poitiers Cedex 9, France
| | - Dolores Remedios Serrano
- Synthesis and Solid State Pharmaceutical Centre, School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Panoz Institute, Dublin 2, Ireland AND Departamento de Farmacia y Tecnologia Farmaceutica, Facultad de Farmacia, Universidad Complutense de Madrid, Plaza Ramon y Cajal s/n, Madrid, 28040, Spain
| | - Peter O’Connell
- Synthesis and Solid State Pharmaceutical Centre, School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Panoz Institute, Dublin 2, Ireland
| | - William Couet
- INSERM, U1070, UFR de Médecine Pharmacie, Université de Poitiers, 1 rue Georges Bonnet, TSA 51106, 86073 Poitiers Cedex 9, France AND Laboratoire de Toxicologie-Pharmacocinétique, CHU of Poitiers, 2 rue de la Milétrie, 86000 Poitiers, France
| | - Sandrine Marchand
- INSERM, U1070, UFR de Médecine Pharmacie, Université de Poitiers, 1 rue Georges Bonnet, TSA 51106, 86073 Poitiers Cedex 9, France AND Laboratoire de Toxicologie-Pharmacocinétique, CHU of Poitiers, 2 rue de la Milétrie, 86000 Poitiers, France
| | - Anne Marie Healy
- Synthesis and Solid State Pharmaceutical Centre, School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Panoz Institute, Dublin 2, Ireland
| | - Frederic Tewes
- INSERM, U1070, UFR de Médecine Pharmacie, Université de Poitiers, 1 rue Georges Bonnet, TSA 51106, 86073 Poitiers Cedex 9, France
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Weers JG, Miller DP, Tarara TE. Spray-Dried PulmoSphere™ Formulations for Inhalation Comprising Crystalline Drug Particles. AAPS PharmSciTech 2019; 20:103. [PMID: 30734187 DOI: 10.1208/s12249-018-1280-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 12/06/2018] [Indexed: 12/30/2022] Open
Abstract
Over the past 20 years, solution-based spray dried powders have transformed inhaled product development, enabling aerosol delivery of a wider variety of molecules as dry powders. These include inhaled proteins for systemic action (e.g., Exubera®) and high-dose inhaled antibiotics (e.g., TOBI® Podhaler™). Although engineered particles provide several key advantages over traditional powder processing technologies (e.g., spheronized particles and lactose blends), the physicochemical stability of the amorphous drug present in these formulations brings along its own unique set of constraints. To this end, a number of approaches have been developed to maintain the crystallinity of drugs throughout the spray drying process. One approach is to spray dry suspensions of micronized drug(s) from a liquid feed. In this method, minimization of drug particle dissolution in the liquid feed is critical, as dissolved drug is converted into amorphous domains in the spray-dried drug product. The review explores multiple formulation and engineering strategies for decreasing drug dissolution independent of the physicochemical properties of the drug(s). Strategies to minimize particle dissolution include spray blending of particles of different compositions, formation of respirable agglomerates of micronized drug with small porous carrier particles, and use of common ions. The formulations extend the range of doses that can be delivered with a portable inhaler from about 100 ng to 100 mg. The spray-dried particles exhibit significant advantages in terms of lung targeting and dose consistency relative to conventional lactose blends, while still maintaining the crystallinity of drug(s) in the formulated drug product.
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Chorepsima S, Kechagias KS, Kalimeris G, Triarides NA, Falagas ME. Spotlight on inhaled ciprofloxacin and its potential in the treatment of non-cystic fibrosis bronchiectasis. Drug Des Devel Ther 2018; 12:4059-4066. [PMID: 30568427 PMCID: PMC6267620 DOI: 10.2147/dddt.s168014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Stamatia Chorepsima
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece, .,Department of Medicine, Henry Dunant Hospital Center, Athens, Greece,
| | | | - Georgios Kalimeris
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece, .,Department of Medicine, Henry Dunant Hospital Center, Athens, Greece,
| | - Nikolaos A Triarides
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece, .,Department of Medicine, Henry Dunant Hospital Center, Athens, Greece,
| | - Matthew E Falagas
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece, .,Department of Medicine, Henry Dunant Hospital Center, Athens, Greece, .,Department of Medicine, Tufts University School of Medicine, Boston, MA, USA,
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Abstract
The medical management of bronchiectasis includes confirming the diagnosis of the disease, evaluating the patient for possible underlying etiologies and then properly assessing the patient for appropriate therapies. Patients with bronchiectasis are heterogeneous and a personalized approach to each patient is needed in order to properly formulate an optimal management plan.
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Affiliation(s)
- Anne E O'Donnell
- Division of Pulmonary, Critical Care and Sleep Medicine, Georgetown University Medical Center, Washington, DC, USA
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González Del Castillo J, Candel FJ, de la Fuente J, Gordo F, Martín-Sánchez FJ, Menéndez R, Mujal A, Barberán J. [Integral approach to the acute exacerbation of chronic obstructive pulmonary disease]. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2018; 31:461-484. [PMID: 30284414 PMCID: PMC6194861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 09/04/2018] [Indexed: 11/12/2022]
Abstract
Chronic obstructive pulmonary disease is a set of clinical processes that have in common a chronic and progressive obstruction to airflow, with episodes of exacerbation. These exacerbations are more frequent and severe over time, deteriorating the lung function. The main cause of exacerbations is bacterial infection. There are multiple guidelines and documents that statement the management of this pathology. However, they focus primarily on the treatment during the stable phase. This document addresses the problem of acute exacerbation due to an infection from a multidisciplinary perspective, focusing on the integral approach to the process, and including etiology, microbiological studies, resistance to antimicrobials, risk stratification and initial empirical therapeutic management (antibiotic and concomitant). In addition, it includes an approach to more complex aspects such as the management of special populations (elderly and immunosuppressed) or therapeutic failure. Finally, more controversial topics such as prophylaxis of infection or palliative treatment are specifically discussed.
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Affiliation(s)
- J González Del Castillo
- Juan González del Castillo, Servicio de Urgencias. Hospital Clínico San Carlos. Calle Profesor Martín-Lagos s/n, 28040 Madrid. Spain.
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Kamaruzzaman NF, Tan LP, Mat Yazid KA, Saeed SI, Hamdan RH, Choong SS, Wong WK, Chivu A, Gibson AJ. Targeting the Bacterial Protective Armour; Challenges and Novel Strategies in the Treatment of Microbial Biofilm. MATERIALS (BASEL, SWITZERLAND) 2018; 11:E1705. [PMID: 30217006 PMCID: PMC6164881 DOI: 10.3390/ma11091705] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/07/2018] [Accepted: 09/09/2018] [Indexed: 02/07/2023]
Abstract
Infectious disease caused by pathogenic bacteria continues to be the primary challenge to humanity. Antimicrobial resistance and microbial biofilm formation in part, lead to treatment failures. The formation of biofilms by nosocomial pathogens such as Staphylococcus aureus (S. aureus), Pseudomonas aeruginosa (P. aeruginosa), and Klebsiella pneumoniae (K. pneumoniae) on medical devices and on the surfaces of infected sites bring additional hurdles to existing therapies. In this review, we discuss the challenges encountered by conventional treatment strategies in the clinic. We also provide updates on current on-going research related to the development of novel anti-biofilm technologies. We intend for this review to provide understanding to readers on the current problem in health-care settings and propose new ideas for new intervention strategies to reduce the burden related to microbial infections.
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Affiliation(s)
- Nor Fadhilah Kamaruzzaman
- Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa 16100, Kelantan, Malaysia.
| | - Li Peng Tan
- Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa 16100, Kelantan, Malaysia.
| | - Khairun Anisa Mat Yazid
- Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa 16100, Kelantan, Malaysia.
| | - Shamsaldeen Ibrahim Saeed
- Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa 16100, Kelantan, Malaysia.
| | - Ruhil Hayati Hamdan
- Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa 16100, Kelantan, Malaysia.
| | - Siew Shean Choong
- Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa 16100, Kelantan, Malaysia.
| | - Weng Kin Wong
- School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia.
| | - Alexandru Chivu
- UCL Centre for Nanotechnology and Regenerative Medicine, Division of Surgery & Interventional Science, University College London, London NW3 2PF, UK.
| | - Amanda Jane Gibson
- Royal Veterinary College, Pathobiology and Population Sciences, Hawkshead Lane, North Mymms, Hatfield AL9 7TA, UK.
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Bell SC, Elborn JS, Byrnes CA. Bronchiectasis: Treatment decisions for pulmonary exacerbations and their prevention. Respirology 2018; 23:1006-1022. [PMID: 30207018 DOI: 10.1111/resp.13398] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 07/20/2018] [Accepted: 08/15/2018] [Indexed: 12/11/2022]
Abstract
Interest in bronchiectasis has increased over the past two decades, as shown by the establishment of disease-specific registries in several countries, the publication of management guidelines and a growing number of clinical trials to address evidence gaps for treatment decisions. This review considers the evidence for defining and treating pulmonary exacerbations, the approaches for eradication of newly identified airway pathogens and the methods to prevent exacerbations through long-term treatments from a pragmatic practice-based perspective. Areas for future studies are also explored. Watch the video abstract.
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Affiliation(s)
- Scott C Bell
- Lung Bacteria Laboratory, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia.,Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Joseph S Elborn
- Adult Cystic Fibrosis Department, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK.,School of Medicine, Dentistry and Biomedical Sciences, Institute for Health Sciences, Queen's University, Belfast, UK
| | - Catherine A Byrnes
- Department of Paediatrics, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,Respiratory Service, Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
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Paredes Aller S, Quittner AL, Salathe MA, Schmid A. Assessing effects of inhaled antibiotics in adults with non-cystic fibrosis bronchiectasis--experiences from recent clinical trials. Expert Rev Respir Med 2018; 12:769-782. [PMID: 30025482 DOI: 10.1080/17476348.2018.1503540] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Non-cystic fibrosis bronchiectasis (NCFB) results from a permanent and progressive destruction of the airways leading to poor lung function. NCFB is characterized by recurrent lung infection, sputum production, and cough, often requiring long-term antibiotic therapy and hospitalization. At present, there are no approved therapies available. Clinical trials of inhaled antibiotics have shown promise against sputum bacterial load, but mixed results on clinical outcomes. Areas covered: The objective of this review is to provide an overview of NCFB and critically evaluate the evidence supporting the outcome measures used in recent clinical trials of inhaled antibiotics. These include quantitative changes in bacterial load, sputum purulence and yield, inflammatory markers, and lung function, as well as clinical changes in exacerbations, exacerbation frequency, hospitalizations, and health-related quality of life. Expert commentary: Recently completed large trials of inhaled antibiotics in NCFB did not consistently meet pre-specified end points, suggesting that we have not yet found the best enrollment criteria or outcome measures to evaluate efficacy, although reduced exacerbation frequency may be clinically most meaningful. Future trials may focus on specific patient populations at high risk with new information obtained through analyses of large international patient registries. ABBREVIATIONS 6-MWT: Six-Minute Walk Test; AIR-BX: Aztreonam for Inhalation Solution in Patients with Non-Cystic Fibrosis Bronchiectasis trial; BSI: Bronchiectasis Severity Index; CAT: COPD Assessment Test; CF: Cystic Fibrosis; CFTR: Cystic Fibrosis Transmembrane Conductance Regulator; CFU: Colony-Forming Units; COPD: Chronic Obstructive Pulmonary Disease; CRP: C-Reactive Protein; DPI: Dry Powder for Inhalation; EMA: European Medicines Agency; ERS: European Respiratory Society; FACED: FEV1, Age, Chronic colonization by P. aeruginosa, Extension of bronchiectasis and Dyspnea; FDA: US Food and Drug Administration; FEV1: Forced Expiration in 1 s; FVC: Forced Vital Capacity; HFCC: High-Frequency Chest Compression; HRCT: High-Resolution Computed Tomography; HRQoL: Health-Related Quality of Life; LCQ: Leicester Cough Questionnaire; MID: Minimal Important Difference; NCFB: Non-Cystic Fibrosis Bronchiectasis; NTM: Nontuberculous Mycobacteria; ORBIT: Once-daily Respiratory Bronchiectasis Inhalation Treatment trial; PRO: Patient-Reported Outcomes; QoL-B: Quality of Life-Bronchiectasis; SGRQ: St. George's Respiratory Questionnaire; SWT: Shuttle Walk Test; TORCH: Towards a Revolution in COPD Health trial; UPLIFT: Understanding Potential Long-term Impacts on Function with Tiotropium trial.
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Affiliation(s)
- Sheyla Paredes Aller
- a Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine , University of Miami , Miami , FL , USA
| | - Alexandra L Quittner
- b Miami Children's Research Institute , Nicklaus Children's Research Institute , Miami , FL , USA
| | - Matthias A Salathe
- a Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine , University of Miami , Miami , FL , USA
| | - Andreas Schmid
- a Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine , University of Miami , Miami , FL , USA
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Amaro R, Panagiotarakou M, Alcaraz V, Torres A. The efficacy of inhaled antibiotics in non-cystic fibrosis bronchiectasis. Expert Rev Respir Med 2018; 12:683-691. [DOI: 10.1080/17476348.2018.1500179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Rosanel Amaro
- Department of Pulmonary Medicine, Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona - Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
| | - Meropi Panagiotarakou
- Department of Pneumonology, Sotiria General Hospital for Thoracic Diseases, Medical School, University of Athens, Barcelona, Spain
| | - Victoria Alcaraz
- Fundació Clínic per la Recerca Biomèdica, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Antoni Torres
- Department of Pulmonary Medicine, Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona - Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
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Regan KH, Hill AT. Risk of Development of Resistance in Patients with Non-Cystic Fibrosis Bronchiectasis Treated with Inhaled Antibiotics. CURRENT PULMONOLOGY REPORTS 2018; 7:63-71. [PMID: 30148049 PMCID: PMC6096916 DOI: 10.1007/s13665-018-0202-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Purpose of Review Bronchiectasis is a debilitating chronic lung disease characterised by recurrent bacterial infection and colonisation with significant associated morbidity and mortality. To date, there are few licenced treatments, and the mainstay of clinical management is prompt antibiotic therapy for exacerbations and regular airway clearance. Inhaled antibiotics are a potential long-term treatment for those with recurrent exacerbations, and represent an obvious advantage over other routes of administration as they achieve high concentrations at the site of infection whilst minimising systemic side effects. The main caveat to such treatment is the development of antimicrobial resistance due to altered selection pressures. Recent Findings Numerous studies of various inhaled antimicrobials have demonstrated favourable safety and efficacy profiles for bronchiectasis patients with chronic infection, which are supportive of their use in clinical practice. Summary There is no convincing evidence of treatment-emergent pathogens or pathogens developing resistance to the inhaled antibiotic therapy.
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Affiliation(s)
- Kate H. Regan
- The Queen’s Medical Research Institute, University of Edinburgh/MRC Centre for Inflammation Research, Edinburgh, UK
- Department of Respiratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Adam T. Hill
- The Queen’s Medical Research Institute, University of Edinburgh/MRC Centre for Inflammation Research, Edinburgh, UK
- Department of Respiratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
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Khadka P, Dummer J, Hill PC, Das SC. Considerations in preparing for clinical studies of inhaled rifampicin to enhance tuberculosis treatment. Int J Pharm 2018; 548:244-254. [PMID: 29983396 DOI: 10.1016/j.ijpharm.2018.07.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/02/2018] [Accepted: 07/02/2018] [Indexed: 01/24/2023]
Abstract
Drug delivery via the inhaled route has advantages for treating local and systemic diseases. Pulmonary drug delivery may have potential in treating tuberculosis (TB), which is mainly localised in the lung (pulmonary tuberculosis ∼75%) while also affecting other organs (extra-pulmonary tuberculosis). Currently, rifampicin, a first-line anti-tubercular drug, is given orally and the maximum daily oral dose is the lesser of 10 mg/kg or 600 mg. Since only a small fraction of this dose is available in the lung, concentrations may frequently fail to reach bactericidal levels, and therefore, contribute to the development of multi-drug resistant pulmonary TB. Pulmonary delivery of rifampicin, either alone or in addition to the standard oral dose, has the potential to achieve a high concentration of rifampicin in the lung at a relatively low administered dose that is sufficient to kill bacteria and reduce the development of drug resistance. As yet, no clinical study in humans has reported the pharmacokinetics or the efficacy of pulmonary delivery of rifampicin for TB. This review discusses the opportunities and challenges of rifampicin delivery via the inhaled route and important considerations for future clinical studies on high dose inhaled rifampicin are illustrated.
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Affiliation(s)
- Prakash Khadka
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Jack Dummer
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Philip C Hill
- Centre for International Health, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Shyamal C Das
- School of Pharmacy, University of Otago, Dunedin, New Zealand.
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Athanazio R, da Costa JC, de la Rosa Carrillo D, Martínez-García MÁ. Current and future pharmacotherapy options for non-cystic fibrosis bronchiectasis. Expert Rev Respir Med 2018; 12:569-584. [PMID: 29806511 DOI: 10.1080/17476348.2018.1481392] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION In recent years, there has been an increasing number of clinical trials investigating the effect of pharmacological treatments on patients with bronchiectasis. Areas covered: This review provides an overview of current drugs used in bronchiectasis patients as well as those that could make a future contribution to the management of this disease. Expert commentary: Bronchiectasis is a very heterogeneous disease, so it can be studied from a phenotypic standpoint and its pathophysiological mechanisms (endotypes) can be defined. This provides an interesting field of research as it enables the identification of patients suitable for inclusion in specific clinical trials on new drugs.
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Affiliation(s)
- Rodrigo Athanazio
- a Pulmonary Division , Heart Institute (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , Brazil
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